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TR A N S A CTIONS
OF THE
INTERNATIONAL MEDICAL CONGRESS.
TRANSACTIONS
OF THE
INTERNATIONAL MEDICAL CONGRESS
OF
P H I L A D E L P H I
I876.
EDITED EOR TEIE CONGRESS
BY
JOHN ASHHURST, JR., A.M., M.D.,
FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, PROFESSOR OF
CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON
TO THE EPISCOPAL HIOSPITAL AND TO THE CHILDREN’s HOSPITAL,
CONSULTING SURGEON TO ST. CHRISTOPHER'S HOSPITAL AND
TO THE HOSPITAL OF THE GOOD SHEPHERD, ETC.
sº
P H I L A D E L PHI A :
PRINTED FOR THE CON GRESS.
1877.

Entered according to the Act of Congress, in the year 1877, by
CASPAR WISTER, M.D., TREASURER,
in the Office of the Librarian of Congress. All rights reserved.
PHILADELPHIA
c o L L IN s, PR IN T E R,
705 Jayne Street.
P. R. E. F. A 0 E.
IN explanation of the delay which has attended the publication of the
present volume, the Editor would invite attention to the diversified cha-
racter of its contents, which has necessitated the sending of proof-sheets
to more than threescore authors, residing in all portions of the country,
and has thus required a much greater expenditure of time than would
have been needed under other circumstances.
The volume contains all the Addresses delivered before the Congress
in its General Sessions, and, with few exceptions, all the Papers read in
the meetings of the several Sections, and by them recommended for pub-
lication. Abstracts of the Discussions which ensued upon the reading
of the several papers, are also appended in many instances, and, it is
believed, will be found to add materially to the interest of the whole.
A few papers have been withdrawn by their authors, and three have
been omitted by the Committee of Publication : one on account of its
inappropriateness to the work of the Section before which it was read,
and of its fragmentary nature, the paper to which it was really but an
introduction not having been furnished by the author; another on ac-
Count of the great expense which would have attended the reproduction
of the drawings with which it was illustrated, and without which it
would have been valueless; and a third because, though it was referred
to the Committee by the Section before which it was read, yet the
President and Secretary, and several prominent members, of the Sec-
tion, afterwards united in declaring that it had been so referred by mis-
take, and that it was not designed for publication. One paper which
was recommended for publication has not been received, and appears to
have been lost before the records of the Congress were placed in the
Committee’s hands.
Two papers were considered too voluminous for the Transactions, and
are, therefore, represented by condensed abstracts, one furnished by the
author, and the other by the Secretary of the Section to which it had
been presented. The Committee of Publication has not felt justified in
rejecting any paper on the sole ground of want of merit, after it had
been deliberately approved by the Section which heard it read, and to
which the responsibility of accepting or refusing it properly belonged;
but, in justice to itself, the Committee cannot avoid expressing the
vi PR E F A C E .
opinion that, in some few instances, the censorship exercised by the
Sections might properly have been more rigid.
To the actual proceedings of the Congress and of its several Sections,
are prefixed Lists of the Officers and Members of the Congress, the
Minutes of the General Sessions, the Address of Welcome of the Presi-
dent, Professor Gross, and, in order to complete the history of the Con-
gress, a brief account of its inception and of the Centennial Medical
Commission, prepared by Dr. Hutchinson.
Though authorized by a resolution of the Congress to call upon each
delegate for a further contribution towards the expense of issuing the
volume, the Committee of Publication determined, after mature delibe-
ration, that it would be better not to make an additional assessment,
but to endeavor, by the exercise of a careful supervision, to reduce the
cost of the volume to the sum actually in hand from registration-fees
and from subscriptions; this has been done, and the Committee has the
satisfaction of terminating its labors with no deficit in the treasury.
The Editor offers his sincere thanks to the other members of the Com-
mittee of Publication for the cordial support which they have uniformly
extended to him in the laborious, and occasionally ungrateful, duties of
his office. For any errors which may be detected in his work, and he
does not presume to hope that many such do not exist, he bespeaks the
friendly indulgence of the reader; and, in bringing his task to a close,
he ventures to express a hope that this volume, on which he has ex-
pended more than a year of arduous labor, may be found to furnish a
not unsatisfactory memorial of the meetings of that important body of
which it records the acts—the First International Medical Congress of
America. -
JOHN ASHHURS C, JR.
2000 WEST DELANCEY PLACE,
PHILADELPHIA, OCTOBER, 1877.
THE
(ENTENNIAL MEDICAL COMMISSION AND THE
INTERNATIONAL MEDICAL CONGRESS.
BY
JAMES H. HUTCHINSON, A.M., M.D.,
OF PHILADELPHIA.
THE project of holding an INTERNATIONAL MEDICAL CONGRESS in Phila-
delphia, during the Centennial Anniversary of the Declaration of Independence
by the United States, seems to have been entertained by the profession as early
as 1872, and to have grown out of a resolution originally introduced by Dr. J.
G. Stetler, at a meeting of the Philadelphia County Medical Society, held in
October of that year. This resolution proposed that a general conference of
the different medical societies and colleges in the city should be held to deter-
mine what part the medical profession should take in the approaching celebra-
tion, which was just then beginning to excite general interest in the community.
The form which the proposed celebration should assume, had not, however, been
fully agreed upon, and the time at which it was to take place was still far off in
the future. Moreover, its advocates had not yet succeeded in convincing our
people that it was destined to be one of the great events in our history. Under
these circumstances it is not surprising that Dr. Stetler's resolution did not
bear immediate fruit, and that the subject was allowed to lie dormant for more
than a year.
The question was, however, reopened in January, 1874, in the same Society,
which then appointed a committee, consisting of Drs. L. Turnbull, J. G. Stetler,
and M. O’Hara, to take the matter into consideration. This committee, in due
time, reported in favor of the project, and proposed the Fourth of July, 1876,
as the day upon which the Congress should begin its sessions. It recom-
mended, also, that the other medical societies of the city should be requested
to appoint committees to co-operate with that of the County Society in pre-
paring a plan. At this time, but one other society responded to the request;
and the committee soon after, finding that it did not fully represent the pro-
fession in the city, extended invitations to several prominent physicians to
take part in its deliberations. These invitations were in most instances
cordially accepted. The committee, thus increased in numbers and influence,
viii THE CENTENNIAL MEDICAL COMMISSION.
Organized on the 29th of March, 1875, as “THE CENTENNIAL MEDICAL COM-
MISSION OF PHILADELPHIA,” with the following officers:—
P R E s I D E N T.
SAMUEL D. GROSS, M.D., LL.D., D.C.L. Oxon.
VI C E . P R E S I D E N T S.
ALFRED STILLE, M.D., LL.D. W. S. W. RUSCHENBERGER, M.D., U.S. N.
T R E A s U R E R.
CASPAR WISTER, M.D.
R. E. co R D IN G SE C R ET A R Y.
WILLIAM B. ATKINSON, M.D.
Fo R E I G N C o R R E S P o N D IN G H o M E C o R. R. Es P o N D IN G
S E C R E T A R Y . S E C R ET A R Y.
RICHARD J. DUNGLISON, M.D. DANIEL G. BRINTON, M.D.
It was at this time also decided that the Congress should meet in September,
instead of in July, as originally suggested, and that it should continue in Ses-
sion for at least six days. It was, moreover, proposed that the mornings
should be devoted to business and to the reading of discourses upon topics of
general interest, and that in the afternoons the Congress should meet in Sec-
tions for the discussion of Scientific questions." After much discussion, it was
determined that there should be nine Sections, as follows: (1) A Section on
Medicine; (2) A Section on Biology; (3) A Section on Surgery; (4) A Sec-
tion on Dermatology and Syphilography; (5) A Section on Obstetrics; (6) A
Section on Ophthalmology; (7) A Section on Otology; (8) A Section on
Sanitary Science; and (9) A Section on Mental Diseases. The Commission
further decided that the Sections should meet on Monday, Tuesday, Wednes-
day, Thursday, and Friday afternoons of the week during which the Congress
should be in session; that, on four of these afternoons, the deliberations of
each Section should be opened by the reading of a paper upon a subject of
scientific interest, by a gentleman specially chosen for that purpose, and that
the paper should afterwards be submitted for discussion. The remaining after-
noon was to be left free for the reception of voluntary papers. The elaboration
of this plan, together with the choice of subjects to be discussed, was left to
special committees.
At the meeting of the Commission which was held on the 19th of April,
1875, another and a successful effort was made to secure the co-operation of
the other medical Societies of the city, all of which appointed committees to
1 The subjects finally chosen for the discourses, with the names of the gentlemen selected
to deliver them, were as follows: 1. Medicine and Medical Progress, Dr. AUSTIN FLINT,
of New York; 2. Surgery, Dr. PAUL F. Eve, of Tennessee; 3. Obstetrics, Dr. THEoPHILUs
PARVIN, of Indiana; 4. Therapeutics, Dr. ALFRED STILLé, of Pennsylvania (declined);
5. Medical Jurisprudence, Dr. STANFoRD E. CHAILLé, of Louisiana; 6. Medical Biography,
Dr. JoséPH M. ToNER, of the District of Columbia ; 7. Medical Institutions and Educa-
tion, Dr. N. S. DAVIs, of Illinois; 8. Medical Literature, Dr. L. P. YANDELL, of Ken-
tucky; 9. Hygiene and Social Science, Dr. H. I. Bowditch, of Massachusetts; 10. Mental
Hygiene, Dr. John P. GRAY, of New York; and 11. Medical Chemistry, Dr. Theo. G.
WoRMLEY, of Ohio.
T H E CENTE N N IA I, M E DIC A. L. C. O M MISSIO N. ix
confer with the Commission. From this time until the meeting of the Con-
gress, the project had the warmest support and sympathy of the whole body
of the profession in Philadelphia.
The addition of so large a number of new members to the Commission, ren-
dered that body rather unwieldy for the transaction of business, and a Com-
mittee of Conference, consisting of members from the various delegations, was
therefore chosen for the purpose of harmonizing, as far as possible, different
views. This Committee, after a thorough review of the work previously done
by the Commission, reported that it would be inexpedient to make any mate-
rial change in the plan already adopted. It recommended, however, in view of
the large amount of labor likely to be imposed upon the secretaries, that two
additional secretaries should be appointed. At the subsequent meeting of the
Commission, Drs. WILLIAM GooDELL and ROBERT M. BERTOLET were chosen
to fill these positions, all the other officers being re-elected by acclamation.
The Committee of Conference having done its work very satisfactorily, it
was thought well by the Commission that thenceforward the perfecting of the
plan of the Congress should be confided to a COMMITTEE OF ARRANGEMENTS,"
consisting of the following gentlemen, who were chosen chiefly on account of
the interest which they had shown in the project: Drs. S. D. Gross, Edward
Hartshorne, Washington L. Atlee, Albert Fricke, Laurence Turnbull, W. W.
Keen, I. Minis Hays, J. Solis Cohen, N. L. Hatfield, A. K. Minich, Thomas
Geo. Morton, George Strawbridge, William Goodell, John S. Parry, R. G.
Curtin, John H. Packard, James H. Hutchinson, Louis A. Duhring, Alfred
Stillé, William Thomson, and Daniel G. Brinton. Prof. Gross was chairman
of this Committee, and Dr. Wm. B. Atkinson acted as its secretary for the
greater part of the time during which it was in existence. The meetings of
the Commission were after the appointment of this Committee very infrequent ;
the larger body being called together only to decide questions of special im-
portance.
A large and influential ExECUTIVE COMMITTEE was also formed about this
time, and bore upon its roll the names of many of the most eminent men of
the profession in various parts of the Union.
In order to secure as full a representation from foreign lands as possible, a
CoMMITTEE of INVITATION was soon after appointed, to which was entrusted
the duty of selecting the medical societies abroad, which should be requested
to send delegates to the Congress, and also of designating the individual mem-
bers of the profession, both in this and other countries, who, by the eminence
which they had attained in medical science, were entitled to the compliment of
a special invitation. A large number of such invitations was sent, and those
to gentlemen in this country were with very few exceptions accepted. Unfor-
| Beside this Committee, two other Committees were appointed at this time, viz., (1)
A Committee of Finance, whose duty it was to collect funds for the entertainment of the
delegates; and (2) A Committee of Publication. The first Committee consisted of Drs.
Caspar Wister, H. Lenox Hodge, Levi Curtis, Thomas Geo. Morton, T. Hewson Bache,
Albert H. Smith, James Tyson, and Charles H. Burnett. The second Committee was
never called together, and the selection of a Committee of Publication was thus left for
the action of the Congress when it should assemble.
X T H E C E N T E N N IA L ME DIC A. L. C. O M MISSION.
tunately, the loss of time and the great expense involved in a journey to Ame-
rica, prevented as many of our foreign brethren from entertaining the idea of
attending the Congress as had been hoped ; but the letters which they sent in
answer, courteously acknowledged the compliment offered, and were expressive
of the regret felt by the writers in being obliged to decline the invitation."
In addition to the members specially invited, in our own country, it was
finally agreed that delegates to the Congress should be received from the fol-
lowing bodies: (1) The American Medical Association, one delegate for every
State and Territory in the Union ; (2) The Association of Medical Superin-
tendents of American Institutions for the Insane, twenty delegates; (3) The
State Medical Societies, each as many delegates as its State had representatives
in the Congress of the United States; (4) The Medical Staff of the Army, two
delegates; (5) The Medical Staff of the Navy, two delegates; (6) The Marine
Hospital Service, two delegates; (7) The American Public-Health Association,
five delegates; and (8) The American Association for the Cure of Inebriates,
two delegates. All the members of the Centennial Medical Commission, includ-
ing members of the Executive Committee, were considered delegates by virtue
of their position in the Commission.
The manner in which the officers of the Congress should be chosen, gave rise
to some discussion in the Commission, some of the members holding that it
would be a graceful compliment to bestow the Presidency upon a distinguished
foreigner; but on the other hand, it was contended that it would be better to
allow the Congress to select its own officers, and this view at length prevailed.
It was made the duty of the President of the Commission to call the Congress to
order when it should first meet, and, after welcoming the delegates, to appoint
a Committee of Nominations, consisting of delegates from all parts of the
world.
It is, perhaps, needless to add, in concluding this short sketch of the labors
of THE CENTENNIAL MEDICAL COMMISSION OF PHILADELPHIA, and of its Com-
mittees, that no pains were spared to render the visit of the delegates to the
Congress a pleasant one, and that there is every reason to believe that the
effort was not unsuccessful.
! An invitation was sent by the Commission, in September, 1875, to the International
Medical Congress, then in session at Brussels, to hold its next meeting in Philadelphia.
While this invitation was courteously declined, the Congress adjourned over until the year
1877, in order to give all its members, who might wish to do so, an opportunity to attend
the sessions of the Centennial Congress in this country.
() FFIC E R S () F T H E () () N G R E S S.
P. R. E S I D E N T .
SAMUEL D. GROSS, M.D., LL.D., D.C.L. Oxon.,
OF PHILADELPIIIA.
V I C E - P. R. E S I D E N T S.
PAUL F. Eve, M.D., Tennessee. JoDLIFFE TUFNELL, F.R.C.S., Ireland.
W. L. ATLEE, M.D., Pennsylvania. C. LANGE, M.D., Denmark.
T. G. RICHARDSON, M.D., Louisiana. WILLIAM. H. HINGSTON, M.D., Canada.
JAMES P. WHITE, M.D., New York. H. MIYAKE, M.D., Japan.
NATHAN R. SMITH, M.D., Maryland. MICHAEL RUDNEW, M.D., Russia.
J. M. To NER, M.D., Dist. of Columbia. PROF. HUETER, M.D., Germany.
J. B. Jon Nson, M.D., Missouri. FREDERICK SEMELEDER, M.D., Austria.
HUNTER McGUIRE, M.D., Virginia. JoBAN HJoRT, M.D., Norway.
HENRY GIBBONs, M.D., California. R. F. HuDSON, M.D., Australia.
GEORGEL.COLLINS, M.D., Rhode Island. PIERRE DEBAISIEUX, M.D., Belgium.
NATIIAN S. DAVIs, M.D., Illinois. WILLIAM ADAMs, F.R.C.S., England.
Louis A. DUGAs, M.D., Georgia. ALEXANDER. R. SIMPSON, M.D., Scotland.
J. K. BARTLETT, M.D., Wisconsin.
H O N O R. A. R. Y V I C E - P R E S I D E N T S.
Jose.P.H. K. BARNES, M.D., JosepH BEALE, M.D.,
SURGEON-GENERAL U. S. ARMY. SURGEON-GENERAL U. S. NAVY.
T R. E A S U R. E. R. .
CASPAR WISTER, M.D.,
OF PHILADELPHIA.
S E C R. E.T A. R. Y - G E N E R A L.
I. MINIS HAYs, M.D.,
OF PHILADELPHIA.
S E C R. E.T A. R. I E S OF T H E M E E TI N G .
WILLIAM B. ATKINsoN, M.D. RICHARD A. CLEEMANN, M.D.
RICHARD J. DUNGLISON, M.D. WILLIAM W. KEEN, M.D.
R. M. BERTOLET, M.D.
COMMITTEE OF PUBLICATION.
JoHN ASHHURST, Jr., M.D.
RICHARD J. DUNGLISON, M.D.
WILLIAM GooDELL, M.D.
JAMES H. HuTCHINson, M.D.
CASPAR WISTER, M.D.
JOHN ASHHURST, J.R., M.D.,
CHAIRMAN, AND EDITOR OF THE TRANSACTIONs.
OFFICERS OF THE SECTIONS.
SECTION ON MEDICINE.
P. R. E. S I D E N T .
ALFRED STILLá, M.D., LL.D.,
OF PHILADELPHIA.
W I C E - P R E S I D E N T S . --
R. P. HowARD, M.D., J. J. WooDwARD, M.D.,
OF MOINT B E A L. U. S. ARMY.
- S E C R. E. T. A. R. Y .
J. Ewing MEARs, M.D.,
OF PHILADELPHIA.
SECTION ON BIOLOGY.
P R. E S I D E N T .
JoHN C. DALTON, M.D.,
OF NEW YORK.
W I C E - P R E S I D E N T S .
AUSTIN FLINT, Jr., M.D., FRANCIs W. CAMPBELL, M.D.,
OF NEW YORK. OF MONTREAL.
S E C R. E. T. A. R. Y .
JAMES Tyson, M.D.,
OF PHILADELPHIA.
SECTION ON SURGERY.
P. R. E S I D E N T .
Joseph LISTER, F.R.S.,
OF EDINBURGH.
W I C E - P R E S I D E N T S .
J. A. GRANT, M.D., John Ash HURST, Jr., M.D.,
OF OTT AW. A. OF PHILADELPHIA.
S E C R. E. T. A. R. Y.
John H. PACKARD, M.D.,
OF PHILADELPHIA.
SECTION ON DERMATOLOGY AND SYPHILOGRAPHY.
P R E S I D E N T .
JAMES C. WHITE, M.D.,
OF BOST ON.
W I C E - P R E S I D E N T S .
S. ENGLESTED, M.D., EDwARD SHIPPEN, M.D.,
OF COPENHAGEN. U. S. NAVY.
S E. C. R. E. T. A. R. Y .
ARTHUR WAN HARLINGEN, M.D.,
OF PHILADELPHIA.
xiv . OFFIC E R S OF THE SECTION S.
SECTION ON OBSTETRICS.
P. R. E S I D E N T .
RoBERT BARNES, M.D.,
OF LONDON.
W I C E - P R E S I D E N T S .
ALEXANDER R. SIMPSON, M.D., WILLIAM H. ByForD, M.D.,
OF ED IN BURGH. OF CHICAGO.
S E C R. E. T. A R Y .
WILLIAM GooDELI., M.D.,
OF PHILADELPHIA.
e SECTION ON OPHTHALMOLOGY.
P. R. E S I D E N T .
R. BRUDENELL CARTER, F.R.C.S.,
OF LONDON.
W I C E - P R E S I D E N T S.
WILLIAM THoMson, M.D., HENRY W. WILLIAMS, M.D.,
OF PHILADELPHIA. OF BOST ON.
S E C R. E. T. A. R. Y .
John GREEN, M.D.,
OF ST. LOUIS.
SECTION ON OTOLOGY.
P. R. E. S I D E N T.
CLARENCE J. BLAKE, M.D.,
OF BOST ON.
W I C E - P R E S I D E N T .
ALBERT H. BUCK, M.D.,
OF NEW YORK.
S E C R. E. T. A. R. Y .
H. N. SPENCER, M.D.,
OF ST. LOUIS,
SECTION ON SANITARY SCIENCE.
P R E S I D E N T .
STEPHEN SMITH, M.D.,
OF NEW YORK.
W I C E - P R E S II) E N T.
JoBN S. BILLINGs, M.D.,
U. S. ARMY.
S E C R. E. T. A. R. Y .
EzRA. M. HUNT, M.D.,
of METUCHEN, NEw JERs EY.
SECTION ON MENTAL DISEASES.
P. R. E S I D E N T .
John P. GRAY, M.D., LL.D.,
OF NEW YORK.
W I C E - P R E S I D E N T S .
F. GRIssomſ, M.D., IsAAC RAY, M.D.,
OF NORTH CAROLINA. OF PHILADELPHIA.
S E C R. E. T. A R Y .
WALTER KEMPSTER, M.D.,
of win NEBAGo, wisconsin.
LIST OF DELEGATES AND INVITED MEMBERS,
REGISTERED DURING THE MEETING OF
THE CONGRESS.
NAME.
O. D. ABBOTT, M.D., Manchester, N. H.
WILLIAM ADAMs, F.R.C.S., London, England.
C. R. AGNEw, M.D., New York, N. Y.
D. HAYES AGNEw, M.D., Philadelphia, Pa.
HARRISON ALLEN, M.D., Philadelphia, Pa.
J. W. ANAWALT, M.D., Greensburg, Pa.
WILLIAM ANDERSON, M.D., Indiana, Pa.
ABRAM. B. ARNOLD, M.D., Baltimore, Md.
JoHN ASHHURST, Jr., M.D., Philadelphia, Pa.
WM. B. ATKINson, M.D., Philadelphia, Pa.
JOHN L. ATLEE, M.D., Lancaster, Pa.
WASHINGTON L. ATLEE, M.D., Philadelphia, Pa.
H. P. AYREs, M.D., Fort Wayne, Indiana.
FRANCIS BACON, M.D., New Haven, Conn.
HENRY T. BAHNson, M.D., Salem, N. C.
WILLIAM H. BAILEY, M.D., Albany, N. Y.
HENRY B. BAKER, M.D., Lansing, Mich.
A. S. BALDWIN, M.D., Jacksonville, Fla.
FoRDYCE BARKER, M.D., New York, N. Y.
JoHN BARKER, M.D., Dublin, Ireland.
ROBERT BARNES, M.D., F.R.C.P., London, Eng-
[land.
GREGORIO BARROETA, M.D., San Luis Potosi,
[Mexico.
ROBERTS BARTHoLow, M.D., Cincinnati, Ohio.
EDWIN W. BARTLETT, M.D., Milwaukee, Wis.
J. K. BARTLETT, M.D., Milwaukee, Wis.
J. M. BARTON, M.D., Philadelphia, Pa.
FLETCHER BEACH, M.B., London, England.
F. W. BEARD, M.D., Vincennes, Ind.
C. E. BEARDSLEY, M.D., Ottawa, Ohio.
DELEGATE FROM
State Medical Society.
Medical Society of London.
State Medical Society.
Centennial Commission.
Centennial Commission.
State Medical Society.
State Medical Society.
Medical and Chirurgical Fa-
culty of Maryland.
Centennial Commission.
Centennial Commission.
State Medical Society.
Centennial Commission.
State Medical Society.
American Medical Association.
State Medical Society.
State Medical Society.
State Medical Society.
State Medical Society.
State Medical Society.
Surgical Society of Ireland.
Royal Medical and Chirurgi-
cal Society, and Obstetrical
Society of London.
Medical Society of San Luis
Potosi.
State Medical Society.
State Medical Society.
State Medical Society.
Centennial Commission.
Invited member.
State Medical Society.
State Medical Society.
xvi
M E M B E R S.
LIST OF DE L E G A TES AN ID IN WITE D
NAME.
JoHN BELL, M.D., Montreal, Canada.
R. M. BERTOLET, M.D., Philadelphia, Pa.
JoHN S. BILLINGs, M.D., U. S.A., Washington,
[D. C.
CLARENCE J. BLAKE, M.D., Boston, Mass.
A. BLITZ, M.D., Nashville, Tenn.
F. Bog ART, M.D., Sweetwater, Tenn.
RoBERT BoILING, M.D., Chestnut Hill, Pa.
AUG. C. BournONVILLE, M.D., Philadelphia, Pa.
HENRY I. BowdTTCH, M.D., Boston, Mass.
RICHARD C. BRANDEIS, M.D., Louisville, Ky.
JoBIN L. BRAY, M.D., Chatham, Ont. Canada.
A. L. BREYSACHER, M.D., Little Rock, Ark.
GEO. E. BRICKETT, M.D., Augusta, Me.
CHARLEs E. BRIGGs, M.D., St. Louis, Mo.
John H. BRINTON, M.D., Philadelphia, Pa.
WM. BRODIE, M.D., Detroit, Mich.
GEORGE W. BRoomE, M.D., Moberly, Mo.
W. H. BROUSE, M.D., Prescott, Ont. Canada.
D. TILDEN BROWN, M.D., New York, N. Y.
JAMEs H. BROWNFIELD, M.D., Fairmount, W.Va.
GEO. D. BRUCE, M.D., Pittsburg, Pa.
T. LAUDER BRUNTON, M.D., F.R.S., London,
[England.
PETER BRYOB, M.D., Tuscaloosa, Ala.
ALBERT H. BUCK, M.D., New York, N. Y.
FREDERICK J. BUCK, M.D., Philadelphia, Pa.
L. DUNCAN BULKLEY, M.D., New York, N. Y.
F. J. BUMSTEAD, M.D., New York, N. Y.
FRANCIS BURDICK, M.D., Johnstown, N. Y.
C. H. BURNETT, M.D., Philadelphia, Pa.
ROBERT BURNs, M.D., Philadelphia, Pa.
DAVID BURPEE, M.D., Philadelphia, Pa.
GEORGE BURR, M.D., Binghamton, N. Y.
W. BURT, M.D., Paris, Ont. Canada.
SAMUEL C. BUSEY, M.D., Washington, D. C.
W. WEBSTER BUTTERFIELD, M.D., Indianapolis,
[Ind.
JAMES D. BUTTON, M.D., Auburn, N. Y.
WM. H. BYFoRD, M.D., Chicago, Ill.
A. W. CALHOUN, M.D., Atlanta, Ga.
IDELEGATE FROM
Medico-Chirurgical Society of
Montreal.
Centennial Commission.
American Public-Health Asso-
ciation.
Invited member.
State Medical Society.
State Medical Society.
Centennial Commission.
Centennial Commission.
American Medical Association.
State Medical Society.
Western and St. Clair Medical
Society.
State Medical Society.
State Medical Society.
State Medical Society.
Centennial Commission.
State Medical Society.
State Medical Society.
Canada Medical Association.
Association of Medical Super-
intendents of American In-
stitutions for the Insane.
State Medical Society.
State Medical Society.
Medical Society of London.
State Medical Society.
Centennial Commission.
Centennial Commission.
Centennial Commission.
Centennial Commission.
State Medical Society.
Centennial Commission.
Centennial Commission.
Centennial Commission.
State Medical Society.
Branch County Medical Asso-
ciation.
Medical Society of the District
of Columbia.
State Medical Society.
State Medical Society.
State Medical Society.
State Medical Society.
LIST OF DE I, E G A TES A N ID IN WITE I) M E M B E R S.
xvii
NAME.
FRANCIs W. CAMPBELL, M.D., Montreal, Canada.
HENRY FRASER CAMPBELL, M.D., Augusta, Ga.
J. A. CAMPBELL, M.D., Grafton, W. Wa.
WILLIAM CANNIFF, M.D., Toronto, Canada.
John T. CARPENTER, M.D., Pottsville, Pa.
Joseph CARson, M.D., Philadelphia, Pa.
RoBERT BRUDENELL CARTER, F.R.C.S., London,
[England.
FRANKLIN D. CASTLE, M.D., Philadelphia, Pa.
EDWARD T. CAs welI., M.D., Providence, R. I.
B. H. CATLIN, M.D., West Meriden, Conn.
STANFORD E. CHAILLá, M.D., New Orleans, La.
CLARENCE B. CHURCH, M.D., Ottawa, Canada.
E. W. CLARK, M.D., Grinnell, Iowa.
RICHARD A. CLEEMANN, M.D., Philadelphia, Pa.
WM. Cogswell, M.D., Bradford, Mass.
J. SolIs CoIIEN, M.D., Philadelphia, Pa.
ABRAHAM COLES, M.D., Newark, N. J.
GEORGE LEWIs CoILINs, M.D., Providence, R. I.
JAMES CoILINs, M.D., Philadelphia, Pa.
EDWARD Cox, M.D., Battle Creek, Mich.
FRANCIs D. CUNNINGHAM, M.D., Richmond, Va.
GEORGE CUPPLES, M.D., San Antonio, Texas.
R. G. CURTIN, M.D., Philadelphia, Pa.
JoHN CURWEN, M.D., Harrisburg, Pa.
J. M. DA Cost A, M.D., Philadelphia, Pa.
J. C. DALTON, M.D., New York, N. Y.
John DAVIs, M.D., Cincinnati, Ohio.
NATHAN S. DAVIs, M.D., Chicago, Ill.
RICHARD DAvy, F.R.C.S., London, England.
PIERRE DEBAISIEUx, M.D., Louvain, Belgium.
CHARLEs DENISON, M.D., Denver, Col.
JoHN R. DICKSON, M.D., Kingston, Ont. Canada.
HENRY D. DIDAMA, M.D., Syracuse, N. Y.
STEPHEN DoDGE, M.D., Halifax, Nova Scotia.
J. LEwis DoRSET, M.D., Genito, Va.
GREEN.svilDE DOWELL, M.D., Galveston, Texas.
THoMAs M. DRYSDALE, M.D., Philadelphia, Pa.
THOMAs S. DUFFY, M.D., Rutherfordton, N. C.
LOUIS A. DUGAs, M.D., Augusta, Ga.
J. J. DUGDALE, M.D., Montreal, Canada.
Lot Is A. DUHRING, M.D., Philadelphia, Pa.
R. J. DUNGLISON, M.D., Philadelphia, Pa.
P
DELEGATE FROM
Invited member.
State Medical Society.
State Medical Society.
Canadian Medical Association.
State Medical Society.
American Medical Association.
Royal Medical and Chirurgi-
cal Society, and Pathologi-
cal Society of London.
Centennial Commission.
Centennial Commission.
State Medical Society.
Centennial Commission.
Ottawa Medico - Chirurgical
Society.
State Medical Society.
Centennial Commission.
State Medical Society.
Centennial Commission.
State Medical Society.
State Medical Society.
Centennial Commission.
State Medical Society.
State Medical Society.
State Medical Society.
Centennial Commission.
Association of Medical Super-
intendents, etc.
Centennial Commission.
American Medical Association.
State Medical Society.
American Medical Association.
Medical Society of London.
Belgian Government.
State Medical Society.
Canada Medical Association.
State Medical Society.
Dominion Medical Association.
State Medical Society.
State Medical Society.
Centennial Commission.
State Medical Society.
State Medical Society.
Medico-Chirurgical Society of
Montreal.
Centennial Commission.
State Medical Society.
xviii LIST OF DE L E G A TES AND IN WITE D M E M B E R S.
NAME.
ALExANDER DUNLAP, M.D., Springfield, Ohio.
CHARLEs W. EARLE, M.D., Chicago, Ill.
S. Y. EARLE, M.D., St. John, N. B.
J. C. EASTMAN, M.D., Hampstead, N. H.
JAMEs H. ELDREDGE, M.D., East Greenwich, R.I.
WILLIAM ELMER, M.D., Bridgeton, N. J.
S. ENGELSTED, M.D., Copenhagen, Denmark.
J. A. EstLANDER, M.D., Helsingfors, Finland.
Joseph A. EVE, M.D., Augusta, Ga.
PAUL F. Eve, M.D., Nashville, Tenn.
DAVID S. FAIRCHILD, M.D., Ames, Iowa.
CYRUs FALCONER, M.D., Hamilton, Ohio.
P. J. FARNsworth, M.D., Clinton, Iowa.
A. G. FIELD, M.D., Des Moines, Iowa.
WILLIAM FINLAY, M.D., Edinburgh, Scotland.
EMIL FISCHER, M.D., Philadelphia, Pa.
GEORGE JACKSON FISHER, M.D., Sing Sing, N.Y.
SIMON FITCH, M.D., St. John, N. B., Canada.
THoMAs DAVIS FITCH, M.D., Chicago, Ill.
THOMAs M. FLANDREAU, M.D., Rome, N. Y.
AUSTIN FLINT, M.D., New York, N. Y.
AUSTIN FLINT, Jr., M.D., New York, N. Y.
DANIEL E. Foot'E, M.D., Belvidere, Ill.
WILLIAM H. FoED, M.D., Philadelphia, Pa.
WILLIAM Fox, M.D., Madison, Wis.
ALBERT FRICKE, M.D., Philadelphia, Pa.
John FRISSELI, M.D., Wheeling, W. Wa.
F. T. FULLER, M.D., Raleigh, N. C.
ANATOLE DE GAINE, M.D., St. Petersburg, Russia.
FREDERIC HENRY GERRISH, M.D., Portland, Me.
HENRY GIBBONs, M.D., San Francisco, Cal.
WILLIAM GOODELL, M.D., Philadelphia, Pa.
H. EARNEST GOODMAN, M.D., Philadelphia, Pa.
THOMAS W. GoRDON, M.D., Georgetown, Ohio.
M. W. C. GoRI, M.D., Amsterdam, Holland.
J. W. S. Gouley, M.D., New York, N. Y.
J. A. GRANT, M.D., Ottawa, Canada.
John P. GRAY, M.D., Utica, N. Y.
John GREEN, M.D., St. Louis, Mo.
TRAILL GREEN, M.D., Easton, Pa.
WM. WARREN GREENE, M.D., Portland, Me.
SAMUEL D. GROSS, M.D., Philadelphia, Pa.
S. W. GRoss, M.D., Philadelphia, Pa.
DELEGATE FROM
American Medical Association.
State Medical Society.
Canada Medical Association.
State Medical Society.
State Medical Society.
Centennial Commission.
Medical Society of Copenha-
gen.
Invited member.
State Medical Society.
Centennial Commission.
State Medical Society.
State Medical Society.
State Medical Society.
State Medical Society.
Obstetrical Society of Edin-
burgh.
Centennial Commission.
State Medical Society.
Invited member.
State Medical Society.
State Medical Society.
American Medical Association.
State Medical Society.
State Medical Society.
Centennial Commission.
State Medical Society.
Centennial Commission.
State Medical Society.
Association of Medical Super-
intendents, etc.
Invited member.
State Medical Society.
Centennial Commission.
Centennial Commission.
Centennial Commission.
State Medical Society.
Invited member.
State Medical Society.
Canada Medical Association.
State Medical Society.
Centennial Commission.
Centennial Commission.
State Medical Society.
Centennial Commission.
Centennial Commission.
I, IST OF DE L E G A T E S A N D IN WITE D M E M B E H. S. xix
NAME.
FRANCIs M. GUNNELL, M.D., U.S.N., Washing-
[ton, D. C.
Josſ AH HALE, M.D., Owensboro, Ky.
CHARLEs C. HAMILTON, M.D., Cornwallis, Nova
[Scotia.
FRANK HASTINGs HAMILTON, M.D., New York,
[N. Y.
J. W. FIAMILTON, M.D., Columbus, Ohio.
D. W. HAND, M.D., St. Paul, Minn.
EDMUND HANSEN, M.D., Copenhagen, Denmark.
CHARLEs J. HARE, M.D., F.R.C.P., London,
[England.
GEORGE C. HARLAN, M.D., Philadelphia, Pa.
ELISHA HARRIs, M.D., New York, N. Y.
JAMES F. HARRIson, M.D., University of Wa.
B. F. HART, M.D., Marietta, Ohio.
ANDREW HARTMAN, M.D., Baltimore, Md.
HENRY HARTSHORNE, M.D., Haverford Coll., Pa.
N. L. HATFIELD, M.D., Philadelphia, Pa.
I. MINIS HAYs, M.D., Philadelphia, Pa.
W. I. HEDDENs, M.D., St. Joseph, Mo.
CHARLEs HEITZMANN, M.D., New York, N. Y.
ALEXANDER ALLAN HENDERSON, M.D., Ottawa,
[Canada.
GEORGE E. HERSEY, M.D., Manchester, N. H.
CHARLEs A. HEWITT, M.D., Red Wing, Minn.
ADDINELL HEWSON, M.D., Philadelphia, Pa.
ALBERT G. HEYL, M.D., Philadelphia, Pa.
E. A. HILDRETH, M.D., Wheeling, W. Va.
WM. H. HINGSTON, M.D., Montreal, Canada.
HoMER O. HITCHCOCK, M.D., Kalamazoo, Mich.
Johan Hjort M.D., Christiania, Norway.
EDwARD M. HoDDER, M.D., F.R.C.S., Toronto,
[Canada.
H. LENox Hodge, M.D., Philadelphia, Pa.
John T. HoDGEN, M.D., St. Louis, Mo.
JoHN H. HollistER, M.D., Chicago, Ill.
T. K. HolyEs, M.D., Chatham, Ont. Canada.
O. A. HoRR, M.D., Lewiston, Me.
R. P. How ARD, M.D., Montreal, Canada.
John C. HUBBARD, M.D., Ashtabula, Ohio.
STEPHEN G. HUBBARD, M.D., New Haven, Conn.
R. F. HuDson, M.D., Ballarat, Australia.
DELEGATE FROM
Medical Staff, U. S. Navy.
State Medical Society.
Canada Medical Association.
American Medical Association,
and State Medical Society.
State Medical Society.
State Medical Society.
Invited member.
Royal Medical and Chirurgi-
cal Society, and Pathologi-
cal Society of London.
Centennial Commission.
American Public-Health Asso-
ciation.
State Medical Society.
State Medical Society.
Medical and Chirurgical Fa-
culty of Maryland.
Centennial Commission.
Centennial Commission.
Centennial Commission.
State Medical Society.
Invited member.
Ottawa Medico-Chirurgical
Society.
State Medical Society.
State Medical Society.
Centennial Commission.
Centennial Commission.
State Medical Society.
Invited member.
State Medical Society.
Medical Society of Christiania.
Invited member.
Centennial Commission.
American Medical Association.
State Medical Society.
Western and St. Clair Medical
Association.
State Medical Society.
Invited member.
State Medical Society.
Centennial Commission.
Medical Society of Victoria.
XX LIST OF DE L E G A TES A N D IN WITE D M E M B E R S.
NAME.
PROF. HuBTER, M.D., Griefswald, Germany.
C. H. Hugh Es, M.D., St. Louis, Mo.
E. W. Hugh Es, M.D., Grenada, Miss.
J. C. Hugh Es, M.D., Keokuk, Iowa.
EDWARD R. Hun, M.D., Albany, N. Y.
EZR.A. M. Hunt, M.D., Metuchen, N. J.
WILLIAM HUNT, M.D., Philadelphia, Pa.
John C. HuPP, M.D., Wheeling, W. Va.
A. HuRD, M.D., Findlay, Ohio.
W. S. HUSELTON, M.D., Allegheny City, Pa.
ALEXANDER HUTCHINS, M.D., Brooklyn, N. Y.
JAMEs H. HuTCHINSON, M.D., Philadelphia, Pa.
Joseph C. HUTCHISON, M.D., Brooklyn, N. Y.
FREDERICK HYDE, M.D., Cortland, N. Y.
JosLAs A. IRELAND, M.D., Louisville, Ky.
WM. IRVIN, M.D., Breakneck, Pa.
T. IsIIIGOURO, M.D., Tokio, Japan.
J. B. S. JACKSON, M.D., Boston, Mass.
HARVEY JEWETT, M.D., Canandaigua, N. Y.
P. A. JEWETT, M.D., New Haven, Conn.
A. H. Johnson, M.D., Salem, Mass.
H. A. JoHNSON, M.D., Chicago, Ill.
John C. JoHNSON, M.D., Blairstown, N. J.
CHRISTOPHER JOHNSTON, M.D., Baltimore, Md.
SAMUEL J. Jon ES, M.D., Chicago, Ill.
L. S. JOYNES, M.D., Richmond, Va.
W. W. KEEN, M.D., Philadelphia, Pa.
WALTER KEMPSTER, M.D., Winnebago, Wis.
H. N. KENDALL, M.D., Quincy, Ill.
J. G. KERR, M.D., San Francisco, Cal.
E. L. KEYES, M.D., New York, N. Y.
S. B. KIEFFER, M.D., Carlisle, Pa.
G. KIMBALL, M.D., Lowell, Mass.
C. B. KING, M.D., Allegheny City, Pa.
R. A. KINLOCH, M.D., Charleston, S. C.
CHARLEs J. KIPP, M.D., Newark, N. J.
THOMAS S. KIRKBRIDE, M.D., Philadelphia, Pa.
DANIEL H. KITCHEN, M.D., New York, N. Y.
HERMAN KNAPP, M.D., New York, N. Y.
W. A. Kou KOL DE YASNOPOLSKY, M.D.,
[St. Petersburg, Russia.
C. LANGE, M.D., Copenhagen, Denmark.
DELEGATE FROM
Med. Verein für Griefswald.
Association of Medical Super-
intendents, etc.
State Medical Society.
State Medical Society.
State Medical Society.
State Medical Society.
Centennial Commission.
Centennial Commission.
State Medical Society.
tate Medical Society.
State Medical Society.
Centennial Commission.
State Medical Society.
State Medical Society.
State Medical Society.
State Medical Society.
Japanese Government.
State Medical Society.
State Medical Society.
State Medical Society.
State Medical Society.
American Public-Health Asso-
ciation.
State Medical Society.
Centennial Commission.
State Medical Society.
State Medical Society.
Centennial Commission.
Association of Medical Super-
intendents, etc.
State Medical Society.
Invited member.
Invited member.
State Medical Society.
Invited member.
State Medical Society.
State Medical Society.
Invited member.
Centennial Commission.
Association of Medical Super-
intendents, etc.
Invited member.
Invited member.
Medical Society of Copenha-
gel).
LIST
M E M B E R S. xxi
O F D E L E G A T E S A N D IN WITE D
N AME.
E. S. LEMOINE, M.D., St. Louis, Mo.
JAMES LESLIE, M.D., Hamilton, Ont. Canada.
JAMEs H. LETCHER, M.D., Henderson, Ky.
VAN S. LINDSLEY, M.D., Nashville, Tenn.
JOSEPH LISTER, F.R.S., Edinburgh, Scotland.
EDWARD G. LoRING, Jr., M.D., New York, N.Y.
WILLIAM T. LUsk, M.D., New York, N. Y.
ALFRED A. LUTKINs, M.D., Jersey City, N. J.
THoMAs LYON, M.D., Williamsport, Pa.
John DUFF MACDONALD, M.D., Hamilton,
[Ont. Canada.
WILLIAM J. McDow ELL, M.D., Portsmouth, O.
THEODoRE A. McGRAw, M.D., Detroit, Mich.
HUNTER McGUIRE, M.D., Richmond, Va.
JoHN W. McILHANY, M.D., Warrenton, Wa.
John H. MACKIE, M.D., New Bedford, Mass.
JOHN A. McKINNON, M.D., Selma, Ala.
THOMAs F. McLEAN, M.D., Goderich, Ont.
[Canada.
HUGH F. McNARY, M.D., Princeton, Ky.
THos. L. MADDIN, M.D., Nashville, Tenn.
T. D. MANNING, M.D., Waco, Texas.
S. MARKs, M.D., Milwaukee, Wis.
DARIUS MASON, M.D., Prairie-du-Chien, Wis.
THEODORE L. MASON, M.D., Brooklyn, N. Y.
CLAUDIUs H. MASTIN, M.D., Mobile, Ala.
F. F. MAURY, M.D., Philadelphia, Pa.
GEORGE W. MEARS, M.D., Indianapolis, Ind.
J. Ewing MEARS, M.D., Philadelphia, Pa.
JAMES AITKEN MEIGs, M.D., Philadelphia, Pa.
MÁRCOS DE J. MELERO, M.D., Havana, Cuba.
H. P. MERRIMAN, M.D., Chicago, Ill.
THOMAs S. MICHAELs, M.D., Richmond, Wa.
JULIUS F. MINER, M.D., Buffalo, N. Y.
ANDREW K. MINNICH, M.D., Philadelphia, Pa.
FRANCIS MINOT, M.D., Boston, Mass.
H. MIYAKE, M.D., Tokio, Japan.
JoBN F. MoRMONIER, M.D., Baltimore, Md.
E. M. MooRE, M.D., Rochester, N. Y.
GEO. R. MoREHOUSE, M.D., Philadelphia, Pa.
DELEGATE FROM
State Medical Society.
Hamilton Medical and Surgi-
cal Society.
State Medical Society.
State Medical Society.
University of Edinburgh, and
Medico-Chirurgical Society
of Edinburgh.
Invited member.
Invited member.
State Medical Society.
State Medical Society.
Hamilton Medical and Surgi-
cal Society.
State Medical Society.
Centennial Commission.
State Medical Society.
State Medical Society.
State Medical Society.
State Medical Society.
County of Huron Medical As-
sociation.
State Medical Society.
American Medical Association.
State Medical Society.
State Medical Society.
State Medical Society.
American Association for Cure
of Inebriates.
Centennial Commission.
Centennial Commission.
Centennial Commission.
Centennial Commission.
Centennial Commission.
La Real Sociedad Económica
de Amigos del Pais, Ha-
TV3 Illila.
State Medical Society.
State Medical Society.
State Medical Society.
Centennial Commission.
State Medical Society.
Japanese Government.
Medical and Chirurgical Fa-
culty of Maryland.
American Medical Association.
Centennial Commission.
xxii
M E M B E R S.
LIST OF DE L E G A T E S A N D IN WITE D
NAME.
THOMAs G. MoRTON, M.D., Philadelphia, Pa.
ALExANDER B. MoTT, M.D., New York, N. Y.
R. B. Mow Ry, M.D., Allegheny City, Pa.
PAUL F. MUNDá, M.D., New York, N. Y.
H. J. MURPHY, M.D., Chatham, Ont. Canada.
GEORGE MURRAY, M.D., New Glasgow, Nova
[Scotia.
RoBERT D. MURRAY, M.D., Keywest, Fla.
S. NAGAYo, M.D., Tokio, Japan.
ANDREW NEBINGER, M.D., Philadelphia, Pa.
WILLIAM B. NEFTEL, M.D., New York, N. Y.
CHARLEs H. NICHOLs, M.D., Washington, D. C.
R. J. NUNN, M.D., Savannah, Ga.
John A. OCTERLONY, M.D., Louisville, Ky.
MICHAEL O’HARA, M.D., Philadelphia, Pa.
WM. OLD RIGHT, M.D., Toronto, Canada.
H. L. ORTH, M.D., Harrisburg, Pa.
J. W. D. OsgooD, M.D., Greenfield, Mass.
GEORGE A. OTIs, M.D., U. S. A., Washington,
[D.C.
John E. Owens, M.D., Chicago, Ill.
John H. PACKARD, M.D., Philadelphia, Pa.
WM. H. PANCOAST, M.D., Philadelphia, Pa.
EDWARD H. PARKER, M.D., Poughkeepsie, N.Y.
JosłPH PARRISH, M.D., Burlington, N. J.
THEoPHILUs PARVIN, M.D., Indianapolis, Ind.
R. S. PAYNE, M.D., Lynchburg, Va.
ENOCH PEARCE, Jr., M.D., Steubenville, Ohio.
E. R. PEASLEE, M.D., New York, N. Y.
WILLIAM PEPPER, M.D., Philadelphia, Pa.
W. H. PHILIPs, M.D., Kenton, Ohio.
GIDEoN L. PLATT, M.D., Waterbury, Conn.
A. M. Pollock, M.D., Pittsburg, Pa.
J. H. PooDEY, M.D., Columbus, Ohio.
CHARLEs H. Port E.R., M.D., Albany, N. Y.
D. R. PoETER, M.D., Kansas City, Mo.
IsAAC G. PoETER, M.D., New London, Conn.
WM. G. PoETER, M.D., Philadelphia, Pa.
ALFRED C. Post, M.D., New York, N. Y.
EDWIN Powell, M.D., Chicago, Ill.
DAVID PRINCE, M.D., Jacksonville, Ill.
J. S. PROUT, M.D., Brooklyn, N. Y.
SAMUEL S. PURPLE, M.D., New York, N. Y.
SUMNER PUTNAM, M.D., Montpelier, Vt.
IDELEGATE FROM
Centennial Commission.
Invited member.
Invited member.
Invited member.
Western and St. Clair Medi-
cal Association.
Medical Society of Nova
Scotia.
Centennial Commission.
Japanese Government.
Centennial Commission.
Invited member.
Association of Medical Super-
intendents, etc.
State Medical Society.
State Medical Society.
Centennial Commission.
Canada Medical Association.
State Medical Society.
State Medical Society.
American Medical Association.
State Medical Society.
Centennial Commission.
Centennial Commission.
State Medical Society.
American Association for Cure
of Inebriates.
State Medical Society.
State Medical Society.
State Medical Society.
Centennial Commission.
Centennial Commission.
State Medical Society.
State Medical Society.
American Medical Association.
State Medical Society.
State Medical Society.
State Medical Society.
Invited member.
Centennial Commission.
Invited member.
State Medical Society.
State Medical Society.
Invited member.
Invited member.
State Medical Society.
LIST OF DE L E G A TES AND IN WITE D M E M B E R S. xxiii
NAME.
G. RAWSON, M.D., Buenos Ayres, Argentine
[Republic.
ISAAC RAY, M.D., Philadelphia, Pa.
L. S. RAYFIELD, M.D., Jefferson, Texas.
A. N. READ, M.D., Norwalk, Ohio.
THOMAS B. REED, M.D., Philadelphia, Pa.
JAMES T. REEVE, M.D., Appleton, Wis.
JAMEs E. REEVEs, M.D., Wheeling, W. Va.
ALEXANDER P. REID, M.D., Halifax, Nova
[Scotia, Canada.
DUDLEY S. REYNOLDs, M.D., Louisville, Ky.
GEORGE A. REX, M.D., Philadelphia, Pa.
JOSEPH G. RICHARDSON, M.D., Philadelphia, Pa.
T. G. RICHARDSON, M.D., New Orleans, La.
W. L. RICHARDSON M.D., Montrose, Pa.
J. M. RIDGE, M.D., Camden, N. J.
S. D. RISLEY, M.D., Philadelphia, Pa.
JACOB ROBERTs, M.D., Philadelphia, Pa.
D. ARGYLL ROBERTSON, M.D., Edinburgh, Scot-
[land.
DAVID ROBERTSON, M.D., Milton, Ont. Canada.
E. ROBILLARD, M.D., Montreal, Canada.
JAMES D. ROBISON, M.D., Wooster, Ohio.
THOMAS F. Roch ESTER, M.D., Buffalo, N. Y.
ROBERT E. RogFRs, M.D., Philadelphia, Pa.
A. M. RosBBRUGH, M.D., Toronto, Canada.
J. W. RosBBRUGH, M.D., Hamilton, Canada.
JAMES Ross, M.D., Toronto, Canada.
JoHN D. Ross, M.D., Williamsburg, Pa.
J. B. ROTTOT, M.D., Montreal, Canada.
MICHAEL RUDNEW, M.D., St. Petersburg, Russia.
W. S. W. RUSCHENBERGER, M.D., U. S. N.,
[Philadelphia, Pa.
GURDON W. RUSSELL, M.D., Hartford, Conn.
IRA RUSSELL, M.D., Winchendon, Mass.
JoHN W. RUSSELL, M.D., Mt. Vernon, Ohio.
THOMAS P. RUSSELL, M.D., Oshkosh, Wisconsin.
THOMAS EDWARD SATTERTHWAITE, M.D., New
[York, N. Y.
WILLIAM SAVERY, M.D., Bryn Mawr, Pa.
LEWIs A. SAYRE, M.D., New York, N. Y.
HENRY S. SCHELL, M.D., Philadelphia, Pa.
JAMES M. Scott, M.D., St. Louis, Mo.
W. Scott, M.D., Cleveland, Ohio.
EDWARD SEGUIN, M.D., New York, N. Y.
DELEGATE FROM
Medical Association of Buenos
Ayres.
Association of Medical Super-
intendents, etc.
State Medical Society.
State Medical Society.
Centennial Commission.
State Medical Society.
Centennial Commission.
Medical Society of Nova
Scotia.
State Medical Society.
Centennial Commission.
Centennial Commission.
Centennial Commission.
State Medical Society.
State Medical Society.
Centennial Commission.
Centennial Commission.
Medico-Chirurgical Society of
Edinburgh.
Canada Medical Association.
Invited member.
State Medical Society.
State Medical Society.
Centennial Commission.
Canada Medical Association.
Hamilton Medical and Surgi-
cal Society.
Canada Medical Association.
State Medical Society.
Invited member.
Russian Government.
Centennial Commission.
State Medical Society.
State Medical Society.
State Medical Society.
State Medical Society.
Centennial Commission.
State Medical Society.
Centennial Commission.
Centennial Commission.
State Medical Society.
State Medical Society.
American Medical Association.
xxiv. LIST OF DELE GATES AND INVITED MEMBERs.
NAME.
AMos SEIP, M.D., Easton, Pa.
FREDERICK SEMELEDER, M.D., Vienna, Austria.
N. SENN, M.D., Milwaukee, Wis.
LEoPold SERVAIs, M.D., Antwerp, Belgium.
EDWARD O. SHAKESPEARE, M.D., Philadelphia,
- [Pa.
CHARLEs SHEPARD, M.D., Grand Rapids, Mich.
B. F. SHERMAN, M.D., Ogdensburg, N. Y.
EDWARD SHIPPEN, M.D., U.S. N., Philadelphia,
[Pa.
J. H. SHOUT, M.D., Las Vegas, New Mexico.
GEORGE E. SHUTTLEWORTH, M.D., Lancaster,
- [England.
ALEXANDER. R. SIMPSON, M.D., Edinburgh,
[Scotland.
WHARTON SINKLER, M.D., Philadelphia, Pa.
HENRY M. SKILLMAN, M.D., Lexington, Ky.
ALBERT H. SMITH, M.D., Philadelphia, Pa.
ASHBEL SMITH, M.D., Houston, Texas.
DAVID P. SMITH, M.D., Springfield, Mass.
EUGENE SMITH, M.D., Detroit, Michigan.
HEBER SMITH, M.D., Stapleton, N. Y.
J. LEwis SMITH, M.D., New York, N. Y.
JOEL W. SMITH, M.D., Charles City, Iowa.
JosłPH. R. SMITH, M.D., U. S. A., Fort Monroe,
[Va.
FRANCIs G. SMYTH, M.D., Philadelphia, Pa.
EDw1N M. S.Now, M.D., Providence, R. I.
S. FLEET SPEIR, M.D., Brooklyn, N. Y.
H. N. SPENCER, M.D., St. Louis, Mo.
EDWARD R. SQUIBB, M.D., Brooklyn, N. Y.
A. J. STEELE, M.D., St. Louis, Mo.
LEWIs H. STEINER, M.D., Frederick City, Md.
GEORGE T. STEvens, M.D., Albany, N. Y.
JAMEs A. STEUART, M.D., Baltimore, Md.
J. L. STEwART, M.D., Erie, Pa.
ALFRED STILLá, M.D., Philadelphia, Pa.
JosłPH A. STILWELL, M.D., Brownstown, Ind.
BARTON WARREN STONE, M.D., Hopkinsville,
[Ky.
DEI,EGATE FROM
State Medical Society.
Invited member.
State Medical Society.
Belgian Government.
Centennial Commission.
State Medical Society.
State Medical Society.
Medical Staff, United States
Navy.
Medical Society of New
Mexico.
Invited member.
University of Edinburgh, and
Obstetrical Society of Edin-
burgh. r
Centennial Commission.
State Medical Society.
Centennial Commission.
State Medical Society.
State Medical Society.
State Medical Society.
United States Marine-Hospital
Service.
Centennial Commission.
State Medical Society.
Medical Staff, United States
Army.
Centennial Commission.
Centennial Commission.
Invited member.
State Medical Society.
State Medical Society.
State Medical Society.
American Public-Health As-
sociation, and Medical and
Chirurgical Faculty of Mary-
land.
Invited member. -
Medical and Chirurgical Fa-
culty of Maryland.
State Medical Society.
Centennial Commission.
State Medical Society.
Association of Medical Super-
intendents, etc.
LIST OF DE L E G A T E S A N ID IN WITE D
M E M B E R S. XXV
NAME.
GEORGE STRAWBRIDGE, M.D., Philadelphia, Pa.
S. S. STRY KER, M.D., Philadelphia, Pa.
ABSALOM B. STUART, M.D., Winona, Minn.
D. F. STUART, M.D., Houston, Texas.
G. E. SUSSDORFF, M.D., Macon, Georgia.
GEORGE SUTTON, M.D., Aurora, Ind.
JOSEPH SwARTz, M.D., Duncannon, Pa.
W. H. TALIAFERRO, M.D., Atlanta, Ga.
B. W. TAYLOR, M.D., Columbia, S. C.
M. A. TAYLOR, M.D., Austin City, Texas.
R. W. TAYLOR, M.D., New York, N. Y.
LAKE J. TEFFT, M.D., Syracuse, N. Y.
S. H. TEwks BURy, M.D., Portland, Me.
WILLIAM THOMson, M.D., Philadelphia, Pa.
JAMES THORBURN, M.D., Toronto, Canada.
F. WALTON ToDD, M.D., Stockton, Cal.
S. S. ToDD, M.D., Kansas City, Mo.
Joseph M. ToNER, M.D., Washington, D. C.
EDWARD H. TRENHOLME, M.D., Montreal,
[Canada.
JoDLIFFE TUFNELL, F.R.C.S., Dublin, Ireland.
HoRACE TUPPER, M.D., Bay City, Mich.
CHARLEs S. TURNBULL, M.D., Philadelphia, Pa.
LAURENCE TURNBULL, M.D., Philadelphia, Pa.
EDWARD BERRIAM TURNIPSEED, M.D., Colum-
º [bia, S. C.
JAMES Tyson, M.D., Philadelphia, Pa.
G. UNDERwooD, M.D., Pittston, Pa.
WILLIAM H. WAN BUREN, M.D., New York, N.Y.
Joseph H. WANDEMAN, M.D., Chattanooga, Tenn.
S. OAKLEY WANDERPOEL, M.D., Stapleton, N. Y.
ARTHUR WAN HARLINGEN, M.D., Philadelphia,
[Pa.
THOMAS H. WAN WALZAH, M.D., Lewiston, Pa.
THEODoRE R. VARICK, M.D., Jersey City, N. J.
ALEXANDER. M. VEDDER, M.D., Schenectady,
[N. Y.
H. D. VosBURGH, M.D., Lyons, N. Y.
CLEMENT A. WALKER, M.D., Boston, Mass.
JAMES P. WALKER, M.D., Mason City, Ill.
CHARLEs D. WATson, M.D., Covington, Ind.
WM. WATSON, M.D., Dubuque, Iowa.
W. MURRAY WEIDMAN, M.D., Reading, Pa.
FANEUIL D. WEIsse, M.D., New York, N. Y.
DELEGATE FROM
Centennial Commission.
Centennial Commission.
State Medical Society.
State Medical Society.
State Medical Society.
State Medical Society.
State Medical Society.
State Medical Society.
State Medical Society.
State Medical Society.
Centennial Commission.
State Medical Society.
State Medical Society.
Centennial Commission.
Invited member.
State Medical Society.
State Medical Society.
American Public-Health As-
sociation.
Medico-Chirurgical Society of
Montreal.
Surgical Society and Patholo-
gical Society of Ireland.
State Medical Society.
Centennial Commission.
State Medical Society.
State Medical Society.
Centennial Commission.
State Medical Society.
Invited member.
State Medical Society.
State Medical Society.
Centennial Commission.
State Medical Society.
Centennial Commission.
State Medical Society.
State Medical Society.
Association of Medical Super-
intendents, etc.
State Medical Society.
State Medical Society.
State Medical Society.
State Medical Society.
Centennial Commission.
xxvi LIST OF
M E M B E R S.
IDE L E G A TES AN ID IN WITE D
NAME.
JAMES C. WHITE, M.D., Boston, Mass.
JAMES P. WHITE, M.D., Buffalo, N. Y.
LUTHER C. WHITE, M.D., Van Buren, Ark.
GEORGE WILKINs, M.D., Montreal, Canada.
DE FoREST WILLARD, M.D., Philadelphia, Pa.
E. WILLIAMs, M.D., Cincinnati, Ohio.
HENRY W. WILLIAMS, M.D., Boston, Mass.
J. M. WILLIs, M.D., Waco, Texas.
ELLwooD WILSON, M.D., Philadelphia, Pa.
F. N. WISE, M.D., Covington, Ky.
CASPAR WISTER, M.D., Philadelphia, Pa.
HoRATIO C. WooD, Jr., M.D., Philadelphia, Pa.
H. D. WooD, M.D., Angola, Ind.
ALFRED H. WooDILL, M.D., Halifax, Nova
[Scotia.
AsHBEL WooDWARD, M.D., Franklin, Conn.
J. J. WooDWARD, M.D., U. S. A., Washington,
[D. C.
John M. Woodworth, M.D., Washington, D. C.
ALGERNoN WooDVERTON, M.D., Hamilton, Ont.
[Canada.
THEO. G. WoRMLEY, M.D., Columbus, Ohio.
FRED. H. WRIGHT, M.D., Toronto, Ont., Canada.
HENRY P. WRIGHT, M.D., Ottawa, Canada.
R. F. WRIGHT, M.D., Dalton, Ga.
LUNSFORD P. YANDELL, M.D., Louisville, Ky.
H. P. YEOMANs, M.D., Mt. Forest, Ont. Canada.
DELEGATE FROM
Centennial Commission.
State Medical Society.
State Medical Society.
Canada Medical Association.
Centennial Commission.
State Medical Society.
Invited member.
State Medical Society.
Centennial Commission.
Invited member.
Centennial Commission.
Centennial Commission.
State Medical Society.
Halifax County Medical So-
ciety.
State Medical Society.
Medical Staff, United States
Army.
Centennial Commission.
Hamilton Medical and Surgi-
cal Society.
Centennial Commission.
Canada Medical Association.
Ottawa Medical Chirurgical
Society.
State Medical Society.
State Medical Society.
Canada Medical Association.
TABLE OF CONTENTs.
PAGE
Preface . º - º e o º - º e º e & e º V
The Centennial Medical Commission and the International Medical Congress.
By JAMEs H. HUTCHINsoN, A.M., M.D., of Philadelphia e & & te vii
List of Officers of the Congress . º º e e º e º e e xi
List of Officers of Sections . e e tº tº e º º & ſº e xiii
List of Delegates and Invited Members e e º e - - º e XV
List of Illustrations tº e e º © e º e & tº e . XXXii
Address of Welcome. By S. D. GRoss, M.D., LL.D., D.C.L. Oxon., President
of the Centennial Medical Commission . e e © e e e xxxiii
Minutes of the General Sessions . e e º e º º º e . xxxvii
Notice . . e e e o º º e o e e e e e l
A D D R E S S E S.
ART.
I. Address on Medicine and Medical Progress in the United States. By AustiN
FLINT, M.D., Professor of the Principles and Practice of Medicine, and Clinical
Medicine, in Bellevue Hospital Medical College, New York o e º - 1
II. Address on Hygiene and Preventive Medicine. By HENRY I. Bowditch, M.D.,
President of the State Board of Health of Massachusetts . e e º . 21
III. Address on Medical Chemistry and Toxicology. By THEO. G. WoRMLEy, M.D.,
Ph.D., LL.D., Professor of Chemistry and Toxicology in Starling Medical Col-
lege, Columbus, Ohio . 49
IV. Address on Surgery. By PAUL F. Eve, M.D., Professor of Operative and Clinical
Surgery in the University of Nashville º e © e e e . 73
V. Address on Medical Biography. By J. M. ToNER, M.D., of Washington, D.C. 91
VI. Address on Obstetrics. By THEoPHILUs PARVIN, M.D., Professor of Obstetrics
and the Medical and Surgical Diseases of Women, College of Physicians and
Surgeons of Indiana © º e g º º g e o o ©
VII. Address on Medical Jurisprudence. With Notes and a Bibliographical Appen-
dix. By STANFORD E. CHAILLE, A.M., M.D., Professor of Physiology and Patho-
logical Anatomy in the Medical Department of the University of Louisiana . 167
VIII. Address on Mental Hygiene. By John P. GRAY, M.D., LL.D., Medical
Superintendent of the New York State Lunatic Asylum, Utica; Professor of
Psychological Medicine and Jurisprudence in Bellevue Hospital Medical College,
New York . e 205
IX. Address on American Medical Literature. By LUNSFORD PITTs YANDELL, M.D.,
138
of Louisville, Kentucky . º e & & - -> º º -> . 223
X. Address on the Progress of Medical Education in the United States of America,
during the Century commencing in 1776. By N. S. DAVIs, A.M., M.D., of
Chicago, Illinois . e º 265
XI. Address on the Medical Staff of the United States Army, and its Scientific Work.
By J. J. WoodwarD, M.D., Surgeon, United States Army g º º . 286
xxviii X
C O N T E N T S.
SECTION ON MEDICINE.
A RT.
XII. Typho-Malarial Fever; is it a Special Type of Fever ? By J. J. Woodward,
M.D., Surgeon, United States Army . e e & e e e º -
XIII. Are Diphtheritic and Pseudo-Membranous Croup Identical or Distinct Affec-
tions? By J. LEwis SMITH, M.D., Physician to the Infant Hospital, New
York, etc. -
XIV. Do the Conditions of Modern Life favor specially the Development of Nervous
Diseases 7 By Roberts BARTHoLow, M.A., M.D., Professor of the Theory and
Practice of Medicine in the Medical College of Ohio . e e e º
XV. Contribution to the Etiology of Epilepsy. By WILLIAM B. NEFTEL, M.D., of
New York . e © º • o e o º e © e - -
XVI. The Influence of High Altitudes on the Progress of Phthisis. By CHARLEs
DENISON, A.M., M.D., of Denver, Colorado e e
XVII. On the Treatment of Simple Ulcer of the Stomach. By M. Le Docteur H.
LEBERT, of Vevey; formerly Professor of Clinical Medicine at Zurich and
Breslau. Translated by CHARLEs WINSLow DULLEs, M.D., of Philadelphia
XVIII. Cases of Pernicious Progressive Anaemia, with some Observations upon the
Ante-and Post-mortem Conditions observed in that Affection. By R. P. HowARD,
M.D., L.R.C.K., Professor of Medicine in the McGill University, Canada .
XIX. Alcohol in its Therapeutic Relations as a Food and as a Medicine. By EzRA
M. HUNT, M.D., of Metuchen, N. J. . º e e º º o º e
XX. Report of Investigations made under the Direction of Professor RUDNEw at the
Institute of Pathological Anatomy of St. Petersburg. Communicated by Pro-
fessor RUDNEw . tº © © ſº © - &
SECTION ON BIOLOGY.
XXI. The Microscopy of the Blood. By CHRISTOPHER Johnston, M.D., of Balti-
more, Md. . e © º e e º g tº e e e º -
XXII. The Excretory Function of the Liver. By AustiN FLINT, Jr., M.D., Pro-
fessor of Physiology and Physiological Anatomy in the Bellevue Hospital Medi-
cal College, New York * tº e ©
XXIII. Report of Investigations made under the Direction of Professor ZAVARIKINI,
at the Institute of Normal Histology of St. Petersburg. Communicated by
Professor RUDNEW e º & e e e º e º e ->
XXIV. On Fungous Growths in Solutions for Hypodermic Medication, and their
Prevention by Salicylic Acid. By JosłPH G. RICHARDsoN, M.D., Attending
Physician to the Presbyterian Hospital, Philadelphia º e (s o e
XXV. The Mechanism of Joints. By HARRIsoN ALLEN, M.D., Professor of Com-
parative Anatomy and Zoology in the University of Pennsylvania, Surgeon to
the Philadelphia Hospital, Surgeon to St. Joseph's Hospital, etc. &
SECTION ON SURGERY.
XXVI. Antiseptic Surgery. By John T. HoDGEN, M.D., Professor of Surgical
Anatomy and of Fractures and Dislocations in the St. Louis Medical College,
St. Louis, Mo.
XXVII. Antiseptic Surgery. Report of Remarks made before the Surgical Section,
during the Adjourned Discussion on Dr. Hodgen's Paper. By Joseph LISTER,
F.R.S., Professor of Clinical Surgery in the University of Edinburgh. (Presi-
dent of the Section.) . © © o º e e e º e - ©
XXVIII. The Treatment of Aneurism. By W. H. WAN BUREN, A.M., M.D., Pro-
fessor of the Principles and Practice of Surgery in the Bellevue Hospital Medical
College, New York . .
XXIX. The Pathology and Treatment of Morbus Coxarius. By LEwis A. SAYRE,
M.D., Professor of Orthopaedic Surgery and of Fractures and Dislocations in the
Bellevue Hospital Medical College, New York, etc. . º º
PAGE
305
341
467
489
à
7
5
C O N T E N T S. xxix
ART.
XXX. Report of a Case of Sub-periosteal Excision and Disarticulation of the entire
Inferior Maxillary Bone for Phosphorus Necrosis. By JoHN W. S. Gouley, M.D.,
Professor of Diseases of the Genito-Urinary System in the Medical Department
of the University of New York, Surgeon to Bellevue Hospital, etc. . ſº
XXXI. The Causes and Geographical Distribution of Calculous Diseases. By
CLAUDIU's H. MASTIN, M.D., of Mobile, Alabama & © tº & e
XXXII. Subcutaneous Division of the Neck of the Thigh-Bone for Anchylosis at the
Hip-Joint. By WILLIAM ADAMs, F.R.C.S., President of the Medical Society of
London, etc. e e ſe e g © * tº º {º} º
XXXIII. Remarks upon Penetrating Wounds of the Abdomen, with the Suggestion
of a change of Practice in such Cases. By L. A. DUGAs, M.D., LL.D., Pro-
fessor of Surgery in the Medical College of Georgia . e tº e e *
XXXIV. On Opening the Sac in Herniotomy. By FREDERICK HYDE, M.D., of Cort-
land, New York . © e ſº e e ſº * § t * tº ©
XXXV. Some Comments on the History of Nitrous-Oxide Gas as an Anaesthetic,
and on the Analgesic Effects of Rapid Breathing. By ADDINELL, HEwson, M.D.,
Surgeon to the Pennsylvania Hospital, Philadelphia . & e e te
XXXVI. Observations on the Temperature of Osteo-sarcoma. By Prof. J. A. Est-
LANDER, M.D., of Helsingfors, Finland e o ge © º o e e
XXXVII. On Stone in the Bladder in Finland. By Prof. J. A. EstLANDER, M.D.,
of Helsingfors, Finland g tº te © & e º e g
SECTION ON DERMATOLOGY AND SYPHILOGRAPHY,
XXXVIII. Variations in Type and in Prevalence of Diseases of the Skin in Different
Countries of Equal Civilization. By JAMES C. WHITE, M.D., Professor of Der-
matology in Harvard University fº tº * e & ſe tº * &
XXXIX. Verrugas, a Disease Peculiar to Peru. By GEORGE A. WARD, M.D.,
Medical Director of the Oroya Railway. [Communicated by the Secretary.]
XL. Are Eczema and Psoriasis Local Diseases of the Skin, or are they Manifestations
of Constitutional Disorders? ... By L. DUNGAN BULKLEY, A.M., M.D., Physician
to the Skin Department, Demilt Dispensary, New York, etc. . te e g
XLI. The Virus of Venereal Sores, its Unity or Duality. By FREEMAN J. BUM-
STEAD, M.D., late Professor of Venereal Diseases in the College of Physicians
and Surgeons, New York . ë * ſº e ſe tº e * g ū
XLII. Leprosy as Observed in the Sandwich Islands. By FRANK H. ENDERs, M.D.,
Government Physician. [Communicated by the Secretary.] . e
XLIII. On the Treatment of Seborrhoea. By C. HEITZMANN, M.D., of New York
City . tº e & wº g g © * tº tº & wº g &
XLIV. The Treatment of Syphilis, with Special Reference to the Constitutional
Remedies appropriate to its Various Stages, the Duration of their Use, and the
Question of their Continuous or Intermittent Employment. By Edward L.
KEYES, M.D., Professor of Dermatology in the Bellevue Hospital Medical
College, New York tº ſº & g e te i.e. e º ë º
XLV. The Treatment of Syphilis. By CHARLEs R. DRysdai.E., M.D., Senior Physi-
cian to the Metropolitan Free Hospital, Physician to the Bolsover Street Lock
Hospital, London. [Communicated by the Secretary.] . ſe
XLVI. Measures adopted in Denmark to Prevent the Spread of Venereal Disease.
By S. ENGELSTED, M.D., Physician-in-Chief to the Copenhagen Hospital
SECTION ON OBSTETRICS.
XLVII. The Causes and Treatment of Non-Puerperal Hemorrhages of the Womb.
By WILLIAM H. BYFoRD, M.D., Professor of Obstetrics and Diseases of Women
in the Chicago Medical College . iº e º te ſº tº º te
XLVIII. The Mechanism of Natural and of Artificial Labor in Narrow Pelves. By
WILLIAM GooD ELL, A.M., M.D., Clinical Professor of the Diseases of Women
and of Children in the University of Pennsylvania
PAGE
605
609
624
631
XXX C O N T E N T S.
ART.
XLIX. The Management of Convulsions, in Children, depending upon a High Tem-
perature of the Body. By T. K. Hoi.MEs, M.D., of Chatham, Ontario, Canada.
L. Ovariotomy by Enucleation. By JULIUs F. MINER, M.D., Professor of Special
and Clinical Surgery in the Medical Department of the University of Buffalo
LI. The Treatment of Fibroid Tumors of the Uterus. By WASHINGTON L. ATLEE,
M.D., of Philadelphia g e g © © & e º & *
LII. The Three Most Important Obstetrical Instruments. By T. LAZAREwiTCH,
M.D., Professor of Clinical Midwifery and Diseases of Women, and Director of
the Gynaecological Clinique, in Kharkoff, Russia. [Communicated by the Secre-
tary.] . * & & e g º e & ſº º & & *
LIII. On the Nature, Origin, and Prevention of Puerperal Fever. By W. T. LUSK,
M.D., Professor of Obstetrics and Diseases of Children in the Bellevue Hospital
Medical College, New York © o ſº º g * & & ge
LIV. On Electrolysis, with Special Reference to the Treatment of Ovarian Cysts.
By FREDERICK SEMELEDER, M.D., of Vienna º e e e ſº gº
LV. Paracentesis, Aspiration, and Transfusion. By SIMON FITCH, A.M., M.D.
Edin., of St. John, New Brunswick, Canada . tº & e g gº &
LVI. Uterine Hemorrhage during Gestation. By E. H. TRENHOLME, M.D., B.C.L.,
Professor of Midwifery and Diseases of Women and Children in Bishop's College,
Montreal; Attending Physician to the Woman's Hospital; Fellow of the Obstet-
rical Society of London, etc. e e te {º º tº e tº e
LVII. Chronic Inversion of the Uterus. By JAMES P. WHITE, M.D., Professor of
Obstetrics in the Medical Department of the University of Buffalo . º e
LVIII. Case of Retroversion of the Gravid Uterus; Treatment by Puncture; Reco-
very. By THoMAs F. Rochester, M.D., Professor of Principles and Practice of
Medicine in the Medical Department of the University of Buffalo & ſº
SECTION ON OPHTHATMOLOGY.
LIX. On the Comparative Value of Caustics and Astringents in the Treatment, of
Diseases of the Conjunctiva, and on the best mode of applying these Remedies.
By HENRY W. WILLIAMs, A.M., M.D., Professor of Ophthalmology in Harvard
University . tº e & tº & & • * * g º tº gº e
LX. On Tumors of the Optic Nerve. By H. KNAPP, M.D., of New York
LXI. Orbital Aneurismal Disease and Pulsating Exophthalmia; their Diagnosis and
Treatment. By E. WILLIAMs, M.D., Professor of Ophthalmology in Miami
Medical College, Cincinnati tº g e ſº g . . e tº e
LXII. Spontaneous Cure of Congenital Pulsating Exophthalmos. By GEORGE C.
HARLAN, M.D., Surgeon to Wills Hospital, Ophthalmic and Aural Surgeon to
the Children's Hospital, Philadelphia . we e tº o * © &
LXIII. Are Progressive Myopia and Conus (Posterior Staphyloma) due to Heredi-
tary Predisposition, or can they be induced by Defect of Refraction acting
through the Influence of the Ciliary Muscle? By EDwARD L. LoRING, Jr., M.D.,
of New York e © ę e º e © g e e & &
LXIV. On the Relations between Corneal Diseases and Refractive Lesions of the
Eye. By GEORGE T. STEvens, M.D., of Albany, N. Y. & & © e
SECTION ON OTOI,OGY.
LXV. The Importance of Treatment of Aural Diseases in their Early Stages, espe-
cially when arising from the Exanthemata. By ALBERT H. BUCK, M.D., of New
York . g * > & * g e § & sº & • g * &
LXVI. On the Best Means of Testing the Hearing. By CHARLEs H. BURNETT, M.D.,
Aural Surgeon to the Presbyterian Hospital, Philadelphia e e &
LXVII. The Function and Utility of the Artificial Drum-Membrane. By H. N.
SPENCER. M.D., of St. Louis e ge * ſe e o e tº e
PAGE
796
80L
808
827
829
859
862
870
890
893
905
912
921
923
942
947
958
974
C O N T E N T S. xxxi
ART. PAGE
LXVIII. Modifications of the Methods of Treating Chronic Non-Suppurative Inflam-
mation of the Eustachian Tube and Middle Ear. By SAMUEL J. Jon Es, A.M.,
M.D., Professor of Ophthalmology and Otology in the Chicago Medical College 988
LXIX. On the Best Mode of Testing the Hearing of School Children, and of Pro-
viding for the Instruction of Partially Deaf Children. By CLARENCE J. BLAKE,
M.D., Instructor in Otology in Harvard University . º
LXX. On Aural Vertigo with Variable Hearing. By CHARLEs H. BURNETT, M.P.,
Aural Surgeon to the Presbyterian Hospital, Philadelphia e ... 1000
LXXI. On the Several Methods of Educating, and on the Selection of Proper
Schools for, the Deaf and Dumb. By LAURENCE TURNBULL, M.D., Fellow of
the American Association for the Advancement of Science; Aural Surgeon to
Jefferson College Hospital; Physician to the Department of Diseases of the Eye
and Ear, Howard Hospital, Philadelphia -
LXXII. On Bathing, Swimming, and Diving, as Causes of Aural Disease. By
LAURENCE TURNBULL, M.D., Fellow of the American Association for the Ad-
vancement of Science; Aural Surgeon to Jefferson College Hospital; Physician
to the Department of Diseases of the Eye and Ear, Howard Hospital, Phila-
delphia e º º º º º º & e e e º ... 1008
992
1004
SECTION ON SANITARY SCIENCE.
LXXIII. The Present Condition of the Evidence concerning “Disease-Germs.” By
THOMAS E. SATTERTHw AITE, M.D., of New York e º e , 1011
LXXIV. Vital Statistics of Buenos Ayres. By G. RAwson, M.D., of Buenos
Ayres . e º ... 1
LXXV. The General Subject of Quarantine, with Particular Reference to Cholera
and Yellow Fever. By John M. Woodworth, A.M., M.D., Supervising Surgeon-
General, United States Mercantile Marine-Hospital Service º º ... 1059
LXXVI. A Universal Pharmacopoeia. By Edward R. SQUIBB, M.D., of Brooklyn 1072
LXXVII. The Relations of the Pharmacist to the Medical Profession. By EzRA
0.29
M. HUNT, M.D., of Metuchen, New Jersey. & º * 1075
SECTION ON MENTAL DISEASES.
LXXVIII. The Microscopic Study of the Brain. By WALTER KEMPSTER, M.D.,
Physician and Superintendent of the Northern Hospital for the Insane, Oshkosh,
Wisconsin e º & º e º o e s t º e . 1083
LXXIX. The Responsibility of the Insane for their Criminal Acts. By Is AAC RAY,
M.D., of Philadelphia. © - ... 1097
LXXX. The Simulation of Insanity by the Insane. By C. H. Hugh Es, M.D., late
Superintendent and Physician of the Missouri State Lunatic Asylum * . 1110
LXXXI. On the Best Mode of Providing for the Subjects of Chronic Insanity. By
CHARLEs H. NICHOLs, M.D., Superintendent of the Government Hospital for
the Insane, Washington, D. C. . e e c © • g º º . 1127
INDEx º º e e & 4- º * * -> e * * º . 1145
LIST () F I L L U S T R A T I () N.S.
PAGE
Cell Wall of Red Blood-Corpuscles. Figs. 1 and 2. (Dr. J. G. Richardson) g . 488
Stercorine from Normal Human Feces. (Dr. AUSTIN FLINT, Jr.) . e g . 496
Pathology and Treatment of Morbus Coxarius. Figs. 1–22. (Dr. L. A. SAYRE) 577–596
Ovariotomy by Enucleation. (Dr. JULIUs F. MINER) * g e g g . 803
Paracentesis, Aspiration, and Transfusion. Figs. 1-6. (Dr. SIMON FITCH) . . 866
Chronic Inversion of the Uterus. Figs. 1–6. (Dr. JAMES P. WHITE) * . 880–884
Progressive Myopia and Conus. Fig. 1 and Tables 1–4. (Dr. EDWARD G. LoRING,
Jr.) © & e e o & o tº e e gº © gº . 927–930
Methods of Treating Inflammation of the Eustachian Tube, etc. Figs. 1–6. (Dr.
SAMUEL J. JoWES) . ſº ſº e tº g * & e g * . 989–990
#
A D D R E S S () F W E L () () M E.
- BY
S. D. GROSS, M.D., LL.D., D.C.L. Oxon.,
PRESIDENT OF THE CENTENNIAL MEDICAL COMMISSION.
GENTLEMEN OF THE INTERNATIONAL MEDICAL CONGRESS:–
My colleagues have confided to me, as President of the Centennial Medical
Commission, the agreeable and honorable duty of opening this International
Medical Congress, so long the object of their solicitude and earnest labor. In
their name, then, as well as in my own and in that of the entire American medical
profession, whose great heart this day throbs in unison with ours, I extend to you
the right hand, and bid you a thrice cordial welcome to the “City of Brotherly
Love.” The occasion which has brought us together this morning is one of no
ordinary kind; it is one also which has been long and, I may add, anxiously
anticipated. It might, perhaps, seem ungracious if I were to tell you how
much time and labor have been bestowed by the Commission, through its
Committee of Arrangements, upon the organization of the Congress; how
often it has met to devise plans and interchange views; how earnestly and
thoughtfully it has performed its work; in a word, how faithfully and con-
scientiously it has discharged the great trust confided to it by the different
medical bodies of the city and county of Philadelphia, in which, nearly two
years ago, the Congress originated. Not a little embarrassment has often
attended our progress; and it has, therefore, not been without a profound sense
of relief, such as a weary traveller may be supposed to experience at the end of
a long and tedious journey, that at length we have found that our task has been
brought to a successful close. If the organization is less complete than to some
of you it may seem to be, no blame will, I am sure, be ascribed to the Commis-
sion on account of any shortcomings. There might, possibly, have been wiser
and more experienced heads at Work; but warmer hearts, or more conscientious
men, never were, I venture to affirm, engaged in a noble enterprise. Such,
then, as the work is, we cordially submit it to your consideration, satisfied that
it will be accepted by you in the same kindly spirit in which it is tendered, and
that any deficiencies which may mar its character will be duly rectified by your
superior wisdom.
It is at all times a source of gratification to welcome friends, especially when
they are united by the bonds of a common brotherhood; but on this occasion,
so pregnant with important events, the feeling is vastly heightened by the fact
that we have assembled around us brethren not only from every section of this
great continent, but from various foreign climes—from the British Dominion,
from England, Ireland, and Scotland, from France, Belgium, and Germany.
from Russia, Sweden, Norway, and Finland, from Greece, from China an:
C
xxxiv. A D D RESS OF W E L C O M E.
Japan, from Australia, from Mexico and South America, and, I had almost
said, from every country in the world. It is interesting to know that some of
these delegates come here accredited by their respective governments. The
invitations sent out by the Commission covered every prominent medical society
and every distinguished medical man in the four quarters of the globe. The
object was to bring together representative men from all nationalities to par-
ticipate in our proceedings, and to afford us the benefits of their wisdom, and
the results of their experience and scientific investigations. If all these, or
even a respectable minority of these, representative men could have been here,
what a glorious spectacle would be presented in this hall this morning ! Men
laying aside for a while their ordinary pursuits, crossing vast continents and
perilous seas, congregating to unite with us in celebrating our first Medical
Centennial, in interchanging cordial salutations, in deliberating upon the best
means of promoting the dearest and holiest interests of our profession, and in
laying their contributions, the accumulations of years of study and observation,
upon a common altar for the common good l In its wide range, the present
Congress is without a parallel. Similar bodies have repeatedly met, but none
on so grand a scale, or with such a cosmopolitan outlook.
In organizing the Congress, the Commission may have been guilty of undue
partiality towards its own country; and yet, perhaps, such a tendency was,
after all, only natural. However this may be, certain members felt an irre-
sistible desire to show the world what the country, since the establishment of
our independence as a free and sovereign people, had accomplished for scientific
medicine. For this purpose, topics illustrative of the progress and present
condition of the different branches of medicine in the United States, have been
assigned, as subjects for addresses, to gentlemen of acknowledged rank in the
profession in different sections of the Union. These exercises will, it is believed,
add greatly to the interest of the occasion. Time was, and that not at all remote,
when we had no medical literature—no medical science—and but few medical
schools—when we were utterly helpless, and wholly dependent upon the aid
derived from Our European brethren, especially the English, whose language,
practice, and habits, we naturally made our own. The poverty of the country,
in these respects, cannot be better illustrated than by the fact that we had no
native works on medicine and the collateral sciences until after the commence-
ment of the present century. Many of you will recall the words of the great
English lexicographer who, in 1769, in speaking to a friend of the American
colonies, exclaimed: “Sir, they are a race of convicts, and ought to be thankful
for anything we allow them short of hanging.” The Abbé Raynal, writing in
the latter part of the last century, declared that America had not yet produced
a single man of genius; and the question of a celebrated English writer: “Who
reads an American book, or goes to an American play, or looks at an American
picture or statue 7” uttered at a more recent period, is still fresh in the memory
of many of the present race of men. The discourses which will be delivered be-
fore you on the progress of American Medicine, will serve to show that the pro-
fession of the United States has earned for itself an enviable reputation, and that
it is fully abreast of all the other pursuits that adorn the human mind and shed
lustre upon the scientific character of the nation. They will serve to show that
we have passed the stage of medical provincialism, and that we stand upon a
A DL) RESS OF W E L C O M E. º XXXV
lofty platform, to which we need not be ashamed to invite the representative
men of the profession of foreign countries, however illustrious, or however ad-
Vanced in the arts of civilization.
The different Sections, organized by the Commission, must speak for them-
Selves. It is in them that the work of the Congress is mainly to be done, in
them that the interchange of scientific ideas is to be perfected, and from them
that the meeting is to derive its chief glory as an international body of edu-
cated and enlightened men.
It will be recollected that attempts have been made of late years, in different
quarters, to establish a uniformity of scientific nomenclature, of weights, mea-
sures, and records of disease for the medical profession in all parts of the
civilized world. The plan, if carried out, could not fail to advance, in an emi-
ment degree, the interests of medical science ; and I am happy to be able to
state that it is proposed to discuss the subject fully in one of the Sections.
We are upon the threshold of a new centennial era. One hundred years
have passed away since the grand old bell upon Independence Hall announced
to the world the birth of a new nation and liberty, not only to our own citizens,
but to all the peoples of the earth. The century that has just elapsed is the
most wonderful in all that pertains to human progress, to discovery, to inven-
tions, to improvements, to refinement and intellectual culture; in short, to all
that exalts and ennobles human nature, in its various aspects and phases, that
has been vouchsafed to man since God said “Let there be light.” The science
of medicine has been completely revolutionized within our day. The saying,
“Old things are passed away; behold all things are become new,” has literally
been fulfilled. The microscope, chemical analysis, clinical observation, and ex-
periments upon the inferior animals, are leading on the medical mind with won-
drous velocity in the pursuit of knowledge, and are daily adding new facts to our
stock of information far beyond what the wildest fancy could have conceived,
even a third of a century ago. Dogmatism, once so dominant in the schools,
has ceased to exist, and no unacknowledged theories are any longer received or
entertained by the scientist. Facts, resting upon the broad basis of observation
and experiment, repeated and varied in a thousand ways, alone are relied upon
as worthy of acceptance and as safe guides in practice. Hippocratic medicine
is the order of the day. Everything bows before its divine beliests.
In every corner of the habitable globe, penetrated by the light of civilization,
busy, active minds, endowed with high culture and actuated by the noblest
resolves, are at work, exploring the mysteries of disease, and devising means or
methods of treatment for the relief of suffering, and the prolongation of life.
The busy bee was never more industriously engaged in gathering honey from the
flower of the field than the modern physician is in gathering knowledge at the
bedside of the sick, and garnering it for future use. Much of what is considered
by many as established, must be reviewed in the light of modern science; new
avenues must be opened ; and the ball, composed of myriads of threads more
delicately formed than any ever spun by Penelope, must be pushed onward and
upward by the united efforts of the medical profession in all parts of the world.
How far the Centennial International Medical Congress shall promote these
desirable objects, time alone can determine. It may safely be predicted that, if
it do not fulfil all the promises of hope that are expected from it, it will at all
xxxvi A D D R ESS OF W E L CO ME .
events accomplish a vast deal of useful work, and thus afford the world an earn-
est of its interest in the advancement of scientific medicine, and in international
unity and kindly feeling. Science can have no higher mission than that of
strengthening the bonds and securing the co-operation of its votaries in various
portions of the globe, assembled to deliberate upon everything calculated to
promote its holiest interests.
Among the many objects of an International Congress, not the least is the
interchange of kindly feelings on the part of its members, the formation of new
friendships, and the cementing of old ties. It is well that men of different
nationalities should occasionally come together, to look at one another, to shake
hands, and to see how they stand in public estimation, as well as in their own;
what the world thinks of them, and what they think of the world; what they
have done to further the interests of scientific progress, to lighten the burdens
of human suffering, and to extend the boundaries of human happiness. All
these and many other things, which need not to be here specified, are objects
well worthy of engaging earnest attention on such an occasion as this.
It has often occurred to me that, if these international reunions were more
frequent and more largely attended, they would be a vast deal more serviceable
in preventing war and international misunderstandings than any arbitrations
that could be inaugurated for the settlement of international difficulties. Much
of the pleasant feeling at present existing between the United States and Europe
is due to the enlarged intercourse which has been going on since the establish-
ment of steam navigation between the two countries, and the consequent inter-
change of hospitality and courtesy on the part of their citizens. It is, therefore,
to be hoped that this may be only one of many such reunions on this side of
the Atlantic.
It needs hardly to be stated that the medical profession and the citizens of
Philadelphia will do all that they can to make your time pass pleasantly, as well
as profitably, during your sojourn among us. Cards of invitation will be issued
to you to inspect the various institutions of interest in and around the city;
and, after the work of the Congress is over, the International Exposition will
no doubt claim, as it assuredly deserves, the earnest attention of every member
of this body. And now that the labor of the Centennial Medical Commission
is completed, it only remains for the Congress, which I now declare open, to
perfect its organization by the election of officers for its own government. To
facilitate this object the Commission has appointed a committee on nomina-
tions, consisting of thirteen members, nine American and four foreign, whose
duty it will be to report the result of their deliberations at the earliest possible
moment this morning.
M IN U T E S.
THE Congress assembled at noon of Monday, September 4, 1876, in the Chapel
of the University of Pennsylvania. Dr. SAMUEL D. GRoss, President of the
Centennial Medical Commission, called the Congress to order, and introduced
the Right Reverend WILLIAM BACON STEVENS, D.D., LL.D., Bishop of the
Protestant Episcopal Church in the Diocese of Pennsylvania, who opened the
session with prayer. Dr. W. S. W. RUSCHENBERGER, U. S. N., one of the Vice-
Presidents of the Centennial Medical Commission, having been then called to
the Chair, Dr. Gross read an Address of Welcome (see page xxxiii.), after which
he announced the appointment of the following Committee of Nomination :-
William Adams, Esq., of England ; Prof. Engelsted, of Denmark; Prof.
Hueter, of Germany ; Prof. Rudnew, of Russia; Dr. J. A. Grant, of Canada;
Dr. H. I. Bowditch, of Massachusetts; Prof. L. A. Dugas, of Georgia; Prof.
J. T. Hodgen, of Missouri; Prof. Christopher Johnston, of Maryland; Prof.
Austin Flint, of New York; Dr. W. S. W. Ruschenberger, U. S. Navy; Dr.
J. R. Smith, U. S. Army ; Dr. Edwin M. Snow, of Rhode Island.
Dr. A UsTIN FLINT, of New York, then delivered an Address on Medicine
and Medical Progress in the United States (see page 1).
The Committee of Nominations presented the following partial report of
nominations for Officers of the Congress:—
President–Dr. S. D. Gross, Philadelphia.
Vice-Presidents—Dr. Paul F. Eve, Tennessee; Jolliffe Tufnell, Esq., Ireland; Dr. W. L.
Atlee, Pennsylvania; Dr. C. Lange, Denmark; Dr. T. G. Richardson, Louisiana; Dr. W. H.
Hingston, Canada; Dr. J. P. White, New York; Dr. H. Miyake, Japan; Dr. N. R. Smith,
Maryland; Dr. M. Rudnew, Russia; Dr. J. M. Toner, District of Columbia; Dr. Hueter,
Germany; Dr. J. B. Johnson, Missouri; Dr. F. Semeleder, Austria; Dr. Hunter McGuire,
Virginia; Dr. Johan Hjort, Norway; Dr. G. L. Collins, Rhode Island; Dr. R. F. Hudson,
Australia; Dr. H. Gibbons, California; Dr. Pierre De Baisieux, Belgium; Dr. N. S. Davis,
Illinois; William Adams, Esq., England; Dr. L. A. Dugas, Georgia; Dr. A. R. Simpson,
Scotland; Dr. J. K. Bartlett, Wisconsin.
Honorary Vice-Presidents—Dr. Joseph K. Barnes, Surgeon-General U. S. A.; Dr.
Joseph Beale, Surgeon-General U. S. N.
Secretary-General—Dr. I. Minis Hays, Philadelphia.
Secretaries of Meeting—Drs. William B. Atkinson, R. J. Dunglison, R. A. Cleemann,
W. W. Keen, R. M. Bertolet.
Section on Medicine—President, Dr. Alfred Stillé, Philadelphia; Secretary, Dr. J.
Ewing Mears, Philadelphia.
Section on Biology—President, Dr. J. C. Dalton, New York; Secretary, Dr. James
Tyson, Philadelphia.
Section on Surgery—President, Joseph Lister, Esq., Edinburgh; Secretary, Dr. J. H.
Packard, Philadelphia.
Section on Dermatology and Syphilography—President, Dr. J. C. White, Boston;
Secretary, Dr. A. Van Harlingen, Philadelphia.
Section on Obstetrics—President, Dr. Robert Barnes, London; Secretary, Dr. William
Goodell, Philadelphia.
Section on Ophthalmology—President, R. Brudenell Carter, Esq., London; Secretary,
Dr. John Green, St. Louis.
Section on Otology—President, Dr. L. Turnbull, Philadelphia; Secretary, Dr. H. N.
Spencer, St. Louis.
xxxviii MIN U T E S.
Section on Sanitary Science—President, Dr. Stephen Smith, New York; Secretary, Dr.
E. M. Hunt, New Jersey.
Section on Mental Diseases—President, Dr. J. P. Gray, Utica; Secretary, Dr. W.
Kempster, Wisconsin.
The report was accepted, and the nominations confirmed.
Dr. GRoss then assumed the chair as President of the Congress. He thanked
that body for the honor conferred upon him, and said that no other would be
dearer to him during the remainder of his life than that of presiding over its
deliberations. He considered it not solely an honor bestowed On him, but a
tribute to the profession of Philadelphia, which had been instrumental in
organizing this Congress.
On motion the Congress then adjourned until Tuesday at 10 A.M.
SECOND DAY'S SESSION.
The President called the Congress to order at 10 A.M. The minutes of the
preceding day were read and approved. The Secretary-General presented a
list of nearly three hundred delegates who had been registered up to this date.
Reports were then received from the various Sections, and, on motion, the
conclusions adopted by them, after debate upon the topics assigned for dis-
cussion, were taken up seriatim, and adopted by the Congress, as follows:—
From the SECTION ON MEDICINE –The Section considered the question,
“Typho-Malarial Fever; is it a Special Type of Fever ?” The debate was
opened by J. J. WooDwARD, M.D., Surgeon U. S. A., and the following conclu-
sion was adopted by the Section :- -
Typho-malarial fever is not a special or distinct type of disease, but the term may be
conveniently applied to the compound forms of fever which result from the combined influ-
ence of the causes of the malarial fevers and of typhoid fever.
From the SECTION ON DERMATOLOGY AND SYPHILOGRAPHY :—The considera-
tion of the subject, “Variations in Type and in Prevalence of Diseases of the
Skin in different countries of equal civilization,” was introduced by JAMES C.
WHITE, M.D., of Boston, and the following conclusions were adopted:—
1. Certain obscure affections, the etiology of which is little if at all understood, even in
those parts of Europe to which they are mostly confined, may be regarded as practically
non-existent among us—such are prwrigo, pellagra, and lichen eacudativus ruber.
2. Certain diseases, directly connected with and dependent upon poverty and habits of
personal uncleanliness, are less prevalent in the United States than in those parts of Europe
of which we have sufficient statistical information for comparison. Examples of this class
are the animal parasitic affections especially.
3. Some cutaneous affections of grave character, which are dependent upon or a part of
serious constitutional disorders, are of less frequent occurrence and of milder type amongst
us than in Europe in general, or those parts of it where they are endemic. Lupus, the
syphilodērmata, and leprosy are the most marked instances of this class.
4. Certain disorders of the skin, especially those of its glandular system, and those
connected more immediately with its nervous system, are apparently more prevalent with
us than in Europe. The most notable examples of the former are seborrhoea, acne, and
possibly the heat rashes; of the latter, herpes, urticaria, and pruritus.
In addition to the above-mentioned conclusions, the following additional proposition was
adopted by the Section –
5. The type of certain acute congestive and nervous diseases of the skin is more severe
in this country than abroad. º -
From the SECTION ON OPHTHALMOLOGY:—A discussion on “The Compara-
tive Value of Caustics and Astringents in the Treatment of Diseases of the
Conjunctiva, and the best mode of applying them,” was introduced by HENRY
W. WILLIAMS, M.D., of Boston, and the following conclusions were adopted by
the Section :-
1. In a considerable number of essentially transient affections of the conjunctiva, and in
pterygium or other growths, no active treatment by caustics or astringents is required.
2. When disease affects only a limited portion of the conjunctiva, as in phlyctenular
inflammation, the mildest stimulating or astringent remedies are usually sufficient.
MIN U T E S. - xxxix
3. In the acute and chronic forms of general conjunctivitis, astringents are, as a rule,
Safer as well as more efficacious than caustics, and are therefore better adapted to the
requirements of the general practitioner.
From the SECTION ON OToLogy :—The subject of the “Importance of Treat-
ment of Aural Diseases in their early stages, especially when arising from
the Exanthemata,” was presented by Dr. ALBERT H. BUCK, of New York,
and the following conclusions were adopted by the Section:—
1. Chronic Otorrhoea is at the present time a very common disease, due in most cases to
the want of proper treatment during the acute stage of the affection.
2. It is by no means a harmless affection.
3. It may be fairly classed as a preventable disease; at least among those who possess a
healthy constitution.
4. Paracentesis of the membrana tympani, if resorted to during the first few days of the
acute attack, and if not carried out too timidly, i. e., if a free incision be made and not a
mere prick, is almost a sure preventive of the subsequent chronic disease.
5. The profession at large, and especially the medical schools, should give the subject
more earnest thought than they have in the past.
From the SECTION ON SANITARY SCIENCE:-" The Present Condition of the
Evidence concerning Disease-germs,” was reported upon by Dr. THOMAS E.
SATTERTHWAITE, of New York, and the following conclusions were adopted:—
1. As far as inquiry has been made as to the results of the active principles in infective
diseases, it is probable that in a certain number the matter is particulate or molecular in
form, and, in the instances named, in no sense a soluble substance.
2. In regard to the causes of septicaemia, pyamia, puerperal fever, erysipelas, and
hospital gangrene, and of cholera, smallpox, the carbuncular diseases of men and animals,
typhoid and relapsing fevers, and diphtheria, there is not satisfactory proof that they are
necessarily connected with minute vegetable organisms.
3. The real nature of these causes is still uncertain.
Dr. LAURENCE TURNBULL, of Philadelphia, announced that, with a desire to
give the posts of honor to gentlemen from a distance, he had resigned the
position of President of the Section on Otology, and that Dr. CLARENCE J.
BLAKE, of Boston, had been chosen by the Section to preside over its delibera-
tions.
Dr. T. G. RICHARDSON, of New Orleans, moved that the Congress should
hold itself in no way responsible for the conclusions adopted by the Sections,
but that the whole responsibility in the matter should rest with the Sections
themselves. -
On motion of Dr. N. S. DAVIs, of Chicago, this resolution was amended, so
that, upon the submission of the reports of the Sections to the Congress, the
question should be merely upon their acceptance and reference for publication.
On motion of Dr. WILLIAM BRODIE, of Michigan, the previous action of the
Congress in adopting the conclusions reported by the several Sections, was
reconsidered, and the reports accepted and referred to the Committee of Pub-
lication.
The Secretary-General then read letters of greeting from the IMPERIAL
SocIETY OF ST. PETERSBURG, Russia, and from the UNIVERSITY OF CHRISTI-
ANIA, Norway. He also read the following letter from Dr. J. S. BILLINGS,
U. S. Army:—
WAR DEPARTMENT. SURGEoN-GENERAL's OFFICE,
WASHINGTON, D. C., July 31, 1876.
SIR : By direction of the Surgeon-General, U. S. Army, I have the honor to forward
here with to your address six (6) copies of a specimen fasciculus of a catalogue of the
library of this office, and to request that they may be presented to the International Medi-
cal Congress. While the object in view in forming this library has been to make a collec-
tion of sufficient extent and completeness to meet the wants of the physicians of the United
States, an attempt is being made to prepare a catalogue and index of its contents, whose
practical usefulness shall not be confined to this country, but shall be, as far as the material
xl MIN U TIES.
available will permit, international and cosmopolitan. The manuscript of the entire work
is so nearly completed that the printing can be commenced next spring if Congress shall
see fit to give the necessary authority.
Very respectfully, your obd’t servant,
John S. BILLINGs,
Assist. Surgeon U. S. Army, in charge of Library.
Whereupon Dr. AUSTIN FLINT, of New York, offered the following preamble
and resolutions, which were adopted :–
Whereas, The institution of a National Library containing all the important bibliogra-
phical and periodical publications relating to medicine and the collateral sciences, in the
past and present time, is of importance, not alone to the medical profession, but to persons
in other pursuits who may desire to refer to works treating of topics embraced in these
departments of knowledge, and also concerns greatly the public welfare in so far as this is
involved in the elevation of the standard of medical education ; and
Whereas, Through the wisdom of the National Legislators of the United States Govern-
ment, a medical library has been established, containing, at the present time, about 40,000
volumes, and about the same number of single pamphlets; and
Whereas, Experience has already shown the practical advantages of the present library,
and, at the same time, the great need of its being made more complete by increasing at
least tenfold the number of publications which it now contains; and
Whereas, In order to render such a library available for reference, especially to medical
men and others residing at a distance, a catalogue wherein publications are classified after
the names of authors and subjects, the scope of each publication being stated, is indispen-
sable; and
Whereas, Such a catalogue of the National Medical Library has been prepared under
the direction of the Surgeon-General of the United States Army by Assistant Surgeon
J. S. Billings, copies of a specimen fasciculus having been forwarded for examination by
the members of the International Medical Congress; therefore,
Resolved, First. That the members of this International Medical Congress regard with
great interest the institution of a National Medical Library in the City of Washington,
and respectfully petition the Congress of the United States to provide for additions to the
number of volumes and periodical publications, until the library is made as complete as
ossible.
p Second. That in view of the necessity of what is known as a Catalogue raisonné, in
order to render the library properly available for reference, this International Medical
Congress urges the importance of an early completion and publication of such a catalogue.
Third. That the Specimen Fasciculus of the Catalogue, which is stated to be nearly
ready for the press, affords evidence of great labor and care, and the arrangements for con-
venience of reference it is believed will prove in all respects satisfactory.
Fourth. That those of the delegates to this International Medical Congress who are
citizens of the United States, and other members of the Medical Profession in this country,
are urged individually to exert their influence to secure the enlargement of the library, and
the speedy publication of the Catalogue.
The Committee of Nominations then presented the following supplementary
report, which was accepted, and the nominations confirmed :—
Committee of Publication (with power to choose its chairman and an editor)—Dr. John
Ashhurst, Jr., Dr. Richard J. Dunglison, Dr. William Goodell, Dr. James H. Hutchinson,
Dr. Caspar Wister, all of Philadelphia.
Treasurer—Dr. Caspar Wister, Philadelphia.
Vice-Presidents of the Sections.
Section on Medicine—Dr. R. P. Howard, Canada; Dr. J. J. Woodward, U. S. Army.
Section on Biology—Dr. Austin Flint, Jr., New York; Dr. F. W. Campbell, Canada.
Section on Surgery–Dr. J. A. Grant, Canada; Dr. J. Ashhurst, Jr., Philadelphia.
Section on Dermatology and Syphºlography—Dr. S. Engelsted, Copenhagen; Dr. E.
Shippen, U. S. Navy.
Section on Obstetrics—Dr. Alexander R. Simpson, Edinburgh; Dr. W. H. Byford,
Illinois.
Section on Ophthalmology—Dr. William Thomson, Philadelphia; Dr. Henry W. Wil-
liams, Boston.
Section on Otology—Dr. A. H. Buck, New York.
Section on Sanitary Science—Dr. J. S. Billings, U. S. Army.
Section on Mental Diseases—-Dr. E. Grissom, North Carolina; Dr. I. Ray, Philadelphia.
MIN U T E S. xli
Dr. HENRY I. BowdTTCH, of Massachusetts, then read an Address on Hy-
giene and Preventive Medicine (see page 21), Vice-President PAUL F. EVE,
of Tennessee, occupying the Chair; and afterwards Dr. THEO. G. WoRMLEY,
of Ohio, delivered an Address on Medical Chemistry and Toxicology (see
page 49).
The Congress then adjourned until Wednesday at 10 A. M.
THIRD DAY's SESSION.
The Congress met at 10 A.M.; the President in the Chair. The minutes
of the previous day were read and approved.
On motion of Dr. JoHN L. ATLEE, of Lancaster, Pa., the Secretary was in-
structed to transmit copies of the Address of Dr. Bowditch, when printed, to
the Governor of each State and Territory, with the request that it be trans-
mitted to the Legislature of such State or Territory; and, on motion of Dr.
TRENHOLME, of Montreal, the government of the Dominion of Canada and
those of its several provinces were included in the terms of the resolution.
On motion of Dr. TRAILL GREEN, of Easton, Pa., Dr. Wormley's Address
was referred to the Committee of Publication, and the name of Dr. Wormley’s
wife, who had assisted him in his labors, was ordered to be entered on the
rolls of the Congress. -
The Secretary-General reported 382 names of delegates on the register. He
announced the reception of a telegram from the NATIONAL TEMPERANCE Asso-
CIATION, respectfully inviting an expression of opinion from the Congress
regarding the use of alcohol.
The Secretary-General also read invitations to the members of the Congress
to visit the following institutions : —The Academy of Natural Sciences of
Philadelphia, Dr. W. S. W. Ruschenberger, President; The University of Penn-
sylvania, Dr. Robert E. Rogers, Dean; The Jefferson Medical College, Dr.
John B. Biddle, Dean; The Pennsylvania Hospital; The College of Physicians
of Philadelphia; and The Archaeological Association; and from Dr. William
Pepper, Medical Director of the Centennial Exposition, extending courtesies
to visiting members. These invitations were, on motion, accepted.
An invitation was also read from the Council of the National Forest Asso-
ciation to attend its convention about to assemble at Cape May, N. J., on
September 7 and 8.
The Secretaries of Sections then reported the conclusions adopted by their
several Sections as follows:–
By the SECTION ON BIOLOGY:—The consideration of “The Excretory Func-
tion of the Liver,” was opened by Dr. AUSTIN FLINT, Jr., and the following
conclusions were adopted :-
1. Cholesterine exists in health in the bile, blood, and nervous matter, also in the crystal-
line lens, the spleen, and meconium.
2. Cholesterine is formed for the most part in the nervous matter, from which it is passed
into the blood. The blood gains cholesterine in its passage through the brain. Its forma-
tion is constant, and it is always found in the blood.
3. Cholesterine is separated from the blood by the liver, and discharged with the bile.
It pre-exists in the blood, serves there no useful purpose, and, if allowed to accumulate,
blood poisoning results.
4. The bile has two separate and distinct functions, one connected with nutrition, to
which the so-called biliary salts, glycocholate and taurocholate of soda, contribute; these
do not exist preformed in the blood, but are products of secretion. The second function of
the bile is eaccretory, connected with depuration or excretion ; this is accomplished by the
removal of the cholesterine which it obtains from the blood.
5. Normal feces do not contain cholesterine. The latter substance is represented by
stercorine, formerly called séroline, into which it is converted in its passage down the intes-
tine. The conversion of cholesterine into stercorine does not, however, take place when
digestion is arrested or when it is not necessary, as is shown by the presence of cholesterine
in its own form in the feces during fasting, and in the meconium.
6. The difference between the two varieties of jaundice, one mild and the other severe,
xlii MIN UTES.
is dependent on obstruction of the bile-ducts in one instance, with reabsorption of the
biliary coloring matters, while in the other there is retention of cholesterine in the blood
in consequence of destruction of the parenchyma of the liver.
7. That condition of the blood dependent upon the presence of cholesterine in the blood
is called cholestercemia. It is characterized by symptoms referable to the brain, and may
or may not be attended with jaundice.
8. Cholesterasmia does not occur in every disorder of the liver, because, even when a
part of the organ is disorganized, there may remain a part still capable of performing the
functions of excreting cholesterine.
9. In cases of simple jaundice, even when feces are decolorized, there is no accumulation
of cholesterime in the blood.
10. Cholesterine bears the same relation to the liver that urea does to the kidneys.
By the SECTION ON DERMATOLOGY AND SYPHILOGRAPHY :—The debate on the
Question, “Are Eczema and Psoriasis Local Diseases, or are they Manifesta-
tions of Constitutional Disorders ?” was opened by Dr. L. DUNCAN BULKLEY,
of New York, and the following conclusions were adopted :—
1. Eczema and psoriasis are distinct diseases. The former is to be clearly distinguished
from artificial dermatitis, and the latter from the eruptions of syphilis, scaly eczema, and
leprosy.
2. Eczema and psoriasis cannot own a double causation or nature at one time local and
at another constitutional; but, with other diseases, may have a twofold cause, a predis-
posing and an exciting.
3. Eczema and psoriasis in many of their features resemble the accepted constitutional
diseases more than they do those recognized as local.
4. Eczema is most properly likened to catarrh of the mucous membrancs; it is very
probable that some attacks called catarrh are eczema and psoriasis of the mucous tissue.
5. Both eczema and psoriasis resemble gout and rheumatism in certain respects, and are
dependent upon a somewhat similar, although as yet unknown, constitutional cause; much
of the skin lesion must be looked upon as the local result or remains of the diseases.
6. There as yet exists no microscopical or physiological proof that eczema and psoriasis
are the sole result of local cell disorder, either congenital or acquired, or due alone to per-
verted nerve action.
7. Local causes play a very important part in the etiology of eczema. They are probably
inoperative in psoriasis. .
8. Local treatment is often insufficient alone to remove the lesions of eczema and psoriasis,
and cannot prevent or delay relapses; its success does not necessarily demonstrate the local
nature of these affections.
9. Constitutional treatment, alone and singly, can cure many cases of eczema and
psoriasis, and prevent or delay relapses in a certain proportion of cases; under constitu-
tional treatment is included every agency not properly classed among local measures.
10. The total weight of evidence and argument is that eczema and psoriasis are both
manifestations of constitutional disorders and not local diseases of the skin.
By the SECTION ON OBSTETRICs:—The discussion of “The Mechanism of
Natural and of Artificial Labor in Narrow Pelves,” was introduced by Dr. WIL-
LIAM GooDELL, of Philadelphia, and the following conclusions were adopted by
the Section:—
1. The unaided first-coming head and the aided after-coming head observe in a flat pelvis
precisely the same general laws of engagement and of descent. Hence, version here means
art plus nature.
2. The forceps, however applied in a flat pelvis, antagonizes more or less with the natu-
ral mechanism of labor. Hence, the forceps here means art versus nature.
3. The aided and the unaided first-coming head observe in a uniformly narrowed pelvis
precisely the same laws of engagement and of descent. But version violates these laws.
Hence, the forceps here means art plus nature; version, art versus nature.
4. At, or above, the brim of a flat pelvis, the fronto-mastoid, or even the fronto-occipital,
application of the forceps interferes less with the moulding of the head, and violates the
natural mechanism of labor less, than the biparietal application.
5. In the flat pelvis, the vectis aids the natural mechanism of labor, and, therefore, meets
the indications better than the forceps.
By the SECTION ON MENTAL DISEASEs:—The consideration of the subject of
the “Responsibility of the Insane for Criminal Acts,” was introduced by Dr.
ISAAC RAY, of Philadelphia, and the following conclusions were adopted by
the Section:— s
MINUTES. xliil
1. There is at present a manifest tendency to hold the insane responsible for criminal
acts. • w -
2. This tendency is unjust, unphilosophical, and contrary to the teachings of pathology,
which clearly point out that insanity is but the expression of disease.
The SECTION ON MEDICINE also submitted the following resolutions for the
action of the Congress, and on motion of Dr. BRODIE, of Michigan, they were
adopted :-
Resolved, That the International Medical Congress of 1876 recognizes the advantages
which would accrue from the introduction of a gradual uniformity in the multiple and hete-
rogeneous elements of physic, as posology, nomenclatures, etc., and in the means and records
of medical observation.
Resolved, That, in consequence, this Congress authorizes the President to appoint three
delegates to the International Congress of 1877, with the special mission of presenting a
schedule of the means of uniformity in physic actually applicable in all countries, and an-
other of those which could soon be made acceptable by the profession at large.
Resolved, That the said delegates be advised to invite the co-operation of the men who
have already worked for the same cause at the International or National Medical or Phar-
maceutical Congresses of Paris, Vienna, St. Petersburg, Brussels, and Buffalo.
Under the above resolutions, the following delegates were subsequently ap-
pointed by the President: Dr. Henry I. Bowditch, of Boston, Dr. J. J. Wood-
'ard, U. S. A., of Washington, and Dr. E. Seguin, of New York.
Dr. PAUL F. Eve, of Tennessee, then delivered an Address on Surgery (see
page 73), Dr. RUDNEw, of St. Petersburg, Russia, Vice-President, occupying
the Chair; after which Dr. J. M. To NER, of the District of Columbia, delivered
an Address on Medical Biography (see page 91), while Dr. L. A. DUGAS, of
Georgia, Vice-President, occupied the Chair.
On motion the Congress then adjourned until Thursday at 10 A.M.
LOn Wednesday evening, at 7.30 P.M., Dr. J. J. WoowARD, U. S. Army, de-
livered in the Lecture Room of Jefferson Medical College an Address on The
Medical Staff of the United States Army, and its Scientific Work (see page
286).]
FOURTH DAY'S SESSION.
The Congress met at 10 A.M., the President in the Chair. The minutes of
the previous day were read and approved. The Secretary-General reported
422 names of delegates on the Register. *
Dr. H. I. BowdiTCH, of Boston, presented the following preamble and reso-
lutions, which were adopted :-
Whereas, The work already accomplished by the officers connected with the Bureau of
the Surgeon-General of the United States Army, in the establishment of a medical library,
and in the preparation of its complete and unique catalogue, in the formation of an ana-
tomical museum from which important scientific results have already been obtained, and
which have been not only a source of honor to these United States, but of value to foreign
lands wherever science is cultivated ; and,
Whereas, This Congress learns with regret that, owing to the lack of a sufficient clerical
force and of pecuniary means, not only some of the work already in progress has been sus-
pended, but that other work of equal value cannot be undertaken, although ample mate-
rials for the same are now lying unused in the Surgeon-General's office; therefore,
Resolved, That a committee of three be appointed to prepare a memorial to be presented
to the Congress of the United States, at the earliest day possible, at its next session, urging
efficient support to these most important works.
Resolved, That it is desirable that said memorial should be signed by the President,
Vice-Presidents, and Secretary-General of this body.
The President appointed Drs. Bowditch, of Boston, Rudnew, of St. Peters-
burg, and N. S. Davis, of Chicago, as the Committee to prepare this Memorial.
On motion of Dr. J. P. WHITE, of Buffalo, New York, it was ordered that
the printed pamphlet containing Dr. Bowditch's Address on Hygiene and
Preventive Medicine be sent to the Presidents of State and Territorial Medical
xliv MIN U TES.
Societies and Sanitary Boards of the United States, and of the Societies and
Sanitary Boards of the Dominion of Canada.
The conclusions adopted by the several Sections were then reported as fol-
lows:–
By the SECTION ON SURGERY:—The subject of the “Medical and Surgical
Treatment of Aneurism,” was introduced by Dr. WILLIAM H. WAN BUREN, of
New York, and the following conclusions were adopted:—
1. Tufnell's treatment of aneurism, by rest, position, and restricted diet, offers a valuable
resource in thoracic and abdominal aneurisms.
2. It should always be tried in innominate, subclavian, subclavio-axillary, and iliac aneu-
risms, before resorting to measures attended by risk to life.
3. For aneurisms of the subclavian and iliac arteries, the Hunterian operation, with our
present means of preventing secondary hemorrhage, is not justifiable.
4. For reasons formally set forth by Holmes and Henry Lee, the “old operation” cannot
properly be formally substituted for the Hunterian operation in these cases, but should be
held in reserve for special cases.
5. It is the most safe and surgical resource in gluteal aneurism, if the circulation can be
commanded by the hand in recto.
6. The mode of cure by embolism, aimed at in the method of manipulation, is a not unfre-
quent explanation of what is called spontaneous cure of aneurism.
7. The value of Esmarch's bandage in the treatment of aneurism is probably not fully
estimated.
8. In view of the promising features presented by the cases of Levis and Bryant, in which
horse-hair was introduced into an aneurismal tumor, the repetition of this operation, or the
substitution for horse-hair of Lister's prepared catgut or other animal substances, may be
properly tried.
By the SECTION ON DERMATOLOGY AND SYPHILOGRAPHY:—The consideration
of the subject of “The Virus of Venereal Sores; its Unity or Duality,” was
opened by Dr. F. J. BUMSTEAD, of New York, and the following conclusions
were adopted by the Section:—
1. The virus of venereal sores is dual.
2. Venereal sores may be due to the inoculation of the syphilitic virus, and also to the
inoculation of products of simple inflammation.
3. These two poisons may be inoculated simultaneously.
4. (Additional.) The present state of science has demonstrated that suppurating inflam-
matory lesions resembling chancroids may be produced on various portions of the body by
inoculation with simple pus from various lesions.
By the SECTION ON OTOLOGY:—Dr. H. N. SPENCER, of St. Louis, opened a
discussion of the question, “In what Percentage of Cases do Artificial Drum-
membranes prove of Practical Advantage 7” The following were the conclu-
sions adopted by the Section:—
1. Of the various forms of artificial drum-membrane in use, the cotton pellet is prefera-
ble for its greater simplicity and its easier introduction, for the greater uniformity of its
effect, and the comparative safety in its employment.
2. It has an advantage over all other forms of artificial drum-membrane in that, in addi-
tion to the functional gain which may be derived, there may be added its value as a means
of treating the tympanum, and this therapeutical use of the artificial membrane has a great
future in otology.
3. The continued use of the artificial drum-membrane as a means of improving the hear-
ing is indicated in rare conditions which can only be determined by the aural surgeon.
By the SECTION on SANITARY SCIENCE:-" The General Subject of Quaran-
tine, with Particular Reference to Cholera and Yellow Fever,” was considered
by Dr. J. M. Woodworth, of the U. S. Marine Hospital Service, and the ſol-
lowing conclusions were adopted by the Section:—
1. The supervision of ocean travel ought to be directed to securing good sanitary condi-
tions of vessels at all times, out of as well as in port.
2. A system of Port Sanitation should be adopted and administered for each country or
place, separately, modified in particular cases by taking into account the liability of the
port to infection, the period of incubation of the disease, the length of time consumed in
the voyage, and the measures enforced by the vessel en route.
MIN UTES. xlv.
3. In some countries the detention of passengers and crews of ships hailing from infected
ports is unwarranted, but for such time only as is necessary to complete the period of incu-
bation of cholera or yellow fever, counting from the date of departure from an infected port,
or of landing from an infected vessel; but in no instance should passengers or sailors be
held for observation on board an infected vessel, and such vessel should not be detained
beyond the period required for inspection and thorough disinfection and cleansing.
4. Recognizing the fact that the morbific causes of infectious diseases may sometimes
elude the most vigilant sanitary supervision of shipping, the importance of wisely-directed
internal sanitary measures can scarcely be over-estimated.
5. As far as America is concerned, it is desirable that prompt and authoritative informa-
tion should be had of the shipment of passengers or goods from districts infected with
cholera or yellow fever, thereby insuring the thorough disinfection of infected articles.
6. The endemic homes of cholera and yellow fever are the fields which give the greatest
promise of satisfactory results to well-directed and energetic sanitary measures, and to
this end an international sentiment should be awakened, so strong as to compel the care-
less and offending people to employ rational means of prevention.
By the SECTION ON MENTAL DISEASEs :—The consideration of the subject of
the “Simulation of Insanity by the Insane,” was opened by Dr. C. H. Hugh Es,
of St. Louis, Mo., and the following conclusion was adopted by the Section –
It is not only not impossible for the insane to simulate insanity for a purpose in any but
its gravest forms of profound general mental involvement, but they actually do simulate
acts and forms of insanity for which there exists no pathological warrant that we can dis-
cover in the real disease affecting them.
On motion of Dr. T. G. RICHARDSON, of Louisiana, Dr. J. J. WooDwARD,
U.S. A., was requested to repeat his lecture of the previous evening, as many
of the members had failed to read the announcement of the lecture on the Pro-
gramme, and had, therefore, been absent.
Dr. THEOPHILUS PARVIN, of Indiana, then delivered an Address on Obstetrics
(see page 138), Dr. H. MIYAKE, of Tokio, Japan, Vice-President, occupying the
Chair, and, after a very brief recess, Dr. STANFORD E. CHAILLE, of Louisiana,
delivered an Address on Medical Jurisprudence (see page 167), while Dr. J. P.
WHITE, of Buffalo, New York, Vice-President, occupied the Chair.
The Congress then adjourned until 10 A.M. on Friday.
FIFTH DAY'S SESSION.
The Congress met at 10 A.M., the President in the Chair. The minutes of
the preceding day were read and approved. The Secretary-General reported
430 names of delegates on the Register.
On motion of Dr. PAUL F. EVE, of Nashville, it was
Resolved, That no papers or addresses read before this body, and ordered to be printed,
shall be furnished either in abstract or otherwise for publication in any journal prior to
the publication of the Transactions.
The conclusions adopted by the several Sections were then reported as fol-
lows:—
By the SECTION ON BIOLOGY:—The consideration of “The Mechanism of
Joints,” was introduced by Dr. HARRISON ALLEN, of Philadelphia, and the
following conclusions were adopted by the Section:—
1. Starting with the idea that joints are of dynamic and static values, it is shown that
in most movable joints the ball-and-socket arrangement predominates. When the ball is
supported by the socket, as at the occipito-atloid articulation, rest is suggested. But when
the ball is suspended from the socket, as at the temporo-maxillary articulation, motion is
suggested.
2. Articular surfaces are of three kinds: aacial, actºnic, and lateral. The acial or
primary surfaces are those situated upon proximal and distal ends of a bone in the line of
its longitudinal axis. The actºnic or secondary (rarely seen) are those placed in a line
which is deflected from the longitudinal axis. The lateral or tertiary are those situated
upon the sides of the shaft or body of a bone, and serve for articulation with corresponding
surfaces of other bones.
3. Axial surfaces, it is believed, are static; actinic surfaces are dynamic ; while lateral
xlvi MIN UTES.
surfaces have subordinate degrees of value—some of them being adventitious. The outer
femoral condyle is active in extension = static; the inner femoral condyle is active in
flexion = dynamic ; but the lateral facets have no independent action.
4. Joints are fixed or locked at extremes of flexion and extension, and are most relaxed
at the intervals between these extremes.
5. When a facet is actively employed, it enters into a combination with which the entire
limb is in harmony. Hence, in the study of any one facet, its relations to all others of its
kind, as well as to the bones, muscles, and fasciae of its limb, become essential.
6. A correct knowledge of the symptomatology and treatment of diseases of the joints is
dependent upon a true conception of the complex nature of articular surfaces.
By the SECTION ON SURGERY:—Dr. LEWIs A. SAYRE, of New York, opened
the discussion of the subject of the “Treatment of Coxalgia.” The Section
adopted the following conclusions:—
1. Morbus coxarius is a disease most frequently met with in early childhood, or the age
of reckless indifference.
2. It is almost always of traumatic origin, and not necessarily connected with a vitiated
constitution.
3. Rest and freedom from pressure of the parts involved, while at the same time the rest
of the body is allowed free exercise in the open air, and a nutritious diet, is the best treat-
ment that has yet been devised for this disease.
4. If this plan of treatment be adopted in the early stages of this disease, the majority
of cases will recover, with nearly if not quite perfect motion, and without deformity.
5. In the advanced second stage of the disease, when absorption of the effused fluid can-
not be produced, then it is better to puncture or aspirate the joint and remove its contents,
than to leave it to rupture by ulceration.
6. In the third stage of the disease, when the treatment recommended in this paper lias
been properly applied without satisfactory improvement, but progressive caries continues,
the exsection of the diseased bone is not only justifiable, but in many cases absolutely
necessary.
7. That the operation of exsection of the hip is easily performed, and in itself attended
with little or no danger.
8. That after exsection of the hip-joint in cases of progressive caries, the recovery is
much more rapid and certain, and infinitely more perfect, as to form, motion, and the use-
fulness of the joint and limb, than when left to the slow process of nature.
[NOTE. —In the second conclusion, the Section does not unanimously coincide.]
By the SECTION ON DERMATOLOGY AND SYPHILOGRAPHY:—After a debate,
opened by Dr. E. L. KEYES, of New York, on “The Treatment of Syphilis
with special reference to the Constitutional Remedies appropriate to its
various stages; the Duration of their Use, and the question of their Continuous
or Intermittent Employment,” the Section adopted the following:—
Negative conclusions, for which there would seem to be no foundation in fact:
. Syphilis commencing mildly needs but little treatment, and does not require mercury.
. Mercury given internally is necessarily debilitating.
. Mercury is only useful in secondary syphilis.
. Iodide of potassium is of considerable value in secondary syphilis.
. Iodide of potassium is of no value unless preceded by the use of mercury.
6. Iodide of potassium acts by liberating mercury which has been lying latent.
Positive conclusions, which, in the present state of our knowledge, may be affirmed:
1. Mercury is an antidote to the syphilitic poison, and of service in controlling all its
symptoms in all, even the latest stages of the disease; its power over gummata being least,
and not to be relied upon.
2. Mercury in minute doses is a tonic.
3. Iodine cures certain symptoms of syphilis, but does not prevent relapses.
4. Mercury, long continued uninterruptedly, as far as practicable, in Small doses from the
time of the earliest eruption, constitutes the best treatment of syphilis.
By the SECTION ON OPHTHALMoLogy :—A discussion on the question, “Are
Progressive Myopia and Posterior Staphyloma due to Hereditary Predisposi-
tion, or can they be induced by Defects of Refraction, acting through the
Influence of the Ciliary Muscle 7” was opened by Dr. E. G. LORING, Jr., of
New York, and the following conclusions were adopted by the Section:—
:
1. From the fact that so many children are myopic, whose parents are not near-sighted,
while the myopia increases directly with the amount of increased tension of the eyes, and
MIN U TES. xlvii
from the fact that an interchange of refraction may occur, whereby an eye which is not
congenitally myopic may become so in spite of hereditary tendency against it, it would
seem to follow that hereditary predisposition, though undoubtedly a potent cause, is not
only not the sole cause, but that it is not even the predominating cause.
2. The action of the ciliary muscle, taken by itself, exerts but little influence on the pro-
duction of myopia, and still less on the formation of the cone. -
[NotE.-Of these conclusions, the first was adopted by the Section unanimously, and
the second by a majority of fifteen to seven.]
Dr. N. S. DAVIs, of Chicago, offered the following preamble and resolutions,
which were adopted :—
Whereas, This Congress marks an era in the history of medicine in the United States of
America, the addresses as delivered presenting a summary of progress in the various de-
partments which will be of great historical value in all coming time; and
Whereas, It is highly probable that these addresses, in connection with the many very
valuable papers read and discussed in the Sections, will require for their early and proper
publication more funds than are at present in the hands of the Treasurer for the purpose;
therefore,
Resolved, That the Committee of Publication be authorized and instructed, as soon as
practicable after the final adjournment of the Congress, to ascertain the probable cost of
publishing the full Transactions in a style appropriate for the work, and, if the money on
hand be found deficient, to address a circular letter to the American members of the
Congress, asking for such additional sum, not exceeding $10 for each of such members, as
will supply the deficiency; and that said committee be authorized to withhold the volume
or volumes, when published, from any member who may neglect to pay the additional sum
required.
Resolved, That the Committee of Publication he authorized and requested to exercise a
careful and liberal discretion in preparing and revising the proceedings and reported dis-
cussions in the several Sections, for publication in the Transactions of the Congress.
The Secretary General announced the receipt of communications from the
Woman’s National Christian Temperance Union, and from the Friends Tem-
perance Union of New York, respectfully inviting an expression of opinion
from the Congress concerning the use of alcohol.
On motion of Dr. N. S. DAVIs, these were referred to the Section on Medi-
cine.
On motion of Dr. J. M. To NER, of Washington, D. C., the communication
previously received from the National Temperance Association was similarly
referred.
After a recess of ten minutes, Dr. J. P. GRAY, of Utica, N. Y., read an Ad-
dress on Mental Hygiene (see page 205), Dr. HUNTER McGUIRE, of Virginia,
Vice-President, occupying the Chair; and afterwards Dr. LUNspoRD P. YAN-
DELL, of Louisville, Kentucky, delivered an Address on Medical Literature (see
page 223), while Dr. T. G. RICHARDSON, of Louisiana, Vice-President, occupied
the Chair. -
On motion, the various addresses read before the Congress were referred to
the Committee of Publication, and the Congress then adjourned until 10 A.M.
on Saturday.
SIXTH DAY'S SESSION.
The Congress met at 10 A.M., the President in the Chair. The minutes of
the preceding day were read and approved. The Secretary-General reported
447 names of delegates on the register (see page xv.), and, on motion of Dr.
ToNER, these were all confirmed as members of the Congress.
The Secretary-General read a request from Dr. RUDNEw, of Russia, asking
the privilege of access to the minutes and proceedings of the Congress, with
a view of reporting them on his return to Russia, which was granted.
The Section on Medicine recommended that the Secretary be directed to
send, in reply to the various Temperance Associations which had sent com-
munications to the Congress, the following conclusions which had been ap-
proved by the Section, and which were contained in a paper read before it by
xlviii MIN U T E S.
Dr. E. M. Hunt, of New Jersey, entitled “Alcohol in its Therapeutic Rela-
tions as a Food and as a Medicine.”
1. Alcohol is not shown to have a definite food value by any of the methods of chemical
analysis or physiological investigation.
2. Its use as a medicine is chiefly that of a cardiac stimulant, and often admits of Sub-
stitution. -
3. As a medicine, it is not well-fitted for self-prescription by the laity, and the medical
profession is not accountable for such administration, or for the enormous evils arising
therefrom. -
4. The purity of alcoholic liquors is, in general, not as well assured as that of articles
used for medicine should be. The various mixtures, when used as medicines, should have
a definite and known composition, and should not be interchanged promiscuously.
On motion of Dr. J. P. WHITE, of Buffalo, it was
Resolved, That the Centennial Medical Commission of Philadelphia is hereby tendered
the cordial thanks of this Congress for the most excellent manner in which its members
have discharged the arduous duties devolved upon them, and by which our pleasure and
profit have been so much enhanced. -
Resolved, That the President and other Officers of the International Medical Congress
of 1876 are hereby tendered the cordial thanks of the Congress for the excellent manner in
which they have discharged the arduous duties devolved upon them, and by which our
pleasure and profit have been so much enhanced. •
Resolved, That the Officers and Trustees of the University of Pennsylvania are hereby
tendered our cordial thanks for the very liberal use of their excellent buildings for the
meetings of this International Medical Congress.
Resolved, That the Officers and Trustees of the Jefferson Medical College are hereby
tendered the cordial thanks of this Congress for the use of their lecture-room for the most
interesting lecture of Dr. J. J. Woodward, U. S. A.
Resolved, That the cordial thanks of the International Medical Congress are especially
due to Drs. Thomson, Wilson, and Strawbridge, and to Messrs. Henry C. Lea and J. B.
Lippincott, for their generous hospitality.
On motion of Dr. H. I. BowdTTCH, of Boston, the following resolution was
adopted :-
Resolved, That we, a brotherhood of physicians from the North, South, East, and West
of this country, hereby tender to our associates from other lands our most earnest wishes
that they may have safe and happy returns to their homes, and we would suggest the hope
that they will carry back many pleasant memories of this fraternal meeting, now closing,
and which has been, most appropriately, held in this generous and noble city of Philadel-
phia.
Dr. J. A. GRANT, of Ottawa, Canada, stated that at a meeting of the mem-
bers of the Canadian medical delegates, held yesterday, the following resolu-
tions were adopted unanimously:—
Resolved, That the Canadian members of the International Medical Congress desire to
express their sense of the great consideration and urbanity with which they have been
treated by the officers and members of the Centennial Medical Commission, and beg, by
this resolution, to tender their warm thanks for the same. .
Resolved, That the Canadian members of the International Medical Congress most cor-
dially join with the other members of the Congress in thanking the physicians and citi-
zens of Philadelphia for the generous hospitality extended to its members throughout the
present session.
Dr. CHARLEs J. HARE, of London, read the following expression of congrat-
ulation from the delegates of Great Britain :—
The delegates from Great Britain to the International Medical Congress of Philadelphia
beg to congratulate the President and the several committees on the complete success of the
Congress, on the high value of the various addresses presented to it, and on the forward
impulse which it has given to the progress of medicine in the widest sense of that word.
They desire at the same time to express in the strongest and warmest terms their sense of
and their thanks for the unmeasured kindness and courtesy and the unbounded hospitality
with which they have been received on this Centennial occasion, and to add that they will
carry back with them a most grateful recollection of that warm right hand of fellowship
which has been so warmly extended to them by their brethren of the United States.
Signed on behalf of the British delegates by CHARLEs J. HARE, M.D. Cantab., F.R.C.P.,
M IN U T E S. xlix
late Professor of Clinical Medicine in University College, and Physician to University
College Hospital; R. BRUDENELL CARTER, F.R.C.S. Eng., Hunterian Professor of Surgery
to the Royal College of Surgeons of England; WILLIAM ADAMs, F.R.C.S., President of
the Medical Society of London.
Dr. L. A. SAYRE, of New York, offered the following:—
Resolved, That this International Medical Congress requests its President, Professor
Samuel D. Gross, to sit for his portrait, and that the Committee of Publication be in-
structed to have the same engraved and printed as a frontispiece to the Volume of Transac-
tions. Adopted.'
The Secretary-General stated that a circular had been received announcing
that an International Medical Congress would be held in Geneva in September,
1877.
Dr. N. S. DAVIs, of Illinois, then delivered an Address on Medical Educa-
tion and Medical Institutions (see page 265), Dr. HENRY GIBBONS, of California,
Vice-President, occupying the Chair.
Dr. GRoss, President, announced that the official programme of the Congress
had been completed. No new business being presented, he addressed the
Congress as follows:—
GENTI.EMEN: Before I put the question of the final adjournment of the Con-
gress, I desire to say a few parting words. First and foremost, I must be
permitted again to thank you for the great honor which you have done me in
electing me as your presiding officer. It is the last honor which I can reasona-
bly expect from my professional brethren, who have always been so kind to me
in the bestowal of their favors and of their good opinion. For these courtesies
I shall never cease to be grateful, for they have served to cheer me in my
labors, and have been as a balm to my soul. -
The International Medical Congress of 1876 is about to pass into history as
a thing of the past; but, although its exercises are at an end, its work will live
and form an interesting era in our profession as marking the reunion of a great
body of men in the Centennial year of American Independence. We have
listened to a number of valuable and instructive discourses, illustrative of the
progress of American medicine and surgery; have been engaged in profitable
debates affecting some of the most vital interests of society; have performed
a large amount of earnest work in the Sections; have met at the festive board;
have clasped hands, and have formed warm and, as I trust, lasting friendships,
all without any discord, one unkind expression, or even one word of misun-
derstanding. Altogether, we have every reason for self-congratulation. When
another Centennial century shall have passed away, the men who shall then
be upon the stage will not fail to commemorate our meeting, and to bless us
for what has been done this week in the interests of humanity and of medical
science. In dissolving this meeting, as I now do, permit me to invoke upon
our labors the choicest blessings of Almighty God, and to wish each and all of
you a safe return to your homes, and a happy reunion with your families and
friends. May we not hope that you may long, if not forever, retain pleasant
memories of our meetings in this Chapel, and that in your leisure moments
your minds may occasionally revert to those of us from whom you are about
to separate 7
The Congress then adjourned sine die.
I. MINIS HAYS, M.D.,
Secretary-General.
WILLIAM B. ATKINSON, M.D., )
RICHARD J. DUNGLISON, M.
RICHARD A. CLEEMANN, M.
WILLIAM W. KEEN, M.D.,
R. M. BERTOLET, M.D.,
•)
#. | Secretaries of the
• ? | meeting.
* [In deference to Prof. Gross's expressed wish, the portrait is omitted.—EDITOR.]
D
NOTICE.
THE Committee of Publication thinks it proper to say that the Con-
gress is to be held in no way responsible for the statements, reasonings,
or opinions set forth in the various papers published in its Transactions.
A D D R E S S E S.
ADDRESS ON MEDICINE AND MEDICAL PROGRESS IN THE
UNITED STATES.
BY
AUSTIN FLINT, M.D.,
PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE, AND CLINICAL MEDICINE, IN
BELLEVUE HOSPITAL MEDICAL COLLEGE, NEW YORK.
AN important object of the Philosophy of History is the study of
agencies concerned in originating and modifying past events. From this
standpoint I propose to survey “Medicine and Medical Progress in the
United States” during the past one hundred years. Whence were derived
influences affecting the progress of Medicine in this Centennial period :
I shall submit certain historical facts and reflections in answer to this
inquiry. Another object of the Philosophy of History, of greater prac-
tical importance, is the study of agencies with reference to future events.
Regarding Medicine in the latter aspect, the inquiry arises, by what in-
fluences is the progress of Medicine in our country to be promoted?
This inquiry opens up a wide range of thought, to which some incidental
reference is all that the limits of my discourse will permit,
Medicine, as I use the term in this discourse, distinguishes a province
of knowledge and art from Surgery and Midwifery. In this restricted
sense it denotes the province called in former times “the theory and
practice of physic.” I assume that medicine has steadily progressed in
our country during the past one hundred years; the rapidity, at different
periods, during this space of time, and the extent of progress, will natu-
rally enter into reflections upon the influences affecting it. The scope of
the term progress, as applied to Medicine, claims preliminary explanation.
In what consists, and what are the criteria of, medical progress in this
country, in past time : This question cannot be summarily answered ;
the answer will lead at once to the influences affecting the progress which
has taken place, and to those which tend to its promotion now and here-
after.
The most striking evidence of progress is a great discovery, the practical
benefits of which are immediate and palpable. Discoveries entitled to
this distinction, within the past century, are vaccination, auscultation,
and the separate functions of different components of the nervous sys-
tem. This brief list cannot be much lengthened. Pre-eminently great
discoveries in medicine are so distributed in respect of intervals, as to
bear the impress of special gifts vouchsafed by Providence. We can
boast of but one discovery which belongs in this category, the annihila-
tion of pain by anaesthetic inhalations. It is true the brilliancy of this
discovery is especially conspicuous in its applications to surgery; but the
2 FLINT,
benefits conferred on medicine are not vastly inferior, and would alone
entitle it to rank with discoveries to be characterized as pre-eminently
great.
Evidence of progress equally obvious, although less striking, is afforded
by enlargement of the boundaries of knowledge in different directions.
Under this head are embraced all facts relating to the nature of diseases,
their anatomical characters, their causation, their discrimination from
each other, their natural history, the principles of treatment, the relative
value of remedial or curative agents, the introduction of new remedies or
therapeutical methods and effective measures of prophylaxis. Not stop-
ping to consider in these relations the history of Medicine in the United
States during the past Centennial period, I pass to another aspect of
progress.
The progress of Medicine in any country is shown by the prompt
recognition of advancements in knowledge and improvements origi-
nating in other countries. After, for example, Harvey’s great discovery,
tardiness of its recognition in any country betokened lack of progress.
So with regard to discoveries of every grade, and improvements great
or small, it is proof of progress when they are promptly recognized in
countries other than those in which they originated. Readiness in the
importation of knowledge is thus a criterion, as it is, of course, a means
of progress. I need not add that the rapid diffusion throughout a country
of knowledge, either imported or of native growth, is both a criterion and
a means of progress. Further, a spirit of progress is shown by the prompt
recognition and diffusion, not alone of actual advancements in knowl-
edge and real improvements, but of doctrines and novelties which fail to
stand the test of time. Thus, in the eighteenth century, a spirit of pro-
gress must have been wanting wherever but little was known of the
theories of Stahl, Hoffmann, and Boerhaave. This statement is not incon-
sistent with the belief that the prevalence of these theories impeded
advancement in actual knowledge of medicine and real improvements in
medical practice.
With these explanations of the term progress in Medicine, let us sur-
vey the medical history of the United States.
We celebrate in this anniversary the lapse of a hundred years of our
existence as an independent people. A hundred years is but a small
space in the life-history of a nation. . We have passed through infancy;
we are hardly beyond adolescence, and, as we hope and believe, senescence
is far in the future. Our infantile and our adolescent condition are, of
course, to be taken into account in our reflections upon the influences
affecting the progress of Medicine.
When, in 1776, by a Caesarean section, we were separated from the
mother country, Medicine existed in a state ready for progressive devel-
opment and growth. The number of educated and able physicians was
by no means insignificant. Conspicuous among these were Rush, Morgan,
Shippen, Thomas Bond, of Philadelphia; John and Samuel Bard, Peter
Middleton, Richard Bailey, Jacob Ogden, Cadwallader Colden, of New
York; Benjamin Gale, of Connecticut; Joseph Warren, William Aspin-
wall, and the centennarian Holyoke, of Massachusetts. At our nation’s
birth, the lives and labors of these men and their coadjutors had a poten-
tial influence in determining the commencing progress of Medicine.
Medical education had an embryonic existence in two medical schools,
one in Philadelphia and the other in New York, and there were germi-
nations of medical literature.
A D D R E S S ON ME DIC IN E . 3
In the history of American Medicine prior to the Revolution we find
in operation a source of influence which has largely affected medical
progress in this country during the last hundred years, namely, the re-
cognition and adoption of advancements, real or apparent, in other
countries. A striking instance in the colonial period was the introduc-
tion of the inoculation of smallpox by Zabdiel Boylston in 1771. Boyls-
ton inoculated his son about two months after the date of the inoculation,
at the instance of Lady Mary Wortley Montague, of her daughter, and
without knowledge of the latter fact. Boylston himself inoculated
two hundred and forty-seven persons within a year after his first inocu-
lation, whereas, in England, during that period, and prior to the inocu-
lation of the daughters of the Princess Caroline, it had been practised
in only twenty cases. Virulent as was the opposition on this side of the
Atlantic, Boylston's life even being endangered, the practice in England
was still more violently opposed. Its sinfulness was proclaimed from
the pulpit, it being likened on one occasion to the smiting of Job with
boils by Satan, “the deluded preacher,” quoting from Boylston's biogra-
pher (Thacher), “wishing to have it understood that the Devil was the
first inoculator, and that poor Job was his first patient.”
The Revolutionary struggle, while it suspended teaching in medical
schools, labors in literature, and studies requiring tranquil leisure, doubt-
less gave an impetus to medical as well as surgical progress. It enlarged
opportunities for, and enforced closer attention to, the observation of
certain diseases; it enhanced the urgency of prompt and successful
methods of treatment; it opened up the subject of hospitals, and it stimu-
lated to measures of prophylaxis. Herein is, in some degree, a compen-
sation for the barbarism of war! It is not surprising, then, that, with
the antecedent history of American Medicine, medical progress was re-
newed with much activity after the achievement of independence. As
illustrations of this activity, after the war had ended (1783), and prior
to the beginning of the 19th century, two rival medical schools in Phila-
delphia had gone into operation, coalesced, and been united with the
University of Pennsylvania, the faculty then consisting of Rush, Kuhn,
Wistar, Shippen, Benjamin Smith Barton, and James Hutchinson; the
Philadelphia Dispensary for the relief of the sick poor, the first institu-
tion of its kind in the United States, had been established ; the trustees
of Columbia College in New York had organized a medical school, which,
however, from local difficulties, had not accomplished much ; a medical
department of Harvard University had been instituted, with John War-
ren, Waterhouse, and Aaron Dexter as professors; medical societies had
been incorporated in Massachusetts, New Jersey, and New Hampshire, and
the publication of the “Medical Repository,” a quarterly journal, which
lived to the completion of twenty-three volumes, had been commenced.
It is worthy of note that, prior to this century, Dr. Ezekiel Hersey, of
Hingham, Massachusetts, had bequeathed a thousand pounds, his widow
the same sum, his brother, Dr. Abner Hersey, of Barnstable, and Dr.
John Cuming, of Concord, each five hundred pounds, to be applied to
the support of a Professor of Anatomy and Surgery in the Harvard Medi-
cal College. The sum of one thousand pounds toward the support of an
additional professor had been bequeathed by William Erving, Esq., of
Boston. It would have been pleasant to have cited these examples as
precedents of many similar contributions for the promotion of medical
education; but, it must be confessed, the subsequent history of Medicine
in the United States furnishes little to boast of in this regard. It is, how-
4 - FLINT,
ever, a question, the discussion of which would be here out of place, how
far the interests of Medicine in this country would have been advanced
by the endowment of professorships in medical colleges. As an illustra-
tion of interest in medical progress felt by persons not members of the
profession, in 1798 Ward Nicholas Boylston secured to the Harvard
School a fund yielding an annuity, for annual prizes for competitive dis-
sertations on medical subjects, of one hundred and thirty-three dollars.
These prizes are continued at the present day. The same public-spirited
citizen of Boston founded the medical library which bears his name, and
contributed in various ways to the promotion of medical education.
Another conspicuous illustration was the active co-operation of the great
Franklin in founding and in the management of the Medical College of
IPhiladelphia. Franklin was president of the board of trustees, and the
meetings were held at his house until within a few months of his death.
During the period in our history of which I am now speaking, Cullen
was the master-spirit in Medicine. Not content with being an expounder
of the doctrines of Boerhaave, or a follower of his commentator Van
Swieten, he promulgated a system of his own. He had the boldness to
abandon giving lectures in the Tatin language. Iſis teachings, with
those of his able colleagues Monro, Gregory, Black, Young, and IIome,
had made Edinburgh the centre of medical education. The College of
Philadelphia, which in 1791 was merged in the Medical Department of
the University of Pennsylvania, had been modelled after the school in
Edinburgh, the latter having been modelled after the famous school of
Leyden. All the professors of the Philadelphia College had graduated
at Edinburgh. Hence, in this period of our history, the Cullenian sys-
tem was adopted, although, as will presently be seen, its supremacy was
not long maintained. It is evidence of activity at this period that an
American edition of Cullen’s work entitled “First Lines of the Practice
of Physic” was published in 1781, his lectures on the Materia Medica
having been published in Philadelphia in 1775. Rush, in a letter to
Cullen, written in 1783, said, in relation to the American edition of the
“First Lines,” that it “had a rapid sale and a general circulation
throughout the United States. It was read with peculiar attention by
the physicians and surgeons of our army, and in a few years regulated
in many things the practice in our hospitals.” He added : “Thus, sir,
you see you have had a hand in the revolution, by contributing indi-
rectly to save the lives of the officers and soldiers of the American
army.”
I have cited illustrations enough to show the activity of medical pro-
gress prior to the nineteenth century. The experience acquired in the
war of the Revolution, the enthusiasm arising from the sense of national
independence, the number of American physicians who had completed
their medical education in European schools and imbibed the spirit of
master minds in the profession, the pressing need of educated and skilful
practitioners—these were potential influences affecting the progress of
Medicine in the early days of the Republic.
Let me refer in this connection to the position held by the city in which
we are assembled, in her relations to the progress of Medicine in the
United States. At the time of the Revolution, Philadelphia was distin-
guished for her able and learned physicians and surgeons. They inau-
For these and other facts relating to the history of this period, I am indebted to Car-
son's History of the Medical Department of the University of Pennsylvania.
A D D RESS ON ME DIC IN E . 5
gurated systematic medical instruction on this continent prior to the
Revolutionary war, and again directly peace was declared. At the
time to which our survey of the history of Medicine has extended,
Philadelphia was the acknowledged seat of medical education. This
pre-eminence she has held from that time to the present. In the number
of medical men who have been educated at her schools; in the great
preponderance of her medical literature, and in her large proportion of
the distinguished representatives of the different departments of Medi-
cine, she has had no compeer in the new world. To the influence of her
example is to be attributed much of the activity of progress in other
cities of the Union. If, in the future, she should cease to preserve the
relative position which she now deservedly holds, it will be, in no small
measure, from the spirit of honorable emulation awakened and sustained
by her admirable example. In saying what I have said, I feel that I may
assume to speak in behalf of the medical profession of the United States.
It was most fitting that an International Medical Congress, in celebra-
tion of our centennial anniversary, should assemble in the city of Phila-
delphia.
We have now to inquire concerning influences affecting medical pro-
gress after the commencement of the nineteenth century. At the end
of the first quarter of this century, there were at least twenty colleges in
active operation, distributed among sixteen of the States of the Union,
the number of students in the year 1825 exceeding two thousand. Of
these twenty colleges, six may be distinguished as Metropolitan, being
situated in Boston, New York, Baltimore, or Philadelphia. Let us do
justice to the so-called Provincial schools as affecting medical progress.
They furnished formal instruction to many who were unable to bear
the expenses of long journeys and a residence in metropolitan towns.
A considerable proportion of students then, as now, pursued their stu-
dies in part at institutions near at hand, and, in part, at schools in the
cities just named. The provincial schools, each within a certain area,
developed interest, inquiry, and study among members of the profes-
sion, thus raising the standard of medical acquirement. They awakened
an ambition to become teachers by affording opportunity for the display
of talent in that direction. If it be said that in the establishment of
these schools the founders were not altogether disinterested, but may
have been actuated by motives relating to personal distinction and suc-
cess; this may be said with not less pertinency of metropolitan Schools,
and, moreover, such motives are not unworthy. If it be said that they
have occasioned local jealousies and feuds; this is not less true of metro-
politan schools. Thacher states with respect to the conferring of degrees
upon the two first graduates of the Harvard Medical College, that,
“from a spirit of envy and jealousy towards the professors, great oppo-
sition was made, and it was by the address and perseverance of John
Warren that the object was finally accomplished.” The success of medi-
cal schools in the city of New York was for several years retarded by
local opposition; and the same difficulties were experienced in the early
history of the schools in the “city of brotherly love.” Not a few of the
professors in the larger schools of our country first tested their powers,
and acquired experience as teachers in the smaller schools. The latter
have had not an inconsiderable share in promoting the progress of Medi-
cine. -
Within the first quarter of the present century, about twenty medical
6 FLINT,
journals were established. These contributed largely to the promotion
and diffusion of medical knowledge. The subsequent multiplication of
journals has not been proportionate to the increase and extension of
our population, those now in existence not much exceeding twofold the
number which had existed in 1825. Hitherto, as now, a considerable
proportion have had a limited local circulation, having been issued gene-
rally in places where medical schools were established, and being in a
certain sense the organs of the latter. These facts are not stated by way.
of disparagement. Of the great service rendered to medical progress by
the larger and widely distributed journals, it is not necessary to speak;
but, in justice to those comparatively small, and circulating within
restricted limits, it should be said that they have in no small measure
been serviceable. They have aided in diffusing medical intelligence.
They have incited to reading, thought, and profitable discussion. They
have increased the number of contributors to medical literature. It
would be easy to cite numerous instances of valuable contributions
which have appeared in journals relatively obscure.
The bibliography of the first quarter of the present century shows a
fair list of original works, foremost in number and influence being the
writings of Rush. Some of the works of this voluminous author, and
other contributions to medical literature during this period, were repub-
lished abroad and translated into different languages. The profession of
this country were by no means wholly dependent on foreign works. It
would, however, have betokened a lack of the spirit of progress had an
acquaintance with foreign authors been restricted by prejudice or indif.
ference. It was far otherwise. English works were the authorities in
Medicine, and many of those who could afford the time and expense,
crossed the Atlantic (the voyages requiring at least two months) in order
to finish their studies in Edinburgh or London, the schools in these cities
at that time taking precedence of those on the continent of Europe. The
reminiscences of the Revolutionary struggle, and a renewal of war with
the mother country during this period, had no repressing influence on
the attachment to the medical literature and the distinguished teachers
of Great Britain. Is it unpatriotic to say this with gratification and
pride 7 May we not claim in behalf of Medicine that it tends to raise
its followers above political contentions! May I not refer to our late
domestic strife as affording illustrations of a brotherhood which the
legitimate objects of Medicine render impregnable !
As a source of influence affecting the progress of Medicine, the forma-
tion of medical societies in the early, and still more in the latter, part of
the present century is to be mentioned. Without going into historical
details, suffice it to say, that thereby the advancement and diffusion of
knowledge have been greatly promoted. Moreover, to voluntary asso-
ciations is due, in a great measure, the character of the profession as
regards medical ethics and its position in relation to illegitimate systems
of practice. I must be content with simply referring, in this connection,
to one of the most important of the agencies concerned in medical pro-
gress.
In pathology and therapeutics during the early part of the present
century, the influence of Cullen, surviving his death, was still great.
Rush, however, a pupil and a fervent admirer of Cullen, was too bold
and independent a thinker to be satisfied with being an expounder of his
teacher's doctrines. In those days an object of medical philosophy was
A DDRESS ON ME DIC IN E. 7
to reach a theory which should reduce to a simple system the practice of
medicine—an object which, were it attainable, would obviate many of
the difficulties in the way of diagnosis, embarrassing the practitioner of
the present day. Rush was the author of a theory, the unity of disease.
According to this theory all morbid phenomena are the varied manifes-
tations of a single entity. This is not the time nor place to enter into any
discussion of the merits of medical theories, or to consider their practical
effects. Whatever may be thought of the “theory and practice of physic”
as taught by Rush, he influenced largely pathological views and thera-
peutics during his lifetime, and the influence of his writings continued
after his death. The system of Brown, the opponent of Cullen, had its
advocates in this country—a system leading to rules of practice directly
in conflict with those inculcated by Cullen and Rush. Even the extrava-
gances of Darwin's Zoonomia, which was republished in New York and
Philadelphia in the latter part of the eighteenth century, with an intro-
ductory address and an appendix by Charles Caldwell, were not without
influence. Toward the close of the first quarter of the present century
(1823) the “Study of Medicine,” by John Mason Good, was republished in
Boston, a work inaugurating the “physiological system” in nosology and
practice. It is evidence of a true spirit of progress that, of the different
systems, none had exclusive sway, and that, although there were enthu-
siastic partisans of each, many, if not the majority of, thinking minds
were guided by a rational eclecticism, selecting from any whatever com-
mended itself to reason and experience. With regard to this point I
quote from the worthy historian of “Medicine in America,” Thacher,
the following, written in 1828: “We recognize in our institutions no
uniform theoretical system as the rule of practice. Medical history
affords abundant evidence of the instability of human systems. Every
age has teemed with theories or visionary hypotheses fleeting as the wind,
scarcely surviving their authors, but yielding to others as transient and
unsubstantial as themselves. The medical authorities most respected are
Cullen, Rush, and Good. These, modified and improved according to
the judgment and views of the respective professors, are adopted and
taught in the various American universities.”
The introduction of vaccination in the beginning of this century was
a striking instance of the prompt recognition and adoption of a great
discovery. Jenner's “Inquiry into the Causes and Effects of the Variolae
Vaccinae” was published in London in 1799. In the following year
Benjamin Waterhouse vaccinated four of his children with virus received
from Jenner, and tested their insusceptibility to smallpox by exposing
them to infection in a hospital for the treatment of patients with the
disease. In 1801, Valentine Seaman commenced vaccination in New
York. Its speedy employment throughout the United States was
unattended by the violent opposition which characterized its early
history in the country honored by this greatest of all discoveries, as
measured by its influence on the physical welfare of mankind.
In 1817, an important event denoting progress was the project for the
formation of a National Pharmacopoeia. This project originated with
Lyman Spalding, and the initiatory steps were taken by the New York
County Medical Society. In 1820, a convention of delegates from the
different medical colleges and societies throughout the Union assembled
at Washington and adopted an American Pharmacopoeia, which, with
decennial revisions, has been continued up to this date.
8 - FLINT,
The second quarter of the present century is an eventful period in the
history of Medicine. The great American discovery of the annihilation
of pain by anaesthetic inhalations was made in this period. It is signifi-
cant of a cosmopolitan spirit pervading the medical profession throughout
the civilized world, that this discovery was at Once recognized and
adopted in other countries. The first application to capital operations
in surgery was in Boston, in September, 1846; and in the following
January the brilliant success of this application was demonstrated in
the hospitals of London and Paris. Directly following the application
to surgery, anaesthetic inhalations entered into the treatment of diseases
both here and abroad.
Surveying the more memorable of the events relating to the medical
knowledge of this period, it began with the advancement of morbid
anatomy to the rank of a distinct department of medical study. This
was the result of the labor of Bichat, which gave birth to General
Anatomy. That great work, the “Anatomie Générale” of Bichat, trans-
lated by George Hayward, was published in Boston in 1822. Bayle and
Hollard’s Manual of General Anatomy was translated by Gross in 1828,
and Béclard's Elements of General Anatomy, which appeared in 1823,
was translated by Joseph Togno, and published in Philadelphia in 1830.
The Profession of this country were prepared by these works, together
with the older works of Baillie, Meckel, Portal, Laennec, and others, for
the grand development of this study by Cruveilhier, Andral, Tobstein,
in France; by Mueller, Gluge, Otto, Henle, Vogel, Hasse, Rokitansky,
in Germany ; and by Carswell, Craigie, Hodgkin, and Hope, in Great
Britain. With the writings of these distinguished authors the Profession
of this country became immediately conversant. Some of the French
and German works were translated, and all were brought to the notice
of medical readers by means of analytical reviews. The spirit of pro-
gress was shown by the efforts to keep pace with the advancement in
other countries. To compete with these in the bibliography of this
study was not to have been expected; yet in 1829 appeared “A Treatise
on Pathological Anatomy,” by Horner, in two volumes; and in 1839 an
elaborate work by the honored President of this International Congress,
then a professor in the State which gave to the profession McDowell.
Horner and Gross were thus pioneer authors in this branch of American
medical literature. It is noteworthy that, for several years prior to the
publication of the work by Gross, he had held a chair of pathological
anatomy in the Cincinnati Medical College. I am fully warranted in
saying that this field of observation was diligently cultivated by not a
few, and that there was a general appreciation of its importance in
relation to the knowledge of diseases. To the study of Pathological
Anatomy during nearly all the period to which our attention is now
directed, and up to the present moment, have been devoted the labors of
one who, had he not been, unfortunately (I would almost say, with the
utmost respect, blamably), satisfied with the gratification pertaining to
his attainments, together with his usefulness as a professor, and his
invaluable services as curator of one of the richest of the museums in
this country, if not in the world, his name would have become so
identified with the study in the medical literature of every country that
it would have been superfluous to refer in this manner to J. B. S.
Jackson.
The discovery of auscultation can hardly be said to have had much
efficient influence on the progress of Medicine prior to the second quarter
A DID RESS ON ME DIC IN E. 9
of the present century. It is true, Laennec's great work was published
in 1819, and the translation by Forbes appeared in London in 1821; but
the discovery met with distrust, and was disparaged by some authorita-
tive authors. Forbes's translation was republished in this country in
1830, and from this date the great value of auscultation began to be
recognized. Soon after this date James Jackson, Jr., opened up the
study of the abnormal modifications of expiratory sounds, which Laen-
nec had, in a great measure, overlooked. In 1835 Gerhard published a
treatise on the diagnosis of thoracic diseases to “supply the wants of his
classes and of others who felt an interest in the subject.” In 1836 the
Massachusetts Medical Society published dissertations, by Oliver Wendell
Holmes, Robert W. Haxall, and Luther V. Bell, submitted in competi-
tion for a Boylston prize, which was adjudged to Holmes. As early as
in 1832 James Jackson, in his visits at the Massachusetts General Hos-
bital, always carried a stethoscope, the counterpart of that which Laen-
nec was accustomed to make with his own hands; and the daily record
dictated at the bedside of each patient embraced signs obtained by per-
cussion and auscultation. It was not long before physical exploration
by these methods entered more or less into clinical and didactic teaching
in most of our medical colleges, and thence speedily found its way into
private as well as public practice. The Profession of this country were
not tardy in accepting the fruits of Laennec's discovery, and this branch
of practical medicine has ever since had with us not a few zealous vota-
ries. Our medical literature, during the past forty years, contains a good
proportion of contributions relating to it.
The physical diagnosis of diseases of the heart, which at the present
time has reached such perfection, may be said to have had its point of
departure in the works of Bouillaud and IIope. Hope's treatise, issued in
London in 1832, was republished, with notes by the late Dr. C. W. Pen-
nock, in Philadelphia in 1842. In the interim Dr. Pennock and Prof.
E. M. Moore, of Rochester, N. Y. (1839), had devised and carried out a
Series of accurate experiments to elucidate the mechanism of the heart
sounds. At the end of the second quarter of the present century, the
progress in this province of medicine had been made familiar to American
medical readers by the republished works of Andry, Raciborski, Barth
and Roger, Aran, Stokes, Latham, Walshe, Blakiston, Watson, and by
the writings of Gerhard, Bowditch, and Swett in our own country.
A memorable event in the medical history of this period was the
publication, in 1827, by Richard Bright, of his “Reports of Medical
Cases.” A full analysis of this work appeared in the February number
of the first volume of the “American Journal of the Medical Sciences,”
in 1828. The editor concluded the article with these words: “As Dr.
Bright’s volume is so costly as to preclude its circulation in this country,
and as its contents are highly interesting, we have been induced to ex-
tend our notice beyond the usual limits, and have placed in our periscope
some of the most interesting cases.” I make this reference to show how
quickly important contributions to our knowledge abroad were brought
to the notice of medical readers on this side of the Atlantic. The
name Morbus Brightii had not as yet been applied to affections, the ana-
tomical characters of which Bright was the first to describe. Naturally,
the morbid anatomy of these affections for some time engrossed atten-
tion; the fruits of their clinical study could not be gathered at once.
It was not until the publication of Christison’s work, in 1839, that the
profession in Great Britain and this country began to grasp the scope of
10 FLINT,
their pathological relations. Bright himself could hardly have dreamed
of the extent of the new field in pathology which his researches opened
up. Our present knowledge of uraemic conditions in etiology and symp-
tomatology, acquired chiefly during the last quarter of the present cen-
tury, he could not have anticipated. I think it not too much to say
that the progressive developments in this field of pathology have been
as fully appreciated and their influence on the practice of medicine has
been as marked in this as in any country.
The quotation just made from the “American Journal of the Medical
Sciences” leads me, in this connection, to refer to analytical reviews and
bibliographical notices as affecting medical progress. This journal, suc-
ceeding the “Philadelphia Journal of the Medical and Physical Sci-
ences,” in fact a continuation of the latter, dates from the year 1827.
In the advertisement accompanying the first volume it was said: “Ar-
rangements have been made to import regularly from London and Paris
every new medical work, and to obtain in exchange almost every medical
journal published in Europe. These will be placed in competent hands
for analysis or review, and whatever is valuable in their contents shall
be laid before our readers as early as possible.” Writing, as I do, after
having examined the volumes issued during the second quarter of the
present century, I am impressed with the fidelity with which this
promise was fulfilled. They contain reviews or notices of the important
publications in England, France, Germany, and other countries during
that period. This journal, continued up to the present time, under the
same title, issued by the several successors of the first publishers, Tea &
Carey, for more than forty years under the editorship of Isaac Hays
(who, although a veteran in journalism, is not yet entitled to be called
venerable), has had a powerful influence on the progress of Medicine in
this country. This influence has been exerted not less by its original
communications than by its reviews, notices, and general intelligence.
Without any disparagement of the numerous able and useful periodicals
during the last half century, may we not, with a feeling of pride, refer
especially to a journal which, with such a history, is now the oldest rep-
resentative of medical periodical literature, and which has probably a
circulation larger than that of any other in Europe or America 7'
The physiological discoveries of Magendie, Charles Bell, and Marshall
Hall, relating to the nervous system, forerunners of a further unfolding
of the functions of this system within late years by Bernard, Brown-
Séquard, and others, had a considerable influence on pathology and prac-
tice; an influence which, by means of republications, reviews, and con-
troversial articles, was perhaps felt as speedily here as abroad. But a
memorable event in physiology, having direct practical bearings, was of
American origin, namely, the observations and experiments of Beaumont
in the case of Alexis St. Martin, published in 1833. Beaumont’s pro-
longed, patient, careful, conscientious researches, demonstrating more
completely than had yet been done the agency in digestion of the gastric
juice, furnished important facts in relation to its quantity, its compo-
sition, the circumstances affecting its secretion, together with the relative
digestibility of different articles of food, and the influence upon digestion
of local and general morbid conditions. These facts have, in the main,
been corroborated by experimental physiologists who have since studied
* The American Journal of the Medical Sciences is the oldest of living journals, consider-
ing it as a continuation of the Journal of the Medical and Physical Sciences.
A D D R E S S ON ME DIC IN E . 11
the functions of the stomach by means of artificial gastric fistulae in infe-
rior animals. Looking at the fruits of his labors as affecting the pro-
gress of medicine, may we not claim for them sufficient value to entitle
the name of Beaumont to be mentioned in connection with the names
of Magendie, Bell, and Hall ?
The writings of Broussais are to be reckoned among the memorable
events of the period under survey. The “History of Chronic Phlegma-
siae” was translated by Isaac Hays and R. Eglesfeld Griffith in 1831; in
the same year his “Treatise on Physiology applied to Pathology”, was
translated by John Bell and La Roche, and in 1832 his work entitled
“Propositions Embodying Principles of Physiological Medicine” was
translated by Hays and Griffith. By these publications the profession in
this country were made acquainted with the so-called new physiological
doctrine more commonly known as Broussaism. For a time it had not
a few ardent supporters, prominent among whom was the late Professor
Samuel Jackson, whose work, entitled “Principles of Medicine,” was
based upon it. The circulation of this work was arrested by the author,
as was understood, because it became inconsistent with his more matured
views, an act which reflected honor upon his character as an honest
inquirer after truth. Like the systems of Rush, Brown, and Cullen,
Broussaism had its day; but, unlike the preceding systems, this has had
no successor. With the fall of Broussaism the race of isms became ex-
tinct; theoretical dogmas as the basis of different schools or sects have
been relinquished to the illegitimate pathys.
Broussais, however, was not the sole last survivor of the race. Coeval
with this doctrine was one of American birth, namely, the doctrine of
Cooke. John Esten Cooke, a man of much ability and of sterling moral
worth, at that time Professor of the Theory and Practice of Medicine in
the worthily distinguished Transylvania University, in 1831 published
at Lexington “A Treatise on Pathology and Therapeutics.” . After com-
menting on the extreme proneness of medical philosophers to frame hypo-
theses instead of following the true spirit of inductive logic, he enunciated
the doctrine that hepatic congestion is the fons et origo of most of the
phenomena of disease. This doctrine was not entirely new, but it was
carried by Cooke to the extreme point of culmination. Its practical
effect on therapeutics was an excessive use of purgatives, and especially
calomel in large doses. In those days of hypercatharsis, patients were
purged by the followers of this system as patients had never been
purged before. Cooke was afterward Professor of Practice in the Medical
School at Louisville, and for a long time a dose of calomel which he had
prescribed was preserved as a curious specimen in the museum of that
school. With the audacious extravagance which characterizes American
humor, it is related of a Kentucky yeoman that, finding in one of his
fields crude mercury in considerable quantity, visions of wealth from a
mine of quicksilver loomed up in his imagination; but they were dis-
pelled when it was ascertained that the spot had been a burial ground
for the remains of patients treated in accordance with this doctrine!
An influence which contributed to prevent the formation of new sys-
tems of medicine, and to promote in not a small degree, true medical
progress, belongs to the works of Louis. Louis’s “Researches on Phthisis,”
translated by Cowen, revised and altered by Bowditch, his “Researches
on the Typhoid Affection,” translated by Bowditch, and his “Researches
on the Effect of Bloodletting in some Inflammatory Diseases,” translated
by Putnam, with a preface and appendix by James Jackson, were
12 - FLINT,
published in this country in 1836. His “Researches on Yellow Fever,”
translated from the manuscript by Shattuck, appeared in 1839. I need
not enter into an exposition of the method of study which Louis exem-
plified in these works. It would be out of place, even if time permitted,
to discuss here the merits of this method. Of its influence, suffice it to
say that it has led to a large proportion of the actual knowledge of the
clinical history of diseases, of their anatomical characteristics, of the
diagnostic value of symptomatic phenomena and of therapeutical agen-
cies, which has been acquired within the past forty years. Of the per-
manency of acquisitions in knowledge to which it has already led, let
this statement suffice; the works of Louis, within the limits of the
means of observation available in his time, are as valuable to-day as at
the date of their appearance. The method of study inaugurated by him
was a new departure of the Philosophy of Medicine, offering now, and in
all time, rich returns for homest work.
The study of medicine in the direction given to it by the labors of
Touis, led to an appreciation of the importance of knowing the natural
history of diseases. Jacob Bigelow struck a key-note in his discourse
on “Self-limited Diseases” in 1835. From that time our teachers and
writers have been alive to the truth that knowledge of the intrinsic
tendencies of diseases must underlie actual progress in therapeutics.
The true spirit of medical philosophy, after its emancipation from the
thraldom of theoretical systems, speedily found expression in the works
of Stillé, Bartlett, Ware, Holmes, and others. The influence was soon
felt in medical practice. Progressively, in this country, practitioners
became more reserved in the use of heroic measures of treatment, and
polypharmacy fell into disrepute; they became less ambitious to be the
masters, and more content to remain the servants of nature; efforts were
made to bring experience to the test of the numerical method of inves-
tigation, and “expectation,” using this term in its true sense, took its
proper place in clinical medicine. Is it presumptuous to affirm that these
criteria of veritable progress have been not less, and perhaps, in some
regards even more marked in the medical practice of American physi-
cians than of those in the older countries, by whose writings and oral
teachings we have largely profited 2 º
Warned by the length already of this discourse, I must not linger
with other topics relating to the history of the second quarter of the
present century. There are two events of importance, belonging to this
period, to be added to those already noticed, namely, the publication of
the United States Dispensatory and the organization of the American
Medical Association. The first edition of the Dispensatory by Wood and
Bache was published in 1833. With the additions and improvements
called for in the successive thirteen editions, this work has met fully
the wants of the practitioner, holding its place still, without a competitor,
and, to say the least, comparing favorably with similar publications in
other countries. The American Medical Association was instituted in
1847, by the Profession, “for the protection of their interests, for the
maintenance of their honor and respectability, for the advancement of
their knowledge and the extension of their usefulness.” Since its
Organization annual meetings have been held, excepting a portion of the
period during which intercourse of the Profession of the North and the
. ." Quoted from the resolution adopted by the Convention which preceded the first meeting
of the Association. - -
A D D RESS ON ME DIC IN E. 13
South was suspended by civil war. At these meetings representative
members of the profession in all parts of the country have been brought
together under circumstances conducive to fraternal union and good
fellowship; and the twenty-six volumes of “Transactions” contain much
that is valuable, more especially in relation to climatology, and the dis-
eases prevalent in different parts of the United States. The Association
has encouraged original papers by prizes, and has kept the Profession in-
formed of important contributions to knowledge by reports on Medical
Science and Literature, and on the Progress of Medicine, Surgery, and
Midwifery. In these different ways its influence has been not incon-
siderable.
The literature of any province of knowledge gives the truest expression
of progress, while it does most toward promoting it. In this period, the
increase of publications was proportionate to the growth of our nation in
population and material interests. I shall enumerate some of the valuable
contributions to practical medicine, without attempting to give a full
list of them. My distinguished friend who will address the Congress on
the subject of American Medical Literature will supply deficiencies here
and elsewhere.
The “Practical Esssay on Typhous Fever” by Nathan Smith, although
printed in 1824, may be reckoned as entering into the literature of this
period. One of our most accomplished writers (Bartlett) in his work on
the Fevers of the United States, published in 1842, says of this “modest
unpretending essay:” “To an American practitioner it is worth in-
finitely more than all the modern English treatises put together.” The
attainments and skill of that great man, united with perfect integrity
and simplicity of character, excite our admiration ; nor can we less
admire the energy and pluck which led him to establish the medical
school of Dartmouth College, himself the sole professor for ten years, a
faculty of one, but that one Nathan Smith, prominent among the medical
heroes of the early age of our republic.
The progress of knowledge of the essential fevers, within this period,
was in no small measure affected by contributions to American medical
literature. Gerhard, Pennock, in 1836, and Shattuck, in 1839, were the
first to contribute ample clinical observations, showing the essential
points of distinction between typhus and typhoid fever. To these
observers belongs the credit of the doctrine of the non-identity of these
fevers, a doctrine which, after twenty years of hesitation and discussion,
was generally recognized as sufficiently established. James Jackson’s
Report, in 1838, and Enoch Hale's paper, in 1839, embodied the results
of the application of the method of study inaugurated by Louis to the
common continued (typhoid) fever of New England. The treatise on
the Fevers of the United States by Elisha Bartlett, published in 1842,
the fourth edition revised after the author's death by Alonzo Clark, has
been, almost up to the present time, a standard work, and is too well
known to need any commendation. Meredith Clymer, in an article on
typhoid fever, published in 1846, was the first to describe in this country
the disease now known as relapsing fever. It may, perhaps, be assumed
that the communicability of typhoid fever was first demonstratively
shown by the circumstances attending an outbreak of the disease in a
small hamlet in Western New York, in 1843."
| Account of an epidemic fever which occurred at North Boston, Erie Co., N. Y., in
October and November, 1843. American Journal of the Med. Sciences, July, 1845.
14 FLINT,
Important contributions relating to the differential characters of
remittent fever and its clinical history were made by Stewardson, in
1841 and 1842; by Swett, in 1845; by Anderson, Frick, Stillé, and
Boling, in 1846. Our present knowledge of this disease rests mainly on
the facts contained in these contributions.
The doctrine of the combination of different fevers, or the “blending
of types,” was taught by Dickson and Drake, in contradiction of the
theory of Hunter, which denied that the special causes of two or more
diseases can act conjointly in the organism. The doctrine is now suffi-
ciently established by clinical proof. Drake, in 1832, contributed a
series of papers in advocacy of the animalcular hypothesis of the origin
and diffusion of epidemic cholera, and subsequently, in his great work,
he argued at length, and cogently, for this hypothesis as applied to
the etiology of other diseases. And in this connection the remarkable
work of Mitchell on the “Cryptogamous Origin of Malarious and Epi-
demic Fevers” may be referred to. This work was published in 1849.
If, as is perhaps more than probable, the truth of the “germ theory,”
as it is now termed, be hereafter confirmed by direct observation, the
writings of Mitchell and Drake on this subject will be cited as evidence
of an insight into the mysteries of etiology beyond that of their con-
temporaries; and at the psesent moment, when this theory is the subject
of so much interest, these writings claim careful study.
In referring to Drake, I cannot forbear a passing tribute of admiration
of the talents and labors of that truly great man. As an eloquent
expounder of medicine he was without a superior; and when we look
at the work which he performed, as a writer, a medical teacher, and in
travelling over large sections of our country, gathering from personal
inquiries and observations materials for his treatise on the “Principal
Diseases of the Interior Valley of North America,” which he did not
live to complete, we must consider his name as worthy to be enrolled in
the list of our medical heroes.
The treatment of the periodical fevers with large doses of quinia,
together with the discontinuance of the so-called preparatory treatment;
the extent to which this drug may be given without risk of harm; the
entire safety of its use in the state of pyrexia; and the advantage of
arresting the paroxysms as speedily as practicable—points at that time
in opposition to the prevalent practice—were set forth in this country as
early as 1841. It may be added that the views which have since pre-
vailed in reference to these points were adopted earlier, and diffused
more quickly with us than in other countries.
The literature of this period embraces many contributions relating to
yellow fever. Prominent among the contributors are the names of Bar-
ton, Barrington, Cartwright, Dickson, Nott, Simons, C. H. Stone, Ashbell
Smith, and Fenner. Our medical literature from the earliest period of
our history has abounded in writings on this subject, to which justice
has been done in that marvel of laborious erudition, the Treatise on
Yellow Fever, by La Roche, published in 1855. The contributions by
the authors just named, and others, led to the present prevailing belief
in the non-communicability of the disease, but the portability of its
special cause, and in the injudiciousness of perturbatory measures of treat-
nment.
Of contributions other than those relating to the essential fevers, and
* Wide article in the American Journal of Medical Sciences, No. for October, 1841.
A D D R E S S O N M E DIC IN E . 15
in addition to those referred to in other connections, I shall mention
several, by no means undertaking to enumerate all, or even the greater
part, of those which promoted progress by extending, more or less, the
boundaries of knowledge.
John Ware, in an analysis of his recorded experience published in 1831,
brought to bear the numerical method upon the use of opium in the
treatment of delirium tremens. The results of the analysis have ever
since been a basis of practice in that disease. The same writer in a series
of articles on croup, published in the latter part of this period, delineated
clearly the different affections then embraced under that name. The
distinctions derived from his recorded experience and founded in nature,
are as valid to-day as at the date of their publication.
John B. Beck’s treatise on infant therapeutics in 1849, had much
influence in restraining the over-use of potential measures in the treat-
ment of diseases in infantile life. The article by Cammann and Clark
on auscultatory percussion, published in 1840, introduced a new method
in physical exploration, and gave the results of its employment in obtain-
ing accurate measurements of internal Organs. The treatise by Amariah
Brigham on “The Influence of Mental Cultivation on Health,” published
in 1832, and the “Inquiry concerning the Diseases and Functions of the
Brain, Spinal Cord, and Nerves,” published in 1840, contained original
views important in their practical applications. Horace Green’s treatise
on “Diseases of the Air Passages,” published in 1846, originated the prac-
tice of making topical applications within the larynx, the feasibility of
which was accepted after considerable distrust and acrimonious discussion.
In 1841 Alonzo Clark began to treat acute peritonitis with large doses
of opium, excluding calomel and venesection. He carried the use of
Opium further than had previously been done, and ascertained that the
disease in some cases causes a marvellous tolerance of this remedy. The
treatment exclusively or chiefly by opium has been generally adopted in
this country, and may properly be called the American method. More-
over, the success of the use of opium freely in peritonitis, has led to the
useful employment of this remedy in other affections. Bowditch’s first
employment of suction for the withdrawal of liquid from the pleural
cavity, through a small canula, was a few weeks after the end of this
period; but he then carried into effect a procedure which he had pre-
viously maturely considered and resolved upon. I may, therefore, in this
connection, refer to an improvement in the practice of medicine, the
merits of which it were needless at this day to discuss. The use of the
term aspiration, in place of the homely word suction, and the invention
of more complicated instruments, have recently given to the procedure
a new and more attractive aspect. The successful practical application
of the method, however, belongs to the history of American medicine;
and, taking into view the wide range of the application, it is certainly
worthy of being reckoned among the important events affecting medical
progress within the past century.
These contributions, cited from personal recollection, without searching
medical annals in order to extend the list, suffice to show that during
this eventful period, the field of practical medicine in this country was
not without efficient workers, and not wholly unproductive. Directing
attention to another aspect of medical literature, the evidence and the
means of progress are shown by the number of works relating to the
Principles and Practice of Medicine. Original works in this department
of literature began to appear prior to the second quarter of the present
16 FLINT,
century; but the number within this period was considerable, namely,
the works of Dewees, Eberle, Dunglison, Cooke, Fort, Gallup, HOSack,
Chapman, Paine, Dickson, Stillé, and Wood. A considerable number of
republished works, generally with notes or additions by American edi-
tors, were added to those of native production. In this list are the works
of Marshall Hall, revised and much enlarged by Jacob Bigelow and
Oliver Wendell Holmes, Craigie, Billings, Elliotson, with notes by Stew-
ardson ; Gregory, with notes by Peixotto, Alison, Williams, and Latham;
Graves's System of Clinical Medicine, with additional lectures by Gerhard,
and Stokes's lectures with an equal number added by Bell; Andral's
Clinique Médicale, translated by Spillan; Chomel’s Pathologie Générale,
translated by Oliver and Morland, and the lectures by Watson. In addi-
tion to works of this character were several on a larger scale designed
for reference in regard especially to the practice of medicine, namely, the
London Cyclopaedia of Practical Medicine, edited with large additions
by Dunglison ; Copland’s Medical Dictionary, with copious notes by Lee;
the Library of Practical Medicine by Tweedie, with American notes and
additions by Gerhard. To this class of works belongs the American
Cyclopædia, edited by Hays. When to these productions, native and
foreign, we add the original treatises by Dewees, Eberle, Condie, and
Stewart on the diseases of children; not a few works, original and im-
ported, treating of particular classes of diseases; the works on materia
medica by Barton, Bigelow, Coxe, Chapman, Eberle, Dunglison, Griffith,
Carson, Paine, Ellis, Beck, Bell, Harrison (all native productions), and
the medical dictionary, by Dunglison, have we not, in this point of view,
evidence of an activity in the means of progress creditable to a nation
under the age of fourscore years? Was not the growth of medical
literature, in this aspect, proportionate, to say the least, to the increase
of population, the extent of territory populated, and the advancement ill
other provinces of practical knowledge 2
Survey for an instant this period from one other standpoint, namely,
the number and character of prominent members of the medical profes-
sion. We must recognize in the personal influence exerted by individuals
in their respective spheres as teachers, practitioners, and members of
society, one of the most potent of the agencies concerned in progress.
Some of those who, regarded from this standpoint, have a record most
honorable to themselves, are still with us—may they live long to receive
the honor which is their due ! On the list of those who have departed
for another life are such names as James Jackson, Samuel Jackson,
Samuel Jackson of Northumberland, Chapman, Mitchell, Hosack, Ware,
Gerhard, the two Becks, McNaughton, Pennock, Revere, Drake, Joseph
M. Smith, Francis, Parrish, the elder Shattuck, Dunglison, Dickson, Fen-
ner, Stearns, Bartlett, Moreton Stillé, Caldwell, LaRoche, Lee, Swett,
Twitchell, Tully, Mussey ; and to these, and such as these, might be
added the names of a host of practitioners who, without engaging in
the labors of literature, or in medical schools, exerted within greater or
lesser spheres, an influence promoting the diffusion of knowledge and
ennobling the character of the physician.
Having reached in our survey the third quarter of the present century,
I hasten to say that the concluding part of my address will be brief. I
shall not enter into historical details for reasons which are obvious, in
addition to the desire not to presume too much upon your patience. The
professional lives of a considerable proportion of those whom I address
A D D R E SS O N M E DIC IN E . 17
embrace the last twenty-five years, and everything of importance per-
taining to the history of this period is familiar to them. Moreover, to
particularize events, to notice contributions to medical literature, and to
refer to individual members of the profession, would involve questions
of delicacy which I prefer to avoid. I shall therefore limit myself to a
few remarks on topics suggested by the inquiry, what are some of the
characteristics of medical progress in the United States within the last
quarter of a century and at the present time : -
The predominant and most distinctive characteristics of progress in
the medical science of this period, are derived from the developments in
histology. Pathological histology followed the acquisition of a new
territory in anatomy by Schwann in 1839, as the morbid anatomy of the
tissues had followed the Anatomie Générale of Bichat; and the devel-
opments by means of the microscope in the study of disease are to be
dated chiefly after the middle of the present century. Prior to this,
however, microscopy had enlisted the interest of medical teachers and
students in this country, as well as in Europe; and as early as 1851, a
prize was awarded to Burnett (whose untimely death was a loss to
science), by the American Medical Association, for an essay on “The
Cell; its Physiology, Pathology, and Philosophy,” embracing deductions
from elaborate original investigations. Histology entered at once into
the formal instruction of many, if not most, of our medical schools.
Our pilgrim sons who previously had paid homage at Paris, Edinburgh,
Dublin, and London, for the past quarter of a century have gathered in
larger numbers at Vienna and Berlin. Histological researches having
been prosecuted with most zeal by our Austrian and Prussian brethren,
German medical literature has thereby acquired a prominence and an
influence which might be cited as a characteristic of Medicine at the
present time. I need hardly say that it would not be fitting on this
occasion to inquire into the actual increase of our knowledge to be
ascribed to the progress of histology. That a vast and fruitful domain
in physiology and pathology has been brought under cultivation, and
that it has already yielded rich harvests, cannot be doubted. Herein
will the history of Medicine in our day be ever memorable. And the
future is full of promise when obstructions from doctrines connected
with bioplasm, cyto-blastema, autogenesis, and the so-called cellular
pathology shall have disappeared. With improved methods and increased
power of microscopical investigation, it may not be long before the
germs (using this word in either a literal or a figurative sense) of infec-
tious and contagious diseases will be brought within the scope of ocular
demonstration. When this is accomplished, it requires no prophetic
sagacity to foresee that the influence on the progress of pathology, thera-
peutics and prophylaxis must be immense. Perhaps in the developments
of the future, the labors of our zealous workers will bear an honorable
part. I will venture to add that we are not to expect from histology a
royal road through pathological mysteries; but, profiting by past experi-
ence, and avoiding doctrines based largely on hypotheses, our researches
in this direction should go hand in hand with the tedious, but, if properly
conducted, safe studies in clinical medicine.
I have alluded to pilgrimages to other countries. The desire to profit
by the distinguished schools abroad has always been an American charac-
teristic. In the first half century of our national existence, the schools
in Great Britain were chiefly resorted to ; in the third quarter of the
century, those of France had the preference, and in the last quarter the
2
18 FLINT,
German schools. Some members of the Profession look with disfavor on
this yearning for foreign instruction. It is thought to be antagonistic to
a proper sense of a national independence, implying a sort of vassalage
unfavorable to original developments. I do not share in these views.
For us, in our adolescent age, to regard with a certain degree of defer-
ence the institutions of older countries, is not a confession of dependence,
but a becoming modesty. It is true that opinions which have travelled
across the Atlantic acquire in the estimation of many an exaggerated
importance; the weight of far distant authority is apt to be over-estimated.
This is, in a measure, counteracted by judgments formed after personal
inspection. A discriminating mind judges fairly from intercourse with
distinguished teachers and writers of their claims as authorities. In this
point of view our sojourners abroad benefit, not only themselves, but their
brethren at home. In some instances, it must be admitted, personal ad-
miration or attachment leads to a discipleship which is exceedingly un-
favorable to the progress of the disciples; yet these render service by
diffusing the opinions of their masters among those who, uninfluenced by
partisan zeal, consider and judge without prejudice. That our independ-
ence in thought and judgment is not compromised, is shown by what I
believe may be stated as a fact, namely, no one who has returned from
abroad and remained a mere satellite of a foreign luminary, has ever
attained to any great distinction in the minds of his countrymen.
A characteristic of the past quarter of a century, and of the present
time, relates to the increase of American medical literature. Native
productions have been and are steadily increasing in number, and this
not to the exclusion of, if, indeed, there have been any decrease in, the
republication of foreign works. In order to appreciate the significance
of this increase, as showing the progress of native literature, we must
consider that American productions are in immediate competition with
English works, the merits of which have been established, and for the
republication of which the authors can claim no royalty. Much has been
said of the injustice done to American authors by the want of an interna-
tional copyright law. Without entering into any discussion of this topic,
I will simply say that such a law is called for, not so much for the encour-
agement of our own literature, as in behalf of the just claims of foreign
authors. The medical profession of this country have given ample evi-
dence of a disposition to receive with discriminating favor native produc-
tions. I presume I am not in error in saying that our medical publishers
are always ready to print any work which, from its intrinsic merits, may
offer a fair promise of success. This is evidence of a demand for native
works, inasmuch as it would imply a marvellous disinterestedness to sup-
pose that publishers are actuated solely by a desire to promote a national
literature. It is noteworthy that not long after French authors were
held in special favor, the proportion of medical readers who were able to
study the works of these authors in the language in which they were
written, became so large as to render translations unprofitable to pub-
lishers; and it is probable that ere long this will be found to be the case
in regard to publications in the German language. There will then be no
occasion for a remark which I have heard imputed to a medical teacher
in this country, that to know the German tongue is as essential for the
student of medicine as a knowledge of anatomy
I cannot forego a few words respecting the disposition of our English-
speaking foreign brethren toward American medical literature. Many
years ago an English reviewer and humorist, in a moment of irritation
A D D R E SS O N M E DIC IN E . 19
from circumstances of a personal nature which rendered it perfectly
natural, exclaimed, “Who reads an American book 7” This has been
over and over again quoted as a fair expression of the estimate in
England of our bibliography. It should never be quoted except to add
that its author was more unjust to his own countrymen than to us. All
who are familiar with the medical periodical literature of Great Britain
must have been impressed with the great candor and consideration
generally shown in reviews and notices of American works. Not unfre-
quently these have received far more approbation abroad than at home.
This is certainly a fitting occasion to declare that there is no ground to
impute a prejudice, either in Great Britain or any other country, against
Our national literature.
That our works and periodical literature have in general a practical
character is readily accounted for by our youth as a nation, and the
rapid extension of population over a vast continent. With increase of
years, and the altered circumstances incident thereto, our future in
medical literature, it may safely be predicted, will show a wider scope.
Thus far in our progress, the pressing claim upon our writers has been
the wants of our widely separated brethren as regards qualification for
the active duties of the practitioner.
The statement just made suggests the leading characteristic of our
medical schools, namely, practical instruction. I shall not encroach
upon the ground of the distinguished physician who is to address us on
the subject of American medical education. He may, perhaps, point
out defects in our educational institutions. That there are defects, is
not to be denied. But, that we may not do injustice to our predecessors
and our contemporaries, let it be considered how peculiar is the situation
of the profession of this country in this regard. The whole responsibility
for medical education, inclusive of the means for its promotion, rests, for
the most part, with the Profession. Medical schools are without the
jurisdiction of the general government, and our numerous States can
only control, of course, those within their respective borders. Hence,
uniformity throughout the country in legislating in behalf of medical
education is impracticable. Legislative provisions for the increase and
diffusion of medical knowledge are apt to be regarded in the light of
appropriations for the benefit of a particular class of citizens. A diploma
or a license to practise medicine from some legally authorized body is
easily obtained, and the law practically places no obstacle in the way of
practising without either. Now, in view of these facts, which are, of
course, familiar to all of us, how are we to explain the annual gatherings
of medical students and practitioners in large numbers in Philadelphia,
New York, and other cities, many coming from distant parts of the
Union, incurring expenses which often involve much exertion and self-
denial 7 What other explanation is there than, first, that certain of our
medical schools afford large opportunities in the way of practical in-
struction ; and, second, that there is a wide-spread yearning for these
opportunities simply on account of their intrinsic worth? Have we not
here the evidence of a spirit of progress in both teachers and pupils,
which is creditable to the past and present, as, also, an earnest for the
future? Let us strive to remove defects, to correct abuses, and to
improve, as fast as practicable, our system of instruction ; but let us not
be led into a disparagement of what has been done, and is now being
done, in behalf of medical education.
20 FLINT, ADDRESS ON ME DIC IN E.
A few words in conclusion, concerning characteristics which relate to
medical ethics. At the Convention held in 1847, resulting in the orga-
nization of the American Medical Association, a code of ethics was
adopted, and it has since been formally recognized as having binding
force upon members of state and local societies throughout the Union.
This code embodies rules which were in accordance with the usages of
worthy members of the profession in this country, and with established
ethical principles in other countries. It defines simply and clearly the
line of conduct to be followed in the relations of medical men to each
other and the profession at large, to their patients, to the public, and to
those who, adopting a practice based on an exclusive dogma, or from
unworthy acts, are not to be considered as professional brethren. This
code has remained unaltered and with undiminished force for more than
a quarter of a century. I state this fact as a characteristic which reflects
honor on the representatives of American Medicine. I claim, in behalf
of the Medical Profession of the United States, that the great majority of
its members have been loyal to the code of ethics. With no penalty for
violations of ethical rules beyond the loss of professional fellowship, a
penalty which may be made subservient to selfish advantage, loyalty is
secured by motives of self-respect, and regard for the power of the Pro-
fession. It may perhaps be claimed that in no other country is the line
dividing legitimate and illegitimate medicine more distinctly defined
than with us; and nowhere are instances of affiliation with irregular
practitioners more infrequent. The same may perhaps be said of the
number of those who, having once been in respectable professional
standing, have yielded to the temptation of originating secret nostrums
and patenting remedies or inventions. These characteristics are consistent
with the fact that in no other country does the l’rofession of Medicine
hold a higher social position or exert a greater public influence than in
these United States of America.
Gentlemen, Members of the International Medical Congress: At this our
Centennial Anniversary it has seemed to me appropriate to survey
“Medicine and Medical Progress in the United States” from the points
of view which excite feelings of gratification, hope, and faith. We
should by no means shut our eyes to errors, defects, and short-comings;
but there are other occasions more suitable for regarding these. The
history of American Medicine for the past century contains much that
we may rightly be proud of; we have no reason to be ashamed of its
present condition, and need we doubt that the spirit of progress which
has thus far guided it, will lead onward to the fulfilment of a glorious
destiny | -
21
ADDRESS ON HYGIENE AND PREVENTIVE MEDICINE.
BY
HENRY I. BOW DITCH, M.D.,
PRESIDENT OF THE STATE BOARD OF HEALTH OF MASSA C H U SETTS.
GENTLEMEN OF THE INTERNATIONAL MEDICAL CONGRESS:
I HAVE been requested to speak to you on Public Hygiene and its great
resultant, State Preventive Medicine, as it appears to an observer looking
back upon the Centennial Period now just closing.
As a measure of vital importance to the well-being of any community,
and, as such, worthy to be cheerfully and amply sustained by great cities
and States, Public Hygiene, as we now understand that term, has, till
within a very short time, been wofully neglected, save when, under the
stimulus of some great and terrible epidemic, frantic but temporary ef-
forts have been made to stay the plague by Hygienic or by other means.
Of late, however, a new and better era seems opening to our view, and
STATE PREVENTIVE MEDICINE affords us higher hopes for all coming time.
To this last, this noblest phase of Public Hygiene, its very gradual evo-
lution out of the dogmatism and skepticism of the past, its present
status, our duties relative thereto, and our golden hopes for its future, I
crave your candid consideration during the brief hour I shall have the
honor of addressing you. If, at the termination of my remarks, our
foreign associates feel that I have given them but little information, and
my countrymen find that I have said but little in praise of my country,
one and all of you, I trust, will generously allow me the credit of having
endeavored at least to speak the exact truth about the various States,
and the United States as a Nation, in their relation to these matters. May
I dare to hope that the plain unvarnished story of our present condition
and short-comings, in regard to practical public hygiene, may do some-
thing to stimulate each State and the United States governments, to do
more thoroughly the plain duties that lie open before them?
Before laying down the propositions I intend to defend, let me say we
cannot, in the consideration of them, confine our view simply to this
country, but must frequently refer to the men and ideas of other countries,
as well as to those of our own.
And let me add that in citing the names of men who have been promi-
ment here or elsewhere, I shall do so without intending either praise or
blame, but simply as those of illustrious representatives of great systems
of medicine or of wide currents of thought, upon which the greater part
of mankind has been borne almost unconsciously along.
NATURAL DIVISIONS OF THE CENTENNIAL PERIOD.
In its Medical and Social ideas, the past centenary easily divides itself
into three unequal epochs, viz.: I. From 1776 to 1832, the era of theory
and of dogmatism ; II. From 1832 to 1869, or that of strict observation,
22 BOW DITCH,
and of bold, often reckless, skepticism; III. From 1869 to 1876, which
is destined to continue and progress while the nation itself lives, the
noblest and most beneficent of all, viz., that in which the profession,
joining heartily with the laity and aided by the material and intellec-
tual resources of great States, will study to unravel the primal causes of
all disease with the object of preventing it. It is the epoch of State
Preventive Medicine.
FIRST EPoCH, OR THAT OF MEDICAL SYSTEM-MA KING, FILLED WITH AN OVER-
WEENING CONFIDENCE IN OUR ART, WITH LITTLE OR NO FAITH IN THE WIS
MEDICATRIX NATURAE.
(From 1776 to 1832, or thereabouts.)
The influences which governed this period and the previous centuries,
may be briefly sketched as follows: The illustrious Boerhaave began to
enunciate his doctrines of disease at Leyden in 1701. His doctrines held
sway in America until about 1765, or ten years before the opening of
our centennial period. Following closely after him came Hoffmann,
Cullen, Brown, and Darwin, and each with his own peculiar system.
Our ingenious and renowned countryman, Benjamin Rush, in 1790,
proclaimed his own idea, viz., that a convulsive motion of the arte-
ries is the proximate cause of all fevers, however different the causes
may be." Benjamin Rush was one of the most noteworthy men this
centenary has produced, and as he had more influence than any other
one person upon medical opinion during the first epoch; as he is called
by one of his admirers “the American Sydenham,” it seems to me not
improper that I should on this occasion mention some facts of his life.
He was born Dec. 24, 1745, on his father's plantation, fourteen miles
from Philadelphia: consequently he was just entering the prime of man-
hood in 1776. Seven years before that, at the early age of twenty-four,
he had been appointed Professor of Chemistry in the University of Penn-
sylvania.
During the Revolutionary war he resigned this professorship, and was
made Medical Director of the Middle Department of the Continental
Army. In 1789 he resumed his professorship of chemistry, and in
October of that year became Professor of the Theory and Practice of
Medicine, which office he held until his death in 1813. During all these
years he energetically and ably defended his system, as he had previously
upheld Cullen's. He has left accounts of various epidemics of yellow
fever and other observations and essays, which are valuable as records
of the period and as evidences of his intellectual and moral worth.
Iſe was essentially a medical system-maker like his predecessors. He
believed fully in heroic remedies, and rather scoffed at Nature's influence
in disease. His pupils spread themselves over some of the Eastern but
more over the Middle, Western, and Southern States, carrying with them
not only the wisdom but the errors of their great master. He thus had
vast influence on the medical ideas of the country. This becomes still
more evident when we remember that he held the chief professorship in
the foremost medical school in the Union, and that, towards the end of
his career, the number of students that listened to his eloquent and per-
* Rush's Med. Inquiries and Observations, Philadelphia, vol. iii. p. 11.
A DT) R. E S S O N H Y G. I E N E . 23
suasive tongue, amounted to about four hundred, annually drawn to
Philadelphia from every part of the country.
The reputation of our profession among the more intelligent of the
laity, when Dr. Rush was in his full glory, is brought out in the follow-
ing extract from a letter from Thomas Jefferson to his friend Dr. Wistar
in 1807. He writes, “I have myself lived long enough to see the fashions
of Hoffmann, Boerhaave, Stahl, and Brown succeed one another like the
shifting figures of a magic lantern, and their fancies like the dresses of
the doll-babies from Paris; becoming from their novelty the vogue of
the day, and yielding to the next novelty their ephemeral favor.” We
may well fear that Mr. Jefferson’s opinion of our profession was not
much improved when Dr. Rush dogmatically proclaimed, during a
heated discussion with some physicians of Philadelphia, that the time
must and will come when the general use of calomel, jalap, and of the
lancet without a physician's advice, will be considered “among the most
essential articles of the knowledge and the rights of man”!
But Dr. Rush's theory and dogmatism were destined to fall under the
influence of the fascinating theories of Broussais. Broussais was born
in 1772, when Rush had already given evidence of his great powers as a
teacher. This great Frenchman died in 1838, after his authority, which
had been world-wide, had begun to decline. Broussaism spread widely
in America, but less in New England, which had been trained more to
close observation under the great masters in medicine, Dr. E. A. Holyoke,
T)r. James Jackson, and others. than it did in the Middle, Western, and
Southern States. In or about 1832, the system began to fall in America,
as it had been previously falling in Europe. With its fall our first
epoch terminates. The whole tenor of medical opinion during the
period, as you readily perceive, with its theories and systems concocted
in great minds, was not in the smallest degree suited to the growth of
State Preventive Medicine.
SECOND EPoCH ; OR THAT OF OBSERVATION, AND ACCURATE RECORDING AND
subsequ ENT ANALYSIS OF FACTS ; WITH AN EXTREME CONFIDENCE IN
NATURE's POWER IN DISEASE ; A CORRESPONDING SKEPTICISM IN REGARD
TO THE USE OF DRUGS ; AND, FINALLY, DIM PRESAGES OF PREVENTIVE
MEDICINE. -
(From 1832 to 1869.)
The second epoch presents characteristics precisely the reverse of the
first. Louis and his numerical method stand prominent in it.
Louis may be called the lineal scientific descendant of such men as
William and John Hunter, Morgagni, etc. His nature rebelled against
the dogmatism of the past, unsupported as it was by well-ascertained and
recorded facts. You all know the great and wide-spread influence of his
works in Europe; Broussaism fell before them. The epoch in America
commenced when Dr. Gerhard, of Philadelphia, and Dr. James Jack-
son, Jr., of Boston, and other pupils of the observation school, returned to
America. Drs. Gerhard and Jackson had high mental powers finely
cultivated. Both came back devoted friends, and admirers of Louis as
a man and as a medical reformer. They were full of the new ideas, and
enthusiastic defenders and expounders of them. The influence of these
' Works of Thomas Jefferson, Washington, 1854, vol. ix. p. 107.
24 - Bow DITCH,
ideas on the currents of medical thought in America was immense. It
extended gradually over the whole country. -
It must be admitted that at times there was something unwarrantably
supercilious in the terms in which some of Louis's disciples, rather than
Louis himself, spoke of the past. It seemed as if they would, if they
could, wholly ignore the past in their desire to build up the medicine
of the present and of the future upon the firm basis of strictly recorded
fact. By this exclusive spirit of many of the “Numerical School,”
while infinite good has been done, a great apparent evil to practical
medicine has arisen. I allude to the more or less complete skepticism on
the part of many of the profession, and of the laity, in regard to every
species of medical treatment, except perhaps that of good nursing. The
pendulum of human thought, as always happens in such cases, has swung
far beyond the line of exact truth, so that from a blind faith in the
supreme power of our art, noticeable in our first epoch, many have passed
into an equally blind and fanatical skepticism in reference to it. Never-
theless I presume all will admit that Louis's school was needed to sweep
away all false systems unsupported by well-recorded and sufficiently
numerous facts. .* -
Louis's doctrines, though vehemently opposed by some who had
grown old under the previous epochs, were received by most young men
with joy, and philosophical minds among the elders were charmed with
the accuracy observable in Louis's Numerical Method, as shown in his
writings. Under the direct or indirect influence of his writings and
Numerical Method, which Dr. Guy" considers the guiding power of the
present time, a very large number of independent observers and workers
have been educated in this country and in Europe. The mottoes selected
by Louis as his own guides are identical with those of modern science.
In addition to the specific disciples of Louis, there were three others,
all men of great intellectual ability, who by their writings and teachings
powerfully influenced this epoch. I allude to Jacob Bigelow and Elisha
Bartlett, of America, and John Forbes, of England. Two of this trio
are now dead. Dr. Bigelow entered his 90th year last February. His
life nearly spans the century, and as it closely unites the first and second
epochs, I hope you will permit me to allude to him somewhat as I did
to Dr. Rush. He was born February 27, 1787; that is, two years before
Dr. Rush resumed his professor's chair in the University of Pennsylvania,
at the close of the Revolutionary war. After a most honorable and
successful life as a physician, and as professor of the Harvard Medical
School, Dr. Bigelow has been, for years, totally blind, and hopelessly
unable to move from his bed for more than eighteen months. To a
casual visitor he seems as bright and as witty as ever, while his beautiful
and uncomplaining submission to what most persons would deem a sad
fate, raises him in the eyes of all beholders even higher than he was at
the period of his greatest energy and fame. A visit to his bedside
affords a delightful sense of repose from the bustle of daily toil. It was
my happiness to have a long conversation with him a few months ago.
I found he retained a vivid reminiscence of the days of his youth. He
was one of Dr. Rush’s class, and bears full testimony to the eloquence
and earnestness with which Dr. Rush advocated his medical theories
more than half a century since, and only a few years before he died.
Public Health; Wm. A. Guy, M.B., F.R.S., London, 1874.
A D D R E SS O N H Y G. I E N E . 25
Dr. Bigelow fully sustains me in my position relative to Dr. Rush's views
of Nature and of our Art.
Dr. Bigelow's influence upon this second epoch was diametrically
opposed to Dr. Rush's, during the first. Dr. Bigelow earnestly supported
the principles and methods advocated by Louis and the Numerical
School. By his writings and teachings he had great power over New
England directly, and indirectly over the medical opinions of the whole
country, by means of his pupils, who migrated to our most distant States.
The skepticism of Louis's School was augmented thereby.
Whilst Dr. Bigelow was thus sapping our faith in drugs, or rather in
the polypharmacy which had come down to us from the past, there was
sent forth from the chief medical journal of that day, viz., The British
and Foreign Medical Review, and apparently under the sign manual
of its able editor, John Forbes, one of the boldest avowals of the same
creed. I allude to Dr. Forbes's article entitled “Homoeopathy, Allopathy,
and Young Physic.” Admired by the few, ignored or violently opposed
by the many, it has nevertheless stood the test of time, as one of the
strongest of protests against the drugging of the day, and an eloquent
defence of the power of Nature in the treatment and cure of disease.
Notwitstanding my high estimate of this manifesto by Dr. Forbes, I
think that very few young men would be led by it to the study of our
most noble profession. It is too destructive of all earnest faith in our
art. It was, however, exactly what was needed at the time. The poly-
pharmacy of a past age then and there received its most deadly blow.
Nature and her powers were glorified. And no one who reads carefully
the record of the preceding time can doubt that such a blow was needed
previously to our entering upon a new phase of development of medical
science, expressed by the term State Preventive Medicine. Dr. Forbes,
indeed, frequently and in glowing terms, hints at the “reformation” that
is impending. He is no prophet, although he sees dimly, what is to be
“ the result of mature reflection, and of the labor of many years and
many hands” (p. 262); “we must,” he says, “ direct redoubled attention
to hygiene, public and private, with the view of preventing disease on a
large scale.” “Here the surest and most glorious triumphs of medical
Science are achieving and to be achieved” (p. 263).
The third individual, who by his writings and as a teacher, seems one
of the noblest types of men of this epoch, is Dr. Elisha Bartlett. He
was undoubtedly one of the most philosophical medical men America
has produced during the Centenary. And his heart was devoted to
medical reform. He was born at Smithfield, R. I., in 1805, and died
July, 1855.” He practised the profession for some years in Lowell, Massa-
chusetts, and was respected as an able and most accomplished physician.
He felt, however, as he said to me, “called to teach.” He was soon sum-
moned to the chair of Theory and Practice at Pittsfield. Subsequently
he held a professorship at Dartmouth College, New Hampshire; at the
schools at Lexington, and at Louisville; subsequently at Baltimore, and
finally at New York, in the University and with the College of Physi-
cians and Surgeons.
From these various chairs he was able to influence North, East, South,
and West of our country. He was an admirable and attractive teacher,
winning belief by his earnestness, his fairness of statement, and fasci-
| British and Foreign Med. Rev., vol. xxi. p. 502.
* Appleton's Cyclopædia.
26 Bow DITCH,
nating address. Though not educated under Louis, he thoroughly ap-
preciated his methods and his writings, and proclaimed them as the dawn
of a new and great era in the history of medicine. In Dr. Bartlett's
Philosophy of Medical Science, published in Philadelphia in 1844, he
says “that to find out the best methods of preventing, of modifying,” as
well as “curing” disease (page 287), “is the great mission which lies
directly before us, and this is to constitute the great work of the next
and of succeeding generations.” He, in these words, appears as one of
the prophets of the present epoch, now in its infancy, which delights and
encourages us rather by its anticipations than by its actual accomplish-
ments. - - -
Thus with beautiful prophecies for the future, I close the list of men
whom I deem most prominent in carrying forward the ideas underlying
this second epoch. But no one of them saw what we now see. Their
mission was chiefly destructive, or constructive only in some degree of
the natural history of disease. The general tendency of their writings,
so far as they bore upon medical practice, was to utter skepticism not only
in regard to the manifest absurdities of our fathers, but likewise in refer-
ence to the good things suggested by them. Although they sometimes,
as we have seen, hinted at prevention of disease, they did not dream of
the noble idea of State Preventive Medicine in its widest scope which
has already commenced in various States of this country, and among the
nations of Europe. Their skepticism, like all skepticism, was chiefly
iconoclastic. We need faith in an idea before we can build it up in ac-
tual life. Such a faith we shall see breaking out in our third and last
epoch, and to this I now call your attention.
But before proceeding to speak of it, let me make two remarks, which
I regret to feel compelled to submit, but for their truth I can vouch from
my own professional experience of nearly half a century:—
First. The medical profession as a body has heretofore taken very little
interest in the ideas underlying preventive medicine, and hygiene, private
or public. This must be patent to every one of us. We all know how
few sanitarians there have been among us until very recently, and how
little they have been to our taste. I confess myself to have been a most
decided sinner in this matter. It is proved likewise by the almost total
neglect hitherto of physical culture in our schools and great seminaries
of learning. I know of but one medical college in which there is a full
professorship devoted to hygiene. The Harvard Medical School, which
has made great advances in medical instruction within the past ten years,
has only a lecturer, and as I learn from students now at the school, and
who for some few years past have been there, the subject is scarcely known,
as compared with other branches of medical learning.
Second. We owe to the laity, rather than to the profession, the first and
strongest efforts in behalf of State Preventive Medicine.
THIRD EPOCH ; OR, THAT IN WHICH THE MEDICAL PROFESSION Is AIDED BY
THE LAITY, AND THE IDEA OF STATE PREVENTIVE MEDICINE FAIRLY IN-
AUGURATED, AS MARKED BY THE LEGAL ESTABLISHMENT OF THE FIRST STATE
BoARD OF HEALTH.
(From 1869, and which will reach into the far-off future.)
The ruling idea of this epoch is still in its infancy, but it shows by
what it has already accomplished, trivial though that performance may
A D D R ESS O N H Y G H E N E . 27
seem, at first glance, to be, its inherent, great, and nascent power. Its
objects are vastly wider than those of any preceding epoch. Its destiny
is as fixed as that of the steam-engine, the telegraph wire, the locomotive,
or the use of anaesthetics. I cannot foresee a time when the ideas under-
lying it will not be held in esteem and acted upon for the welfare of
mankind.
Among the men who stand prominent in their relations to this epoch,
and in connection with the English speaking race, are two laymen. One
of them I fear may be but little known to most of my hearers, or even
to the people of his native State: I allude to Lemuel Shattuck, of Boston.
The other is Edwin Chadwick, a Barrister of London, for many years
known and honored by every civilized nation as one of the ablest and
most earnest of sanitarians.
Mr. Shattuck, in 1850, presented to the legislature of Massachusetts,
a most exhaustive State Paper entitled, “Report of the Sanitary Com-
mission of Massachusetts.” In that document are laid down all the
principal ideas and modes of action which underlie the present sanitary
movements in Massachusetts, and I think I may also add in America.
By this document were laid deep in the second epoch the fundamental
ideas of the third. It was seed well sown, but destined to lie dormant
for nearly a quarter of a century.
The report fell flat from the printer’s hands. It remained almost un-
noticed by the community or by the profession for many years, and its
recommendations were ignored. Finally, in 1869, a State Board of Health
of laymen and physicians, exactly as Mr. Shattuck recommended, was
established by Massachusetts. Dr. Derby, its first secretary, looked to
this admirable document as his inspiration and support. In giving this
high honor to Mr. Shattuck, I do not wish to forget or to undervalue the
many and persistent efforts made by a few physicians, among whom stands
pre-eminent Dr. Edward Jarvis, and occasionally by the Massachusetts
Medical Society, in urging the State authorities to inaugurate and to
sustain the ideas avowed by Mr. Shattuck. But there is no doubt that
he, as a layman, quietly working, did more towards bringing Massachu-
setts to correct views on this subject than all other agencies whatso-
ever. Of the second layman, Mr. Edwin Chadwick, I need say nothing.
You all know him. Fortunately for himself, he has lived to see rich fruits
from his labors. That was not granted to Mr. Shattuck.
But other influences have been at work tending to the same end. Europe
has influenced us more than at any preceding time. France long since
entered on a career of study and of publication on public health. The
Annales d’Hygiène Publique are proof of this. The labors of Parent-Du-
chatelet are recognized by all. The zeal of Quetelet, of Belgium, has
been like a household word everywhere among the laity and profession in
every civilized State. Pettenkofer, of Munich, more recently has labored
successfully in the same field ; and, still nearer to the present, comes up
that extraordinary genius, Virchow, of Berlin, great in every depart-
ment of science or of State upon which he enters. But by far the
greatest influence has been exerted upon us in America by England,
who, by her unbounded pecuniary sacrifices and steady improvement in
her legislation, and her able writers, has far outstripped any country in
the world in the direction of State Preventive Medicine. I think I
may, with perfect truth, say that the consummate skill in the discovery,
removal, and prevention of whatever may be prejudicial to the public
health, shown under the admirable direction of Mr. Simon, late Medical
28 Bow DITCH,
Officer of England’s Privy Council, by his corps of trained inspectors, is
wholly unequalled at the present day, and unprecedented, I suspect, in
all past time in any country on the globe. -
In this country the papers published more recently by several of the
State Boards of Health, have tended to interest the whole community
on the subject of public hygiene. The number of single laborers in the
same field is daily augmenting. The United States Government, by its
Army and Navy publications, previous to, during, and since the late
Civil War, has done a vast sanitary work. The library and museum in
the Surgeon General’s Department at Washington, commenced during
the horrors of that contest, are also invaluable in the same direction. If
they be hereafter thoroughly sustained by the government, as in the past,
we cannot estimate the great advantage that will arise in all depart-
ments of medicine, and in none more than in that of public hygiene.
As the Crimean war taught the world very much in reference to this
subject, so our war, dreadful as it was to both parties, was the means of
bringing into life several most beneficent institutions which were never
before thought of, or at least never carried out on so grand a scale. I
allude to the Sanitary and Christian and Western Sanitary Commissions
of the North ; to the Wayside Hospitals, Christian Relief Associations,
and State Hospitals at Richmond, etc., of the South. Through these,
money and food were distributed without stint to the sick and wounded,
often to foes as well as friends, wherever found, either on the battle-field
or in hospital. We can never know how many human lives were saved,
or bow much torture prevented, by the agents of these noble institutions
on both sides of the line of battle. But we can estimate how much the
desire to save life, prevent disease, and promote health, and to provide
Some of the means for so doing, were, under their blessed influence, in-
stilled into the minds and hearts of our people from Maine to Texas.
Great strides in Public Hygiene were also made during the war, by
the fact that the people outside the military lines, and the officers and
soldiers within them, very soon began to learn, by dire experience, or by
the urgent appeals of experts in Sanitary matters, the all-important
advantages of cleanliness, sobriety, and strict methods of action, as op-
posed to the distress consequent on filth, intennperance, and chaotic rule;
and we cannot doubt that every surgeon, whether National or Confederate,
who served during the war, became more practically versed in the advan-
tages of prevention of disease than he was before. All that knowledge
is now brought back to civil life. -
The National Quarantine Conventions, so called, had also important
influence. Four were held before the breaking out of the war, viz.: in
Philadelphia, 1857; in Baltimore, 1858; in New York, 1859; and in
Boston, 1860. The war closed their labours. From the eminent persons
engaged in them, and attendants at the meetings, and the characters of
the papers published, there can be no doubt that they contributed very
much to lead the public mind to the ideas prevalent at the present time.
In April 18, 1872, was held the primary meeting whence has sprung
the successor of the National Quarantine Conventions, above alluded to.
I refer to the American Public Health Association, which has held meet-
ings in New York, Philadelphia, and Cincinnati; and will this autumn
hold its session at Boston. Able papers have been published by it on
various Sanitary matters, on the transmission and prevention of disease,
on quarantine, longevity, hospital hygiene, etc.
A D D R ESS O N H Y G.I.E N E . 29
The American Social Science Association has, of late years, done most
valuable work in the same direction.
Among the more strictly professional institutions that, have helped
forward the cause of Public Hygiene and Preventive Medicine, may be
named the American Medical Association. In 1847, this Association was
instituted, and almost from its inception, it has annually published
papers relating to our subject, and still more recently very earnest efforts
have been made by some of its members to obtain a definite National
Health Organization from the United States Government. The frequent
intermingling of men, brought about by this Association, from all parts
of the Union, has contributed to the same end. It must be confessed,
however, that, judging from the small number of members attending the
Section on Hygiene, that subject seems to afford less interest than any
other.
Finally I may assert that, during the past three or four years there
has sprung up in many parts of the country, a wide-spread thoughtful-
ness about the necessity and value of hygienic measures. Almost all
persons in their various spheres, have become more accessible to the pro-
tests of the sanitarian. Still further, it may be asserted that during this
last epoch, short as it is, more practical work has been done among the
people, tending to prevent and crush out disease, and more valuable
papers written, illustrative of Public Hygiene, the world over, than since
the Christian era began. In every State there are active and earnest
laborers in this field, and their number is daily increasing. It would be
impossible on this occasion, to name even a tithe of them. Some States
in their corporate capacity, have sustained these workers for the public
good. But I regret to say a large majority of the States and Territories
of this Union are not yet sufficiently enlightened to appreciate the duty
devolving on them to be careful of the health of their people.
With these general historical remarks on the gradual evolution of
State Preventive Medicine and Public Hygiene, during the past centen-
nial period, I now pass to the consideration of the actual condition of
the Country at the present time with regard to these all-important topics.
THE PRESENT CONDITION OF STATE PREVENTIVE MEDI-
CINE IN THE WARIOUS STATES, TERRITORIES, AND THE
NATION.
Several months ago I issued a circular containing several questions
bearing on this subject, and tending to elucidate it as far as I thought I
could do so with the means at my command. Doubtless, to critical eyes,
objections may be made to the small number and to the relevancy and
character of the proposed questions. It appeared to me, however, that
a few interrogations, all or most of them, answered, even monosyllabi-
cally, from all quarters of the Country would enable the inquirer to get
a glance at the present condition of Public Hygiene and of State Preven-
tive Medicine better than he could from any large number, very many
of which would not be answered at all from some of the States. The
paper was sent to two hundred and sixty-seven (267) medical men living
in the thirty-eight States, nine Territories, and the District of Columbia,
30 *. BOW DITCH,
making in all forty-eight governments. These embrace an area covering
(25°) twenty-five degrees of latitude and (47°) forty-seven degrees of lon-
gitude, between the Atlantic and Pacific Oceans. In the South they lie
almost in the tropics; at the North they reach close to the coldest inha-
bitable portion of the Globe; in all embracing an area of 3,603,884
square miles. -
Of the character and ability of my correspondents, I would say that I
tried to select the ablest men, and, as far as possible, those known or
supposed to be interested in Public Hygiene; representative men, in
fact, resident in the various regions. I may have failed to apply to all
who perhaps would have willingly answered my questions. If, however,
I have selected with any accuracy, I think you will admit that their
various reports will together constitute as full and as accurate a state-
ment of the whole matter, so far as my questions cover it, as it is possi-
ble for me, without governmental aid, to obtain. Replies have come
from one hundred and sixty-seven (167) physicians, residents in every
State and territory except the Indian Territory, which last is a reserva-
tion held still in an unorganized state as the residence of Indians, in
various conditions from barbarism up to a low civilization, and where
ideas of Public Hygiene are little thought of. -
ANALYSIS OF CORRESPONDENTS’ REPLIES.
FIRST QUESTION.—Does your State by its legislation show a due appreciation
of the duty devolving upon a State to be careful of the health of its people?
I considered this a fundamental question. The answers from the forty-
eight States and Territories were as follows:—
Thirty-four, (34) NO.1
Eight, (8 Yes."
Four, (4) Indefinite.”
Two, (2) No Reply.
In other words, of the forty-eight governments in this Union, thirty-
four (nearly three-quarters), by their legislative acts, have, according to
correspondents resident therein, shown but little care for the health of
their people. Among those thus failing in duty, appear the great States
of New York and Pennsylvania; I cite these two, not in invidious dis-
tinction, but simply because they have been the chief States of our Union
since Colonial times, and because they hold that proud position now.
Moreover, it will be admitted by those States which have replied affirma-
tively (1) that it is only within six or eight years that they have shown
any marked interest on the question of State Preventive Medicine, and
(2) that the number of deaths from preventable diseases, in every State,
is still frightfully great, which ought not to be the fact if these States
had really shown, for any length of time, this due appreciation claimed
for them by my correspondents. Let not us, however, who have traced
the very gradual evolution of the idea of State Preventive Medicine
during the past centenary, wonder at this apparent neglect of Public
Hygiene, shown by the various States; let us rather rejoice at even this
small awakening of the public interest upon these matters, wheresoever
a European civilization has any foothold.
* Yes or No means that a unanimous opinion was returned by all correspondents in the
State or Territory.
* This term is used when the opinions of correspondents were not unanimous on any ques-
tion.
A DI) F. ESS O N H Y GIE N E . 31
SECOND QUESTION.—Is the State willing to expend money (a) to support
State or Local Boards of Health? (b) to carry out Scientific Investigations as
to the causes of Disease ? (c) to repress norious or offensive trades 2 (d) to
prevent adulteration of food? (e) to prevent the Cattle Disease 2 or (f) to carry
on any other investigations tending to promote Public Health, or to prevent ill
Health 2
The touchstone which tests the earnestness of an individual or of a
Nation in reference to any subject, is a willingness to spend money in
furtherance of it. Tested by this talisman, how stands our Country in
reference to Public Hygiene and State Preventive Medicine? Let us look
at the answers to the above questions.
Is the State willing to spend money (a) to support State or Local Boards of .
Health 2 The following answers were received from correspondents.
Thirty-six, (36) No.
Ten, (10) Yes.
Two, (2) No Reply.
The fact here brought out is that three-quarters of all the governments
of this country are unwilling to spend money to support a State Board
of Health. Now I contend that the legal establishment of such a Board
is the first step towards any definite sanitary organization in a State, and
the fact that so many States have done nothing towards the formation of
such Boards, or when legally established, have refused to pay money for
their ample support, plainly shows the very small advance yet made by
this country on these vital questions. Still, further, if we look at the
States from which an affirmative reply has been received, we shall find
that only very recently, since 1869, have any such Boards been estab-
lished, and generally that the amount of money appropriated for their
support is small, compared with what is spent in other departments of
government vastly less important to human welfare.
Is the State willing to spend money (b) to carry out Scientific Investigations
as to the Causes of Disease ? The following are the replies:–
Thirty, (30) NO.
Twelve, (12) Yes.
Five, (5) Indefinite Reply.
One, (1) No Reply.
Thus thirty governments out of the forty-eight are reported as being
unwilling to spend money for the scientific study of the causes of disease.
Twelve reply affirmatively. But from several of these we find some
qualifications of answer, e.g., “rather unwillingly,” or “not much,” or
“when importuned,” or “to a limited extent.” Some of the foremost
decline to make grants for special investigation. One of the most known
and respected Sanitarians in the Union declares that his State “grants as
much as is asked for,” which fact, coupled with a second one, viz., that
his State has not yet established a State Board of Health, seems to sup-
port the idea that he and his medical associates are at fault: Does the
State even now need an efficient layman to stir it up to efficient
action ? Only during the past year, has Massachusetts done anything in
this precise direction, viz., when it appropriated ten thousand dollars
($10,000) for the investigation of the question of the Pollution of Streams.
As I had nothing to do with the making of that report, and as the
majority of the committee having it in charge, was selected as the ablest
men who could be found, though residents of other States, I feel at
liberty to express the opinion that the sum expended was infinitely
small in comparison with the very valuable and exhaustive report made;
32 BOW DITCH,
a report which will be of importance to every other State undertaking
the same or similar trains of investigations.
Is the State willing to spend money (c) to repress moacious or offensive
trades 2 The following answers were made :-
Twenty-six, (26) No.
Fourteen, (14) Yes.
Seven, (7) Indefinite Reply.
One, (1) No Reply.
A priori, one would consider this a most legitimate and imperative duty
of a State to so govern noxious and offensive trades that they should not
bring ill health to the people, yet it appears that more than half of the
States do nothing. Fourteen only seem attempting to do something.
In this connection I cannot help referring to some results in Massachu-
Setts.
The town of Brighton is beautifully situated in an undulating country,
within easy access of Boston, and as such admirably fitted for residences
of the business men of the city. This beautiful suburban district was,
Only a few years ago, a disgusting place, in consequence of about fifty
vile smelling and filthy looking slaughter houses, which were dotted all
over the township. No one could drive or go by rail through it without
offence, and at times almost nausea. New slaughter houses were daily
springing up. Under the influence of a law, empowering the State
Board of Health to attend to the matter, and giving it very wide power,
every private slaughter house has been swept away within the past eight
years. A very large, cleanly conducted abattoir, which burns up in a
great measure, if not wholly, its own noxious odors, and which is built
a little distance from the village, now includes the whole of the indi-
vidual slaughter houses above named. One can now drive in any direc-
tion without offence to eye or sense of smell. Meanwhile, the price of
land has more than doubled in value. Before this was brought about,
however, many hearings and personal examinations were made by the
IBoard. Eminent lawyers appeared and protested against its proceeding
under the extraordinary powers which the legislature had given it, and
which those advocates said were unconstitutional, because, as they con-
tended, contrary to the “Bill of Rights” of Massachusetts.
The Court, however, when appealed to, always sustained the decisions
of the Board, and once it threatened a contumacious butcher, who refused
to obey, with imprisonment for contempt. For these reasons and for
others that might be named, I heartily commend the law, as it stands in
Massachusetts, as worthy of consideration by those who wish to control
noxious trades in other States.
Is the State willing to spend money (d) to prevent the adulteration of food 2
Twenty-three, (23) No.
Sixteen, (16) Yes.
Seven, (7) Indefinite Reply.
Two, (2) No Reply.
Certainly an extraordinary result, but one which possibly might have
been anticipated, when we remember the widespread system of sophistica-
tion and adulteration known to exist among us. Rapidity and quantity
of work rather than excellence are sought for. ... When Public Hygiene
is duly thought of, and State Preventive Medicine has full sway, the
adulteration of the food of the people will be deemed one of the most
heinous of crimes. Practically, now it is allowed to flourish unrestricted
in the majority of the States, even in those which have laws intended
A D D R E S S O N H Y G. I.F. N. E. 33
to prevent it. Europe is undoubtedly far in advance of America on this
Subject. •.
Is the State willing to spend money (e) to prevent the cattle disease? The
following answers were received:—
Twenty-one, (21) No.
Ten, (10) Yes.
Sixteen, (16) Indefinite Reply.
One, (1) No Reply.
(For remarks on this subject see Question Sixth.)
Is the State willing to spend money (f) to carry on any investigations tend-
ing to promote public health or to prevent ill-health 2 The answers were
these:–
Twenty-eight, (28) NO.
Ten, (10) Yes.
Nine, (9) Indefinite Reply.
One, (1) No Reply.
That is, one-half the governments seem unwilling, and less than a
quarter claim to be willing to spend money for this purpose. This seems
a most natural consequence to all preceding answers.
THIRD QUESTION.—Has your State established a State Board of Health 2
If so, (a) when was it established 2 (b) What amount of annual appropria-
tion is made for its support 2 (c) Are any occasional grants made for specific
investigations? (d) Has the Board any organized body of correspondents
throughout the State? (e) What executive powers have been given to the Board
in reference to local nuisances or moacious trades?
Some of these questions have been fully or partially answered already.
I shall in this place summarily include them in one answer as follows:
Twelve only of these States have State Boards of Health. The first one
was legally established in Massachusetts in 1869. It operates equally
over every portion of the State. The amount of money paid, as I have
already stated, is small considering the wealth and population of the State.
For special purposes, Louisiana and the District of Columbia have at times
spent large sums. Not a single State has as yet a perfect list of corre-
spondents or inspectors. Massachusetts has done much in this direction,
and is annually improving her position by selecting the ablest men, phy-
sicians or laymen, who can be found in the various towns.
The position of correspondent of this Board is frequently considered
an honor, though there is no pay attached to the office, and often it is
no sinecure. In reference to executive powers given to the Board, it
cannot be said that any State Board has plenary powers, as town Boards
have, in some States. It is, perhaps, well that their duties should gene-
rally be advisory merely, on certain occasions only having plenary
powers conferred upon them, and with the right to appeal to the Courts
to sustain their decrees, whereby the moral force of the Boards is mate-
rially augmented.
FourTH QUESTION.—Have County Boards of Health been established by
law 3
The answers are—
Twenty-three, (23) No.
Four, (4) Yes.
Seven, (7) Indefinite Reply.
Four, (4) No Reply.
3
34 BOW DITCH,
That is, only four of the States report affirmatively. Evidently the
necessity of such Boards is not admitted. Yet I cannot but think that
eventually, when Public Hygiene shall have its thorough organization,
these County Boards will form an integral part of it; certainly in the
Southern, Western, and sparsely settled States.
FIFTH QUESTION.—Have any Town Boards of Health been established by
law 3
The answers are—
Eight, (8) No.
Fourteen, (14) Yes.
Twenty-two, (22) IIave them by local or municipal
rather than state law.
One, (1) Indefinite Reply.
Three, ( 3 ) No Reply.
Which replies, as I understand them, intimate that in one-half of the
governments many towns have established, by their inherent right of
self-defence, local Boards of Health without first appealing to State
Authority.
SIXTH QUESTION.—Has the State passed any law leading to a thorough and
definite improvement of the Public Health 3 (a) by a Sanitary Survey of the
State 2 (b) by a law for the registration of Births, Deaths, and Marriages?
(c) If so, how long has it been in operation ? (d) Has the Registrar been able
to draw from such records any law governing the Public Health? (e) Has any
law been passed relating to drainage of land? (f) to irrigation 2 (g) to
checking the influence of rivers by levees 2 (h) to the introduction of water into
cities 2 (i) to the prevention of contagious diseases 2 (a) Smallpoa 2 (3)
Cholera 2 (y) Yellow Fever? (8) Cattle Plague? etc. etc.
It is impossible on this occasion to consider all of these questions. I
shall make selections from the answers which will best illustrate my main
subject.
(a) By a Sanitary Survey of the State 2 The returns are as follows:–
Forty, (40) No.
None, (0) Yes.
One, (1 ) Indefinite Reply.
Seven, (7) No Reply.
One would suppose that this would be one of the first questions asked
by the settlers of a new country, and yet, judging from our returns, not
one of the States in this Union has ever made such a survey, save per-
haps indirectly in Connection with some matter of trade or a geological
or other examination for the purposes of gain. Doubtless very grave
mistakes have been made in consequence of this neglect. Considerations
of trade and personal safety from external danger have too often decided
the question of the site of a town. It is to be feared, moreover, that with
the keenest examination of a locality, the emigrant, upon a new and
virgin soil, would be unable to decide the question. For often, not until
months after the plough has passed through it, and the colony has become
firmly established, does the deadly malaria show itself. But when a
State has arrived at sufficient strength and power to be able so to do, it
would seem that a thorough Sanitary Survey should be considered the
first of duties. And yet I doubt if any State Legislature of this Union,
at the present time, would for a moment consider the question. It would
be deemed a useless expense ! The people will demand it ere long.
A D D RESS O N H Y GI E N E . 35
(b) By a law for the registration of Births, Deaths, and Marriages?
Sixteen, (16) No.
Twenty, (20) Yes.
Eight, (8) Indefinite Reply.
Four, (4) No Reply.
That is, one-third definitely declare that this fundamental law, upon
which all vital statistics are founded, has never been passed. Twenty,
less than half, have such a law. But eighteen out of the twenty use
various qualifying phrases in regard to the character or enforcement of
the law, e.g., “imperfect,” “not carried out,” “defective,” “no regular
registration,” “carried out only for certain great cities.” In one it is “a
dead letter,” and in another “not enforced ;” others have it “a farce,” or
that “it was enforced before the late war.” Some have “only marriages,”
some “only deaths.”
The sum total of the matter is that only two States have made affirma-
tive replies without special qualifications. Knowing what I do of one
of these, viz., Massachusetts, I cannot claim that to be perfect in many
respects. If, turning from the States, we look at the United States cen-
suses, we find the same short-comings. For further remarks on this topic
I refer to Question Eighteenth; remarks by Messrs. Walker and Elliott.
No one can regret more than I do the necessity of stating these facts.
May the sting of their severe truth, stimulate us and our children to
better work in the coming centuries!
(c) If so (that is, if a registration law has been enacted), how long has it been
£n operation ? After the facts stated in regard to the last query, the further
question of time seems unimportant. It is evident, however, that for the
last ten or twenty years only, have State Registrations been carried on
in a very few States, although some of the larger cities have had imper-
fect returns for a much longer period. The United States Government
has had decennial censuses since 1790. To judge of their value in certain
respects, we have simply to look at the remarks made upon them by the
superintendent of the last. (Wide Question Eighteenth.)
(d) Has the Registrar been able to draw from such records any law govern-
ing the Public Health 2 I shall make my remarks in connection with this
subject, under the last question of the entire series.
(e) Has any law been passed relating to the drainage of lands 2
Twenty-four, (24) No.
Seven, (7) Yes.
Six, (6) Indefinite Reply.
Eleven, (11) No Reply.
That is, one-half report that nothing has béen done by the State. Only
one-seventh report affirmatively. But I do not understand that in any
case such a drainage was made for a sanitary object, but rather to im-
prove the land for agricultural purposes. How much the Sanitary,
Physical, Moral, or Intellectual wealth of a people is wrapped up in simple
drainage of the land, we may judge from the glowing account given by
my correspondent, Dr. Breed, at Princeton, Illinois. By that it appears
that no less than 36,000 acres of land lying in one mass, and compre-
hending at least half of three counties in Illinois, were drained by the
State, with the most gratifying results upon the health and character of
the settlers thereupon. Moreover, a great sum accrued to the Common
School Fund of the State, from the enhanced value of the land for all
purposes. One cannot but recommend the example of Illinois to the
consideration of the Legislatures of many of her sister States.
36 BOW DITCH,
(f) Has any law been passed relating to irrigation of land? The answers
a l'e ...—
Thirty-one, (31) No.
Five, (5) Yes.
Five, (5) Indefinite Reply.
Seven, (7) No Reply.
All the affirmative replies except one, viz., Utah, report that it was
done for “Agricultural Purposes.” Apparently no one thought of Health
in connection with it. Even Utah probably was induced to irrigate more
by its actual wants than by any thought of Sanitary improvement. Near
Salt Lake, which itself is utterly impotable, pure water was of prime
necessity for two imperative reasons, viz., for culinary purposes, and for
agriculture. What the Moors did for Granada, the Mormons have, to a
certain extent, done for our American Desert, by their “thousands of
miles of ditch under a general law,” as my correspondent graphically, if
not scientifically, describes the immense work done by this people.
(g) Has any law been passed relative to checking of rivers by Levees, etc.?
The answers are:—
Twenty-eight, (28) No.
Four, (4) Yes.
Five, (5) Indefinite Reply.
Eleven, (11) No Reply.
In proposing the question, I had my mind chiefly on the great cities
situated upon our mighty Mississippi, and its various tributaries.
|Bventually, it would apply to other rivers, like the Yellowstone and
others. In various parts of the land, I regret that my correspondents
enable me to state but little in reference to sanitary measures connected
with the question. It is evident that New Orleans, e.g., depends for its
very existence upon them. Correspondents from Arkansas state that
some levees have been made for agricultural purposes, and one adds sig-
nificantly, “but it has improved the land and the health of the people
living near the place.”
(h) Has any law been passed for introducing water into cities? The an-
swers are as follows:—
Twenty-three, (23) No.
Fourteen, (14) Yes.
Four, (4) Indefinite Reply.
Seven, (7) No Reply.
Indiana and Pennsylvania have general laws upon the subject. Pro-
bably all the States have permitted, either by general or special statutes,
this introduction of water, because of its prime necessity. More particu-
larly within the last ten years have towns and cities waked up to the
propriety of introducing fresh water from distant sources, in order to
avoid the evil results of the possible contamination of wells from privies,
etc., in the immediate neighborhood.
But it is a singular fact that while thus bringing in new water, cities
| In the very able and interesting report of the United States Bureau of Topographical
Engineers (Philadelphia, 1861), prepared by Capt. A. A. Humphreys and Lieut. H. S.
Abbott, U. S. A., on the Physics and Hydraulics of the Mississippi River, etc., it is
suggested that, eventually, there should be a uniform and scientifically constructed system
of levees for that river, from the Ohio to below New Orleans (p. 417, etc.). Surely such a
plan would be worthy of the nation, and, under the idea of its value to commerce between
the several States and foreign nations, would it not be legitimate national work under our
Constitution ?
A L) D R E S S O N H Y G. I E N E . 37
have not often scrutinized its exact purity, nor have they sufficiently pro-
vided against its future impurities. Boston, Albany, and I fear Chicago
and Philadelphia, and I doubt not many other cities in this Union, might
be cited in proof of the truth of this proposition. Some of these cities
have wholly ignored the warnings of sanitarians in this respect, listening
to selfishness and political partisanship, rather than to the dictates of
Hygienic Law. As they have sown the wind, so, at some future time,
they will doubtless reap the whirlwind, if an epidemic like Cholera
should sweep over the land.
(i) Has any law been passed relative to the prevention of contagious dis-
eases 2 (a) Smallpox. The answers are:—
Sixteen, (16) No.
Twenty-one, (21) Yes.
Seven, (7) Indefinite Reply.
Four, (4) No Reply.
There must be some error here, for I cannot think that sixteen of the
States have, as yet, passed no law relative to smallpox. And yet from
the way in which the laws on this subject are neglected, or limited of
operation even in those States which claim that they have proper laws;
and from the fact that we have smallpox epidemics all over the country
constantly prevailing, which could easily be prevented by vaccination;
from all these facts, I feel sure that great ignorance and carelessness on
the subject are to be found every where in this country. The recent
events in Montreal, relative to vaccination, in which a mob of infuriated
and ignorant men attacked and over-awed the Common Council of the
city, show what might happen in these States.
A late city physician of Boston, used to declare that he could keep
Boston free from smallpox if he could prevent the citizens from meeting
immigrants from Maine, who flocked, most of them unvaccinated adults,
into the city limits. This assertion, though not perhaps strictly true,
I have no doubt is partially so, and it illustrates an important fact, viz.:
that it is indeed impossible for one State to free itself from this scourge,
until the United States shall, by a general law, require that every child
born shall be vaccinated at a very early period, and afterwards occasion-
ally revaccinated. Yet more, we shall never be free from it until every
foreign nation shall adopt the same method, and an international code
of health in this respect shall have been established. Though such a code
may be in the far future, it must eventually come, not only in reference to
smallpox, but in regard to every other pestilential scourge of our race.
(3) Has any law been made relative to the prevention of Cholera 2 The
3,1] SW6. I’S a.I’62 ...—
Twenty-one, (21) No.
Sixteen, (16) Yes.
Four, (4) Indefinite Reply.
Seven, (7) No Reply.
Entirely similar reports came in regard to this disease as in regard
to smallpox; all indicate a “laissez aller” method in regard to it, so that
if the cholera were to strike any State at the present time, there is pro-
bably not a town in the land which would not be liable to fatally suffer
from its ravages in consequence of “filth” within the town limits.
! Used in its broadest signification. Simon on “Filth Diseases and their Prevention.”
Wide Report of Medical Officer of the Privy Council and Local Government Board (Eng.),
New Series, No. 2. Reprinted in Boston, Campbell, 1876, under the direction of the Mass-
achusetts State Board of Health.
38 Bow DITCH,
But the United States Government, through the War Department, has
recently published an invaluable history of cholera in this country. By
this volume alone we can judge of the immense importance to the whole
country, a central power, such as I have suggested above, would speedily
become. It would grasp the whole country in one mass, rather than as
separate States, and immensely broader, almost cosmic views of disease
would be thereby given instead of those derived from detached local ob-
servations. In order to gain this desirable end we need a National IIealth
Council composed of representatives from each State, and a Secretary of
Health, the peer of other Secretaries in the National Cabinet.
For further elucidation of my views on this subject, I beg leave to
refer to my address delivered before the American Medical Association
at its session in Louisville, in 1875.
(y) Has any law been passed relative to the prevention of Yellow Fever ?
The answers are:—
Twenty, (20) NO.
Twelve, (12) Yes.
Ten, (10) Indefinite Reply.
Six, (6) No Reply.
I suspect the above data and other replies of my correspondents repre-
sent in a general way the present uncertainty in the country about the
prevalence and characteristics of this disease. There seem, however, to
be some facts that are quite patent. Yellow fever is said (1) by some to
exist as a permanent endemic disease in some of our southern cities (New
Orleans, e.g., according to Chaillé); “with waves of increase and decrease
down almost to no prevalence at all.” Some equally eminent (Herrick),
declare that it cannot be called endemic in New Orleans, and that it
might be extirpated but for importation. From both of these parties
we may infer that it virtually has a permanent habitation there. But
for an accurate and minute knowledge of the essential cause of the dis-
ease and means for its prevention we must look to the coming century.
It seems (2) equally plain that during the last centennial period, yellow
fever has virtually wholly disappeared from Boston, New York, and
Philadelphia, in which latter city it prevailed to a terrible degree in the
latter part of the last and in the earlier part of this century.
May we not hope that as in the past, so in the future, there may be a
gradual pushing back of this frightful disease until it shall be fairly ex-
cluded from our borders'
(8) Has any law been passed relative to the prevention of the Cattle Disease?
The answers are:—
Twenty, (20) No.
Eleven, (11) Yes.
|Five, (5) Indefinite Reply.
Twelve, (12) No Reply.
As at one time pleuropneumonia among cattle threatened very seriously
to interfere with the food of the people, I deemed this a proper question.
It is evident from my correspondence that it has influenced very dif-
ferently the different States. In those States where it occurred, as e. g.
in Massachusetts and in Some of the Western States, much money was
expended, large meetings were held, and many cattle were slaughtered
in order to check it. I may refer on this subject to my correspondent of
Illinois (Dr. Breed) for an interesting notice of what was done at a Con-
vention of Cattle Dealers of the Northern States and Canada ; to the
Report of the Metropolitan Board of Health in New York, and also to
A D D RESS O N H Y G. I E N E . 39
the action of the Massachusetts Legislature. By strict quarantine and
care in sanitary matters connected with the cattle, and absolute destrue-
tion of those earliest seized with the disease, and above all by a national
co-operative action rather than by that of any single State, I believe we
may keep that and all such pests at bay. But eternal vigilance will be
needed on all the great ways for cattle traffic, so that the disease shall
not get a foothold in the country, otherwise disaster may follow. In
connection with this subject I would refer to the report made by the
United States Commissioner of Agriculture on the Diseases of Cattle,
containing investigations by Prof. Gamgee, and by Drs. Billings and
Woodward of the United States Army.
(j) Has any law been passed regulating Tenement Houses for the poor 3
The answers are:—
Thirty-three, (33) No.
Four, 4 Yes.
Three, (3) Indefinite Reply.
Eight, (8) No Reply.
That is, on this most important measure, on which so much depend
the health and morality, and intellectual progress of a people, only four,
('s) one-sixteenth of the various governments, have, according to my
correspondents, done anything, while (; 3) fifteen-sixteenths either reply
negatively or indefinitely, or not at all. -
In the light of what is doing in England by public law, and in New
York and Philadelphia by less comprehensive, but most opportune private
work, on the basis of pecuniary gain, combined it may be with philan-
thropy, this report seems meagre. In this connection, I beg leave to refer
to interesting correspondence with Drs. Harris and Thayer of New York,
and Dr. Ford and Mr. Blodget of Pennsylvania.
(k) Has any law been passed relative to incorporating Building Companies
for the improvement of the dwellings of the poor 2 The answers are:—
Twenty-nine, (29) No.
Six, (6) Yes.
Four, (4) Indefinite Reply.
Ten, (10) No Reply.
This question, allied to but more comprehensive than the preceding,
has, as we see, received as little attention. Yet, strictly speaking, I know
of no two questions more important at the present hour than this and the
previous one. The fact is patent to every one that there are in every city
and township in this land, and in every other country, dwelling places
in which the poor are obliged to live, which are a disgrace to modern
civilization. Such abodes are moral pests in the community, and sources
of unmitigated evil to the Body Politic. They are, in fact, places in
which it is impossible for the majority of human beings to grow up, ex-
cept to filth, crime, and disease. These I fear will always exist, unless
the public authority takes charge of these tenements and either builds
others under State laws, or authorizes associations, partly for pecuniary
and partly for philanthropic and sanitary reasons, to erect them. Having
erected them it will be necessary to faithfully supervise them at all times
and seasons, otherwise filth, and consequently disease, will come as here-
tofore.
We have one house in Boston yelept in derision the “Crystal Palace,”
which is occupied, when full, by about three hundred people, and which
has been for years the abode of drunkenness and crime. It was well
known to the officers of the State's Prison as its chief primary school of
Crime. I know it well. It is impossible to tell at this time the rich
40 Bow DITCH,
though painful experience gained from it by the Boston Co-operative
I3uilding Company. This, as its name partially indicates, was incor-
porated by the State in order to enable philanthropy and capital to unite
on an equitable basis, viz., in newly building or in renovating the houses
of the poor, with the hope of receiving an adequate return for the capi-
tal expended. This corporation has been a success in building many
houses, united in a block, and giving a perfect home to every family, only
one, or at the most two, families being on one floor. But desirous of
trying the plans followed so successfully, by Mrs. Octavia Hill, of London,
in her renovation of some of the most wretched houses in that Metropo-
lis, the Boston Association took possession of this “Crystal Palace.”
We forthwith drove tenants from the filthy cellars and opened windows
into every bed-room, the large majority of them having previously had
none. We shut two of the dark passages leading as common corridors to all
the tenements in the building, but we could not shut up a third. At first
our success seemed very certain, but the commercial panic came in 1873,
and that drove away many, and paralyzed the labors of others of the
tenantry. Finally the lease was given up for this reason chiefly, that we
were losing money. But even if it had been a pecuniary success, it be-
came the decided opinion of most of the Committee, who had charge of
it, that morally it must, from the inherent vices of its construction,
remain vile.
Whilst so many are congregated in one house, with long dark com-
mon corridors actually inviting vice and crime of the lowest kinds, it is
impossible to check the tendency thereto. The committee saw young
girls and boys grow up into vice (without a possibility of saving them),
owing, as it appeared in a great measure, to the very structure of the tene-
ment, and of its out-buildings. f
Whilst taking this opposition to the idea of large buildings, with dark,
easily accessible, common corridors, instead of rows of moderate-sized
buildings, containing but few families, it was gratifying to the committee
to find that the death-rate in the building was much lessened by the alter-
ations made in it, and by constant vigilance in regard to sanitary rules,
as far as it was possible to have any rules, in a place provided with a
few common privies and slop receptacles, which were constantly, day and
night, resorted to by people having small ideas even of the comfort of
cleanliness, and totally ignorant of its immense value in a hygienic point
of view. -
I have cited this case simply because of my four and half years of
personal experience upon it. But the same facts of wretchedly con-
structed abodes for the poor exist everywhere, and human nature is the
same. Our experiment, I think, proves very conclusively the folly of
expecting people to be temperate, or honest, or healthy in badly con-
structed houses. I commend this topic of providing suitable homes,
not houses only, for the people, as one of the most important that can
command the attention of Philanthropy and Capital during the coming
Century.
SEVENTH QUESTION.—(a) Are there well-attested facts proving that any
disease formerly prevalent in your State has ceased to appear 2
The answers are:—
Twenty-five, (25) No.
Nine, (9) Yes.
Eight, (8) Indefinite Reply.
Six, (6) No Reply.
A. I.) I) RESS O N H Y G. I. E N E - 41
Of the nine affirmative replies not one can present positive proof of
the statement, but some suggest a lessening of some diseases. This
seems to be undoubtedly the fact in regard to malarial fevers, yellow
fever, etc.
That intermittents have disappeared from some localities, which have
been drained, seems to be true. Smallpox is wonderfully lessened and
quite shorn of its terrors. A few special diseases, as, for example, the
“milk sickness,” and the “black tongue,” are mentioned as having pre-
vailed formerly, but not of late. These statements, though less reliable
than accurate statistic proofs, give us hopes for the future when State
Preventive Medicine shall have obtained its due influence.
(b) Are there any well-attested facts proving that any disease formerly
prevalent in the State has been crushed by State or Individual action ? The
a, Il SW eI’S a.I’é –
Thirty-seven, (37) No.
None, (0) Yes.
Four, (4) Indefinite Reply.
Seven, (7) No Reply.
The returns give a most decided negative, and not a correspondent
takes the affirmative of the question.
EIGHTH QUESTION.—Are there any similar facts proving that any special
disease has arisen or been generated, or has been introduced into the State
during the past century, which did not exist in Colonial Times, and which
mow remains endemic 2
The answers are:—
Twenty-seven, (27) No.
Six, (6) Yes.
Two, (2) Indefinite Reply.
Thirteen, (13) No Reply.
The same indefiniteness of statement prevails on this question as on
the preceding. In one of the six affirmative replies, Dr. Denison, of
Denver, claims that perhaps phthisis has been introduced into Colorado.
Of course it has been, as a great many go there now as a place most
fitted for the cure for the disease. And future statistical mortuary data,
unless care be taken, will lead to great errors of judgment in regard to
the value of that climate, and its influence on phthisis. In some of the
Northern States some physicians claim that cerebro-spinal meningitis,
diphtheria, and even croup, have been introduced during the centenary.
There are grave doubts about the truth of all such statements. Others
claim that yellow fever and cholera are such diseases; “yellow chills”
are named by one, “trichiniasis” by another. I feel that there is no
proof that any new disease has been introduced, and become endemic
here.
NINTH QUESTION.—If there be any such new disease, has it been investi-
gated by the State or by individuals 3
The answers are:–
Twenty-seven, (27) No.
Six, (6) Yes.
Two, (2) Indefinite Reply.
Thirteen, (13) No Reply.
My correspondents cite investigations by a commission of the city of
New Orleans in 1853, relative to typhoid fever; by Dr. Kedzie, of
te
42 BOW DITCH,
Michigan, on cerebro-spinal meningitis; on diphtheria, by the N. Y.
Metropolitan Board of Health ; on “yellow chills” by various persons in
Alabama.
Of course this meagre statement falls far short of the truth in regard
to the number of investigations undertaken by individuals, corporations,
and commissioners, on the various diseases of the country, some of which
have no more right to be classified as new diseases, than typhoid fever
and diphtheria; and none of them can be certainly said to be diseases
never seen before the past century.
TENTH QUESTION.—Has the town or city in which you reside taken any
measures for the improvement of the Public Health 3
(a) By health laws 3
The answers are:—
Nine, (9) No.
Twenty-five, (25) Yes.
Nine, (9) Indefinite Reply.
Five, (5) No Reply.
From the above, it seems that the majority of the towns have done
what mere self-defence would inculcate. But of the twenty-five affirma-
tive replies very many report either inefficient enforcement or complete
abeyance of such laws. Many towns have special laws for drainage, and
other objects seem partially or wholly ignored. For my own State of
Massachusetts, I think I can say that in not a single town has there ever
been a complete system of health laws enacted and thoroughly enforced.
But, notwithstanding this unsatisfactory statement, I also believe that I
may with equal truth assert that so recently has the idea of State Pre-
ventive Medicine begun to take hold of our people, that our advance has
been quite as much as could be expected. Very many more years will be
needed before this country or Europe will even approximate to that point
which, at present, only an ideal sanitary legislation would require, but
which the coming century will bring forth into actual operation.
(b) By special action in specific cases 2
Three, (3) No.
Twenty-five, (25) Yes.
Eleven, (11) Indefinite Reply.
Nine, (9) No Reply.
The remarks made on the previous question apply to this.
ELEVENTH QUESTION.—Does your town use well-water for culinary uses 2
TwPLFTH QUESTION.—Is care taken to prevent pollution 2
THIRTEENTH QUESTION.—Do you have a water supply from distant lake
O) river 3
FourTEENTH QUESTION.—Is care taken to prevent pollution ?
Including all these questions under one category; of 143 towns 82 use
wells, 61 use rivers or lakes. In regard to the care taken to keep either
class of waters pure, I find as follows:–
49 or 34.26 per cent. try to keep it pure ;
69 or 48.25 per cent. make no attempt to do so;
25 or 17.48 per cent. make no, or an indefinite reply.
In other words, taking my returns as furnishing at least an approxima-
tion to the general state of the country in this respect, 34.26 per cent.
only of the towns make any claims, even the most trivial, to be careful
of the purity of their water; while 65.73 per cent., or nearly twice as
A D D R E S S O N H Y G. I. E N E . 43
many, are totally neglectful. That is to say, nearly two-thirds of the
people of this Union are living in a senseless disregard as to whether they
are drinking pure water or water which, though “sparkling and tasting
pleasant,” may be loaded with every species of filth !
FIFTEENTH QUESTION.—Have you sewers to carry off such water supply?
The answers are:—
Eleven, (11) No.
Thirteen, (13) Yes.
Twenty, (20) Indefinite Reply.
Four, (4) No Reply.
These replies coincide with all the preceding, and intimate very fully
the primitive ideas held by the people of this country in regard to the
necessity of carrying off water once made impure. What happens in
• Boston I fear happens elsewhere, viz.: that abundant supplies of water
have been introduced into certain parts of the city without any imme-
diate provision being made for its removal by sewers. The consequence
has been that the cesspools have been overflowed, and that the land has
been soaked with water, perchance containing the elements of disease,
and certainly tending to develop phthisis, from the soil moisture induced
by such overflow. Of course, evil must result.
I might refer to other particular cities and places, now the common
summer resorts for the most wealthy people, where a most scandalous
condition exists in this respect, making it at times more dangerous to
visit the “health resort,” so called, in country and sea-side, than it would
be to remain at home, even in a poorly-sewered, offensive-smelling city.
But we have no need to visit health resorts to find great imperfections
of sewerage. That of Boston, which I have already quoted in reference
to its suburbs, has been, even within its city limits, notoriously bad, not-
withstanding it has been claimed to be nearly as perfect as could be.
Some of the main sewers of that city are even now nearly filled with
refuse, more or less solid. One of the main conduits is occupied to a
great depth by so-called “mud,” composed of dirt from the open street
gutters and of human excreta. Others are more or less partially ob-
structed. The whole congeries of them form one vast network of cess-
pools, belching out at times filthy odors from “manholes” along the
streets. The mouths of the sewers, which open all around the city
limits, and in the closest proximity to it, pour forth volumes of similar
foul exhalations while the tide is low, and the quantity of refuse
issuing from them has been declared, under oath, to interfere very
much in certain places with trade, by preventing vessels which were
formerly able to approach certain wharves, from so doing at the pre-
sent time.' I summon thus significantly my own city to the bar of
public sanitary rebuke, not because I think her really a worse sinner in
these respects than many other and some greater cities, but for two
reasons: (1) that I know whereof I speak, and can vouch for the truth
of the assertions, extraordinary as they may seen to some of you, and
(2) that I rejoice to say that, in this centennial year, Boston is seemingly
repentant, and is prepared to amend her system at a large expense.
Thank God | Her citizens are beginning to feel that the worst prodi-
gality is the waste of human life, and that mere money is as nothing before
the idea of perfect human health /
' Wide Tyler et al. v. Squire et al., before the State Board of Health of Massachusetts,
1873.
44 Bow DITCH,
SIXTEENTH QUESTION.—How far are the sewer outlets from the source of
water Supply?
Upon this question it may be generally stated that these distances in
different cities of the Union vary from what may be practically called
zero to 20 or even 30 miles. It would seem that, where it is convenient
so to do, a distance more or less great is always chosen ; but strange as
it may seem, some of our great cities have been wholly thoughtless. If
my correspondent be correct, even in this great city of Philadelphia in
which we meet, although the majority of the sewerage is carried far
below the water supply, we cannot claim the same for all of it. And not
a few cities which take water from rivers and lakes are practically re-
gardless of the quantity of impurities that enter the stream or lake at
some distance, it may be, but nevertheless above the part whence the city.
gets its own water supply. I might cite Albany as a great and most
glaring example of this latter statement.
SEVENTEENTH QUESTION.—What is your method of disposing of sewerage 2
House offal 2 Slops or filth liable to accumulate about homesteads 2
I have received answers from eighty-four towns, and the summary of
them is, that only in about one-fifth (sixteen) are there any proper and
efficient means for the removal of these various sources of contamination.
A great many have still most primitive ways of disposing of them ;
“they are thrown away carelessly.” Many have “surface drainage.” In
some they are “thrown into open lots,” or “to the hogs;” and in some
“each inhabitant does as his own will dictates.” Nothing can be more
chaotic than the present method pursued in this country, considered as
one great whole.
EIGHTEENTH QUESTION.—Have any State, County, or City reports of Health
or Deaths been published 2
The answers are:—
Thirty, (30) No.
Nine, (9) Yes.
Two, (2) Indefinite Reply.
Seven, (7) No Reply.
That is, 62.50 per cent., or more than half of the correspondents, say
there is no registration in their States; 18.75 per cent. have had some
registration, most of them only for a few years past; and 18.75 per cent.
make indefinite or negative replies. Adding together the first and last
items as being essentially the same, we have, as the final probable result,
that 81.25 per cent., or more than three-fourths of these States, have vir-
tually ignored vital statistics during the whole centennial period. Add
to this that among those which claim to have had registration, it is like-
wise stated by my correspondents that in not a few the registration is
very imperfect.
The United States commenced its national censuses in 1790, and has
continued them decennially ever since, but never with the accuracy
which is desirable. I judge this from the opinion of experts whose
opinion I have asked of even the latest, that of 1870. The following
remarks by General Walker and Mr. Elliot seem also to indicate that
my inference is true.
General Walker says: “The gross incompleteness of the returns of
deaths in the census of the United States is shown by Mr. Elliott's Ap-
proximate Life Table. What, it may be asked, is the value of statistics
A D D RESS O N H Y GIF, N E . 45
confessedly so imperfect 7”. He elsewhere admits that the number of
deaths falls short 40 per cent. of what must actually be the fact.
Mr. Elliot, who calculates life tables from these returns, admits that he
is obliged to “resort to the somewhat arbitrary assumption of 40 per
cent. limited, however, by an investigation of the rates of mortality rela-
tive to population which obtain in other communities, so far as accessi-
ble, and in portions of our own country.”
NINETEENTH QUESTION —How many years, approacimately or definitely,
have these registration reports been published 2
I regret that, owing to imperfect returns, I cannot give any but gene-
ral statements.
But when I think of the comparatively brief period of time since the
registration has been commenced in the different States where any is
made, and knowing as I do, the imperfections of those which may be sup-
posed to be the best, I feel sure I am within the limits of truth, when
declaring that not a State in this Union has a registration which has
been in progress a sufficient number of years, or which has been con-
ducted with sufficient accuracy, to be fairly comparable with that regis-
tration which will be eventually demanded by an enlightened State
Preventive Medicine, after that idea has been firmly grasped and acted
upon for some years by the intellect and conscience of our people.
In confirmation of this assertion, I state the following fact. I was
desirous of learning definitely, not from theorizing on the influence of
civilization, not from the records of foreign countries, but from accessible
statistics collected and printed in this country, whether man lives longer
now than at the commencement of the centennial period. I consulted
several eminent American experts in statistical data. I asked them to
point out to me any such data. Not one of them could do so. One who
stands pre-eminent, and whose word is listened to by Europe, advised me
as follows: “You may consult bills of mortality; grave-yard records;
family Bibles; traditions of the former and later times, and they will
show whether we have gained or lost in longevity.” I have no doubt
that, provided we could find those records, we should perhaps partially
gain the end proposed. My question was whether he could point out to
me any printed document, derived from accurate records made in the
United States, answering my question. He could not do so.
TWENTIETH QUESTION.—Has any law of development, or of partial develop-
nvent, of any disease been discovered by individual or State action, by attention
to which in coming centuries we may hope to greatly lessen or destroy such
disease ?
I proposed this question of fact as the test question, so to speak, of the
Centennial Period. It was the culmination of all these questions hitherto
proposed.
The answers are:—
Thirty-nine, (39) No.
Six, (6) Yes.
None, (0) Indefinite Reply.
Three, (3) No Reply.
The returns indicate that my correspondents have a more decided
opinion upon this question than upon any other of the series. There are
1 Statistical Atlas of the United States. By F. A. Walker.
* Ibid. Approximate Life Table for the United States. By F. B. Elliott.
46 Bow DITCH,
only three who fail to make any answer, and not a single State has replied
indefinitely. Again, thirty-nine out of forty-eight States, or 81.25 per
cent., reply in the negative ; six of the forty-eight, or 12.50 per cent.,
reply affirmatively. -
But let us look carefully at the affirmative replies, and interpret more
closely their exact meaning. The replies I think may be justly arranged
in two categories:–
First. Those in which it appears that by close attention to sanitary
arrangements, and their rigid enforcement, certain diseases are checked.
One correspondent remarks, “all the acquired knowledge concerning all
and each of the typho-contagia, and the factors of their propagation is
equivalent to discovery.” (Dr. Harris, of New York.) From other States
we are informed that “the laws of development of typhoid fever are
known better.” (Drs. Plummer, of Oregon, and Butler, of Vermont.) Drs.
Stuart and Toner, of Washington, D.C., say they are “able to control
and prevent zymotics by sanitary enforcement.” Dr. Baker, of Lansing,
the self-sacrificing, efficient Secretary of the State Board of Health of
Michigan, writes as follows: “It seems proper to modify very much the
‘Yes,’ which I have placed opposite the question ; if we substitute for
‘law of development, or ‘partial development of, the words ‘general truth
respecting,' I think the answer will be truthfully ‘Yes.’” IIe then
cites scarlet fever “which will be lessened in the near future, because of
the accumulated evidence of the great mortality caused by it.” He also
thinks “croup and pneumonia will be eventually greatly lessened from
the fact that a cold and dry atmosphere causes the greatest mortality
from both. And by securing such favorable conditions in our houses,
and particularly in our sleeping rooms, it is reasonable he thinks, to
hope that many deaths from pneumonia and croup may in the future be
prevented.” These may be considered as one category.
Second. Let us grant that all this is true, nevertheless I do not see that
any “law” of development of disease, similar in degree at least, if in
character, to that of “soil moisture” as a very prominent cause of
phthisis, has been presented by any of the above respected correspond-
ents. Massachusetts, through the agency of the Massachusetts Medical
Society, proved many years ago by data received from her three hundred
and twenty-five towns, and where consumption had been previously con-
sidered every where equally endemic, that there were dry spots where it
was very rare, and wet where it was very rife. By accurate statistical
data, laboriously gathered, it was further proved that of two families
growing up, one on a wet soil and the other on a dry soil, the one resident
on the wet by that fact became twice, if not three times, as liable to
phthisis as the other, resident on a dry spot. That law was first dis-
Covered and announced in New England, and subsequently by ample
statistical data proved to exist in Old England. I think it may now be
said to be a Cosmic Law, and as such it seems to me I am justified in
placing it alone in the second category under this final question.
In order to meet the numerous similar questions which will inevitably
arise in the future, we need, as Mr. Elliot suggests, a National System
for the registration of all the Births, Marriages, and Deaths taking place
in the country. Moreover, the Registrar should, for the whole country,
learn the exact character of the localities in which the deaths take place,
if we would know exactly and broadly the endemic influences of any place.
* Topographical Distribution of Consumption. Annual Address before Mass. Med.
Society, 1867.
A D D R E SS O N H Y GI E N E . 47
SUMMARY.
GENTLEMEN: My work is done. I have endeavored to place before
you the exact truth in these matters so far as I could obtain it. No one
can feel more keenly than I do that it has at times been most umpalata-
ble, and that it seems to be but little creditable to the country. Never-
theless, looking at the very recent growth of a regard for Public Hygiene,
and at the certain though small advances made in various parts of the
country in State Preventive Medicine, I have the strongest hopes for the
future of our Country and the world in this regard. We could not, with
the influences hitherto pressing upon us, have advanced further. System
making, the outgrowth of many previous centuries, prevented all pro-
gress in this direction during our first epoch. The overthrow of these
theories and theory makers, and the bringing of medical inquiries into line
with the methods pursued by modern science, was the great fact gained
during the second. Although this has been followed by a sweeping and
widespread skepticism in our own art, we must remember that this same
skepticism is found everywhere within the domains of modern thought.
Good will ultimately result from it. But these facts have not allowed
of the growth of Preventive Medicine until within a very recent period
of time.
We stand now at the very dawn of the grandest epoch yet seen in the
history of medicine. While philosophically, accurately, and with the
most minute skill, studying by means of physiology, pathological anatomy,
chemistry, the microscope, and, above all, by careful clinical observation,
the natural history of disease and the effects of remedies, our art, at the
present time, looks still higher, viz.: to the prevention of as well as to the
cure of disease. And this is to be done by Sanitary organizations
throughout each State and the Nation, the laity and the profession
heartily joining hands in this most noble cause.
OUR PRESENT DUTY.
Our PRESENT DUTY is organization, National, State, Municipal, and
Village. From the highest place in the National Council down to the
smallest village Board of Health, we need organization. With these
organizations we can study and often prevent disease.
This great and beneficent object of the prevention of disease appeals
to all. The aged may give counsel. To the young of this and of future
generations belongs the solid work which is to bless the coming centu-
ries. I appeal therefore with all the earnestness at my command to the
young men of the present hour. Can there be anything more inspiring
to a generous hearted, intelligent youth than the thought that, by labo-
rious research into the causes of disease, by the discovery of means for
its prevention, and by the teaching of these various causes and means to
the people, he may help to save even a few of the more than two hun-
dred thousand human beings now annually slaughtered in this country
by preventable disease ?
48 BOW DITCH, ADDRESS ON HYGIENE.
OUR HOPES FOR THE FUTURE.
I trust that this discussion will have given rise in your minds to some
of the bright hopes for the future which have arisen in my own. Al-
though Public Hygiene has made but few advances hitherto, it is never-
theless founded upon Natural law. It has been legitimately and health-
fully growing during a portion of the past quarter of a century. Modern
Science greets it and brings it within its domain as one of its most pre-
cious objects for thorough investigation. I hope therefore that, standing
as we now are near to the close of this fair Centennial Birth-year of our
Nation, up to whose festival all nations of the earth have been invited,
I may be allowed to appeal to all, whether young or old, American or
collaborating friends from other lands, to join with me in a Cordial All
Hail to Coming Centuries, not only in America but in every civilized spot
of God’s earth; because everywhere, and to all coming time, human life
will be lengthened, made more healthy, and consequently more truly
happy, by the potent influence of
STATE PREVENTIVE MEDICINE.
49
ADDRESS ON MEDICAL CHEMISTRY AND TOXICOLOGY.
BY
THEO. G. WORMLEY, M.D., PHD., LL.D.,
PROFESSOR OF CHEMISTRY AND TOXICOLOGY IN STARLING MEDICAI, COLLEGE, COLUMBUs, OHIO.
WHEN it is remembered that nearly all human thought and labor are
devoted to the promotion of the welfare of the human body, and that
agriculture, manufactures, and commerce have this as their chief end, it
will not be deemed strange that a science so comprehensive and withal
so flexible in its applications as Chemistry, should be laid under contri-
bution to preserve that body in health, or to restore that health when
impaired. Before chemistry had become a true science, its aid was in-
voked by the old alchemists in their search for the “Elixir of Life.” A
universal remedy was the dream of many a toiler in secret places, whose
occult science had for him a strange fascination. There were among the
Arabians many who, in their rude way, applied such chemical knowledge
as they possessed to the discovery of new medicines. The same was
true of the earlier physicians of Europe. There was everywhere an effort
to make nature reveal some secret which might be turned to account in
the healing art. This, more than any other, was deemed the true func-
tion of Chemistry.
It was not until Bacon announced the true method of scientific inves-
tigation, and declared that the Kingdom of Science, like the Kingdom
of Heaven, was to be entered as a child, rather than with the spirit of a
dictator, that the mists of earlier times were gradually swept away, and
the path prepared for the appearance of Science with exact methods and
with exact results.
It is now only about a century since Chemistry took shape as a Science.
The labors of Black, Priestley, Scheele, Lavoisier, and others showed
that a vast field of research lay before them. For a century chemists
have been exploring this field, and have taken possession of many a spot,
and secured permanent title-deeds for posterity ; but, it must be con-
fessed, that a century is far too short for the survey of the whole domain,
and our descendants will have ample scope and incentive for the pro-
foundest labor and research. Only two years since, the chemists of Great
Britain and America celebrated the centennial of Chemistry, dating the
birth of the science from the discovery of Oxygen by the distinguished
Priestley, August 1, 1774. The commemoration in this country took
place at Northumberland, Pa., the American home of Dr. Priestley.
The general progress of the century was there ably set forth by men of
note in their several departments of investigation. The very valuable
address of Prof. Benjamin Silliman, on this occasion, on American Com-
tributions to Chemistry (a complete compendium to which we are greatly
indebted) shows that in this country we have not been idle in advancing
this department of science.
After the discovery of oxygen, nitrous oxide, and other gases, by
4
50 WO R M L E Y,
Priestley and others, Sir Humphry Davy, then a young man with ma-
jority unreached, was employed at Bristol, through the generosity of
Messrs. Watt and Wedgwood, to undertake a careful series of experi-
ments with gases as remedial agents. So important and intimate is the
connection between chemistry and medicine, that we should naturally
look to those who feel the imperative need of this science in its sanitary
applications, for the best labors in the science. There could be no other
incentive more potent. The air and vapors we breathe, the food we eat,
the fluids we drink, the medicines we take, and the poisons we seek to
avoid, all come within the range of the analyst, and his words of counsel
and caution are to be heeded. In this field of labor many eminent
chemists have labored with exclusive devotion, while others, as Davy,
Scheele, and Liebig, commenced their distinguished careers as pharma-
cists, and may be said to have emerged from the apothecary’s shop.
Indeed, we may not overlook the close connection between chemistry
and pharmacy. As we trace the history of medical chemistry in the
United States, it will be seen that the contributions of the pharmacists
have been so many and various, that the historian must give them a
high and honorable place in the annals of American progress.
One hundred years ago we find that the only medical college in the
land, with an occupied chair of chemistry, was the Philadelphia Medical
College, soon after (1791) merged into the University of Pennsylvania,
the institution in whose halls we are now assembled, an institution not
only venerable in years, but renowned for the great and noble work it
has accomplished. The Occupant of this chair, elected August 1, 1769,
was none other than Dr. Benjamin Rush, distinguished alike for his
professional labors, which brought honor upon medical science, and for
his devoted patriotism in the dark days when our national independence
was won. He graduated at Princeton, and afterwards studied medicine
in Philadelphia, Edinburgh, London, and Paris. While in Edinburgh
he studied chemistry with the eminent Dr. Joseph Black. He was one
of the signers of the Declaration of Independence, which this centennial
year commemorates. In 1777 he was made surgeon-general of the army
in the middle department. Ever a distinguished physician and medical
professor, ever active in all public and philanthropic movements, his long
life was one of singular usefulness and honor, and no name in our annals
should be mentioned with more reverence and respect than that of Ben-
jamin Rush, the earliest American professor of chemistry. The only
other chair of chemistry in the colonial days was that established in
William and Mary College, Virginia, in 1774, and filled by the Rev.
James Madison.
In 1779 a professorship of chemistry and natural philosophy was
established in the literary department of the University of Pennsylvania.
Thus two of the first three chemical professorships in America were
established in Philadelphia. In the medical department of Harvard
University, Aaron Dexter was elected Professor of Chemistry and Ma-
teria Medica in 1783; and in 1792 Dr. Samuel Latham Mitchell was
elected Professor of Chemistry in Columbia College, New York. T)r.
Mitchell graduated in medicine in Edinburgh in 1786. Two years after
entering upon his professorship of Chemistry, he published an essay on
the Nomenclature of the New Chemistry. In 1797 he, with others, estab-
lished the Medical Repository, the first scientific periodical ever published
in the United States. He is now widely known as an early student of
A D D R E S S ON MIE DIC A. L. C H E M IST R Y . 51
natural history, and his publications on Zoological subjects are yet
prized.
In 1795 Professor John McLean, a young chemist of Scotland, was
elected Professor of Chemistry in Nassau Hall, Princeton. In 1803 Pro-
fessor Benjamin Silliman, the first professor of chemistry in Yale College,
entered upon his duties. Iſe became widely known as an able and elo-
quent expounder of chemical science. In 1818 he established The Ame-
rican Journal of Science and Arts, which became, more than any Ameri-
can journal, the means of disseminating discoveries in chemistry and in
cognate sciences. IIis name will ever remain an honored one in the his-
tory of American science.
The work done in chemistry in the medical schools has not always
been marked by Scientific thoroughness; indeed, in too many cases, very
little practical benefit has resulted from the lectures, often only heard to
be forgotten. But a change is now being effected in this respect, and
we note with satisfaction that a two years’ course of systematic labora-
tory practice is made part of the regular curriculum of study in the
Medical Department of Harvard University.
The earlier professors of chemistry in the Medical Schools did not con-
tribute largely to the advancement of the science in the way of original
research. The science was in its infancy, and the circumstances sur-
rounding them were not generally such as to awaken that measure of
enthusiasm which is necessary to scientific discoveries. A marked ex-
ception, however, is found in the case of Dr. Robert Hare, who became
Professor of Chemistry in the University of Pennsylvania in 1818. In
his youth he was a member of the Chemical Society of Philadelphia, to
which belonged Priestley, Seybert, and others. At the early age of
twenty, he announced the discovery of the oxy-hydrogen blowpipe, which
at once gave him distinction in both hemispheres. This became a valu-
able instrument in certain departments of chemical investigations, and
in the arts. Dr. Hare had great mechanical skill, and with his ingenious
apparatus was enabled to perform experiments with great brilliancy and
success. In addition to many valuable contributions, he published, in
1828, a Compendium of Chemistry, a valuable and useful work at the time.
In this connection it should be mentioned that in 1819 Dr. John Gor-
ham, Professor of Chemistry in the Medical Department of Harvard.
University, published the first original systematic treatise on chemistry
ever issued in this country, entitled the Elements of Chemical Science, a
work in two volumes, which reflected great credit upon its author. It
should be stated, however, that there had been, before this, American
republications of foreign chemical works.
We now conne, in the order of history, to the name of Prof. John
Redman Coxe, who deserves mention for the part he played in inaugu-
rating a movement, which, as we shall see, has contributed, perhaps,
more than any other to the progress of Medical Chemistry in the United
States. A part of his medical education was obtained in the University
of Edinburgh, but he graduated in the University of Pennsylvania in 1794.
He afterwards spent considerable time in London, Edinburgh, and Paris.
In 1809, he was elected by his Alma Mater Professor of Chemistry, and
was transferred to the chair of Materia Medica in 1818. While in this.
latter chair he was the “leading spirit” in a movement to provide a
special course of lectures in Pharmacy for the young druggists and
druggists’ clerks of Philadelphia. This was early in 1821. This move-
ment arrested the attention of the leading druggists of the city, and led
52 WOR MILE Y,
them at once to establish a new and independent institution –first called
the College of Apothecaries, but changed the next year to the Philadel-
phia College of Pharmacy—to secure the same results, but upon a more
liberal plan.
The founders of this college were wise men, and secured for their new
institution professors of high scientific character. The first course of
lectures was given in 1821–2. Dr. Samuel Jackson, a medical graduate
of the University of Pennsylvania, was the first Professor of Materia
Medica. In 1827 he was elected to a professorship in his Alma Mater.
His career as a lecturer, as an author, and as a practitioner, was in all
respects distinguished. Dr. Gerard Troost, afterwards eminent in other
departments of science, was the first Professor of Chemistry, but was
succeeded within a year by Dr. George B. Wood, happily still living to
enjoy the rewards of a life well spent in the service of science and of
humanity. His published works, at once so complete and scholarly,
have honored the profession of which he has so long been a distinguished
member.
In 1831, Dr. Wood was transferred to the department of Materia
Medica. His successor in the chair of Chemistry was Dr. Franklin
Bache, a worthy descendant of the eminent statesman and philosopher
whose name he bore. In 1833, Professors Wood and Bache published
the first edition of the United States Dispensatory, a work which has
passed through thirteen (13) editions, and is still the indispensable hand-
book of the physician and pharmacist. These eminent professors im-
pressed upon the College of Pharmacy a character for thorough science
which it has never lost. Our brief sketch would be imperfect should we
here fail to mention the name of the late Prof. William Procter, Jr.,
who became the Professor of Pharmacy in this college in 1846, and who
by his scientific labors, prosecuted through many years, contributed
more to the special department of Medical and Pharmaceutical Chemistry
than, perhaps, any other American. It should here be mentioned that,
four years after the establishment of the Philadelphia College of Phar-
macy, its friends founded the American Journal of Pharmacy, a journal
still issued, and which has contributed very greatly to the dissemination
of a knowledge of chemistry in its relations to medicine.
The second College of Pharmacy in this country was established in
New York in 1829, through the instrumentality of George D. Coggeshall,
a graduate of the Philadelphia College. The first Professor of Chemistry
was the late Dr. John Torrey, whose labors in science, and especially in
American botany, have given him a name which will ever be honored.
MEDICAL CHEMISTRY.
Having thus glanced at the history of the introduction of chemistry
into our schools, in passing on to discuss the theme assigned us, MEDICAL
CHEMISTRY, we find ourselves entering upon a broad domain of investi-
gation. We might enlarge upon the many and wide bearings of chemistry
upon medical practice, and show how indispensable it is to the best suc-
cess of the practitioner; point out its grand achievements in the depart-
ments of physiology and pathology, and show how inseparable is its
connection with the progress of medical science in all its departments;
A. D. D. R. E S S O N M E DIC A. L. C H E M IST R Y . 53
but, perhaps, as more consonant with the occasion and with the limita-
tions of the hour, we may restrict ourselves to a brief consideration of
the more prominent of the American Chemical Contributions to the Medical
Progress of the Century. In this review, we find that these contributions
relate largely to the examination of the chemical and therapeutic pro-
perties of our indigenous plants.
One of the first of these plants examined was Sanguinaria Canadensis,
or Blood-root. Attention was first called to this plant in 1803, by Dr.
Wm. Downey, of Maryland, as a powerful emetic ; and in 1819, Dr.
Wm. Tully, of New Haven, investigated with care its therapeutic pro-
perties. In 1828, Dr. J. F. Dana, of Dartmouth, first chemically exam-
ined the plant, and succeeded in isolating a basic or alkaloidal principle
which he called Sanguinarine (N.Y. Lyc. Nat. Hist., ii. 245, 1828). The
identity in ultimate composition of this alkaloid with the alkaloid of
Chelidonium majus, subsequently discovered by Probst and called chelery-
thine, was fully established by Dr. Joseph Schiel, of St. Louis, in 1865
(Amer. Journ. Sci. (2), xx. 220). A second principle was extracted from
Sanguinaria Canadensis by Riegel, which he considered identical with
Merck’s porphyroxime, from opium ; but this identity was subsequently
denied by Dr. G. D. Gibb. A third proximate principle derived from
this plant was described by Prof. E. S. Wayne, of Cincinnati (Amer.
Journ. Pharm., 1856, 521); and for it Dr. Gibb proposed the name
puccine. Prof. Wayne has also recognized in blood-root the presence of
chelidonic acid, first found in the plant Chelidonium majus.
In 1819, Dr. John Torrey, while investigating a curious underground
fungus called Tuckahoe or Indian-bread (Scleroticum gigantium), dis-
covered a new principle which he termed Sclerotime, an account of which
was read before the Lyceum of Natural History, New York, Nov. 15,
1819, and published in the N. Y. Med. Repository, Dec. 1820. In 1824
Draconnot described pectic acid, a principle now obtained from many
succulent plants. In 1827 Dr. Torrey republished his former paper with
additions, and showed the identity of the two substances (Amer. Journ.
Sci. (2), xxvii. 439).
Another interesting native plant that early received attention is Lobelia
ânflata, known as Indian tobacco, and used as a medicine by the abori-
gines. The attention of the medical profession was first called to this
plant by Rev. Manasseh Cutler, of Ipswich, Mass., eminent as a botanist
in the latter part of the last century. Lobelia was first examined chemi-
cally in 1833 by Dr. S. Colhoun, Professor of Materia Medica in Jefferson
Medical College, Philadelphia, who announced the existence of a basic
principle capable of forming salts with acids, but failed to isolate the
principle (Amer. Journ. Pharm., v. 300, 1833). Wm. Procter, Jr., who
has already been referred to, in his Inaugural Thesis, in 1837, on Lobelia
inflata, demonstrated that the active principle of the plant is a liquid
alkaloid, which he succeeded in isolating. He named this principle
lobalina, and he described the salt formed by it with the leading acids.
His very elaborate thesis was published in the American Journal of
Pharmacy for July, 1837. In November, 1850, Wm. Bastick read a
paper before the Pharmaceutical Society of Great Britain on Lobelia
inflata, in which he described the same alkaloid, and his name is often
mentioned in foreign publications as its first discoverer. A number of
cases of poisoning have occurred in this country from the use of this
plant, chiefly as administered by empiries.
The next indigenous plant to be noticed is Veratrum viride, or Ameri-
54 WO RMLEY,
can hellebore. This plant was known to the Indians chiefly as a poison.
According to Joselin, an early visitor to this country, it was used by them
in the selection of their chiefs, the individual found least susceptible to
its effects being regarded as the “strongest of the party, and entitled to
command the rest” (Amer. Journ. Pharm., vii. 203). It was brought to
the attention of the medical profession about the year 1830, by Drs. Tully
and Ives, of New Haven. Its therapeutic properties were more fully
investigated by Dr. Charles Osgood, of Providence, in 1835 (Amer. Journ.
Med. Sci., xvi. 296). In 1851 Dr. W. C. Norwood, of South Carolina,
again brought it before the profession in a series of papers highly extoll-
ing its medicinal virtues.
The chemical history of this plant presents some features of peculiar
interest. Very contradictory conclusious have been reached by different
investigators in regard to the exact chemical nature of its active princi-
ple or principles. The first chemical examination of this plant was made
in 1835 by Dr. Charles Osgood, but he failed to obtain satisfactory results
(Amer. Journ. Pharm., vii. 202). It was again examined by Dr. Thos.
R. Mitchell in 1837, who also failed to determine the true nature of its
active principle (Ibid., ix. 181). After a somewhat extended examination,
Henry W. Worthington, in 1838, concluded that the plant contained
an alkaloid identical with veratria, previously obtained from veratrum
album, its European congener (Ibid., x. 89). In 1857, Dr. Jos. G. Rich-
ardson, after a very elaborate investigation and an extended series of
parallel chemical experiments, with the alkaloids of both these plants,
came to the same conclusion (Ibid., 1857, 204). In 1862 Mr. G. J. Scat-
tergood announced that in addition to the alkaloid veratria, the plant
contained a resin, to which he ascribed the sedative action of the drug,
and he also obtained some evidence of the probable existence of the
alkaloid jervia in the plant (Proc. Amer. Pharm. Assoc., 1862). Mr.
Charles Bullock, of Philadelphia, in 1865, claimed that the alkaloid in
question was not identical with veratria, and that the resin of Scatter-
good owed its activity to the presence of another alkaloid. These prin-
ciples were afterwards named respectively veratroida and viridia (Amer.
Journ. Pharm., 1865, 321). . In 1872 Dr. Eugene Peugnet, of New York,
also assented to the want of identity between veratroida and veratria,
and he announced the identity of the viridia of Bullock with the alka-
loid jervia, first discovered in, veratrum album by Simon (Med. Record,
May, 1872). These views of Dr. Peugnet were endorsed by Mr. C. L.
Mitchell, of Philadelphia, after an elaborate investigation in 1874 (Proc.
Amer. Pharm. Assoc., 1874, 436). Lastly, in this singular history, in a
paper in the January number of the American Journal of Pharmacy for
the current year, it is again elaimed that the alkaloid, other than jervia,
of this plant is identical with veratria, it fully responding to all the
known tests for this alkaloid. The paper just cited, by Dr. T. G. Wormley,
also points out the behavior of jervia with reagents, and cites cases in
which both alkaloids were recovered from the blood of animals poisoned
with veratrum viride.
In 1875 Mr. Charles Bullock contributed a valuable paper on the
methods of preparation and properties of jervia (Amer. Journ. Pharm.,
1875, 449). In this connection we should not fail to mention the inter-
esting and valuable series of experiments upon the physiological action
of the alkaloids of this plant by Prof. Horatio C. Wood, Jr., of Phila-
delphia, published in the American Journal of the Medical Sciences,
January, 1870, and the Philadelphia Medical Times, vols. ii. and iii.
A D D RESS ON ME DIC A. L. C H E M I S T R Y . 55
*
Leaving this protracted notice of the American hellebore, let us turn
to a plant of milder name and properties, the Wax Myrtle or Bayberry,
the Myrica cerifera of the botanists. In 1819 the berries of this plant
were examined chemically by Dr. J. F. Dana, then chemical assistant in
Harvard University (Amer. Journ. Sci., i. 294). Mr. G. E. Moore, in
1862, made a complete analysis of the Wax of the Bayberry, and found
it to consist of palmitin and palmitic acid, with a small quantity of lauric
acid (Ibid. (2), xxxiii. 313). In 1863 the bark of the root of this plant
was examined by Mr. Geo. M. Hambright, of Philadelphia, who found
that it contained a new crystallizable principle, to which he gave the
name myricinic acid (Amer. Journ. Pharm., 1863, 193). The bark of this
plant, as a remedial agent, was first brought to the attention of the pro-
fession in 1822, by Dr. W. M. Fahnestock, of Harrisburg, Penn. t
According to Rev. F. Heckewelder, the Indians of this country em-
ployed Podophyllum peltatum, or May apple, as a poison to destroy them-
selves (Eberle's Therapeutics, i. 205). This plant was long used as a
popular cathartic, and was brought to the attention of physicians, by Dr.
Bigelow, about 1818.
The first chemical examination of this plant was made in 1831, by
Wm. Hodgson, who obtained a crystallizable bitter principle, which he
believed to be the active principle of the plant, and which he named podo-
phyllin (Amer. Journ. Pharm., iii. 273); but Prof. T. F. Mayer was led to
believe that the principle obtained by Hodgson was the alkaloid berberina
(Ibid., 1863, 98); and this fact was fully established by Prof. J. M. Maisch
(Ibid., 303). After an elaborate examination of the plant by John R.
Lewis, the results of which he presented as an Inaugural Essay, he con-
cludes that the active properties of the root are due to the presence of
two peculiar resinous principles, the one soluble, the other insoluble, in
ether (Ibid., 1847, 165). According to Prof. Mayer, the root contains,
besides berberina, a colorless alkaloid, a neutral volatilizable principle,
and saponine (Ibid., 1863, 98).
A native plant that has received considerable attention at the hands of
the physician and chemist is Hydrastis Canadensis, or Yellow puccoon.
It was known both as a medicine and as a dye to the aborigines of this
country, and employed by irregular practitioners before being used by
the regular profession. The first chemical examination of this plant was
made in 1851, by Alfred A. B. Durand, of Philadelphia (Am. Journ.
Phar., 1851, 112). He obtained a colorless crystallizable base, which he
named hydrastia, but he failed to obtain it in a pure state. In 1862, Mr.
J. D. Perrins, of Worcester, England, obtained it pure and determined
some of its properties. He read his paper before the London Pharma-
ceutical Society, April 2, 1862, an abstract appearing in the Chemical
News (v. 204), and the paper in full in the London Pharmaceutical Journal
for May, 1862. In 1863, F. Mahla, of Chicago, Illinois, in a very valu.
able paper published in Silliman's Journal (op. cit. (2), xxxvi. 57) very fully
describes the properties of hydrastia and gives its ultimate composition.
We have given the history of this alkaloid somewhat in detail, since
there have been different claimants for the honor of its discovery.
Mr. F. Mahla, in 1861, fully established the presence of berberina in
the hydrastis Canadensis (Sill. Journ. (2), xxxiii. 43). This was the first
instance in which this alkaloid—now known to be so widely distributed
in plants—was found in a plant belonging to the Ranunculaceae, and it
thus established the fact that the same alkaloid may occur in plants
belonging to different families. The chemical history of the alkaloid
56 WO RMLEY,
berberina is somewhat remarkable. In 1826, Chevallier and Pelletan
discovered it in the bark of Xanthozylum clava Herculis, and named it
acanthopicrite. In 1835, it was found as berberina, by Buchner, in Berberis
vulgaris. These observers erroneously regarded it as a weak acid. Fleit-
man established its basic character ; and Perrins, in 1862, showed the
identity of xanthopicrite with berberina, and established its formula.
The probable existence of a third alkaloid in hydrastis canadensis, “ more
resenbling berberina than hydrastia, but decidedly different from the
former,” was announced in 1873, by A. K. Hall, of Ann Arbor, Mich.
(Am. Journ. Phar., 1873, 247). This third principle was more fully
examined in 1875, by John C. Burt, of the University of Michigan (Ibid.,
1875, 481).
Cimic fuga racemosa, or Black snakeroot, a native of the United States,
was first introduced to the attention of the regular profession by Dr.
Thos. J. Garden, of Charlotte, Va., in 1823. This plant was examined
chemically in 1834, by John H. Tilghman (Amer. Journ. Phar., vi. 14);
in 1843, by J. S. Jones (Ibid., xv. 1); and in 1861, by Geo. H. Davis
(Ibid., 1861, 391); but neither of these gentlemen succeeded in obtaining
the active principle of the plant. At a meeting of the N. Y. Academy
of Medicine, April 3, 1871, Dr. S. R. Percy exhibited a sample of a new
alkaloid obtained by him from the cimicifuga racemosa, which he
named cimicifugia (Amer. Med. Times, N. Y., April, 1861).
The poisonous nature of the leaves of Prunus Virginiana, or Wild
cherry, has long been known. As early as 1806, Dr. Coxe, of Philadelphia,
conjectured that the poisonous properties of water distilled from the
leaves of this plant were due to the presence of prussic acid (see Am.
Journ. Pharm., 1859, 433). In 1834, Stephen Procter determined the
proximate composition of the bark of the tree, and established the pre-
sence of hydrocyanic acid and a volatile oil, as products of distillation
with water (Amer. Journ. Pharm., vi. 8). In 1838, Prof. Wm. Procter,
Jr., established the existence of amygdaline and of a decomposing agent,
identical with emulsine, in the bark, leaves, and kernels of the wild
cherry, and showed that these principles (as had before been shown by
Liebig and Woehler in the case of bitter almonds) were the source of
the volatile oil and hydrocyanic acid obtained by distillation (Ibid., x.
197). -
#. 1856, Prof. E. S. Wayne, of Cincinnati, obtained from the root of
Leptandra Virginica, or Black root, a peculiar, bitter, crystallizable prin-
ciple, which possessed the properties of the plant, and which has been
named Leptandria (Amer. Journ. Pharm., 1856, 510). Prof. Wayne also
found that the root contained mannite (Ibid., 1859, 557). In 1863, Prof.
F. F. Mayer announced the presence in the plant, of a glucoside closely
resembling Senegin in its properties, but more readily decomposed by
alkalies (Ibid., 1863, 298).
We may next notice Rhus to cicodendron, or Poison oak, a native plant
well known from its peculiar action upon the skin of some individuals.
It was used by the Indians, both as a poison and as a medicinal agent.
The first chemical examination of this plant seems to have been made in
1857, by Dr. Joseph Khittel, of Munich, who determined its principal
proximate constituents, among which he claimed to have obtained a
volatile alkaloid upon which the poisonous properties of the plant
depended; but of this he failed to give any proof. In 1865, Prof. John
M. Maisch, of Philadelphia, obtained from the fresh leaves of the plant,
a new volatile, organic acid, which he named Toxicodendric acid, and fully
A D D R E S S O N M E DIC A. L. C H E MIS T R Y . - • 57
established that it was to the presence of this principle the plant owed
its peculiar poisonous effects. Prof. Maish failed to obtain any evidence
of the presence of a volatile alkaloid (Proc. Amer. Pharm. Assoc., 1865,
166). Several cases of poisoning of children who have eaten the fruit of
this plant, have been reported.
The beautiful climbing plant Gelsemium sempervirens, or Yellow jasmine,
a native of the South, was brought to the notice of the profession by an
accident, in which a decoction of the root was administered for that of
another plant. Its claims as a therapeutic agent were strongly urged
upon the profession by Prof. Wm. Procter, in 1852 (Amer. Journ. Pharm.,
1852, 307). This plant is now not only used quite generally by the pro-
fession of this country, but has found favor with the profession of
Europe, having been first employed there more especially as a remedy
for neuralgia. Its physiological effects were very carefully studied by
Prof. Bartholow, of Cincinnati, in 1870 (London Practitioner, Oct. 1870);
and very recently by Drs. Ringer and Murrell, of University College,
England (Lancet, March and April, 1876). The first attempt to deter-
mine the chemical composition of the root of this plant was made in
1854, by M. H. Kollock (Amer. Journ. Pharm., 1855, 197). It was again
examined in 1868, by C. L. Eberle (Ibid., 1869, 35). Both these gentle-
men, however, failed to isolate the active principle. In 1869, Dr. T. G.
Wormley obtained from the plant a new alkaloid, gelseminia, and an
organic acid, gelseminic acid, the properties of both of which he fully
described in the American Journal of Pharmacy for January, 1870.
This paper also contains a report of a case of poisoning by the fluid
extract of the plant, in which the alkaloid was recovered some months
after death. On physiological grounds, Drs. Ringer and Murrell are
inclined to the view that the plant contains two active principles, one
capable of paralyzing, the other of exciting, the spinal cord.
An indigenous plant, used more especially as a domestic remedy, that
early received chemical attention was the Prickly ash, Xanthoxylum
frazineum, which was examined in 1829, by Dr. Edward Staples, who
found that it owed its active properties to the presence of a peculiar crys-
tallizable principle which he named acanthocyline (Amer. Journ. Pharm.,
i. 163). After the discovery of berberina and its identity with xanthopi-
crite had been shown, it was generally believed that Dr. Staples's Xantho-
xyline was identical with berberina, especially when the wide distribu-
tion of this alkaloid became known ; but Mr. Perrins, who first pointed
out the identity of the two former alkaloids, states that xanthoxyline is
an entirely distinct principle (Amer. Journ. Pharm., 1863, 459, note).
In connection with this early contribution of Dr. Staples may be men-
tioned that of TJr. J. F. Dana, who in 1819 discovered the existence of
the animal alkaloid cantharidine in the Potato fly, Lytta vittata, the alka-
loid having been first obtained in 1812 by Robiquet from the Spanish
fly, L. vesicatoria. Other American contributions to the chemistry of
cantharidine have been made by Prof. Procter, in 1852; by Wm. B.
Warner, of Maryland, in 1856; and by Prof. Maisch, in 1872.
A stately American tree, named from its large and beautiful flower,
the Tulip tree or Liriodendron tulipifera, affords a bark which was recom-
mended to the profession by Dr. Young, of Philadelphia, in 1792, as a
substitute for Peruvian bark in intermittent fevers, and in diseases
requiring a gentle stimulant and tonic. In 1831, Prof. Emmet, of the
University of Virginia, obtained from this bark a neutral, bitter principle
58 WO RMLEY,
which he named liriodendrin, and which he described as a white crystal-
lizable solid (Amer. Journ. Pharm., iii. 5).
Apocynum cannabinum, or Indian hemp, long known as a powerful
emetic and cathartic, was examined chemically by Dr. Knopp, who found
it to contain, among other proximate constituents, a peculiar, bitter,
active principle to which he gave the name apocymin. This plant was
subsequently examined by Dr. Griscom (Amer. Journ. Med. Sci., May,
1836). This plant is different from Cannabis indica, also popularly known
as Indian hemp, which was examined chemically in 1865, by Prof. Wm.
Procter (A mer. Journ. Pharm., 1865, 23).
The American water hemlock, Cicuta muculata, found abundantly
throughout the United States, was examined in 1855, by Jos. E. Young,
who found it to contain a peculiar acid (probably the comic acid of Per-
Schier), and the volatile alkaloid comine, first obtained from conium macu-
latum, by Geiger, in 1831.
Wahoo, Euonymus atropurpureus, so well known throughout the
Western States, and sometimes called “burning bush,” from the brilliancy
of its crimson fruit, was made the subject of a very elaborate chemical
examination by Wm. F. Wenzell, in 1862, who found it to contain a
peculiar basic principle, which he named Euonymine, and a new organic
acid, euomic acid (Amer. Journ. Pharm., xxxiv. 387).
Many other American plants have contributed to the wants of the
physician, and have been the subjects of chemical examination, but special
reference to them is necessarily omitted.
We now come to consider the history of the discovery of a compound
which is not only interesting in itself, but is more especially so on account
of its subsequent applications and the important position it now holds in
the medical world. -
In 1831, Dr. Samuel Guthrie, of Sackett’s Harbor, N. Y., a man of
unusual chemical knowledge for his time, discovered a substance which
he prepared by distilling a mixture of chloride of lime and alcohol, and
an account of which he published in the American Journal of Sciences,
Oct. 1831, under the title “A new mode of preparing a spirituous solution
of chloric ether.” In this paper Dr. Guthrie states that in order to ascer-
tain the effect of this substance in full doses on the healthy subject, and
thus discover its probable value as a medicine, he had, during the last
six months, administered it to a great number of persons, not only very
freely, but frequently to the point of intoxication, and that the effects
were grateful both to the palate and the stomach, and he concluded that
“it would seem to promise much as a remedy in cases requiring a safe,
quick, emergetic, and palatable stimulant.” IIis attention was, as he
states, first directed to this subject by a statement in Prof. Silliman’s
Elements of Chemistry (vol. ii. p. 20), then just published, to the effect
that an alcoholic solution of chloric ether, when diluted, was a grateful
diffusible stimulant and might probably be introduced in medicine.
Prof. Silliman distributed samples of this substance to Dr. Eli Ives, of
the Medical Department of Yale College, and to others, to be used in
their practice. Under date of January 2, 1832, Dr. Ives reported that he
had administered it in a number of cases with marked advantage, and
had also used it by inhalation with good results (Amer. Journ. Sci., xxi.
406). The product thus produced by Dr. Guthrie was regarded by him
at the time as the substance then known as “chloric ether” or “ Dutch
liquid,” whereas it was an entirely new and distinct substance, that now
A DD RESS ON MEDICAL C H E MISTRY. 59
known as chloroform. Chloroform was also discovered by Soubeiran, of
France, and an account of it published in February, 1831, under the name
of Ether bichlorique. So, also, Liebig, in 1832, made another independent
discovery of the same substance, naming it Chloride of carbon. It was
named chloroform by Dumas, who discovered its true chemical constitu-
tion in 1834. A committee of the Medico-Chirurgical Society of Edin-
burgh awarded Dr. Guthrie the credit of having first published an account
of its therapeutical effects as a diffusible stimulant in 1832 (Amer. Journ.
Sci. (2) vii. 143).
As this substance afterwards became a prominent agent in producing
anaesthesia, it leads us naturally, but very briefly, to notice the use of
this and other substances inhaled for anaesthetic purposes, and the part
which Americans have taken in a discovery which has proved an inesti-
mable blessing to mankind.
In this memorial year, we naturally follow the years back to the be-
ginning of the century we commemorate, and find that in 1776, or just
one hundred years ago, Dr. Priestley, who had previously made the bril-
liant discovery of oxygen, discovered Nitrous Oxide, which he called Dephlo-
gisticated Nitrous Air. In 1779, Sir Humphry Davy, then a very young
man, entered upon a series of experiments in Bristol with this nitrous air,
which he named nitrous oxide, and on the 11th of April of that year,
made the first inhalation of the gas, and recorded its effects upon himself.
By his investigations he ascertained its exhilarating effect, and discovered
its power, when inhaled, to remove intense physical pain. His remark-
able generalization from his experiments was expressed in the following
oft-quoted words: “As nitrous oxide in its extensive application appears
capable of destroying physical pain, it may probably be used with advan-
tage during surgical operations in which no great effusion of blood takes
place.” (Researches, etc., concerning Nitrous Oxide and its Respiration,
Bristol, June, 1800.) While this suggestion appears to have been for-
gotten, yet nitrous oxide became widely known and used as a stimulant,
and its administration as “laughing gas” was a matter of popular exhi-
bition. In like manner, ether, the date of the first inhalation of which
is in some obscurity, was used for the same purpose in the United States,
as mentioned by the earlier writers on chemistry. In the experiments
with both nitrous oxide and ether, there were cases in which these agents
produced perfect insensibility, but the anaesthetic condition was not spe-
cially observed.
In the fall of 1844, Horace Wells, a dentist of Hartford, having wit-
nessed an exhibition of the inhalation of nitrous oxide, and observed that
a person under the influence of the gas was injured without being con-
scious of suffering, boldly inhaled the gas, and had a tooth removed
without sense of pain, and gave it to others for the same purpose, with
similar results. Thus the suggestion of Sir Humphry Davy in Bristol,
England, published in 1800, was realized by Horace Wells at Hartford,
Conn., in 1844.
In 1846, Wm. T. G. Morton, a dentist of Boston, a former student of
Wells, and aware of his labors with nitrous oxide, commenced experi-
ments with ether for the same end. The administration, in the Massa-
chusetts Hospital, of ether by inhalation to a patient upon whom the
eminent Dr. John C. Warren performed a surgical operation, authenti-
cated it as an anaesthetic agent to the surgical and medical profession,
and from that time the knowledge and practice of anaesthesia extended
rapidly over the world.
60 WO R M LEY,
As already shown, chloroform was employed by inhalation by Dr. Ives,
of New Haven, in his practice in the winter of 1831–32 with marked
benefit. In March, 1847, M. Flourens experimented with this agent
upon lower animals, and in November of the same year the distinguished
Prof. James Y. Simpson, of the University of Edinburgh, employed it as
an anaesthetic agent with success, and introduced it into surgical and
obstetrical practice.
Thus, in summary, we find that anaesthesia, first suggested by Sir
Humphry Davy, in 1800, was demonstrated with nitrous oxide as an
agent, by Horace Wells, in 1844; with ether as an agent, by Wm. T. G.
Morton, in 1846; and with chloroform, by Sir James Y. Simpson, in 1847.
The next American chemical contribution to medicine that we may
mention, is that on the “Origin of Urea in the Body,” by Prof. John C.
Draper, of the University of the City of New York (New York Journal
of Medicine, Feb. 1856). In this paper the author shows the error in the
statement of Liebig that muscular action increases the amount of urea
secreted. The process employed was the decomposition of urea by
nitroso-nitric acid, and weighing the carbonic acid produced as carbonate
of baryta. The results obtained by Prof. Draper have since been verified
by Fick and Wislicenus, but the credit of the first disproval of the state-
ment of Liebig belongs to Dr. Draper.
Dr. Draper has also contributed papers, which may be mentioned in
this connection, on “Products of Respiration,” New York Med. Times,
July, 1856; “Insensible Perspiration,” Proceedings of the New York
Academy of Medicine, May, 1864; “The Heat produced in the Body,
and the Effects of Exposure to Cold,” American Journal Science and
Arts, Dec. 1872.
The last contribution we shall mention in this connection, is a valuable
paper in the department of Physiological Chemistry, entitled “Experi-
mental Researches into a new Excretory Function of the Liver,” by Pro-
fessor Austin Flint, Jr., widely known in the field of experimental phy-
siology. This paper was published in the American Journal of the Medical
Sciences for October, 1862; and afterwards presented to the French Aca-
demy of Sciences, from which it received in 1869 honorable mention and
an award of 1500 francs. The important discoveries put forth in this
memoir were the production of cholesterine in the physiological wear of
the brain and nervous tissue, and its elimination by the liver, and dis-
charge from the body in the form of stercorine. Dr. Flint's researches
and interesting conclusions upon this subject have lately been confirmed
in Germany, by experiments in which cholesteraemia has been produced
in animals by injection of cholesterine into the blood.
TOXICOLOGY.
We now enter upon the other and not less important branch of the
subject assigned us, namely that of ToxicoLOGY: This science is one of the
highest moment to the race. While health and life are assailed by various
diseases, by the ill-adjustment of outward circumstances, such as climate,
locality and the like, by the unsuitableness of food and drink, or by an
excessive use of these, and by a thousand other harmful conditions, these
A D D R ESS O N M E DI C A L C H E M IST R Y . 61
assaults are generally made by slow and noticeable approaches, and are
within the ken of the physician. But there have always lurked in the
inineral and organic kingdoms, foes which may be likened to assassins
who spring upon the unwary and destroy life as by a secret blow. These
assailants are the poisons, the very Thugs of nature.
Before the present century little was known of poisons beyond their
deadly effects and the attending physiological circumstances. Indeed,
any true knowledge of poisons was unattainable until the advent of
Chemistry as an exact science. Poisons are naturally grouped into two
kinds—inorganic and organic.
In noticing the inorganic or mineral poisons, that one which holds the
highest position in historical toxicology, and the one which until recently
has been used as a toxic agent very much more than any other, is Arsenic.
Although known in its metallic state, and as arsenious acid, as early as
the eighth century, to Geber, the Arabian, and although it had been used
as a poison for centuries, yet so little progress had been made in regard
to its chemical detection under these circumstances, that Sir R Christi-
son, as late as 1824, declared that the tests for arsenic at that time in
general use were so fallacious, when applied to complex mixtures, as to
be unfit for medico-legal investigations. He then proposed a process for
the detection of this metal which, as modified by Fresenius and Babo,
continues in use to the present day. At the time of introducing this
method, Prof. Christison remarked that by it he was able to detect the
one-sixteenth of a grain of the poison. This, at the time, was regarded
as a great triumph of analytical skill. Not long before this (1795) Dr.
Black stated that one grain was the least he could detect ; and at a
somewhat earlier period, yet less than a century since (1786), Hahne-
mann stated that ten grains was the least quantity he could recover.
In 1836, Mr. Marsh, of Woolwich, England, proposed for the detection
of this metal, a method which has since been known by his name, and
which has proved of the highest value in chemico-legal practice. As
originally employed by Mr. Marsh, this test was restricted to obtaining
deposits of the metal from the ignited jet of the arsenide of hydrogen;
but in 1841 Berzelius proposed the reduction of the arsenical gas by heat
applied to the exit tube of the apparatus, and it has been found that this
method is even more delicate than that proposed by Marsh. In 1841 Dr.
Hugo Reinsch proposed, for the detection of this metal, his copper test,
which has proved a most admirable method for the recovery of the poison,
especially from complex organic mixtures. In point of delicacy, as now
employed, this test is not inferior to the process of Marsh, and it has in
certain cases even the advantage over the latter in simplicity of appli-
cation. The two tests now mentioned, both in regard to simplicity of
application and delicacy of reaction, leave little or nothing more to be
desired in regard to the recovery and identification of this poison.
One of the first American contributions relating to the detection of
arsenic was by Prof. James F. Dana, a graduate of Harvard University,
who studied chemistry in London, and was afterwards Professor of
Chemistry in Dartmouth College and in the College of Physicians and
Surgeons, New York. As early as 1816, he prepared a paper on the
“Tests for Arsenic,” for which he received the award of the Boylston
prize. In 1818, Dr. Thomas Cooper announced the use of chromate of
potash as a test for arsenic ; but it did not prove to be a distinctive test.
In the same year, he read a paper on the subject before the American
Philosophical Society (Amer. Journ. Sci., iv. 16). In 1830, Prof. John
62 WO RMLEY,
P. Emmet. of the University of Virginia, proposed iodide of potassium
as a test for this metal. In the next year (1831) Dr. Lewis Feuchtwanger
published a paper entitled “Remarks on Arsenic, with drawings of the
color of its precipitates,” in which he gave a full account of the processes
then known for the detection of this poison (Amer. Journ. Sci., xix. 339).
An important and original contribution on this subject was made in
1832, by Prof. J. K. Mitchell, of Philadelphia. In this paper, “On the
Properties of Arsenic,” Dr. Mitchell determined the specific gravity of
the different varieties of arsenious acid; its solubility under various
conditions; and the vaporizing temperature of metallic arsenic and of
arsenious acid (Amer. Journ. Med. Sci., x. 126).
The next contribution to be mentioned is that “On the Detection of
Arsenic in Medico-Legal Investigations,” by Dr. Wm. R. Fisher, of the
University of Maryland, in a paper read in 1836 before the Maryland
Academy of Science and Literature, and published in their Transactions
(vol. i. p. 117). In 1838, Dr. Robert B. Hall published a Summary of
Experiments upon dogs, with hydrated peroxide of iron as an antidote
in arsenical poisoning (Amer. Journ. Pharm., x. 263). And in 1840, Dr.
Fisher, already mentioned, contributed a paper on the same subject
(Ibid., xii. 1). In 1841, Prof. J. Lawrence Smith, of Louisville (to
whom science is indebted for many original researches, and whose special
investigations of meteoric bodies have given him a wide and lasting
reputation), when a student in Paris, prepared a valuable paper On the
Tests and Antidotes for Arsenic (Am. Journ. Sci., 40, 278). Two years
later (1843), Dr. D. P. Gardner, Professor of Chemistry in Hampden-
Sidney College, Va., contributed an elaborate paper On the Application
of Reinsch's test for detecting Arsenic in Medico-Legal Investigations
(Amer. Journ. Sci., 44, 240). In 1862, Charles II. Porter, Professor of
Chemistry and Medical Jurisprudence, Albany Medical College, pre-
sented to the Medical Society of New York an excellent paper entitled
Medico-Legal Contributions on Arsenic, which contains reports of a
number of cases of arsenical poisoning, together with an account of the
methods employed in their chemical examination.
We next notice a very valuable contribution by Prof. John C. Draper,
of the University, of the City of New York, On the Quantitative Deter-
mination of Arsenic, published in the American Chemist for June, 1872.
Professor Draper suggests a modification of Marsh’s apparatus, and the
use of a ribbon of magnesium for decomposing the arsenical solution ;
and, also, the use of a fagot of platinum wire on which the arsenic
forms a coating, the weight of which can be determined. By re-heating
the fagot in dry oxygen, the arsenic is obtained in the form of oxide,
which may be dissolved in water and submitted to the usual tests. In
July of the same year, Dr. Draper published in the same journal a paper
On the Distribution of Arsenic in the Body. Another contribution to
this subject that deserves mention, is a record of The Chemical Testimony
in the Sherman Poisoning Case, by Prof. George F. Barker, of the Uni-
versity of Pennsylvania (Amer. Chemist, June, 1872). This paper con-
tains a detailed account of the methods pursued and results obtained in
the examination of the different tissues submitted for analysis. In this
case, a quantity of arsenic, corresponding to about five grains for the
entire organ, was obtained from a portion of the liver. The bodies of
four (4) of the eleven (11) persons supposed to have been poisoned by
Mrs. Sherman were examined by Prof. Barker, and arsenic found in
each.
A D D R E S S O N M E I) I C A L C H E MIS T R Y . - 63
Having thus noticed the principal American contributions relative to
arsenic, it is proper in this connection to refer to some of the more im-
portant American contributions relating to other poisons.
In 1827, Prof. Robert Hare proposed a method for determining the
presence of opium by the reaction of one of its constituents, mecomic acid,
in striking a red color with a persalt of iron. He asserted that this test
would show the presence of laudanum when only ten (10) drops were
contained in one-half gallon of water (Amer. Journ. Sci., xii. 290). With
but little modification this test is the one employed at the present time
for the detection of opium.
In 1856, Dr. Lewis H. Steiner, of Baltimore, made a report to the
American Medical Association, On Strychnia, in which, in addition to a
discussion of the chemistry of the subject, he gives a detailed history of
the noted case of Dr. Gardner, of Washington, who destroyed himself
with that poison. In a paper On the Chemical Reactions of Strychnia,
published by Dr. T. G. Wormley, in 1859, in the American Journal of
Science, the relative delicacy of the various tests for this poison is
pointed out. The fact that the color-reaction of strychnine is interfered
with by the presence of morphine, having first been noticed by A. W.
Brieger in 1850, this interference is fully considered in this paper, and
the conclusion reached, that the interference increases both with the
relative proportion and absolute quantity of morphine in the mixture
submitted to the test. Another paper to be mentioned in this immediate
connection, is that of Prof. John J. Reese, On the Detection of Strychnia
as a Poison, and the Influence of Morphia in Disguising the usual Color-
test, published in the American Journal of the Medical Sciences for
October, 1861. So also in this connection may be mentioned a valuable
contribution On the Behavior of the Color-test for Strychnine, with other
Vegetable and Animal Proximate Principles, by Dr. Thomas E. Jenkins,
of Louisville, Ky. (Semi-monthly Med. News, April, 1859). The be-
havior of this test with a number of proximate principles other than
strychnine, was first examined in 1856, by M. Eboli, Professor of Chem-
istry at the Academy of Medicine. Lima. Dr. Jenkins so extended this
examination as to include about fifty of these principles; and Prof. Wm.
A. Guy, of London, in 1861 investigated some sixteen additional sub-
Stances. -
Another contribution to this subject is a Report of a Trial for Poison-
ing by Strychnia, by Prof. Geo. F. Barker, recorded in the American
Journal of the Medical Sciences for October, 1864. In this paper Prof.
Barker gives a very complete history of a case remarkable in that violent
symptoms were present in about three minutes after the poison had been
taken by an adult, the effects thus manifesting themselves perhaps more
rapidly than in any other instance yet reported of poisoning by this
substance.
An elaborate paper entitled Experiments of Poisoning with Vegetable
Alkaloids, by Dr. J. H. Salisbury, was published in the American Journal
of the Medical Sciences for 1862. In regard to the limit of the reactions
of poisons and other principles, with chemical reagents, Dr. T. G.
Wormley has contributed papers on the reactions of "the following:
Atropine, Chemical News, London, June, 1860; Brucine, Ibid., July,
1860; Morphine, Ibid., Sept. 1860; Narcotine and Meconic Acid, Ibid.,
Sept. 1860; Corrosive Sublimate, Ibid., Sept. 1830; Veratrine, Ohio
Med. and Surg. Journ., vol. xii., No. 6; Nicotine and Daturine, Ibid.,
vol. xiii., No. 1 ; Solanine, Ibid., vol. xiii., No. 2; Codeine, Meconine,
64 º W ORM I, EY,
Narceine, and Aconitine, Ibid., vol. xiii., No. 4; Conine, Ibid., vol. xiv.,
No. 1; Oxalic Acid, Ibid., vol. xiv., No. 5. -
Mention may next be made of a curious plant, Erythroacylom coca, the
leaves of which have arrested considerable attention because of their use
by the Indians of Peru for the purpose of producing excitement, and
giving strength for prolonged physical exertion. Dr. Samuel R. Percy,
of New York, presented a paper on this subject before the N. Y. Academy
of Medicine, Dec. 2, 1857, and exhibited fine colorless crystals of the
alkaloid of the plant, for which he proposed the name Erythroacyline
(Amer. Med. Times, Nov. 1860). In 1860 Prof. Woehler and Dr. Nie-
man, of Gottingen, obtained the same alkaloid, giving it the name
(2OC(lº,726.
In 1866, Dr. Percy, of New York, presented a paper to the American
Medical Association, On Digitaline, its Chemical, Physiological, and The-
rapeutic Action, for which the Association awarded a prize ; and, in
1868, the same gentleman received a prize from the Alumni Association
of the Medical Department of Columbia College for a paper On Atropia,
its Chemical, Physiological, and Therapeutic Action, with Experiments
instituted to ascertain its Toxicological Properties. In January, 1871,
Prof. John J. Reese, of Philadelphia, published a communication On the
Antagonism of Poisons, in the American Journal of the Medical Sciences,
in which he examined the antagonism of morphia with hydrocyanic acid,
atropia, Strychnia, aconitia, and arsenic, and also of Strychnia with
tobacco, aconite, iodine, and Calabar bean. For the destruction of the
organic tissues, in searching for poisons in medico-legal investigations,
Prof. Henry Wurtz, in 1851, proposed the use of bromine as an agent
possessing certain advantages over the ordinary agents used for this pur-
pose (Silliman's Journal (2), xi. 405).
We now notice a very interesting and valuable paper on Experimental
Researches relative to Corroval and Vao, two new varieties of Woorara,
the South American Arrow Poison ; by Drs. Wm. A. Hammond and
S. Weir Mitchell, published in the American Journal of the Medical
Sciences, July, 1859. This is an original and exhaustive examination
of the physiological effects, and the chemical properties and physical
characters, of these varieties of Woorara. The authors extracted from
both varieties an alkaloid, for which they proposed the name corro-
valia, obtaining it in larger quantity from the variety corroval. This
substance was not obtained in a crystalline state, nor were any of its
salts. One of the authors of the last-named paper, Dr. S. Weir Mitchell,
published in the Smithsonian Contributions, vol. xii. (1860), a very elabo-
rate and complete monograph, entitled, Researches upon the Venom of
the Rattlesnake. This contribution is marked by the same patient and
thorough research which characterizes the other scientific labors of this
original investigator. It considers the anatomy of the venom apparatus,
the physiological mechanism of the bite, the toxicological action of the
venom on warm-blooded animals, and the various antidotes for the poison.
IIis chemical investigations show the toxicological element of the venom
to be a peculiar albuminoid principle, which he names crotaline.
Again, in 1868, Dr. Mitchell instituted a series of experiments on the
Insusceptibility of Pigeons to the Toxic Action of Opium, in which he
showed that this bird was almost wholly insusceptible to the action of
that drug. The same immunity was observed whether the drug itself,
or morphia, was employed, and also whether it was administered inter-
nally or employed hypodermically. In his final experiment, Dr. Mitchell
A. I.) I) RESS O N M E DIC A. L. C H E MIS T R Y . 65
administered to a large pigeon twenty-one grains of powdered opium,
without producing any evidence of opium poisoning (Amer. Journ. of
the Med. Sci., Jan. 1869). Dr. B. W. Richardson, of London, on repeat-
ing Dr. Mitchell's experiments, fully confirmed his results. As a com-
parison of the relative susceptibility of the pigeon and the child, Dr.
Richardson states that a pigeon can receive at once as much opium as
would produce dangerous or even fatal symptoms, if divided equally and
administered to twenty children under one year old, the weight of the
bird being two hundred times less than the combined weight of the
children (Brit. and For. Med. Chir. Rev., April, 1869). Continuing his
researches, Dr. Mitchell extended his experiments to the physiological
effects of the derivative alkaloids of opium, including morphia, narcotina,
thebaia, meconine, codeia, narceia, and cryptopia, employed both inter-
nally and subcutaneously. In these experiments, Dr. Mitchell obtained
Some very interesting and novel results. Thus, he found that while
opium, which is a poison to man, is with difficulty hurtful to the pigeon;
on the other hand, narcotina, which is nearly inert in man, is fatal to
birds (Amer. Journ. of the Med. Sci., Jan. 1870).
We next notice some very original and interesting investigations of
Dr. James Blake, of San Francisco, who has been engaged for many
years in examining the connection between Isomorphism, Molecular
Weight, and Physiological Action (Amer. Journ. Sci. (2) viii. p. 193).
Dr. Blake has investigated the effects of compounds or salts of forty (40)
of the elements, including substances contained in all the more important
isomorphous groups, and in all of these, with the exception of the com-
pounds of potassium and ammonia, finds that when introduced directly
into the blood of living animals, the substances in the same isomorphous
group exert analogous effects; and also that amongst the more purely
metallic elements, the intensity of physiological action is in proportion
to the atomic weight of the substance compared with other substances
in the same isomorphous group. From experiments made by others,
Dr. Blake believes that the same law will apply to organic or carbon
compounds, and that living matter will be found to be a valuable reagent
for elucidating their molecular relations. His latest researches on Lan-
thanium and Didymium place the former evidently in the magnesium
group and the latter with aluminium. These researches, with those of
Drs. Crum Brown and Fraser, and with those of Dr. Richardson, are in
a new field of inquiry, and promise very interesting and important
results to science.
Having thus glanced at the more important American contributions to
toxicology, the way is prepared to take a broader view of this science,
and observe the progress of its development, especially in its chemical
features. This progress will be seen to be greater in regard to the organic
poisons, the marked advance in methods of chemical analysis having
made such progress possible.
At the opening of the present century, the fact that the toxic effect
of certain vegetable poisons was due to the agency of a peculiar active
principle, resident in the plant, had not been determined. The vegetable
substance in which the existence of a principle of this kind was first
observed was opium, in which Sertürner and also perhaps Seguin in 1804
recognized the presence of a new substance; but it was not until 1817
that Sertürner obtained it in a pure state, and examined its properties.
IIe found that the alcoholic solution of this new principle acted upol,
o
66 w or MI, EY,
vegetable colors like solutions of the mineral alkalies, and that the sub-
stance combined directly with acids, forming neutral salts which were
soluble in water, and that it was precipitated from solutions of its salts
by the mineral alkalies. To this substance Sertürner gave the name
morphine, and from the properties just mentioned he regarded it as a
kind of alkali; hence the name vegeto-alkali or alkaloid for principles
of this kind.
Very soon after the discovery of morphine it was found that nux
vomica, white hellebore, cinchona bark, belladonna, tobacco, and certain
other vegetable products which had been long known as capable of
exerting marked physiological effects, owed their activity to the presence
of similar alkaline principles. The number of such natural principles
now known is quite considerable. Since 1848 a great number of organic
alkalies have been obtained artificially, some of which rival potash and
soda in the degree of their alkalinity. The study of these artificial
alkaloids has thrown much light upon the constitution of the natural
alkaloids, which is, as yet, imperfectly understood.
The discovery of the natural alkaloids has been of great service to the
physician, giving him a more concentrated and manageable form of me-
dicine; but to the toxicological chemist this discovery has been of the
very highest value, enabling him in cases of poisoning by crude vegetable
substances, in just so far as he can recover the alkaloid or active principle
from complex mixtures (such as the contents of the stomach), and can
separate and determine it by special chemical properties, to identify the
toxic substance employed. There are, however, many vegetable and
animal poisons, the exact nature of the active principle of which has not
yet been determined.
Formerly, about the only method of detecting vegetable poisons was
by means of the physical and botanical characters of the subtance taken,
such as the leaves, seeds, etc., and this method is yet of service in furnish-
ing corroborative evidence in cases even in which the nature of the pecu-
liar principle is known. It is obvious that in poisoning by crude vege-
table and animal substances, we can determine the presence of the poison
by chemical methods only, first, when we know that the substance con-
tains an alkaloid or other principle peculiar to itself; second, when we
are able to recover this principle from complex mixtures; and third,
when we are acquainted with one or more chemical reactious character-
istic of this principle. Thus, in poisoning by opium, we cannot prove
the existence of opium as a whole, but only inferentially, by proving the
presence of a principle peculiar to this drug. Our success in the dis-
covery of organic poisons, where the existence of a peculiar principle is
already known, depends largely on our ability to recover such principle
from complex mixtures in a state sufficiently pure for the application of
special tests.
It was not until 1851 that any real progress was made in this direction,
when Prof. Stas, of Brussels, introduced a systematic method for such
recovery. This method has proved of the highest importance, and marks
an era in toxicological Science. It is based upon the fact that the salts
of the alkaloids, as a class, are soluble in water and alcohol, but are in-
soluble in ether; and that these salts when in solution are readily decom-
posed by the mineral alkalies with the elimination of the alkaloids, which
in their free and uncombined state are more or less readily soluble in ether.
In any given case therefore, in so far as the active principle or alkaloid
A D D RESS O N M E DIC A.L C H E M IST R Y. 67
is soluble in ether, and this liquid fails to extract foreign animal and
vegetable matter, in just so far can we obtain the alkaloid in its pure
state. Professor Stas successfully applied his method for the recovery of
the principal alkaloids likely to be met with in chemico-legal investiga-
tions, employing for this purpose the usual extracts of the plants in which
they are found. Professor Otto, of Brunswick, proposed to modify the
method of Stas, in the case of the fixed alkaloids, by first washing the
acid aqueous solution of the alkaloidal salt with ether as long as this fluid
was colored ; the solution is then rendered alkaline and the liberated alka-
loid extracted with ether as before proposed. Professor Otto claimed,
and justly, that in this manner the alkaloid might be obtained in a state
of greater purity, and almost invariably in a crystallized condition.
In 1853, Professors Graham and Hoffman, of London, proposed a method
for the recovery of strychnine from organic mixtures, which was after-
wards extended to other alkaloids; it is based upon the fact that when
a solution of strychnine in its free state is agitated with charcoal, the
charcoal absorbs the poison and yields it up to boiling alcohol (Quart.
Journ. Chem. Soc., 1853). In practice, in chemico-legal investigations,
this method is inferior to that of Stas. In 1856, Messrs. Rogers and
Girdwood, of London, proposed the use of chloroform instead of ether,
as advised by Stas, for the extraction of the alkaloids. They also pro-
posed to destroy the last traces of foreign matter by charring the chloro-
form residue with concentrated sulphuric acid over a water-bath (Lancet,
London, June, 1856). The use of chloroform as advised by these gentle-
men has proved of value in researches of this kind, since it is a better
solvent of most of the alkaloids than ether, and has therefore an advan-
tage in certain cases; but, on the other hand, it has sometimes the dis-
advantage of taking up more freely than ether foreign animal and vege-
table matters. Another method for the extraction of the alkaloids from
complex mixtures is that of Usler and Erdmann, who proposed the use
of amylic alcohol, the principle of the process being much the same as in
the method of Stas. Amylic alcohol is especially adapted to the recovery
of morphine, solanine, and certain other alkaloids, which are more or less
freely soluble in this liquid, whereas they are but very sparingly soluble
both in ether and chloroform, and therefore are but imperfectly extracted
by these liquids.
In 1862, Professor Thomas Graham, of London, in his very important
contribution on liquid diffusion, showed that moist organic membranes
have the remarkable property of separating crystallizable substances when
in solution from such as are uncrystallizable, the former readily passing
through such membranes when surrounded by a liquid, whereas the latter
fail to pass or pass only very slowly. These classes of substances he named
respectively crystalloids and colloids, and to this method of separation he
applied the term dialysis. This method is applicable to both inorganic
and organic bodies, and is often found very useful in toxicological inves-
tigations.
The latest contribution to this department of research is that of Prof.
Dragendorff, of the University of Dorpat, who, in 1868, proposed a very
elaborate and exhaustive method for the extraction of the alkaloids and
similar principles, and for their separation from each other, based upon
their behavior with petroleum-naphtha, benzole, chloroform, and amylic
alcohol, dividing them into several groups according as they are affected
by these different liquids under certain specified conditions.
68 WO RMLEY,
From this brief historical sketch, we learn that very considerable
attention has been directed to this important and essential part of toxi-
cological chemistry; and, it may be added, the results have been such as
to leave little to be desired in regard to the recovery of a large number
of organic poisons. We are now prepared to take a rapid survey of the
progress made in regard to the special identification of poisons by chem-
ical and other tests. Even less than a third of a century ago, there were
but few of the organic poisons for which special and unerring tests were
known, especially when present in the minute quantity usually met with
in chemico-legal investigations.
In September, 1843, E. Marchand made the important discovery that
if strychnine be treated with concentrated sulphuric acid containing a
little nitric acid and peroxide of lead, it dissolves with the production
of a series of colors peculiar to that alkaloid. The tests employed for
the detection of this poison prior to the discovery of this color reaction,
which has since been known as the color-test, gave reactions more or less
common to substances other than Strychnine. In fact, this color-test is
the only one yet known the reaction of which, taken alone, is peculiar
to strychnine. It was considered a marvel of delicacy of reaction when
Marchand announced that this test would reveal the presence of a quan-
tity of strychnine not exceeding the one-thousandth of a grain in weight.
This test has since been modified by Mack, Otto, and others, by substi-
tuting for the nitric acid and lead compound other oxidizing com-
pounds; and it will now, in the hands of a skilful manipulator, show the
presence of strychnine when in quantity not exceeding, perhaps, the one-
millionth of a grain.
The discovery of this test did much to stimulate chemists to search for
special or characteristic tests for other alkaloids and vegetable principles
likely to be encountered in chemico-legal investigations, and in many
instances with success. Much remains, however, to be done in this
direction, even in regard to some very well known poisons of this class.
There are some poisons, the presence of which may be determined by what
is known as a combination of tests, no one of which is in itself peculiar
or exclusive; but there are others for which we have as yet neither
peculiar and distinctive tests, nor any peculiar combination of tests for
their detection, especially when present in minute quantity.
It is less than a quarter of a century since the aid of the microscope
was, to any marked extent, invoked in this department of research, yet
within this comparatively brief period its use has very greatly extended
our means of determining the specific nature of the results of chemical
tests. This instrument not only often enables us to determine the true
nature of a precipitate or sublimate by its crystalline or other form, the
character of which would otherwise be doubtful, but it enables us to
recognize and identify certain substances when present in quantities so
minute as to be far beyond the reach of the ordinary methods of exami-
nation. Thus by micro-chemical analysis we are able to identify with
absolute certainty the reaction of the one hundred thousandth part of a
grain of hydrocyanic acid, and of certain other poisons in quantity
equally minute. Even a sublinnate, consisting of a few crystals, each of
which does not exceed the one hundred millionth of a grain in weight,
may, under certain conditions, serve to characterize the presence of
arsenic beyond a question of doubt. The chief contributors to the micro-
chemistry of poisons have been Professors Guy and Taylor, the eminent
A. I.) I) RESS O N M E DIC A.L C H E M IST R Y . 69
toxicologists of England; Drs. Helwig and Earhard, of Germany ; and
Professor Wormley, of the United States.
For the final purification and subsequent examination by means of the
microscope either directly or under the action of reagents, the process of
Sublimation has been proposed, as applicable to both inorganic and
organic substances. In 1858, Professor Wm. A. Guy, of London, called
special attention to the process of sublimation for the detection of arsenic,
corrosive sublimate, and certain other inorganic poisons; and in 1865,
Dr. Helwig, of Mayence, announced that in like manner certain alkaloids
and vegetable principles furnished sublimates, some of which were cha-
racteristic in their microscopic forms and in their behavior with reagents,
and he gave photographic illustrations of many of the forms thus
obtained. In 1867, Dr. Guy modified somewhat Helwig's method,
extended it to a much larger class of objects, and proposed to add to the
diagnostic value of the method by a simple arrangement for noting the
temperature at which changes in form and color, and sublimation itself,
OCCUll’. *
The brilliant discoveries of Bunsen and Kirchhoff, in 1859, which
enable us by means of spectrum amalysis to recognize and identify with
unerring certainty the elementary forms of matter and certain com-
pounds, even when present in quantities so minute as to be far beyond
the reach of the ordinary methods of analysis, have not been without
some fruit in the department of chemico-legal investigations. Thus Dr.
Bence Jones found by this method thallium in the liver, when the ordi-
nary chemical tests failed to reveal its presence.
It is a proof of the great activity and sagacity displayed in modern
science that the spectroscope with its amazing capabilities should so soon
be combined with the microscope, an instrument of scarcely less capabili-
ties, thus forming the micro-spectroscope, by which we are enabled to
make new discoveries of the highest value in Medico-legal Chemistry.
For this combination of the two instruments we are chiefly indebted to
Mr. H. C. Sorby, who has with its aid determined the spectra of a large
number of organic coloring principles when in solutions. One of the
most important applications of this instrument thus far made in legal
medicine, is that for the detection of blood, its delicacy being such as,
according to Mr. Sorby, and as confirmed by our own observations, to
reveal the presence of a single corpuscle, or less than the one thirteen mil-
lionth of a milligramme, or one five hundred millionth of a grain, of that
fluid. Although this method will serve to discriminate the coloring
matter of the blood from other coloring principles, yet it does not enable
us to distinguish the blood of any one animal, including man, from that
of another. This, however, can be done within certain limits, but only
within certain limits, by means of the microscope; this instrument
enables us to specify with great certainty certain animals, even of the
same class, from which the blood was not derived, but it does not enable
us to positively individualize the animal from which it was derived.
Our discussion of toxicology would be very incomplete without some
notice of the subject of the absorption of poisons. Prior to the important
discoveries of Magendie on venous absorption, in 1809, it was believed
that all poisons produced their effects by impressions transmitted through
the nerves. The chief argument in support of this view, was that the
rapidity of action of certain poisons was incompatible with any other
mode of transmission. Dr. Blake successfully met this argument, and
showed from experiments that sufficient time elapsed for absorption even
70 WORMLEY,
in the case of those substances the most rapid in their action, such as
hydrocyanic acid and conine. Through the labors and experiments of
Dr. Blake, Sir Benj. Brodie, Sir Robert Christison, M. Bernard, and
other physiologists, the views of Magendie were confirmed, and it was
accepted that the entrance of the poison into the blood was a condition
essential to its action.
That certain substances were absorbed and widely distributed, was
early observed from the color imparted to various tissues of the body,
and to the urine, by certain coloring principles, as indigo, picric acid,
and the like; and by the characteristic odor perceived throughout the
body in poisoning by prussic acid and other odorous substances. When
we consider how minute is the quantity of certain poisons required to
destroy life, the imperfect character of the methods of analysis early
employed, and the fact that certain poisons may soon pass beyond
recovery, it is not surprising that the progress in recovering poisons from
the blood and tissues was somewhat slow. We find, however, that in
1821, Tiedeman and Gmelin found lead, mercury, and barium in the blood
of animals poisoned by salts of these metals; that, in 1827, Woehler
recovered certain administered poisons from the urine; and that, in 1829,
Wibmer satisfactorily proved the presence of lead in the tissues of
animals poisoned by that metal. It was reserved, however, for Professor
Orfila, whose original and profound labors in this department have
brought honor upon science, to show the absorption and distribution of
arsenic throughout the animal body. In January, 1839, this distin-
guished investigator announced to the Parisian Academy of Medicine,
that in poisoning by this substance, the arsenic diffuses itself in such
quantity that it may be recovered by chemical methods from the blood,
tissues, and various secretions of the body. In 1840, he proved these
facts to the satisfaction of a committee of the Academy. This discovery
inaugurated a new era in medical jurisprudence. Subsequently, Orfila
proved that the same wide distribution of poison throughout the body
held in regard to mercury, antimony, lead, and other metallic poisons.
It has generally been believed that in the absorption of metallic poisons,
and in their deposition in the soft tissues of the body, a larger proportion
is to be found in the liver than in any other part, the least proportion
being found in the muscles; but, according to the quite recent researches
of M. Scolosubroff, absorbed arsenic, both in acute and chronic poisoning,
is deposited specially in the nervous system. Thus, if the quantity found
in the fresh muscle be taken as 1, that in the liver is 10.8; that in the
brain 36.5; and that in the spinal marrow 37.3 (Ann. d’Hygiène, Jan.
1876). Under the present improved methods of analysis, it now rarely
happens, in cases of poisoning by mineral substances, that the poison
cannot readily be detected in the various organs and tissues of the body;
yet it is well known that even in this kind of poisoning the toxic agent
may be entirely removed from the body prior to death.
Our experience in regard to the recovery of the vegetable poisons has
not been so satisfactory. While there are some of this class which may
be readily detected in the blood and tissues, and others that have been
found only rarely, there is still a large number that have never as yet
been found in the absorbed State.
That all the organic poisons enter the blood and are diffused through-
out the body is no longer doubted. The first instance of the recovery of
a vegetable alkaloid, after it had undergone absorption, was announced
by Stas, as late as in 1845, and less than a third of a century ago; in this
A D D R E S S O N M E DIC A. L. C H E M IST R Y . 71
case he recovered morphine from the viscera of a body that had been buried
for thirteen months. Many instances have occurred since, however, in
which, even under more favorable conditions, there has been a total failure
to recover this alkaloid from any part of the body. So, also, in 1851, Stas
detected nicotine in the blood of a dog poisoned by that substance, employ-
ing his ether process for the extraction of the alkaloid.
Perhaps no one circumstance did so much to call the attention of toxi-
cologists to the subject of the detection of the vegetable poisons in the
blood and tissues, as the remarkable trial, in London, of Palmer for the
poisoning of Cook by Strychnine, in 1856. Prior to May, 1856, according
to Prof. A. S. Taylor, in no instance had strychnine been recovered in an
absorbed state from the blood, tissues, or soft organs of the body. This
trial directed special attention to this poison, and led to its more careful
investigation, and from that time instances of its recovery after absorp-
tion have become quite frequent. In fact, under the recent improved
methods of analysis, a failure to recover this poison in its absorbed state,
should rarely happen. Since this time, chemists have been gradually
adding to their triumphs in this important department of research, and
now authentic instances have been recorded of the recovery and identifi-
cation by chemical tests, of at least the following alkaloids: morphine,
nicotine, Strychnine, brucine, atropine, daturine, veratrine, jervine, and
comine. It may be added, that considerable difference exists in regard to
the readiness with which the different poisons just mentioned may be
recovered when in the absorbed state.
That all poisons, except those endowed with corrosive action, have to
enter the circulation in certain quantity before producing their peculiar
effects, is now universally conceded. We may now inquire what is known
of the mode or manner in which when diffused in the blood they destroy
life. It is well known that some poisons produce an appreciable change
in the physical and chemical properties of the blood, as shown in the
difference of color and consistency of that fluid. These changes are well
marked in the cases of sulphuretted hydrogen, prussic acid, carbonic acid,
chloroform, and comine, under the action of which the blood becomes
more liquid and of a darker color. In most of these cases the poisoned
blood, when examined by the spectroscope, gives the spectrum of deoxi-
dized blood.
It was long since observed that certain poisons on being introduced
into the blood were either wholly, or in great part, decomposed. Thus,
Sir R. Christison failed to obtain any chemical evidence of the presence
of oxalic acid in the blood of the vena cava of a dog, killed in thirty
seconds by the injection of eight grains and a half of that poison into
the femoral vein. Even with the improved methods of analysis, chemists
have never yet been able to recover this poison, as such, from the blood.
In some cases we can very clearly trace the changes which take place in
the substance absorbed by the blood. Thus Erdmann and Marchand, in
1842, found that cinnamic acid was converted during its progress through
the animal system into hippuric acid; and in 1862, Dr. Letheby found
that under like conditions nitro-benzole was changed into aniline. In
like manner it has been found that hydride of benzole is changed into
benzoic acid, which in its turn becomes converted into hippuric acid. In
1832, Liebig showed that hydrate of chloral under the action of an
alkali, was changed into chloroform and formic acid; and in 1868,
Liebrich showed that the same change took place when this substance
72 W ORM LEY, ADDRESS ON MEDICAL CHE MISTRY.
entered the blood by absorption, and to this change is attributed the
peculiar sedative effects of chloral.
Even in regard to the action of strychnine, brucine, morphine, vera-
frine, nicotine, and certain other organic poisons, which may be recovered
from the blood in their unchanged state, it has been claimed by some that
they are changed in part at least before they produce their toxic effect,
but of this there is no direct proof. When we consider the extremely
minute quantity of substances of this kind which may destroy life (a
quantity sometimes certainly not exceeding in weight the one three
hundred thousandth part of the blood), and the ready demonstration of
their presence in the blood after death, it would appear that in certain
instances at least, the fatal issue is not dependent upon the decomposi-
tion of any part of the toxic agent.
Although the various facts that have been presented are of great value
and interest, yet it must be admitted that the whole subject of the final
action of poisons is left in great obscurity. While it is believed by all
that poisons are absorbed and taken into the circulation, it is found that
only some produce any marked changes, physical or chemical, in the
blood ; and on the other hand, while some poisons are themselves decom-
posed in that liquid, yet others equally fatal, appear to suffer little or no
change. We may trace the destroyer in all its subtle insinuations through
the blood and tissues, and see life quickly driven from the body, but we
know not where nor how the fatal stroke is given. These are questions
which modern science, with all its refined methods of research, has left
unanswered.
In conclusion, it may be said that the field in which the toxicological
chemist labors, is one of the highest responsibility. He must not only
be consecrated to his science, know all its best methods, and be able to
practise them in all their most delicate and skilful manipulations; but
he should have a higher consecration to truth, ever remembering that in
toxicological jurisprudence his words should be weighed in balances even
more delicate and exact than those in which he weighs his material sub-
stances. Human life on the one hand, and the security of society and
the vindication of law on the other, may hang upon the slender thread
of a chemical reaction, or tremble in the final adjustment of a most deli-
cate instrument. The highest skill, and a regard for truth that knows
no shadow of turning, can alone fit the toxicological chemist to meet the
grave responsibilities of his profession.
73
ADDRESS ON SURGERY.
* BY
PAUL F. EVE, M.D.,
PROFESSOR OF OPERATIVE AND CLINICAL SURGERY IN THE UNIVERSITY OF NASH WILLE.
GENTLEMEN OF THE INTERNATIONAL MEDICAL CONGRESS:
THE language of the Aborigines of America has ever been admired for
its simplicity and significance. In the State of Mississippi, itself imply-
ing the father of all waters, is a County called Itawambi, derived from
the title given an Indian Chief, upon whom all possible honors had been
conferred, so that nothing more could be done for him. Standing here
this day, the representative of the most demonstrative and efficient de-
partment of the healing art; the recipient too of many unmerited favors;
fully conscious of the inability to do justice to the subject proposed,
or satisfactorily improve the illustrious occasion—an event without pre-
cedent, and which no living man will ever see again—language fails to
convey or words express what is now felt. With all the simplicity of
the Indian and the sincerity of the Christian, I would say to you, my
professional brethren, who have done so much for me, Itawambi.
Precisely fifty years ago, he who is now to address you, landed on
Chestnut Street wharf of this city, enquiring for the office of the late
distinguished accoucheur, Charles D. Meigs, to become his private pupil;
fifty years before that, his father, born in Philadelphia, had been the
associate of Rush, Shippen, and James; and now, at the end of those
hundred years, the son is invited back to declare before this Interna-
tional Medical Congress, and at the celebration of the first Centennial of
these United States, what his countrymen have done for Surgery. Here
too in the Medical Department of the University of Pennsylvania, the
first chartered Medical College on this Continent, where so many have
been taught by Rush and Chapman, Hare and Jackson, Physick and
Gibson. To me it is but the coming back to my dear old Alma Mater.
Surely “There's a divinity that shapes our ends, rough hew them how
we will.”
“God moves in a mysterious way,
His wonders to perform ;
He plants his footsteps in the seas,
And rides upon the storm.”
A mere enumeration of what we have contributed to Surgery, even
were that possible during the hour assigned to the subject, might not
prove the most profitable occupation of it; and moreover, while this may
be the Centennial of our National existence, it is not that of our profes-
sion; for, as is well known, the War of Independence left us an impover-
ished people, almost destitute as regards the sciences, certainly without
any peculiar medical literature. Even the reputed father of American
Surgery was not admitted a house-surgeon in St. George's Hospital,
London, though a private pupil of the celebrated John Hunter, until
74 EVE,
1790; nor was he elected Professor of Surgery in the University of Penn-
sylvania until 1805. It was as late, too, as 1820, forty-four years after
the Declaration of Independence, that the taunt was uttered, with pro-
bably as much truth as sarcasm, “what does the world yet owe to an
American Physician or Surgeon l’’ Then again, all our early teachers
had of necessity to be educated abroad, so that in the very nature of
things no national characteristics could have been given to medicine
until years after the colonies became the United States. Notwithstand-
ing all this, in a little over fifty years, the sarcasm of Sydney Smith was
answered by a professor of Surgery in the city of Paris, M. Chassaignac,
remarking as is said to an American medical student, “Sir, you ought
to be proud of your country, for at this moment she holds the sceptre of
Surgery in the world.”
He whom we have ever regarded as the father of American Surgery,
PHILIP SYNG PHYSICK, was born in Philadelphia in 1768, and was there-
fore only eight years old at the declaration of our Independence ; he
graduated in the literary department of the University of Pennsylvania,
received his diploma at the Royal College of Surgeons, London, and the
degree of doctor of medicine in Edinburgh, in 1792. Returning home
soon after, the appearance of yellow fever, for the first time in Philadel-
phia, brought him prominently before the public. For services rendered
the city hospital in 1794, Dr. Physick was presented with silver plate
valued at one thousand dollars.
As early as 1794, he recommended curved forceps holding a needle to
secure deep seated arteries. In 1802, he proposed the Seton for ununited
fractures. In 1836, Mr. Liston gave him credit for this valuable sugges-
tion; and in the Contributions to Practical Surgery, published by Dr.
Norris, formerly Surgeon to the Pennsylvania Hospital, in 1873, the
seton and its modifications are declared to be safer, speedier and more
successful than resection or the caustic.
In 1809, Dr. Physick by a suture removed the projecting duplicated
portion of the intestine in Artificial Anus, and thus re-established the
integrity of the alimentary canal. Dupuytren’s enterotome has since
somewhat supplanted the Seton.
Physick improved Desault's splint by extending it higher up on the
fractured side, thus making extension and counter-extension more in the
axis of the broken limb. He was among the first to apply animal liga-
tures; employing buckskin for this purpose, while his nephew and favor-
ite pupil, Prof. Dorsey, preferred French kid deprived of its tanned cuticle,
a substance with which he successfully ligated the femoral artery. Deer
sinew torn into shreds of suitable size for the vessel to be ligated, is pre-
ferred by others, though silk is generally employed. Animal ligatures
certainly irritate less, are readily absorbed, and thereby promote reunion
of wounds. In the use of them for some forty years, though not exclu-
sively, the knot of a deer sinew has never been seen, while the metallic
ligature or suture ever remains a foreign body in the flesh.
Dr. Physick was the first to employ blisters in gangrene threatening
mortification, as in anthrax, or over an inflamed vein The late Prof.
Chapman, long his colleague in the University of Pennsylvania, published
a case in which he attributed the life of the patient to this suggestion.
He improved the gorget, an instrument employed in his day in litho-
tom V.
#. invented the tonsillotome, in 1848, by which a hazardous operation
A D D RESS ON SU R G E R Y . 75
has been greatly simplified and made safe. Formerly, attempts were
made to cut out the entire tonsils at the imminent risk of fatal hemor-
rhage, or they were painfully strangulated with a double canula. For-
tunately the day has passed for the total excision of these bodies, except
when malignant. Intra or extra-oral this is a dangerous proceeding. In
a recent attempt twelve arteries had to be tied ; now we are content to
remove the projecting portion beyond the lateral half arches of the fauces.
When reminded that it is the internal carotid which is exposed in these
operations, the value of Dr. Physick’s method must be greatly enhanced.
Of course the recent modifications of the tonsillotome, some of them
quite ingenious, are due to the original forceps containing his concealed
blades. º
Dr. Physick early advocated putting inflamed joints and diseased bones,
as in cases of coxalgia, caries of the spine, etc., in perfect repose, as if in
splints.
To him also Monsieur Reybard, then surgeon to the hospital of Lyons,
France, declares that the profession is indebted for the first accurate
account of cystic or Sacculated rectum, which he described in the early
part of the present century ; Reybard moreover asserts that to Dr.
Physick was due the starting point of all improvement which has been
made in the treatment of abnormal anus.
It fell to his lot to remove successfully, in one case, a greater number
of urinary calculi than has ever been done before or since in Surgery.
They amounted to upwards of a thousand, varying in size from a small
bean to a bird shot. The patient, who was quite aged, held at the time
the office of Chief Justice of the United States, and subsequently resumed
his seat on the bench.
A striking proof of Dr. Physick’s great influence even in Europe was
the fact that, when his nephew, then the Professor of Anatomy in the
University of Pennsylvania, published his Elements of Surgery, in two
volumes, containing, as was well known, the peculiar views and practice
of his uncle, that work, the first of the kind ever issued from the Ameri-
can press, actually became the text-book of Surgery in the University of
Edinburgh ; which was certainly a high compliment to our distinguished
countryman.
Physick's name has ever been the most familiar and favorably known
of all American surgeons in Europe; and, in 1825, he was elected a mem-
ber of the Royal Academy of Medicine of France. He was also an early
advocate of conservative Surgery; was a favorite pupil of the renowned
John Hunter, the great anatomist, physiologist, and surgeon. As he
grew older, Dr. Physick became more chary with instruments, and trusted
more to the recuperative powers of nature. Of him, it has been said,
that he never spilt a drop of blood uselessly, nor wasted a word in his
lectures. With the simplicity of a child, the modesty of a maiden, the
industry and integrity of a martyr, he quietly worked out a surgical
character which will endure so long as his loved science shall be culti-
vated.
Intimately connected with the origin, rise, and progress of Surgery in
America, were four other professional gentlemen, the contemporaries of
Dr. Physick, who were long spared beyond the allotted period of man on
earth, as if to illustrate in their lives and characters the benefits of tem-
perance, industry, and benevolence. These were Warren, Mott, Dudley,
and Gibson, whose average age was eighty-three years.
76 EVE,
There were three distinguished Drs. Warren, of Boston, Mass.; Joseph,
the early martyr of American Independence, was the senior, the most
talented, most patriotic, most heroic. He it was who fell—musket in
hand, having declined the position of commander-in-chief—at Bunker's
Hill. Dr. John Warren, his brother, studied medicine under him, and
graduated in letters in 1771. He gave the first course of dissections in
Boston, which, no doubt, led to the organization of the Medical De-
partment of the well-known Harvard University, in which he was the
Professor of Anatomy and Surgery for a quarter of a century. His son,
the third of the name, JoHN CollTNS WARREN, was born in 1778, and
died in 1856. After the advantages of a thorough education in this
country and Europe, he succeeded his father in 1815. He was a liberal
contributor to our literature, and author of a work on Tumors, which is
Said to have shed lustre on our science. His last contribution was pub-
lished when in his seventy-seventh year. He was the first to operate on
a patient put in the anaesthetic condition from ether, and was thereby
connected with one of the greatest professional events in the world. Of
him Velpeau declared that he first performed the operation for dropsy
of the pericardium, for he declared that of all the cases then published,
his alone was worthy of full credence; and well he might, for the War-
rens were ever the soul of integrity. Mr. George Pollock, in the Me-
dico-Chirurgical Transactions of London for 1838, gives credit to Dr.
Warren for first closing the fissure in the vault of the mouth. Of him
and his son, J. Mason Warren, the worthy representative of the family,
and, we deeply regret now to add, deceased, Sir Wm. Fergusson, the
prominent worthy representative of British Surgery, recently declared
that in regard to the claim of priority in operations for cleft palate, “the
first idea I had of this portion of the operation was obtained from
• Mason Warren. I deem it but fair,” he continues, “to the reputation of
that distinguished surgeon to state that I know of no originality before
his, and that I look upon all modern claims to such originality as arising
either from ignorance or the desire to rob the fair reputation of a name,
which in son as in father, will stand for generations among the brightest
in Surgery.” It is certainly a nice point to decide which is the most
honored, he who utters such magnanimous sentiments, or the recipient
of so disinterested a compliment.
VALENTINE MOTT, a native of Dong Island, near the city of New
York, was born in 1785, graduated in 1806, and went immediately to
Europe, where he remained pursuing his professional studies three years.
On his return home he was elected in rapid succession to the chairs of
Surgery in Columbia University, Rutgers Medical College, and the Col-
lege of Physicians and Surgeons, all in the city of New York. When
only twelve years in practice he performed one of the boldest, most ori-
ginal, and difficult operations in Surgery, one too, never attempted before,
and yet, to the wonder and astonishment of the profession, the patient
survived to the twenty-sixth day, and then died, in our opinion, from im-
prudence in being permitted to exercise in the hospital grounds. Dr.
Mott first tied successfully the common iliac artery, doing this in 1827.
He first exsected the clavicle, tying, as he said, Over forty arteries, besides
the external jugular vein twice, and dissecting out the thoracic duct from
the diseased mass. This, which he always considered his most formid-
able operation, required four hours for its performance. Dr. Gross adds
that, as a brilliant and daring operation, it is without a parallel in the
A DI) RESS O N S U R G E R Y . *
77
annals of Surgery. Dr. Mott was the first to exsect the inferior maxilla,
except its articulations, doing this successfully in 1833. He is said to
have tied the carotid fifty-one times, and to have amputated about a
thousand limbs. Dr. Gross declares that no surgeon, living or dead, ever
tied so many vessels or so successfully, whether for the cure of aneurism,
the relief of injury, or arrest of morbid growth. And of him, England's
greatest Surgeon, Sir Astley Cooper, generously confessed that Dr. Mott
had performed more of the great operations than any man that ever lived.
His axiom too, through life, was the liberal one of operating in every
case which allowed a rational hope of success, either to improve the
patient’s appearance or to preserve life. No one probably ever handled
an instrument more gracefully, was more nimble fingered, or more skil-
ful than the late Valentine Mott. As an operator, he was probably never
Surpassed. -
BENJAMIN WINSLow DUDLEY, the great Surgeon of the West, was a
native of Virginia, born in 1785, the same year, and graduated the same
time that Dr. Mott did, viz., in 1806; he, however, in Philadelphia and
the latter in New York. Dudley also spent years in Europe, chiefly
under Cline, Abernethy, and Cooper in London, and Larrey, Dubois,
and Boyer in Paris. Soon after returning home, he organized the Medi-
cal Department of the Transylvania University, at Lexington, Kentucky,
in which he occupied the chairs of Anatomy and Surgery, and was ever
its ruling spirit. Dr. Dudley was the strenuous advocate of thoroughly
preparing for all operations; and taught that if the chylopoetic viscera
were properly cared for they would provide for the rest of the system.
He gave little medicine, but insisted upon the observance of hygiene,
diet, rest, travelling, and even sea-voyages. An Englishman, alluding
to Dr. Dudley, is said to have remarked that it had been reserved for a .
backwoodsman of America to teach how to prepare the patient for a
capital operation. He justly claims to have first cured a case—and it was
a formidable one too—of intracranial aneurism by due preparation and
ligature of the carotid. No one ever did so much with the roller—re-
lying upon it even in fractures—of which he was emphatically the master.
He was best known, however, as the lithotomist of the West, if not of
America. We unfortunately have no statistics of his operations. If a
record of his cases operated upon was ever kept, it must have been lost
during the late war. We know that he used the gorget, and he is said
to have cut two hundred and twenty-five patients, only six of whom are
known to have died. He was truly a surgeon of the conservative school,
and was for years the surgical patriarch of the West.
WILLIAM GIBSON was born in Baltimore, Maryland, in 1784, and after
receiving a classical education went abroad. He took his medical degree
in Edinburgh, and through the friendship of Sir Charles Bell obtained
extraordinary advantages. He was at Corunna, Spain, when Sir John
Moore fell, and at Waterloo, where he himself was slightly wounded.
It was he too who extracted the ball from Gen. Scott, long after the battle
at Lundy’s Lane. He had met Sir Astley Cooper, Sir Henry Halford, Aber-
nethy, Baron Dupuytren, Napoleon Bonaparte, Velpeau, Lord Byron, and
other celebrities. Such was his influence in the profession, that, upon the
death of Dr. Dorsey in 1818, Dr. Gibson, though Professor of Surgery in
the University of Maryland, actually secured that professorship in the
University of Pennsylvania, which was then occupied by the father of
78 EVE,
American Surgery, Dr. Physick consenting to take the chair of Anatomy
with an adjunct. Dr. Gibson was probably the best lecturer on his branch
in the United States; in addition to oral instruction, he illustrated his
course by splendid collections of paintings, models, and other appliances.
His memory was so retentive that he had been known to repeat three
hundred lines of Virgil. He was also a bold and successful operator; he
was the first to tie the common iliac artery, for a gunshot wound in the
streets of Baltimore, the patient surviving thirteen days. He also per-
formed the Caesarean operation twice upon the same patient, saving each
time the mother and child; an operation since repeated by Drs. William
Byrd Page, and John Neill, with like success, so that the good city of
Philadelphia has been peculiarly favored in this respect. Much has
recently been said—this being the Centennial year—of those who first
rocked the cradle of American Liberty; but not a word in commendation
of those, who resorted to such extraordinary measures, to keep in motion
the little one called into requisition at each accession to her infant
population. Alas! for the glory of poor doctors.
In the brief biographical sketches of those to whom we are so much
indebted for the present position of Surgery in our country, reference has
been made to what they did on the kindred subjects of Aneurism and
the Ligation of Large Arteries; and while we may not yet report a
successful tying of the aorta, notwithstanding the encouragement implied
by finding that vessel occasionally obliterated, and the success by compres-
sion reported by Dr. Murray, of Newcastle-upon-Tyne, England, we can,
nevertheless, quote what Mr. Erichsen, the well-known author and sur-
geon, has recently published—“the bold and difficult operation of arrest-
ing the circulation through the brachio-cephalic, is one of the most
remarkable, and the only one found recorded in the annals of Surgery”
—referring to what was done by Dr. Andrew Woods Smyth, of Charity
Hospital, New Orleans, Louisiana, the 15th of May, 1864. The patient
was a mulatto, aged 22, a steward on a steamer; the tumor, which
was of the size of an orange, was developed in four months, after a
collision at sea, to which it was attributed. On the 15th of May, 1864,
a ligature was applied on the innominate artery, a quarter of an inch
below its bifurcation; and one also on the right carotid, an inch above
its origin. Pulsation returned at the wrist in forty-eight hours. On the
28th, the ligature came away from the carotid, and the next day, the
fourteenth after the operation, hemorrhage occurred to syncope. This
recurring the two following days, the wound was filled with small shot.
On June 1, the detached ligature was removed from the brachio-cephalic.
Hemorrhages still continuing at intervals, on July 9, the right vertebral
was tied; being the fifty-third day after the original operation; and to
this, the success in the case is fairly attributable. The shot remained in
the wound thirty-eight days. The patient now moved to Galveston,
Texas, but returned in 1874, ten years afterwards, to New Orleans, with
another tumor in the neck causing great pain. Dr. Smyth now detected
an aneurism larger than the former one, which the patient said had been
developing for about a year. On October 5, 1874, he tied the internal
mammary artery in the third intercostal space. Abscesses now began to
form under the clavicle and were cautiously opened. The patient again
returned to Galveston, and then once more to New Orleans, where he
lingered until the 6th of April, 1874. A post-mortem examination
A D D R ESS O N SU R G E R Y . 79
revealed the facts, confirming the history above given of this deeply
interesting case.
The patient lived within a few days of ten years after the innominate
was tied; enjoyed the best of health, and had gained twenty pounds. In
this case Dr. Smyth tied not only the innominate, but the common caro-
tid, vertebral, and internal mammary arteries, and did more to relieve
the affection than was ever attempted before in Surgery. This patient
lived in a hot, moist climate, and was probably purpurie.
Attempts to ligate the aorta successfully thus far have failed. In this
country, Prof. Hunter McGuire, of Richmond, Va., tied it unsuccessfully
in 1868; and the next year, Dr. Stokes, of Dublin, Ireland, met with a
similar result, though he reached the vessel by an almost bloodless inci-
sion through the lumbar region.
Maisonneuve is reported to have tied the vertebral artery. We know
that Prof. Willard Parker, of New York, did this in 1863, and as has
been noticed, Dr. Smyth, of New Orleans, tied it in 1864. Prof. Warren
Stone, of New Orleans, is reported, in a case of gunshot wound of the
vertebral artery, to have arrested the hemorrhage by compression with
pledgets of lint.
The common carotid, Dr. Gross claims was first secured by Dr. Cogs-
well, of Hartford, Conn., who in exsecting a scirrhous tumor from the
neck in 1803, applied two ligatures to that vessel. Heretofore Sir Astley
Cooper's case in 1805, had been considered the first one. In 1875, a sur-
geon recently from Europe, now Prof. Frothingham, of Ann Arbor, Michi-
gan, boldly laid open a traumatic aneurism of the common carotid,
turned out the clots, with a piece of glass, tied both ends of the wounded ſ
vessel, as also the internal jugular and lingual veins, and saved his patient.
This was certainly a very creditable operation. Dr. Mussey, in 1829,
tied both carotids successfully after an interval of twelve days. In Dr.
Mott's case the simultaneous application of ligatures to these vessels
proved fatal.
Of the branches of the common trunk, the internal and external caro-
tids, the latter is the one which is most frequently tied. Indeed Mr.
Bryant in his Practical Surgery, in 1872, declares that, owing to the diffi-
culty of finding the bleeding point, the ligature to the internal branch
has been abandoned. Nevertheless it has occasionally been tied by some
of our practitioners. In 1845, Dr. J. H. B. McClellan, son of the late
Prof. George B. McClellan, founder of the Jefferson Medical College, in
removing a portion of the parotid gland found it necessary to ligate this
artery ;. so did Prof. Gurdon Buck, of the New York University, for a
deep wound in the parotid region, tie successfully the common and inter-
nal carotids; Dr. Stephen Smith, in 1864, secured this vessel after pressure
had failed, and he performed a similar operation for sloughing of the
tongue; finally, my colleague in the chair of Surgery in the University
of Nashville, Dr. William T. Briggs, has the credit of first applying two
ligatures, one on each side of a wound which resulted in an aneurism,
tying also the common carotid at the same time. This was done in Feb-
ruary, 1871. Then again Dr. Sands, Professor of Anatomy in the College
of Physicians and Surgeons of New York, without knowing what Dr.
Briggs had done, did the same thing in October, 1872, besides securing a
lateral wound made in the internal jugular vein.
The method adopted in these latter cases was carrying out the principle
of Mr. Guthrie—the application of two ligatures to a wounded artery in
contradistinction to the one only insisted upon by John Hunter. This
80 EVE,
then is an American illustration of a new principle in tying wounded
arteries, which fortunately has occurred in the practice of two of our
best anatomists.
The late Prof. Wright Post, of New York, succeeded first with liga-
ture to the left subclavian artery in 1817, a feat which made him quite
famous, since some of the most distinguished surgeons of Europe had
failed to do this. In 1866, Dr. T. G. Morton also tied the left subclavian,
when the upper extremity of that side becoming gangrenous, he ampu-
tated it at the shoulder joint and saved the patient. In two cases of
subclavian aneurism, Dr. J. Mason Warren succeeded with ice and direct
compression, when the disease was too far advanced for the ligature.
To Dr. Warren Stone, in 1850, is given the credit of first applying a
metallic ligature to a human artery, and in 1866, Dr. Claudius H. Mastin,
of Mobile, Alabama, applied one successfully to the external iliac. Dr
S. W. Gross, son of the professor, has recently proven by numerous experi
ments how innocuous are ligatures to veins; and the late Dr. Levert, at the
suggestion of Dr. Physick, published his thesis, in 1829, proving thus
early, the advantage of metallic sutures.
It is difficult to decide who first suggested the ligature to arteries
supplying the extremities for affections threatening mortification. Our
English friends have generally given us the credit, but it does seem that
tying the carotid for internal aneurism, as was done by Dudley, or the
femoral for elephantiasis, as was done by Carnochan; the use of pressure
to check, the redundant supply of blood to a vascular tumor; or even
elevating the inflamed part—all apparently illustrate one and the same
principle of cutting off the redundant supply of blood.
Arterial compression as an antiphlogistic has long been recognized in
the profession. T)r. March published a brochure on the value of compress-
ing the brachial artery in cases of whitlow, a notice of which may be
seen in the American Journal of the Medical Sciences, Vol. 18, for 1849.
It is there stated that this seemed to be more efficacious than the plan
proposed by Mons. Gerdy, of keeping the limb elevated.
Sir James Paget, moreover, declares that the proposition to treat cases
of active inflammation threatening gangrene by putting a ligature on
the main arterial supply, emanated from the American School of Surgery.
In the Tettsomian Lectures on Surgery, published in the London Lancet,
Mr. C. H. Maunder, Surgeon to the London Hospital, expressly declares
that the operation originated in America; and in Holmes's System of
Surgery, Mr. Simon mentions that Henry Campbell, of Augusta, Georgia,
then Professor of Anatomy in the New Orleans School of Medicine, and
who was an army surgeon during the late war, had even raised the
question whether the hand or foot, wrist or ankle, forearm or leg, should
ever be amputated for destructive inflammation, specially resulting from
traumatic causes, whenever the state of the patient admitted this to be
done, without first resorting to previous experimental ligation of the
artery supplying the affected region. Dr. Druitt, who contributed the
article on Inflammation to the last edition of Cooper's well-known Sur-
gical Dictionary, in 1872, refers, moreover, to Dr. Campbell as the in-
troducer of what he terms the Hunterian ligation of arteries to prevent
or relieve destructive inflammation. The operation, first practised by
Onderdonk, in 1813, and D. L. Rogers, in 1824, has been revived and
systematized by Prof. Campbell, who recommends it as a definite mode
of treatment.
Prof. Campbell claims that (1) Compression prevents drainage; liga-
A D D R E S S O N S U R G E R Y . 81
tion prevents blood going to a part. (2) Ligation to prevent inflamma-
tion he repudiates as unjustifiable and dangerous, and even liable to
produce mortification; while ligation to cure inflammation already
existing, he says is invariably safe, and will prevent mortification, or
even stop it after it has begun. These distinctions he declares were
never brought previously before the profession. Iſe believes that no one
before himself ever tied an artery with the distinct view of curing
inflammation and preventing gangrene.
One of the most remarkable cases connected with the subject of aneu-
rism, whether considered in reference to its origin, the organ affected,
or the extent of the disease and the result of treatment, was reported to
the American Medical Association by the late Prof. Mussey, of Cincin-
nati, when chairman of the Committee on Surgery in 1850. It was that
of a mechanic of St. Louis, Missouri, aged 25 years, whose right eye pro-
truded and pulsated; the transverse suture near the external angle of the
eyed admitted the tip of a finger, and the functions of both ear and eye
of the affected side were no longer performed. After thorough prepara-
tion by Dr. Dudley, and ligation of the right common carotid, the patient
so completely recovered that he actually resumed the labor of a black-
smith. .
Mr. Erichsen acknowledged, in 1851, that to Prof. Carnochan, of New
York, was due the credit of recommending a ligature to the femoral
artery to cure elephantiasis; when this gave way from the extension of
the disease, he tied the external iliac, and finally had to resort to com-
pression on the distal side of the bleeding orifice. Sixteen months after
the first operation, the patient was in robust health.
American surgeons have not failed to try compression for the cure of true
aneurisms. The late Prof. Jonathan Knight, of New IIaven, Connecticut,
than whom few ever had a better record, has the credit of first relieving
a case of popliteal aneurism by digital compression, the case being pub-
lished in the Transactions of the American Medical Association for 1848.
In the Philadelphia Medical Times for 1875, Dr. R. J. Levis, one of the
Surgeons of the Pennsylvania Hospital, published a very creditable case
of successful compression for aneurism of the internal iliac. This was
effected by means of a simple steel band, having a hollow pad for counter
pressure and a convex one with a screw upon the artery. In five and a
half hours the current of blood was totally arrested through the tumor;
there was some Oedema and discoloration, yet the patient fully recovered
in thirty-seven days.
Of twenty-three cases of digital compression, comprising a successful
one of his own, collated by Dr. S. W. Gross, of Philadelphia, fifteen were
reported as cured. In two cases of inguinal aneurism, compression failed.
Within a few days a pamphlet has been received from Walter Reid,
M.D., Staff Surgeon Royal Navy, Plymouth, England, in which the
author proposes to cure external aneurism by connpression in a few hours.
Concluding from Cohnheim’s experiments that in warm-blooded animals
a stasis of circulation may be safely continued for from six to eight
hours, he made a successful experiment in a case of popliteal aneurism.
Esmarch’s elastic bandage was alone applied with the usual pressure of
a roller above and below, while the pressure was diminished upon the
tumor itself. The proposition certainly deserves further consideration.
In 1860, Dr. John H. Brinton, of Philadelphia, published in the Ame-
rican Journal of the Medical Sciences, an accurate description, with illus-
trations, of the valve at the termination of the right spermatic vein in the
6
82 EVE,
vena cava ascendens, and its absence on the left side, where the corre-
sponding vein terminates in the renal. Here then is an obvious and satis-
factory reason, though it may not be the only one, of the frequency of
varicocele on the left side as compared with the right. A suggestion for
the treatment of varicocele, originating, if I mistake not, with myself,
is the application of animal ligatures to the spermatic cord, excluding, of
course, the was deferens; then the ablation of some four inches square of
the scrotum ; and the closure of the wound with pin sutures. By this
operation, both pathological conditions, the varicose veins and redundant
scrotum, are removed.
In the treatment of affections of Bones and Joints, we claim to have
made valuable suggestions, if not important additions. An unusual
recovery from undoubted fracture at the base of the cranium, which
recently occurred on one of our national ships, may deserve brief notice.
The sailor was seen to fall from a spar to the main deck, and was taken
up insensible; he had stertorous breathing, followed by a copious flow of
colored serum from the right ear, estimated at fifty or sixty ounces; and
became partially comatose. Brain substance was also detected in the
discharges. Iſe, however, gradually improved under treatment, and was
returned to duty a little over a month after his fall, though slightly
epileptic, and with some little discharge still from the ear.
We find in an early number of the New England Journal of Medicine
and Surgery, that Dr. Luke Howe treated a fracture of the inferior
extremity by the means now employed, excepting the omission of the
sand bags to prevent the rolling of the injured limb; and believed it to
be original. His case is reported in 1823, more than half a century ago.
In the American Journal of the Medical Sciences for August, 1829, 1)r.
William C. Daniel, then an eminent practitioner of Savannah, Georgia,
described how he applied a silk handkerchief around the ankle and tied it
at the sole of the foot, a weight being then attached and passed over a
roller for extension. That veteran of American Medical Journalism, Dr.
Isaac IIays, says that Dr. Daniel has precedence of all modern claimants
for introducing the weight and pulley as a means of extension in treating
fractures; for he himself had published two cases thus successfully treated,
one in 1819 and the other in 1824. Dr. Hartshorne also, formerly one
of the surgeons to the Pennsylvania Hospital, declared in 1869, in the
same journal, that the credit of priority in introducing the weight
extension in practice was justly due to this gentleman.
To Dr. Gurdon Buck, of New York, credit is given for introducing
adhesive plaster to secure extension in the treatment of fractures of the
inferior extremity. Prof. Gross, however, in his account of American
Surgery, claims this for his preceptor, Dr. Joseph K. Swift, of Easton,
Pennsylvania, who employed it as early as 1829.
Dr. William Gibson, of St. Louis, Missouri, devised in 1867, a ring for
fractures of the patella; and Dr. P. S. O’Reilly, of the same city, in 1871,
described what he calls a new splint for fractures and dislocations of this
bone. This consists in an open ring, with a thumb-screw, that it may fit
the more accurately; to which a strap extending under the sole of the foot
may be added, and also a posterior padded splint for the thigh and leg.
This seems the perfection of an apparatus for these injuries.
On the subject of deformities after fractures of the thigh, two of our
most distinguished Professors and Surgeons in the Jefferson Medical
College hold the position which we also sustain; that a fractured
A DT) RESS O N S U R G E R Y - 83
femur cannot be fully extended to its normal length, nor could it be so
retained without impairing its nutrition. They declare that a certain
degree of shortening, and perhaps deformity, cannot be prevented, what-
ever may be the treatment. And it may be added that no measurement
whatever can detect the difference in some cases, though one to a limited
extent actually exists, as may be verified in a post-mortem examination.
The method of reducing dislocations by manipulation was first systema-
tized and proposed as such by the late Dr. William R. Reid, of Rochester,
New York, and published in 1859; though probably first suggested by the
late Nathan Smith, of Connecticut. This seems to have created a new
era on the subject, notwithstanding that it had occasionally occurred to
some practitioners how easily reduction was effected, sometimes even
during the examination of the case. Prof. Spence, of Edinburgh, in his
Lectures published in 1875–76, calls this the rotatory or circumduction
Inethod, and adds, “we generally hear it spoken of as the American
method.” He also admits that it is undoubtedly to the writings of
Drs. Reid and Bigelow, of the United States, that we owe the more
general use of the practice. He notices too, specially, the ilio-femoral,
or inverted Y ligament, and the different views entertained by Mons.
Chassaignac, of Paris, from those expressed by Dr. Bigelow, who was the
first to note minutely its functions. Dr. Reid’s conclusions regarding dis-
locations are: (1) That the impediment to reduction is due to the stretch
of the muscles, by the malposition of the dislocated bone, and not to their
contraction; (2) That in reducing luxations these muscles should be re-
laxed ; (3) That dislocation on the dorsum of the ilium is reduced simply
by flexing the leg upon the thigh, and carrying the thigh over the sound
one, upwards over the pelvis as high as the umbilicus, and then rotating it.
As is well known to the profession, Prof. Nathan Smith, of New Haven,
had taught and published similar views to those of Dr. Reid. The late
Prof. Brainard, of Chicago, Illinois, reported, in 1852, the reduction of
four cases of dislocation of the head of the femur into the thyroid fora-
men, with the aid of a billet of wood four inches in diameter, well
padded, placed in the perineum as a fulcrum, the displaced limb being
then carried as a lever across the sound one.
The substitution of manipulation to reduce dislocation at the hip, is
claimed therefore to be American, and in connection with anaesthesia,
the great boon to suffering humanity, also introduced by us, to be inesti-
mable. -
Old as the world may be, it has been reserved for an American to
point out a pathognomonic sign by which a fractured clavicle can always
be distinguished from a dislocation at the shoulder joint. Prof. L. A.
Dugas, of the Medical College of Augusta, Georgia, asserts that if the
fingers of the injured limb can be placed by the patient or surgeon upon
the sound shoulder, while the elbow touches the thorax, there can be no
dislocation; in other words, he asserts that it is physically impossible to
bring the elbow in contact with the sternum, or front of the thorax, if
there be a dislocation, and that no other injury of the shoulder-joint can
induce this inability. Ample experience has shown this rule to be axio-
matic. - -
The late Prof. Crosby, of New Hampshire, in dislocations at the
metacarpo-phalangeal articulation pushed the phalanx backward until
it assumed a position perpendicular to the metacarpus; then pressing for-
ward the base of the dislocated finger, reduction was easily effected. T)r.
Lewis, Surgeon to the Pennsylvania Hospital, suggested a small splint,
84 EV E,
having four large gimlet holes bored in it through which tapes are
passed to secure a luxated finger or thumb, by which means extension
can be effectually made.
As a substitute for the pulley, Dr. Fahnestock, of Pennsylvania, sug-
gested a rope doubled several times upon itself, which by a stick—a
walking cane—placed in its centre could be twisted gradually so as to
produce extension in dislocations.
In reference to resections and exsections of the bones and joints, our
surgeons have been active and ingenious. As early as November, 1826,
T)r. John Rhea Barton, then one of the surgeons of the Pennsylvania
Hospital, sawed through the femur just between the trochanters, and
then straightened the limb, which became so useful that the patient
went out gunning and actually brought home his own game; owing,
however, to his habits, those of a common sailor, he did not derive the
full benefit expected from the operation ; but a similar one, in which, how-
ever, a disk of bone was removed, performed by Dr. J. Kearney Rogers,
of New York, in 1830, resulted by gentle manipulation in the formation
of an artificial joint, and in an excellent recovery: good success has
attended other cases similarly treated by our practitioners. Mr. Erichsen
declares that the first operation for Osseous angular anchylosis was per-
formed by Dr. Barton. He also asserts that, in 1837, Dr. Mussey excised
the whole of the scapula and clavicle for an enormous Osteo-sarcoma, the
patient being in good health fifteen years afterwards. These successes no
doubt induced others to enter the new field of investigation, and resulted
in Dr. Brainard, then Professor in the Rush Medical College, Chicago,
Illinois, submitting, in 1854, to the American Medical Association, an
essay on a new method of treating ununited fractures, and certain de-
formities of the osseous system, which secured the prize for that year.
The main feature in Dr. Brainard's method was that by making perfo-
rations in the osseous structure with drills, and then waiting for the
softening process of inflammation, almost any bone, or anchylosed joint,
might be straightened, broken up, or the deformity relieved. Barton,
Brainard, and Buck, were undoubtedly the pioneers in correcting de-
formity and restoring to usefulness, limbs, which before their day were
considered hopelessly useless, or were sacrificed by amputation.
The first resection of the inferior maxilla was performed in what was
then known as the back-woods of America, and this too without known
precedence, or even professional counsel or assistance. The case is ad-
mitted by Mr. South, who translated Chelius's Sūrgery, Drs. Mott, Gib-
son, Gross, and others. The operator was William H. Deadrick, then of
Rogersville, East Tennessee, who in February, 1810, exsected about three
inches of the lower jaw, including the whole of its circumference and one
of its angles, from a boy, fourteen years old, who recovered and was alive
years afterwards. Dr. Carnochan, of New York, is believed to have first
disarticulated this bone in its entirety in the Emigrants’ Hospital, of
New York, in 1851; and this was again done the next year, by Prof.
Wedderburn, then in the Medical College at New Orleans.
The late Prof. Horatio G. Jameson, of Baltimore, claimed for his
country the honor of having led the way in resections of the superior
maxilla. Dr. Gross admits that the first severe and difficult operation of
this kind was performed by him successfully in 1829, by removing nearly
the entire bone on one side.
The removal of the clavicle, or a portion of it, was probably first
attempted by Dr. Charles McCreary, of Hartford, Kentucky, and was
A D D R E S S O N S U R G E R Y . 85
reported by James H. Johnson, in the Medical Journal then published
in New Orleans, in 1850. In his System of Surgery, Dr. Gross mentions
that the operation was performed in 1815, on a boy who survived long
afterwards.
As early as 1853, Dr. Compton, of New Orleans, exsected the entire
ulna and all of the radius, except its lower extremity, in a patient fif-
teen years old, who made an excellent recovery.
In 1843 Josiah C. Nott, then Professor of Surgery in the Mobile Me-
dical College, excised two segments of the coccyx, for neuralgia, in a
lady after twenty-five years of great suffering. The case, first published
in the New Orleans Medical Journal for 1844, was copied into the
American Journal of the Medical Sciences, and Prof. T. Gaillard Thomas
has added that this was fifteen years before a similar operation was per-
formed by the late Sir James Y. Simpson.
Prof. Lewis A. Sayre, of New York, reports that, up to January, 1876,
he had exsected the head of the femur fifty-one times, with a mortality
of only twenty; eight of these fatal cases too had recovered from the
operation. He removed also portions of the acetabulum in some of these
instances. At the late meeting of the American Medical Association
in Philadelphia, he introduced a little patient, suspending him by the
shoulders and head ; plaster of Paris bandages were then applied, and in
a few minutes the little boy walked about the room, though he had not
done so for months before.
In connection with affections of bones and joints, did time permit,
there might be noticed what has been done here in Kyllosis and Ortho-
paedy. Dr. James A. Dickson, of North Carolina, is believed to have
first performed tenotomy by dividing the tendo Achillis in 1835, fol-
lowed by Dr. D. L. Rogers, of New York, in 1845. Then came Dr. Det-
mold, a pupil of Stromeyer, who in 1837 settled in New York, where he
introduced myotomy. Dr. Mott, however, founded the first Orthopaedic
Institution in America. In 1844, Dr. Henry J. Bigelow, of Boston,
Massachusetts, obtained the Boylston prize for that year for his work on
Orthopaedy. Dr. Sayre, however, has done more on this subject than any
other American. His work just published is undoubtedly the best ever
issued from the press. He has called particular attention to genital irrita-
tion, even in very young children, in connection with deformity. He
gives special credit to Mr. Barwell, of London, and Dr. H. G. Davis, of
New York, for devising apparatus for extension while the little patients
exercise in the open air ; and has himself introduced a new method of
doing this by plasters, elastic cords, or artificial muscles, as they are
called. For contracted limbs and congenital deformity much is being
done here by early attention, so as to prevent development in unnatural
positions, by gradual or forced flexion and extension under ether, elec-
tricity, etc., before resorting to tenotomy or myotomy.
In the Compendium of Practical Surgery, published in 1851 by
Bérard, Denonvilliers, and Gosselin, of I’aris, in referring to a paper
written by Dr. M. Smith, son of the celebrated Dr. Nathan Smith, com-
menting on incisions of the periosteum and trephining of bones in suppu-
rative inflammation, is found a compliment to the heroic measures pro-
posed by the Americans.
In reference to the Genito-urinary Organs, we refer first to the case of
Dr. Charles L. Stoddard, of Wisconsin, who is reported to have exsected
the kidney successfully in 1861, eight years previous to the operation of
86 EVE,
Prof. Simon, of Heidelberg, who operated in 1869. In 1870 Prof. Gil-
more, of the Mobile Medical College, successfully cut out an atrophied
kidney from a colored woman, then five months pregnant, who, never-
theless, went to her full term, and was safely delivered of a living child.
Our early surgeons performed almost exclusively the lateral operation
for urinary calculus, and almost as exclusively employed the gorget—an
instrument of which it can happily be said requiescat in pace.
Ribes, of Paris, first described accurately the bilateral operation for
stone in the bladder. Dupuytren, however, gave it character by proving
its advantages to be easy and more direct access to the bladder, and that
the prostate is cut in its central portion, and in double the extent of the
section in the lateral operation, without endangering nerves, vessels, or
other important structures. Dr. Ashmead, of Philadelphia, in 1834, first
performed the bilateral operation in the United States.
Mr. Erichsen asserts that Civiale recommended a combination of the
median and bilateral operations, for in this way, he declares, the chief
objections to both are removed. The medio-bilateral is gaining ground
as an operation for urinary calculus.
As is well known, when Mr. Erichsen, among others, denied the possi-
bility of the intromission of foreign bodies below the vocal cords, Dr.
Horace Green passed a tube through the rima glottidis some inches into
the trachea, and then withdrawing the stilet, directed the patient to close
his lips and blow through the canula. This he did several times, even so
forcibly as to extinguish a candle. Sponging below the vocal cords was
first done in October, 1854, by the same gentleman.
The case reported by Profs. Crosby and Peaslee, of New Hampshire,
of a sponge one inch and three-quarters in breadth and fifteen-six-
teenths of an inch in thickness, passing the rima glottidis, in a patient
aged forty-five, on July 23, 1850, and who lived fifty-four hours, ought
surely to have convinced every one of the possibility of at least intro-
ducing sponge-probangs into the larynx.
In 1844, Dr. Charles Hall, of Burlington, Connecticut, removed, after
tracheotomy, a piece of pipe-stem by means of a probe, which fortunately
entered the hollow or canal of the pipe-stem and stuck fast. This certainly
was a fortunate hit. Mr. Liston once extracted a piece of sponge from
the right bronchus of an adult; and Mr. Dickin, in 1832, a bell button
from the right bronchus of a child eight years old.
Mr. Spence, Professor of Surgery in the University of Edinburgh,
succeeded, in June, 1862, in extracting, by tracheotomy, the inner portion
of a tracheal tube which had lodged in the bronchus, and concluded that
it was the first and only instance of the kind thus relieved. A child,
however, was brought from Alabama in May, 1853, to Augusta, Georgia,
where, after the trachea had been opened, a four-penny nail was removed
from the left bronchus with a pair of dressing forceps lengthened in the
blades.
American surgeons present a creditable report on amputations. Sta-
tistics on the subject, whether derived from hospital records or army
reports, or more especially from private practice, sustain this position.
Much, no doubt, is due to our open climate, sunny country, cleanly habits,
good nourishment, and free exercise. Even in regard to the dreadful
operation of amputation at the hip-joint, it is probable that the second
successful case, if not the very first ever performed, was that of Dr. Walter
A D D R E SS O N S U R G E R Y . 87
Brashear, of Bardstown, Kentucky. This was done in August, 1806,
On a youth of seventeen years, who survived long after it. His method
was the circular, as if for the upper third of the thigh ; and, after secur-
ing the arteries, then the head of the bone was disarticulated through a
long incision over the trochanter major. May not this prove to be the
best method for this amputation ? The case of Perault, of St. Maure,
France, in 1773, was only the semblance of an amputation, since the limb
had been destroyed by mortification up to the hip.
Mr. Erichsen, Baron Larrey the second, and M. Legouest, of the
French army, declared most emphatically that there had not been a
case of recovery from primary hip-joint amputation recorded in military
surgery previous to our late war. In the Schleswig-Holstein, French,
German, and Italian wars, not a case survived, whether operated upon
by German, English, French, Italian, or Russian surgeons; whereas,
during the late war between the States, some three or four were reported
as successful, though subsequently this number was reduced, because, on
account of the difficulty in the condition of the country, after our
gigantic internecine war, these cases could not be accurately determined.
We may judge, however, of the impression of our success in operations at
the hip-joint in Europe, when the Surgeon-General of the Prussian army,
the distinguished Dr. Von Langenbeck, declared that, but for these
operations, it might be questioned if immediate amputations and resec-
tions at the hip should not be hereafter prohibited.
In the New York Journal of Medicine, for 1852, it is stated that up
to that date there had been on the Continent of Europe thirty-five ampu-
tations at the hip, with fourteen recoveries, or forty per cent. ; in Eng-
land twenty-five, with eleven recoveries, or forty-four per cent. ; and in
the United States eleven, with eight recoveries, or seventy-three per
cent. -
In civil practice, we have the recent remarkable case of Dr. Jerome
Sands, of Portchester, New York, who, without waiting for reaction
after the injury by a passing train, performed hip-joint amputation by
antero-posterior flaps, on a boy eleven years old. The administration
of ether, performing operation, and dressing wound, all consumed only
three hours. Prof. Spence, of Edinburgh, under similar circumstances,
waited several hours before he operated ; his case too, was a success, and
it may be the first and only one of the kind in Europe. In Philadelphia,
where surgery has been so successfully practised, two of her Professors in
one College, Drs. Gross and Pancoast, have each performed two amputa-
tions at this articulation, and saved the four patients. Yet this is the opera-
tion, it will be remembered, of which the great English military surgeon
Hennen, asserted, only fifty years ago, that there was not one in a thousand
who would not prefer instant death to the attempt.
No one can be expected to do justice to so prolific a subject as the
history of American Surgery, in the brief space allowed the occasion.
An enumeration of our contributions to this department of medicine
would alone require a volume. Time will permit now only a brief sum-
mary of some suggestions or improvements not yet noticed.
The extensive use of silver wire in surgery and gynaecology is un-
doubtedly due to Dr. J. Marion Sims. This is acknowledged in Holmes's
Surgery. To him also is given the credit of publishing the first work
ever issued on Uterine Surgery in the English language.
Paracentesis thoraeis was made a safe operation by Drs. Bowditch
88 EVE,
and Wyman, of Boston, before the introduction of Dieulafoy's aspira-
teur. -
Dr. A. L. Pierson, of Salem, Massachusetts, was the first to operate for
hare-lip with scissors and sutures, within six to twelve hours after birth.
Prof. Alex. H. Stevens first suggested the important principles to be
observed in exsecting tumors, viz., by the first incision to expose fairly
the morbid growth, and secondly to remove it and nothing more.
The oesophagus forceps of Dr. Bond, of Philadelphia, are so constructed
that, by narrow bevelled edges, a pin or fish-bone can be removed without
pinching the mucous coat.
Of Dr. Sayre's vertebrated probe, Mr. Erichsen declares that it is a most
ingenious and valuable one, by accommodating itself to the tortuosities
of a canal or sinus.
Dr. Levis, of the Pennsylvania Hospital, recommended pure carbolic
acid liquefied, as a local anaesthetic, before using the actual cautery, and
the late Prof. Josiah C. Nott, of Mobile, declared that this same agent
in carbuncle was antiseptic, escharotic and anaesthetic.
Prof. Joseph Jones, of the University of Louisiana, New Orleans,
one of the most indefatigable laborers in the profession, after a most
thorough examination of the important subject of traumatic tetanus,
concludes that the remedial agents most to be relied upon, are chloral
hydrate, Calabar bean, chloroform, sulphuric ether, cannabis Indica,
tobacco, bromide of potassium, and opium. He also suggests that im-
portant advances will be made in the therapeutics of this affection, if the
attention of the entire profession can be concentrated on a few remedial
agents, as chloral hydrate, Calabar beam, and bromide of potassium. In
regard to the prevalence of this terrible affection, the census of the
United States for 1850 gave six cases for the six New England States,
while for Louisiana alone there had been two hundred and fifteen.
|Prof. F. H. Hamilton, of Bellevue Hospital, New York, is the author
of a well-known Treatise on Fractures and Dislocations, which has
reached its fifth edition. He has recently issued a System of General
Surgery, of about one thousand pages, with illustrations; and has also pub-
lished a Treatise on Military Surgery and Hygiene. Turing the war, he
held a high rank, and has long been known as one of our ablest surgeons.
The Principles and Practice of Surgery, by John Ashhurst, Jr., M.D.,
issued by Henry C. Lea, Philadelphia, 1871, a volume of a thousand pages,
containing five hundred and thirty illustrations, has probably done more
than any other publication to announce what Americans have done for
surgery.
The founder of the Jefferson Medical College, Prof. George McClellan,
reported, long ago, eleven excisions of the parotid gland with only one
fatal case.
Prof. Van Buren, M.D., of Bellevue IIospital, recommended the French
method of relieving anal fissure, by sudden dilatation from within out-
ward with the thumbs, so as to rupture or tear open the Sphincter muscles.
The British and Foreign Medico-Chirurgical Review stated in 1870 that,
in plastic operations on the face, and in closing of wounds and unnatu-
ral openings in the urinary organs and parts of generation, Americans
must have the position of precedence.
Another surgeon, Professor Gouley, of New York, has distinguished
himself in external urethrotomy without a guide, and in relieving stric-
tures.
Dr. John T. Hodgen, Professor of Surgery in the St. Louis Medical
A D D RESS ON SU R G E R Y . 89
College, proposed a few years ago the removal of calculi lodged in the
urethra, by passing a double wire concealed in a catheter, and expanding
it after its introduction into that canal.
Prof. Henry J. Bigelow has recently published an article on “The true
Neck of the Femur,” another on “Exstrophy of the Bladder,” and a
third on “Turbinated Corpora Cavernosa.”
Dr. Addinell Hewson, Surgeon to the Pennsylvania Hospital, found a
mortality, after amputations performed with an ascending barometer, of
about eleven per cent. ; when it was stationary, some twenty ; and when
descending, amounting to twenty-eight per cent. This certainly deserves
investigation.
In proof of the industry exhibited, and of the contributions made by
Americans to Medical Science, a long catalogue of periodicals, numerous
monographs, and extensive systems in the three practical departments of
the profession might be enumerated. One of these, on Surgery alone,
has reached the fifth edition, contains fourteen hundred engravings, and
requires a text of more than two thousand pages in small type; being
equivalent to more than half a dozen volumes of ordinary size. Then
there are some forty Journals devoted to medical science, from the weekly
to the quarterly, containing reports of cases, lectures, movements in the
profession, etc.
We can point, too, to the admirable publications issued from the
office of the Surgeon-General U. S. A., pronounced to be incomparably
the most minute, comprehensive, and valuable ever issued from the press.
And, as evidence of the industry and efficiency of our corps of Surgeons,
it is said in the official reports of the late war between the States, that
the mortality in the medical staff was greater than in any other.
The commendations from foreign sources respecting these publications,
have been most gratifying to our national pride. The Medical Inspector
of the French army, and director of the school for the Medical Staff of
that army, Mons. Sédillot, wrote, in 1866, that American Surgery had
proved itself equal to cope with the exigencies of a war of incomparable
magnitude; surgeons every where, said he, were proud of the marvels
accomplished in science and self-devotedness.
In Circular No. 6, are classified 87,822 wounds and injuries, and 17,125
operations. These reports have been translated into the German, French,
and Italian languages. The Director-General of the British Medical
Department returned thanks for the gift of a work so replete with interest
of the highest professional value. Sir Wm. Fergusson said in the fifth
edition of his standard work on Surgery, that modern surgery owed much
to our American brethren—referring to conservatism, which he says was
signally displayed both in the United States Army, and by their gallant
contemporaries in the Confederate service. Baron Von Haurowt, chief
Surgeon of the Russian Marine, in a report for 1867, after an official
inspection of the medical institutions of this country, speaks of the Army
Medical Museum, at Washington, as the most valuable collection of the
kind in existence. :-
In an address to the students of St. Thomas’s Hospital, London, Oct.
1874, Mr. McCormac said, no European nation, probably, can point to
such a nonument of industry, or so great a mass of valuable material,
carefully preserved and digested, as the records of the Medical Depart-
ment of the U. S. Army. It is, he continues, an undertaking simply
gigantic, reflecting credit on the government that originated, and the
men who carried it out. Such records, he says, are of the utmost value
90 E VE, ADDRESS ON SURGERY.
both to the military and civil service. No less than fourteen foreign
medical journals noticed our Army medical reports.
In 1875, Dr. Crothers, of Albany, New York, stated that Dr. Swin-
burne's attachments for extension and counter-extension were being intro-
duced into the French army, with the American pattern and minutiae for
the battle-field. Dr. Swinburne, himself, formerly Port Physician of New
York, while travelling in Europe in 1870–71, by request took charge of
a hospital, and he and Dr. Evans, Dentist to the French Emperor, received
the Cross of Honor for services rendered. Dr. Monsereau declared before
the Faculty of Paris, that the American Ambulance was the best of all.
In the Prussian Service, our ambulance was also adopted. So again,
Mons. Sarcey, who wrote the “Siege of Paris,” announced the superiority
of this method of treating the wounded on the battle-field. It was freely
confessed that American Surgeons had done more for Military Surgery
than the ordinary experience of a century, and that never before was the
business of life-saving done more thoroughly and successfully than during
Our great war.
The discovery of the circulation of the blood in 1628, and the intro-
duction of vaccination in 1796, were the significant events of the past
two centuries in our profession. That of the present one will, in all
probability, prove to be the crowning glory of American Surgery. For
it is that which Poets and Philosophers, Philanthropists and Physicians,
and the Humane of all ages, had sought for in vain for six thousand
years. The search had been for that agent which could suspend con-
sciousness and obtund sensibility, so that the most painful manipulations
might be made, or capital operations performed, with little or no risk to
life. It has been reserved for American Surgery to teach the world how
to prevent or relieve human suffering. God in his mercy has condescended
to teach us how to relieve pain. We can now say to the agonized mother,
Awake! behold your babe; to the tetanic limb, Peace! be still.
Well has it been said that no imagination can conceive and no tongue
express, the accumulated woe that anaesthesia has assuaged, and is yet
destined to prevent or relieve.
Fifty years ago, there were probably not a half-dozen Americans known
abroad as Surgeons. As early, however, as 1830, Dr. Reese, in preparing
an American Edition of Cooper’s Surgical Dictionary, introduced no less
than one hundred and nine American contributions to it; and Mr. Cooper,
himself, soon after, publicly expressed his regret for not having noticed
what we had done in this department of medicine; admitting, too, that
we had performed operations never attempted in Europe, and had led the
way by our splendid achievements in operative Surgery, and demonstrated
their practicability and success. The hour assigned me for presenting
what we have done in Surgery, during the past century, especially its
latter half, has expired; the result, however imperfect, is before you. Time,
if nothing else, has prevented even the naming of all that is worthy of
special mention. I trust, however, that quite enough has been shown to
warrant us in committing the interests of our time-honored calling, the
noblest of earth, to our successors of a second centennial, in the full per-
suasion that all its interests, its usefulness, its honor, and its dignity,
will be fully sustained.
91
ADDRESS ON MEDICAL BIOGRAPHY.
BY
J. M. TONER, M.D.,
OF WASHINGTON, D. C.
GENTLEMEN OF THE CENTENNIAL INTERNATIONAL MEDICAL CONGRESS:
I APPEAR before you to discharge the duty assigned me of preparing a
biographical retrospect of the medical profession of the United States
during the centennial period just past. Though apparently an easy task,
I cannot approach it without hesitation. Apart from the feelings of
diffidence, which under any circumstance this occasion and this audience
must inspire, I am fully aware of the caution with which the office of
the biographer should be assumed, and that his best efforts are never
above criticism.
It is admitted that the measure and the character of the renown which
attaches to the hero is, in a great degree, qualified by the fitness of the
chronicler who undertakes to record and perpetuate his achievements.
With what intimate knowledge and forecast, then, should even the most
ready pen essay the work of writing the life of the good and great;
when, through natural inability for the task, or want of care, the noblest
actions may be placed in a false light, obscuring what should be dis-
played, or obtruding defects that the mantle of prudence and charity
should cover ! Conscious of the many difficulties and the very brief
time allotted to the reading of this discourse, I shall confine myself to
the narration of a few simple facts in the lives of the more illustrious,
and to a record of the names of physicians who attained distinction
during the century, and I trust that this limitation may be some excuse
for the dryness which must necessarily characterize such details.
In glancing over the period to be embraced in this retrospect, I am
struck by the paucity of really striking events which have influenced
the practice of medicine, and which have left special marks at the end of
the first century of our national existence.
Wars have generally been promotive of medical science, and our pro-
fession was no doubt much benefited by the contest for Independence.
For the first quarter of a century after this armed struggle, the leading
physicians and surgeons were those who had served in the army." The
most notable event of this period was the occurrence of epidemies of
yellow fever, which appeared in the summers of 1793 and 1798 in nearly
all Our Atlantic cities. This disease tested the courage and taxed the
energies and best skill of the profession, and prompted the more eminent
* The following are the names of the leading practitioners in each State who served
during the Revolutionary War: Connecticut, Aneas Munson; Delaware, James Tilton;
Georgia, Lyman Hall; Maryland, John Archer: Massachusetts, John Warren : New
Hampshire, Josiah Bartlett; New Jersey, William Burnett; New York, Charles Mc-
Knight: North Carolina. Charles Harris; Pennsylvania. Benjamin Rush : Rhode Island,
Isaac Senter; South Carolina, Peter Fayssoux; Virginia, James McClurg.
92 TO NER,
to reduce their observations to writing, and to have them published,
either in defence of their practice, or for the laudable purpose of making
contributions to medical science. To us of the present day, it is an
agreeable surprise to find that there were then so many medical men of
literary ability' in our country.
The second quarter of the centennial period was distinguished by the
introduction of vaccination, the occurrence of spotted fever, and the war
of 1812. All of these were events which stimulated the profession to
more extended studies, and became incentives to authorship; this was
especially true of the disease known as spotted fever.” The war of 1812
proved to be another great school of experience, although it was not
fruitful in medical reports or publications. The aspirations which it
aroused in the profession, however, gave an impetus to the establishment
of medical periodicals, and to the founding of medical colleges” and
hospitals.
In following out the plan of dividing the century of our independence
into quarters, the third may be marked as noted for the discovery of
anaesthesia, the epidemics of Asiatic cholera of 1832 and 1848, and the
war with Mexico, as well as the discovery and the application of many
new and improved methods of physical exploration in the search of dis-
ease. These aids to diagnosis encouraged more than ever the recording
of clinical observations and their publication. Medical journals multi-
plied," and new medical colleges were founded in most of the States."
The last quarter, which has just closed, is specially distinguished by
the vast experience of the late war, which was a great school, and which
* In my own library I find pamphlets on the epidemics of yellow fever of 1793, and 1798
published before 1800, by the following authors: Dr. J. S. Addoms, Dr. Richard Bayley;
Dr. Thaddeus Brown, Dr. C. Caldwell, Mathew Carey, Dr. Isaac Cathrall, Dr. W. G.
Chadwell, Dr. Colin Chisholm, Dr. Thomas Condie. Dr. William Currie, Dr. John Beale
Davidge, Dr. M. S. Davis, Dr. Jean I)eveze, Dr. Richard Folwell, Dr. James Hardie, Dr.
J. Henry C. Helmuth, Dr. Charles Holt, I)r. Alexander Hosack, Dr. William Linn, W.
Marshall, Dr. D. Nassy, Dr. Pascalis, Dr. J. Patterson. Dr. Benjamin Rush, Dr. Charles
Scot, Dr. James Tytler, Dr. Washington Watts, Dr. Noah Webster, and Dr. Nathaniel
Weeks. There are also many reports by committees and boards of health, besides numerous
articles on the subject in the “New York Medical Repository.”
* The following are a few of the most noted writers on spotted fever : Elisha North, Job
Wilson, Thomas Miner, William Tully, L. Danielson and E. Mann, Elijah Lyman, Samuel
Woodward, Abraham Haskell, Mason Spooner and Jacob Holmes, John Bestor, Q. Fiske,
and G. Williamson. -
* In 1800, there were in the United States but four medical colleges organized and giving
instruction, viz.: University of Pennsylvania, Pa.; Columbia College, N. Y.; Harvard
College, Mass.; and Dartmouth College, N. H. The number of medical colleges fully
organized and giving instructions in the United States in 1825, was eighteen, viz.: Univer-
sity of Pennsylvania, Pa.; College of Physicians and Surgeons, N. Y.; Harvard College,
Mass.; Dartmouth College, N. H.; University of Maryland, Md. ; College of Physicians
and Surgeons Western N.Y., N.Y.; Yale College, Conn.; Medical College of Ohio, Ohio;
Vermont Academy of Medicine, Vt. ; Transylvania University, Ky., Brown University,
R. I. : Medical School of Maine, Me. ; University of Vermont, Vt. ; Berkshire Medical
College, Mass.: Medical College, S. C.; Jefferson Medical College, Pa.; Columbian Medi-
cal College, I). C.; University of Virginia, Va.
* It has been ascertained that about two hundred medical journals have been started in
the interest of regular medicine in the United States within the centennial period. Of this
number, about thirty are now being published. From an estimate, based on pretty good
data, I am persuaded that something over seven hundred medical men have been engaged
as editors and assistant editors of journals within this period. Medical editors, as a class,
are ready writers, well informed, enterprising, and progressive in their profession. The
influence of medical journal literature is elevating, and encourages study and the reporting
of cases.
* At the end of the third quarter, 1850, the United States census gave a list of thirty-
seven medical colleges fully organized and giving instruction.
A D D R E S S O N M E DIC A. L. B [O G R A PHY. 93
has benefited the medical profession of the whole country;' by the ex-
tended use of anaesthesia in painful surgical operations; by the increase
of scientific means for exact diagnosis, and the introduction of new and
potent remedies and modes of administration; and by the founding of
hospitals and medical colleges in nearly all the large cities.”
It is from the professional men who labored not only in these more
notable scenes, but from the whole profession who practised during this
period, that I shall select for comment those who acquired honorable
distinction among their contemporaries. It is well known to you that
owing to the peculiar condition and growth of our country, from thir-
teen Colonies to forty-nine States and Territories during the century, it
is difficult to so treat the subject as to be entirely impartial, and not to
neglect the claims of any section of the country, old or new.
I will first speak of the medical men of the United States who have
by their discoveries, writings, or special skill and devotion to their pro-
fesson, won national fame, and then of those who have attained distinc-
tion within the several States. Having an earnest desire to make the
address acceptable to this Congress, and for the sake of making it worthy
of the occasion, I have collected formal biographies of one hundred of
the most eminent medical men of the United States for the century.
These sketches have been prepared at my request by physicians of note
in possession of the requisite data.”
We know that greatness in any avocation, and particularly in the
medical profession, is not a birthright, nor can it be thrust upon the
undeserving. A kind of popular transitory applause may be achieved
without merit, but only those who have done something to advance
medical knowledge or to improve the methods of cure, will live in
history. The discoverer or the expounder of a new truth, the recorder
of an additional fact or a hitherto unobserved symptom, or of an im-
proved procedure in surgery or in the treatment of disease, deserves and
will secure a more enduring place in history than he who has gained
great popularity or the largest fortune. The qualities and acquirements
and the degree of these which can make a medical man illustrious either
in his day or in history, I shall not attempt to define. The talent differs
in kind and degree that attains eminence in different periods of time,
and in the city as compared with the rural districts, in the surgeon" as
compared with the physician,” and in the writer" as compared with the
| The late war did for us what the wars of Europe in 1848 and 1856 did there. It im-
proved surgery much, and developed pathology wonderfully, brought hygiene into active
exercise, improved the treatment of bone injuries by exsection and resection, and the treat-
ment of wounded joints. The conservative treatment of limbs, the postponement of the
period of operation, and the improvement in hospital construction and treatment, mark this
period not less than the actual number of operations performed by the extended use of
anaesthetics.
* The close of the last quarter of the centennial period records sixty-five medical colleges,
not including dental schools or colleges of pharmacy.
* [The biographies referred to in the text, are necessarily omitted for want of space.—
EDITo R.]
* Professor Samuel D. Gross, in the “Century of American Medicine,” published in the
American Journal of Medical Sciences, names nearly three hundred American surgeons,
who, by their operations and reported cases, have won an enduring place in the literature
of the profession.
* Dr. T. Gaillard Thomas, in the “Century of American Medicine,” published in the
American Journal of Medical Sciences, names nearly one hundred and thirty American
physicians who have won distinction in obstetrical practice and gynaecological surgery.
* Professor S. D. Gross, in his Introductory Lecture entitled “ History of American Medi-
cal Literature,” names nearly three hundred medical authors for the century. From an
94 TO NER,
teacher.' Dut that there is a something in talent or character which
commands success, and that this element stands in the relation of cause
to effect, is generally conceded. Even when an elevated standard of pro-
fessional ability has been adopted, I am embarrassed not only by the
difficulty of selection, but by the superabundance of good material.
The names here presented as having won pre-eminence in the medical
profession of America, have acquired their distinction chiefly by the
possession of high natural endowments and of good education and medi-
cal knowledge, with the exercise of unceasing study, and devotion to
professional duty. My study is too limited to assume that names not
included may not be equally deserving.
The natural ability, habits of industry and systematic study, and
scientific knowledge of Dr. Benjamin Rush, added to his acquaintance
with men and public affairs, easily place him at the head of the list of
the eminent medical men of the century. His professional skill, high
moral and benevolent character, and frequent participation in the affairs
of his country, rendered him popular with the profession and endeared
him to the people. His fame has suffered but little by the lapse of time.
His writings are numerous and valuable. (b. December 24, 1745; d. April
19, 1813.) But as the subject of medical literature has been assigned to
an abler pen, I shall leave that branch entirely to him.”
Dr. Valentine Mott, by his daring and brilliant operations in surgery,
held for many years the front rank. He had the physical and mental
endowments, as well as scientific acquirements, application, and profes-
sional training, essential to a great surgeon. There is scarcely an opera-
tion, however hazardous or delicate, that he did not perform with con-
summate skill and success. His genius, too, was equal to devising new
operations and important surgical procedures, and undertaking and
executing some operations which before his day were passed over as too
formidable to be attempted. He was scarcely less eminent as a writer
and teacher than as a surgeon, and no American name is better known
to the profession throughout the world. (b. August 1785; d. April 26,
1865.)
Dr. Philip Syng Physick was a surgeon of rare ability, self-possession,
and fortitude. As was usual, when he commenced practice, he attended
to the general business of physician and surgeon, but as early as 1794 he
was appointed one of the surgeons to the Pennsylvania Hospital, and in
1805 Professor of Surgery in the University of Pennsylvania. He
always carefully prepared his lectures, and was therefore particularly
impressive, for he had thought over and mastered the subjects he pre-
sented. He was the author of so many improvements in the department
estimate I have made on this subject, I conclude that there are some four hundred authors
who have published works, which from their size are entitled to be termed books. If we
include pamphlets, it is probable that there are over fifteen hundred medical authors
| From a computation which I have made of the teachers of medicine in our country, for
the century, I am inclined to think that the list will include nearly two thousand names.
* Professor L. P. Yandell, of Kentucky, has been designated to deliver the address on
“American Medical Literature” for the centennial of our national existence, and to Prof.
N. S. Davis, of Illinois, has been given the task of preparing an address on “American
Medical Education” for the same period. To Prof. Austin Flint, has been assigned the
duty of preparing a history of medicine in our country for the hundred years just past. A
careful regard for the field of labor given to each of these essayists, has made me solicitous
not to traverse their province, but to adhere strictly to biographical detail at the risk of
being tiresome.
A D DRESS ON MEDICAL BIO G R A PHY. 95
of surgery that he was justly entitled to the appellation given him of
“The Father of American Surgery.” His influence upon practice is
felt to the present day. (b. July 7, 1768; d. Dec. 15, 1837.)
Dr. John Warren was an eminent physician and surgeon, and medical
teacher. He acquired experience and reputation in the hospitals of the
Revolution. While attached to the hospital at Boston, in 1782, he
founded the Medical Department of Harvard College, in which he was
Professor of Anatomy and Surgery. He was a man of great industry,
and enthusiastically attached to his profession, and was during his life-
time the leading surgeon of New England. His genius and aptitude for
this branch of the profession has continued to show itself in his descend-
ants. (b. July 27, 1753; d. April 4, 1815.)
Dr. Daniel Drake possessed wonderful powers of original observation,
and was the most indefatigable worker for the accumulation of know-
ledge and the elevation of the profession, that our country has produced.
He was the founder of medical colleges in the West, and a writer and
teacher of great force and ability. His systematic inquiries into the
causes of disease are models worthy of study. The Doctor's valuable
labors are certain to be appreciated in the future. (b. Oct. 20, 1785 ; d.
Nov. 6, 1852.)
Dr. John Collins Warren was one of the founders of the Massachusetts
General IIospital, and the surgeon in daily attendance to the time of his
death. Iſe was the first to use ether, and did much to hasten its intro-
duction into general use in surgery. He was a brilliant operator, popu-
lar as a lecturer, and wrote on a great variety of subjects, in all of which
he showed his exact knowledge and extensive scientific acquirements.
(b. 1st Aug. 1778; d. May 4, 1856.)
Dr. Nathan Smith was a man of extraordinary natural endowments.
His ability to acquire knowledge, his industry, perseverance, and success
under almost insurmountable difficulties, have rarely been equalled. His
founding of the Medical Department of Dartmouth College, and his teach-
ing, by himself, for ten years, all the usual branches, show the character
of the man. He was an admirable anatomist, a bold and successful sur-
geon, and a good general practitioner. By his teachings he did much to
advance medicine. (b. Sept. 30, 1762; d. Jan. 26, 1829.)
Dr. Reuben Dimond Mussey was a distinguished surgeon and good
general practitioner. His experiments on cutaneous absorption would
have of themselves entitled him to a high rank, had he not become still
more eminent as a surgeon. For daring and success, some of his capital
operations have never been excelled. He was also a popular and success-
ful teacher of surgery. The esteem in which he was held by the pro-
fession may be inferred from his election to the presidency of the Ame-
rican Medical Association. (b. June 23, 1780; d. June 21, 1866.)
Dr. James Jackson was a noted physician and author. He was one of
the founders of the Massachusetts General Hospital. His great skill in
diagnosis, and his eminent success in the treatment of disease, led to his
appointment to the professorship of Theory and Practice in Harvard
College. His observations, teaching, and writings, almost mark an epoch
in medicine in this country. His professional life and labors were great
lessons to the profession of high and honorable principles. (b. Oct. 3,
1777; d. Aug. 27, 1867.)
Dr. Nathaniel Chapman was a learned and eminent physician, and
teacher of medicine. His special qualifications and success as a physi-
eian speedily attracted attention, so that his business was very large and
96 TONE R,
responsible. He was for a long time a professor in the University of
Pennsylvania, and was in some respects the most popular lecturer with
students ever resident in that great centre of medical education. His
writings have had much influence over the medical opinions of his time.
He was President of the American Philosophical Society, and the second
President of the American Medical Association. (b. May 28, 1780; d.
Jan. 1, 1853.)
Dr. Theodoric R. Beck was a prominent physician, author, and teacher.
He was particularly notable for his literary and scientific attainments,
power of classification, and scope of studies. Professor in several colleges,
he filled one of the first chairs of medical jurisprudence established in
this country. His work on this science would of itself entitle him to
rank with the most cultivated medical men of the Union, and has been
for years the class-book in foreign schools of medicine. (b. Aug. 11,
1791; d. Nov. 19, 1855.)
Dr. Samuel Jackson was a learned and accomplished medical man and
teacher. In every department, whether at the bedside, or as President
of phe Board of Health, or in the lecture room, he showed himself the
great physician. He filled a chair with eminent success in the Univer-
sity of Pennsylvania from 1825 till 1863 when he resigned. His member-
ship in learned societies as well as his able writings testify to his distin-
guished ability. (b. March 22, 1787; d. April 4, 1872.)
Dr. Wm. Potts Dewees deserves prominent notice as a physician and
author. He possessed a methodical and discerning mind, and was an
extensive and careful reader of the best works in the profession. His
great powers were brought out at the bedside. He was a good writer,
and an admirable oral teacher. His lessons were law in the practice of
obstetrics and diseases of women and children. Some of his works ran
through many editions. (b. May 5, 1768 ; d. May 20, 1841.)
Dr. Samuel G. Morton was a conspicuous physician and naturalist.
He was a most careful and laborious student, and did a prodigious amount
of valuable original scientific work. His love for science, however, did
not lessen his devotion to his profession, as his writings on consumption,
and other medical works, prove. His fame is enduring, and rests chiefly on
his original observations in medicine and craniology. (b. Jan. 26, 1799;
d. May 15, 1851.)
Dr. Elisha Bartlett was a highly accomplished scholar and physician.
He was a very popular medical teacher, and a ready lecturer, holding
chairs in several leading medical colleges. His work on the “Fevers of
the United States,” published in 1842, at once secured him a place in the
front rank of physicians. His purity of life and eminence as a clinical
physician, as well as the high character of all his writings, have secured
for his name an abiding place in the history of his profession. (b. Oct 6,
1804; d. July 19, 1855.)
Dr. John K. Mitchell was an able physician and a polished writer.
He possessed a vigorous intellect, which was well trained and by careful
study stored with facts. In the sick room he is said to have had a most
encouraging influence over patients and their friends. He was an origi-
nal thinker, with a vivid imagination, and one of the most charming of
lecturers. His writings cover a variety of subjects, all exhibiting ability
and versatility of talent. (b. May 12, 1796; d. April 4, 1858.)
Dr. Réné La Roche was a learned physician and author. He was a
most laborious and conscientious student, exhausting all sources of infor-
mation to the fullest extent on whatever subject he took up. He was for
A D D R ESS O N M E DIC A. L BIO G R A PHY. 97
many years connected with the Board of Health of Philadelphia, and was
a most valuable member. His practice for years was large and responsi-
ble. His studies and writings on yellow fever are a marvel of labor and
systematic presentation of all the known facts relating to this disease.
(b. 1795; d. December 9, 1872.)
Dr. David Hosack was a celebrated physician, botanist, and author.
He had a large practice, and yet found time to lecture in different col-
leges, and to write exhaustive treatises on medical subjects. He held
important positions in the Almshouse, in the New York Hospital, and in
the Bloomingdale Asylum. Iſis contributions to medical science are
numerous and valuable. (b. August 31, 1769; d. December 22, 1835.)
Dr. John Morgan was a man of learning and an eminent physician
and surgeon. He enjoyed the distinction of being the founder of the first
medical school in America. At that time he was perhaps the most
thoroughly educated and accomplished physician in this country. He
was a good writer, and was the first to suggest that pus was formed by
a secretory process. Ile was surgeon-general of the Continental Army,
and one of the founders of the American Philosophical Society. (b. 1735;
d. Oct. 15, 1789.)
Dr. Josiah C. Nott was a prominent physician and surgeon, and a
learned ethnologist. IIe was a man of commanding powers of intellect,
with great industry and capacity for study. While he won a world-wide
fame as an ethnologist, he did not neglect the duties of a large practice.
He was eminent as a teacher, and as the founder of the Medical College
of Mobile. His ethnological writings, however, are those which are best
known, but he was equally distinguished as a physician and surgeon.
(b. March 31, 1804; d. March 31, 1873.)
Want of time will prevent comment upon all our medical worthies.
I however present the following list of names, incomplete though it be,
in which it would be difficult to assign a precedence, for all of them have
won national reputations, and are eminently deserving of commemoration.
I am persuaded that I might more than double the list, and yet not
include all who have won reputations that have extended beyond the
confines of their own country:-J. Mason Warren, Caspar Wistar, Wm.
Shippen, Samuel Bard, Wright Post, Chas. Caldwell, Benjamin S. Barton,
Benjamin Waterhouse, David Ramsay, John D. Godman, Wm. E. Horner,
Franklin Bache, Robley Dunglison, Warren Stone, John Ware, James
Thacher, Wm. W. Gerhard, C. D. Meigs, Hugh L. Hodge, Edward
Miller, Wm. Gibson, J. W. Francis, George McClellan, Henry Miller,
P. S. Dorsey, B. W. Dudley, J. B. Davidge, J. A. Swett, Samuel Jackson,
H. Green, C. A. Pope, Jeffries Wyman, John Eberle, T. Miner, John
Jones, G. T. Elliot, A. A. Gould, S. L. Mitchell, S. H. Dickson, J. P.
Harrison, Jonathan Knight, Ernest Krackowizer, Daniel Brainard,
Charles Frick, G. C. Blackman, J. W. Heustis, Alexander H. Stevens,
E. Hale, Erasmus Fenner, B. R. Welford, J. M. Galt, James McClurg,
James Moultrie, Henry F. Askew, G. Mendenhall, Nicholas Romayne, J.
R. Barton, R. S. Kissam, A. Brigham, T. D. Mütter, Ephraim McDowell,
R. Bayley, W. Curry, John Jeffries, J. A. Cartwright, L. V. Bell, D. F.
Condie, S. Forry, J. A. Gallup, S. G. Morton, W. Beaumont, Thomas
Sewall, E. H. Barton, S. Brown, J. Watson, Jos. Parrish, C. A. Lee, J.
Torry, Alden March, Lyman Spalding, Josiah Bartlett, J. M. Smith,
Dixi Crosby, Valentine Seaman, E. A. Holyoke, Amos Twitchell, E. H.
Smith, J. B. Beck, Usher Parsons, Caleb Fiske, J. E. Holbrook, William
* g
pººr
ſ
98 TO NER,
Baynham, F. T. Stribling, L. M. Lawson, J. R. Coxe, T. C. James, R.
W. Gibbes, John P. Mettauer.
In looking over the available records of the lives of the medical men
who have labored in the several States during the century, I am struck
with the evidence of the high average professional ability, and wonder-
ful fidelity, with which they have discharged their duties. The testi-
mony, too, is ample as to the high esteem in which the vast majority of
medical men have been held by the communities in which they resided.
I am aware there are those who would draw this picture less rosy.
And I will concede that the opinion held on the point depends to some
extent upon the temperament and motive of the inquirer. If he seeks to
find the illiterate, the incompetent, or the unworthy, bearing the title of
doctor, I am sorry to say such can be found. But if, on the contrary, he
looks as I have done to find the educated, the intelligent, the skilful,
the conscientious and faithful physicians, they are to be found in great
numbers in every city and village in our broad and prosperous republic.
I am persuaded that the medical profession of the United States, not-
withstanding all that has been said by its friends in their desire to ele-
vate it, really has within its ranks proportionately more talent, nobility
of character, and high scientific acquirements, than are to be found in
any other profession in this or any land.
The number of great physicians who have by their discoveries and
writings added new facts and extended the boundaries of medical science,
is limited in any century and every country. This fact ought not to be
lost sight of.
To the young and to the inconsiderate only do great reputations seem
a matter of course. To the conceited nothing seems beyond their untried
powers. Age and experience, however, demonstrate the limitations and
possibilities of human intelligence and acquirements, which, it is con-
ceded by the wisest, are comparatively narrow and circumscribed.
Medical science and the medical profession in America have made vast
progress in the hundred years just passed, and have brought into promi-
mence during that time many medical men of genius and rare abilities,
and sometimes from unexpected quarters. If there is any one thing in
which the American people has a united faith, it is in progress. As a
nation and a people we believe we shall be better physically, morally,
and intellectually, in the future than we have been in the past.
From a careful study of the average proportion of physicians to popu-
lation, it is rendered probable that about 65,000 physicians have died in
the United States during the century. Of even the few whose genius,
skill, and devotion to medicine, in the several States, have rendered
their lives notable, it is not possible to present more than the merest
outline; little, indeed, beyond an imperfect list of names. To do even
this meagre justice to my subject, I was obliged to correspond with phy-
sicians in different parts of our country, and beg them to assist me in
collecting the necessary facts; and to these gentlemen I wish to return
my most sincere acknowledgments for their valuable assistance. What-
ever defects appear in this paper, and doubtless there are many, they are
my own.
ALABAMA.”—In this State Josiah Clark Nott, a native of South Caro-
1 Alabama was visited by De Soto as early as 1541. The first successful settlement was
made upon Mobile Bay in 1702, by Bienville. This State formed a part of Georgia until
A D D RESS ON ME DIC A. L. B I O G R A PHY.
lina, was for years the leading medical spirit. His eminence as a surgè833AN º
author, and teacher, placed him in the front rank; he has already been men- ºr "
tioned. (b. March 31, 1804; d. March 31, 1873.) Dr. J. W. Heustis
wrote on the diseases of the South as early as 1817. In 1825 he pub-
lished a more systematic treatise on the “Bilious and Remittent Fevers
of Alabama.” (b. 1784; d. 1841.) Dr. Wm. M. Boling, of Montgomery,
was a physician of education, and extensively patronized. Dr. Thomas
Fearn and his brother Dr. Richard Lee Fearn, of Mobile, were natives of
Virginia, and accomplished physicians. Dr. Silas Ames, of Mobile, was
a physician of skill, and esteemed remarkably successful in the treatment
of fevers. The following also deserve mention, viz.: T)rs. Samuel D.
IIolt, Leroy Anderson, A. Lopez, A. G. Mabry, H. S. Levert, James C.
Iſarris, Nicholas Merriwether, P. H. Lewis, Edward Gant, and R. C.
Armstrong.
ARKANSAs."—T)r. Benj. P. Jett, of Washington, Hempstead Co., came
from Virginia, and enjoyed a large and responsible practice. (b. Oct. 25,
1808; d. Dec. 29, 1865.) Dr. Craven Peyton, of Little Rock, served as a
surgeon in the war with Mexico, and thereafter retained a preference
for the practice of surgery, in which he was very successful. The great
esteem in which he was held was manifested by the closure of the banks.
and business houses, in order that their employés might attend his
funeral. (d. Nov. 7, 1872.) Dr. Charles B. Mitchell, a native of Ten-
nessee, practised in Washington. His business habits, intelligence, and
enterprise, made him many friends, and caused him to be elected U. S.
Senator, 1860–61. (b. Sept. 19, 1815; d. Sept. 20, 1864.) Dr. Shephard
Laurie, a native of the District of Columbia, was for many years one of
the leading physicians and surgeons of Little Rock. I will also men-
tion Drs. Geo. Eving, Bumford, G. G. Shumard, Alden Sprague, Burton,
and Gibson.
CALIFORNIA.”—This new State holds out such golden promises as to
1802; from this time till 1817 it was included in the Mississippi territory, and was then
organized into a separate territorial government, and admitted as an independent State to
the Union in 1819. Alabama has advanced rapidly in population and wealth, and has
given much encouragement to general education and the advancement of the Sciences. In
1870 she had 996,992 inhabitants. She has no large cities; about one in twelve of her
people live in cities and towns of over five thousand inhabitants. One medical college
exists, located at Mobile. (NoTE.—Summer schools, as adjuncts to colleges, are in no in-
stance enumerated.) A State Medical Association, formed in 1847, has, by recent legisla-
tion, also the legal powers of a State board of health, and publishes a volume of Transac-
tions annually. Institutions, sufficient for the care and treatment of unfortunates, have
been established.
! In Arkansas Settlements were first made about 1685; it was a part of the Louisiana
purchase of 1803. In 1819 it was formed into a territory, and was admitted as an inde-
pendent State in 1836. The population in 1870 was 484,471. It has no large cities, and
only about one in thirty of its people live in cities and towns of over five thousand inhabit-
ants. The State in 1870 had 1206 physicians. Its population is gradually increasing. A
State Medical Association, formed in 1870, publishes annually a volume of Transactions.
Institutions for the care of the insane and other unfortunates have been founded.
2 The earliest settlement in the territory of the present State of California was in 1769,
by a party of Franciscan friars who came from the Peninsula of Lower California . In
1821 it became a territory of Royal Mexico, and continued a province under the republic.
In 1846 the American navy seized Monterey, and from that time it has been under the
control of the United States. The gold mines were discovered in 1848, population was at
once led to them, and California was admitted as a State in 1850. She has been, there-
fore, but a little over a quarter of a century a member of the Union. Her population in
1870 was 582,031. Nearly one-third of her people live in cities of over five thousand
inhabitants. She had at the date mentioned 1257 physicians. Two medical colleges.
have been established, and a State Medical Society, formed in 1870, publishes annually a

100 TON E R ,
attract to it many able physicians. Dr. Thomas M. Logan, a native of
South Carolina, in 1849 located at Sacramento. IIe was a close observer
of the causes of disease, and a frequent contributor to the medical jour-
nals. IIe was influential in organizing the Medical Society of California
and the State Board of Health, and was president of the latter at the
time of his death. He was President of the State Medical Society in
1871, and of the American Medical Association in 1873. (b. Jan. 31,
1808; d. Feb. 13, 1876.) Dr. E. S. Cooper, a native of Ohio, was an excel-
lent surgeon and a successful medical teacher in San Francisco. He
founded and published the San Francisco Medical Press, and made valu-
able suggestions as to the physiological mode of repair in wounded joints
and tendons. He was a careful student, a bold surgeon, and a frequent
contributor to medical serial literature. (d. Oct. 13, 1862, aet. 40.) Dr.
Isaac Rowell, a native of New Hampshire, enjoyed an extensive practice
in San Francisco, and was particularly influential in organizing the Uni-
versity of the Pacific, in which he was a professor. (b. 1818; d. Jan. 4,
1871.) Dr. Wm. Burnett, of Petaluma, was a physician of culture. The
following also deserve mention: Drs. Henry M. Gray and John T. Morse,
of San Francisco. -
CoNNECTICUT.”—Dr. A neas Munson, of New Haven, served as a sur-
geon in the Revolutionary war. He was an observing and successful
practitioner and surgeon. He contributed papers to the Connecticut
Medical Society, and was an active promoter of art and science. He was
one of the originators of the State Medical Society, and for some years
its president. (b. June 24, 1734; d. June 16, 1826.) Dr. Jared Potter,
of Wallingford, was a scholar, and had a passion for acquiring knowl-
edge. His office was much frequented, and his instruction eagerly
sought by young men entering the profession. (d. 1810, aet. 67.) Dr.
Jonathan Knight, of New Haven, was remarkable for his urbanity and
sound professional judgment. He held a chair in Yale College for
twenty-five years. He was the first president of the American Medical
Association. (b. Sept. 4, 1789; d. Aug. 25, 1864.) Dr. Wm. Tully was
an earnest cultivator of the science of medicine. He was an author of
merit, and published, along with Dr. Thomas Miner, in 1823, a work on
fevers. (d. Feb. 28, 1859.) Dr. Thomas Miner was one of the founders
volume of Transactions. A State board of health, which also publishes annual Transac-
tions, has been established by law. Institutions for the care of unfortunates have been
created by the State, sufficient for the wants of the people.
The following medical journals have been published: California Medical Gazette, 1868;
California State Medical Journal, 1856; Medical Gazette, 1870; Pacific Medical and Sur-
gical Journal, 1858; San Francisco Medical Journal, 1858; San Francisco Medical Press,
1860; Western Lancet, 1872.
Connecticut is one of the thirteen original States. The Tutch had a trading house at
Hartford as early as 1631. An offshoot of Plymouth had also a settlement at Windsor
about the same time. New Haven was for some years an independent colony. All the
separate interests, however, were consolidated in 1665. The State took an early and an
active stand in favor of American Independence. The population in 1870 was 537,454,
with about two-thirds of the people living in cities and towns of over five thousand inhabi-
tants. At the same time there were 680 physicians. Great encouragement has been
given to education and the advancement of science. A State Medical Society was founded
in 1792, and was one of the first in the country to publish Transactions. There is one
medical college, a department of Yale. It was in this State that anaesthesia in surgical
operations was first tried. The first school in America for the education of the deaf and
dumb was organized at Hartford. Institutions for the care of the insane and other unfor-
tunates have been founded by the State, sufficient for the wants of the people.
The following journal of a medical and scientific character has been published in Con-
necticut: American Journal of Sciences and Arts, 1846.
A D D RESS O N M E DIC A. L. B I O G. R. A. P. H. Y. 101
of the Medical Department of Yale College. He was particularly in-
terested in the cure and treatment of the insane. His life and labors
were important to his day and generation. (d. April 23, 1841.) Dr. Eli
Todd, of Hartford, was an educated and intelligent physician. He was
much interested in the treatment of the insane, and was chosen superin-
tendent of the Retreat at Hartford. (d. Nov. 17, 1833.) IDr. Lemuel
Hopkins, of Hartford, was a scholarly physician, writer, and wit. IIe
was devoted to scientific studies and to the elevation of the profession.
(b. June 19, 1750; d. April 14, 1801.) Dr. Eli Ives, of New Haven, was
a distinguished physician and botanist. He was a man of quick percep-
tions, sound judgment, great industry and perseverance. For years he
filled with ability a professorship in Yale College, and in 1860 was Presi-
dent of the American Medical Association. (b. Feb. 7, 1779; d. Oct. 8,
1861.) T)r. Mason F. Cogswell was a surgeon of the Revolution, and
during his day the leading surgeon in Connecticut; he was the first per-
son in this country to ligate the carotid artery. (b. 1761; d. Dec. 1836.)
Dr. Thomas Hubbard succeeded to the chair of surgery in Yale College
On the death of Dr. Nathan Smith, and was a worthy successor to one
of America's most eminent surgeons. (d. June 18, 1838, act. 63.) Dr.
Worthington Hooker, of New Haven, was an accomplished physician
and a writer of many educational works of merit. His brother Charles
also enjoyed an enviable reputation. (b. March 3, 1806; d. Nov. 6,
1867.) I will also name Drs. Seth Bird, George Sumner, Samuel Wood-
ward, Daniel Worden, and Horace Wells, the dentist and discoverer of
anaesthesia.
DELAWARE."—T)r. Edward Miller was an accomplished writer. He
practised at Dover until 1796, when he removed to the city of New York.
His reputation had preceded him, so that he rapidly acquired a lucra-
tive business. In connection with Drs. E. II. Smith and S. L. Mitchell,
he founded in 1797 the New York Medical Repository, the first medical
journal in our country. (b. May 9, 1760; d. March 17, 1812.) Dr.
James Tilton, of Wilmington, served as a surgeon in the hospitals of the
Revolution, and proved himself remarkably well informed on the subject
of hospital construction and management. He was a member of the
Continental Congress from 1783 to 1785. During the war of 1812 he
was appointed Surgeon-General of the U. S. Army. In 1813 he pub-
lished a pamphlet on Military Hospitals. He was a man of clear per-
ceptions and practical good sense, and in his official position did much
to promote the efficiency of the medical department of the army. He
was President of the Delaware State Medical Society. (b. June 1, 1745;
d. May 14, 1822.) Dr. James Sykes was a physician of great personal
and professional popularity ; and was chosen to represent his district in
| Delaware was one of the thirteen original States. It has the smallest area of any State
except Rhode Island. The earliest settlements were made by the Swedes and Finns in
1627. The Dutch of New York held the government in the year 1655, but it passed to
the English in 1764. Delaware formed a part of the Pennsylvania grant of 1682, under
the name of the “ Three Lower Counties of Delaware.” In 1701 it was permitted, in part,
to have a separate government, but was subject to the Governor of Pennsylvania down to
the Revolution. Delaware's population in 1870 was 125,015, about one in four of her
people living in cities of over five thousand inhabitants. She had at the same time one
hundred and seventy physicians. Her proximity to Philadelphia, and her position on the
Delaware Bay, give her great commercial and manufacturing advantages. Her population
and wealth are steadily increasing. She has a State Medical Society, formed in 1789, which
publishes Transactions annually, and she has made ample provisions for the care and treat-
ment of her insane and other unfortunates.
102 TO NER,
the State Legislature, and also in the State Senate for fifteen consecutive
years, being much of the time the presiding officer. In 1801–2 he was
acting Governor. He practised for a few years in the city of New York,
but returned to Delaware, where he ended his days. (b. March 27, 1761;
d. October 18, 1822.) Dr. James Couper, of New Castle, was a highly
gifted physician. In 1840 he was a delegate from the State Medical
Society to the Convention for revising the U. S. Pharmacopoeia. He was
President of the Delaware State Medical Society, and Vice-President of
the American Medical Association in 1863. (b. Oct. 3, 1803; d. 1865.)
Dr. Henry F. Askew was a physician of sound judgment and great expe-
rience. His professional life was characterized by close attention to pro-
fessional duties. He had a well-trained mind, was a constant reader of
the latest literature, and had a high regard for the dignity of the profes-
sion. He was President of the American Medical Association in 1867.
(d. March 6, 1876.) Dr. George Munroe was a surgeon in the Revolu-
tionary War. He practised at Wilmington, and was through life one of
the foremost medical men of the State, and an occasional contributor to
the “New York Medical Repository.” (d. Oct. 11, 1819.) Dr. John
Vaughn, a native of Pennsylvania, was a man of science and physician of
ability. His manners in the sick room were gentle and assuring. In the
winter of 1778–79 he delivered a course of lectures on Chemistry and
Natural Philosophy. In the following year he published a “Chemical
Syllabus;” he also contributed articles to the “New York Medical Re-
pository.” (d. March 25, 1807.) I will also name the following: Drs.
Charles Ridegley, Allin McLane, Wm. Gibbons, Henry Latimer, Nicholas
Way, John McKinley, Ebenezer Smith, Joseph Hall.
DISTRICT OF COLUMBIA."—T)r. Thomas Sewall, a native of Maine, was
for many years extensively engaged in practice in Washington. He held
the chair of Anatomy in the Medical Department of Columbia College
from its organization in 1825 until 1839, and from that time to his death
the chair of Pathology and Theory and Practice. His address at the
opening of the school in 1825 gave a history of the Medical Colleges of
the country up to that time. He was a good writer, and published a
number of papers on Phrenology, Temperance, and Medicine. (d. April
10, 1845.) Dr. Tobias Watkins, a native of Maryland, was a physician,
scholar, and author. He published in Baltimore, in 1809, “The Medical
and Philosophical Recorder,” and was for a time one of the editors of
the “Portfolio.” He served as a surgeon in the war of 1812, and was
acting Surgeon-General from 1818 to 1821, and Fourth Auditor of the
Treasury from 1824 to 1829. He translated a number of medical works
from the French. (d. Nov. 14, 1855.) Dr. Thomas Henderson was a
physician and surgeon of the U. S. Army, and an author. From 1825
to 1833 he was Professor of Theory and Practice in the Medical Depart-
* For three-quarters of a century Washington has been the seat of the government of
the United States. Originally, the District or Territory of Columbia comprised a territory
of ten miles square, but that part of it lying south of the Potomac River, containing thirty-
six square miles, was retroceded to Virginia in 1844. The population in 1870 was 131,700.
At the same time there were three hundred and twenty-six physicians. There are three
medical colleges now giving instruction. A district medical Society was organized in 1817,
and publishes Transactions. Institutions for the care of insane and other unfortunates,
sufficient for the wants of the District, have been established by the United States
government.
The following Medical Journals have been published in the District of Columbia: American
Botanical Register; National Med. Journal, 1870; Register and Library of Medical and
Chirurgical Science, 1835.
A D D RESS ON ME DIC A. L BIO G. R. A. P. H. Y. 103
ment of Columbia College. After his admission to the army he pub-
lished “IIints on Examination of Recruits for the Army,” which has
gone through several editions. (b. Jan. 6, 1789; d. Aug. 11, 1854.) Dr.
B. S. Bohrer, of Georgetown, was a fine scholar and an accomplished
physician. He held for some years a chair in the Ohio Medical College.
He possessed a fine library of medical and classical literature. He was a
good practitioner, and a man of most courteous and agreeable manners.
(d. Aug. 19, 1862.) Dr. Joseph Lovell, a native of Massachusetts, was
Surgeon-General of the Army, and long a resident of Washington.
Although not engaged in private practice, he was a member and
supporter of the local medical organization, and was frequently called
in consultation. (b. 1788; d. Oct. 17, 1836.) Dr. Thomas Lawson, a
native of Virginia, was a surgeon in the army, and held the office of
Surgeon-General. He was a man of great professional abilities and
personal worth, and made a number of valuable reports on the diseases
of the army and the climate of the western military posts. (d. May 15,
1861.) Dr. Frederick Dawes was a physician of fine abilities, and en-
joyed for years an extensive practice. (d. Feb. 10, 1852.) To these I
will add the names of Drs. Frederick May, Bailey Washington, R. K.
Stone, Thomas Miller, John M. Thomas, the two Worthingtons, R. H.
Coolidge, J. A. Brereton, and Joshua Riley.
FLORIDA.”—Dr. Bosquet was a physician of note at St. Augustine, as
early as 1800. Dr. Thomas Travers was in practice there in 1812. About
the time the territory was purchased from Spain, Dr. Darcy was a leading
physician. Dr. Henry Perrine was a physician, and a man of scientific
attainments. The United States gave him a township of land near
Biscayne Bay, for the purpose of encouraging the introduction and culti-
vation of tropical plants. The “Sisal Hemp” is now growing abundantly
in Florida, the result of his enterprise. The Doctor was murdered at the
light-house, by the Indians, during the Florida war (1841). Dr. Lewis
practised as early as 1813, at Fernandina, and enjoys the distinction of
having introduced vaccination into that section of country. Dr. Charles
W. McCroskey was a good physician. He was connected with the army
at St. Augustine, and died of yellow fever. Dr. W. H. Simmons, a native
of South Carolina, lived at St. Augustine. He was a physician of skill,
and a man of literary accomplishments. TXr. Richard Weightman, a
native of Washington city, after serving in the army, settled on the St.
John's River, and engaged for years in the practice of his profession.
Dr. Seth Peck was also a physician of note in Florida. To the names
already mentioned, I will add those of Drs. Lewis Willis, W. W. Wad-
dell, Andrew Anderson, Theodore Turnbull, and William Davis.
GEORGIA.”—Dr. Lyman Hall was a well-educated physician, a member
1 Florida was visited by Ponce De Leon in 1512, and in 1536 by DeSoto. A settlement
was made in 1564, the earliest by Europeans in any State of the Union. Florida belonged to
Spain till 1820, when it was purchased by the United States, and admitted as an indepen-
dent State in the Union in 1845. It has a large territory with almost tropical climate, but
a sparse population. In 1870 it had 188,248 inhabitants. The census gave it 240 physi-
cians. There are no large cities in the State. The United States Government maintains a
navy yard, and also a military garrison. The State has a Medical Association, formed in
1874, which publishes annual Transactions. Provision has been made for the care and
treatment of the insane, and other unfortunates.
* Georgia is one of the thirteen original States. The first settlement by the English was
in 1732, the latest of any of the American Colonies. The population at the close of the
Revolution did not reach 30,000. The population in 1870 was 1,184.109, with about one in
every fourteen living in cities and towns of over five thousand inhabitants. It had at the
104 - TO NER,
of the Continental Congress, and a signer of the Declaration of Indepen-
dence. (b. 1725; d. Oct. 19, 1790.) Dr. Milton Antony, of Augusta,
was a teacher and practitioner of ability. He was the founder of the
Medical Academy at Augusta, in 1828, and of the Medical College of
Georgia. In 1831 he started the first medical journal published in the
Southern States. (b. August 7, 1789; d. Sept. 19, 1839.) Dr. Noble
Wimberly Jones was a physician and a patriot. In the discharge of his
professional duties he was attentive and skilful. Dr. W. C. Daniell, of
Savannah, was a physician and author of note. His best known work is
entitled, “Observations on the Autumnal Fevers of Savannah.” In 1826
he advocated the use of capsicum internally and externally in yellow
fever. (b. January, 1792; d. Dec. 28, 1868.) Dr. Richard Banks, of
Savannah, and a native of Georgia, was a physician and surgeon of
ability, and filled the chair of Surgery in the Savannah Medical College.
(d. May, 1856, aged 62.) Dr. R. D. Arnold, of Savannah, a native of
Georgia, was an accomplished physician and writer. He was one of the
original members of the American Medical Association, and its Vice
President in 1852. He was for many years Professor in the Savannah
Medical College. He wrote and published papers of decided merit in the
Transactions of the American Medical Association, and in the Medical
Journals. (d. July 10, 1876, aet. 68.) Dr. W. R. Waring was for many
years a leading physician of Savannah, and Professor in the Medical
College. Dr. George M. Newton was a physician and successful teacher
of Anatomy at Augusta. He left a fortune of about $200,000, to found
an orphan asylum. (b. Jan. 30, 1810; d. Jan. 6, 1859.) In addition
to the foregoing, I will name Drs. Tomlinson Fort, of Milledgeville,
Thomas N. Hamilton, of Rome, G. B. Gorman, Charles W. West, Joseph
H. Eve, of Augusta, Dr. Wildman, of Savannah, and Dr. Curtis B. Not-
ingham. -
ILLINOIs.”—Dr. Daniel Brainard, a native of New York, was a physician
and surgeon of distinction. He settled in Chicago as early as 1835, and
soon acquired a leading professional business, especially in Surgery. He
was one of the founders of the Rush Medical College, and long one of its
same time 1537 physicians. It has one good seaport, but no large cities. It has three
medical colleges, distributed, one each, at Atlanta, Augusta, and Savannah ; a State
Medical Association was formed in 1849, and a State Board of Health has been organized
and publishes reports. Institutions for the care of the insane and other unfortunates have
been established.
The following medical journals have been published in Georgia: Atlanta Medical and
Surgical Journal, 1855; Georgia Medical Companion, 1871; Georgia Medical and Surgical
Encyclopædia, 1860; Oglethorpe Medical and Surgical Journal, 1861; Savannah Journal
of Medicine, 1858; Southern Medical and Surgical Journal, 1837.
| The French had trading posts in Illinois as early as 1700. The earliest permanent
settlement, however, was by the French about 1763. In 1783 this State formed a part of
the “Northwestern Territory.” In 1800 it was a part of the territory under the name of
Indiana. Illinois was admitted as an independent State in the Union in 1818. Her popu-
lation in 1870 was 2,539,891, with about one in five of her people living in cities and towns
of over five thousand inhabitants. She then had 4861 physicians. Population and wealth
are rapidly accumulating in this State. Three medical colleges are now giving instruction.
A State Medical Society was organized in 1851, and publishes a volume of Transactions
annually. Institutions for the care of unfortunates have been established, sufficient for the
wants of the people.
The following medical journals have been published in Illinois: American Journal of
Materia Medica, 1860; Chicago Journal of Nervous and Mental Diseases, 1874; Chicago
Medical Examiner, 1860; Chicago Medical Journal, 1858; Chicago Times, 1869; Illinois
and Indiana Medical and Surgical Journal, 1846; Illinois Medical and Surgical Journal,
1844; Lens, 1872; Northwestern Medical and Surgical Journal, 1849; Pharmacist, 1868;
Tripod, 1871.
A DI) RESS ON ME DIC A. L. B I O G R A PHY. 105
professors. He contributed articles of value to the Medical Journals,
and to the Illinois State Medical Society’s Transactions. (b. 1812; d. Oct.
10, 1866.) Dr. Wm. B. Herrick, a native of Maine, was one of the early
physicians of Chicago. He served as a surgeon in the Mexican war,
and was a physician of extensive experience and skill. He filled the
chair of Anatomy in Rush Medical College with ability for twenty
years. (d. Dec. 31, 1865.) Dr. Henry Wing settled in practice in Col-
linsville. He was a physician of education, and a scientist of extensive
acquirements. He was one of the founders of the Chicago Medical
College, and for years, held in it a professorship. His notes on the Botany
of the Rocky Mountains form a part of Prof. Powell’s Geological Report
of that region. (b. 1822; d. Feb. 18, 1871.) Dr. Elijah D. Harmon, a
native of Vermont, was one of the earliest physicians to settle in Chicago.
IIe was physician to the Military Post of Fort Dearborn in 1832. He
was a good physician and surgeon, and for his day, and the demands
made upon his skill, was an efficient and successful practitioner. (b.
Aug. 20, 1782; d. July 3, 1869.) Dr. J. V. Z. Blaney, a native of Dela-
ware, was an educated and successful physician. He was one of the
founders of the Rush Medical College, and the originator and publisher,
in 1844, of the “Illinois Medical and Surgical Journal.” (b. 1820; d.
I)ec. 11, 1874.) Dr. Rudolphus Rouse, a surgeon of the war of 1812,
settled in practice in Peoria. He deserved, and soon attained, the first
rank among physicians in that part of the State. (b. July 20, 1793; d.
April 30, 1873.) The following physicians are also deserving of mention:
Drs. Samuel Thompson, George W. Richards, Nicholas Hard, Harrison
Noble, Stephen W. Noble, Levi T. Hewins, Josiah Goodhue, Alexander
Walcott.
INDIANA.”—Dr. John Thomas Plummer, a native of Maryland, was a
learned physician and excellent practitioner. IIe enjoyed in Indianapolis
and its vicinity, a high reputation for skill and devotion to professional
duty. In the natural sciences he was quite proficient, and was an excellent
philologist; he assisted Noah Webster in collecting and defining the mean-
ing of Western words for his unabridged Dictionary. (d. April 10, 1865,
aged 58.) Dr. Isaac Casselberry, a native of Indiana, and long a leading
physician in Evansville, added to skill in his profession a love of study,
and good business habits. He was a successful promoter of medical or-
ganizations, and in every new enterprise worked with great intelligence
and success. He was a member of the Board of Health, and a trustee of
the Evansville Medical College, also President of the State Medical So-
ciety. (b. Nov. 26, 1821; d. July 9, 1873.) Dr. Charles Parry, of Indian-
apolis, was especially careful in diagnosis, and was a superior surgeon.
He possessed the ability to make original observations, and was a writer
of force. Prof. Geo. B. Wood quotes from a paper of his on pernicious
fever. (d. August, 1861.) I)r. Asahel Clapp, a native of Massachusetts,
practised with great success in New Albany, where he settled in 1817,
* Indiana was admitted to the Union in 1816. There were in it a few French settlements
as early as about 1700. Immigration from the old States commenced about 1802. The
population in 1870 was 1,680,637. It has no very large cities, about one in eight of its
population living in cities and towns of over five thousand inhabitants. It had at the same
time 3615 physicians. It has a State Medical Society, formed in 1849, which publishes
annually a volume of Transactions, and has three medical colleges giving instruction. In-
stitutions sufficient for the care of unfortunates have been established.
The following medical journals have been published in Indiana: Indiana Journal of
Medicine, 1870; Indiana Journal of Medicine and Surgery, 1855; Indiana Medical Journal,
1854; Indiana Scalpel, 1860; Western Retrospect of Medicine and Surgery, 1872.
106 TO NER,
and was for forty years actively engaged in the duties of his profession.
He was a good botanist, and made a report to the American Medical
Association on the medicinal plants of the United States. He was fond
of the study of the natural sciences, and collected a large cabinet of spe-
cimens which he presented to Yale College. Dr. John L. Richmond, a
native of Massachusetts, although a well-read and intelligent physician,
won his reputation by a single operation. He performed the Caesarean
section on the 23d of April, 1827, in a log cabin in the country, with no
assistance except that rendered by the husband of the patient, and two
women. The operation was successful, saving the mother's life. The
child died. (b. April 5, 1785 ; d. Oct. 12, 1855.) Dr. John S. Bobbs, a
native of Pennsylvania, was a successful physician and teacher of medi-
cine in Indianapolis. He was for some years Professor of Surgery in the
Indiana Central Medical College. In his will he left means for the
establishment of a public Dispensary. He was President of the State
Medical Society in 1868. (b. Dec. 28, 1809; d. 1870.) In addition to
the above list, I will name Drs. T. Fry, E. Demming, W. Kersey, and J.
W. Moody.
Iow A.”—Dr. David L. McGugin, a native of Pennsylvania, served as
a surgeon in the Mexican war, and was for years the leading physician
of Keokuk. IIe filled a chair in the University of Iowa at the time of
his death. The State Medical Society in 1851 elected him President.
As a practitioner he had no superior in the State. (b. 1807; d. June 23,
1865.) Dr. George Reeder, a native of Maryland, and a graduate of
William and Mary College, Va., was a successful practitioner of medicine
at Muscatine. He was one of the founders of the State Medical Society,
and its President in 1854. The following also deserve mention: Drs.
Ezra T. Fountain and G. W. Richards.
RENTUCKY.”—Dr. Benjamin W. Dudley, a native of Virginia, was
an eminent surgeon and teacher at Lexington. After graduating, he
spent four years in Europe perfecting himself in his professional studies.
In 1817 he was elected Professor of Anatomy and Surgery in Transyl-
* Iowa was admitted into the Union in 1846. It was a part of the Louisiana purchase
of 1803. Its earliest settlements were by the French. In 1870 it had a population of
1,194,320, with about one in ten of the population living in cities and towns of over five
thousand inhabitants. It had at that time 1865 physicians. It has a rich and productive
soil, and is rapidly increasing in wealth and population. Two medical colleges are giving
instruction. A State Medical Society was founded in 1850, and publishes an annual volume
of Transactions. Institutions sufficient for the care of the insane and other unfortunates
have been established.
The following medical journal has been published in Iowa : Iowa Medical Journal, 1855.
* Kentucky was admitted to the Union in 1792. The first account we have of this region
was by Dr. Thomas Walker, of Virginia, who visited it in 1745, and again in 1750. Dr.
John Connolly had made location of a tract of land at the falls of the Ohio as early as 1770.
The earliest emigrations to Kentucky were under Daniel Boone, who made a settlement
at Harrodsburgh in 1774. The soil is very rich and productive; wealth and population
are rapidly flowing in. The population in 1870 was 1,321,011, with about one in seven of
her people living in cities and towns of over five thousand inhabitants. She had then 2414
physicians. Four medical colleges are now giving instruction in the State, and a State
Medical Society, formed in 1851, publishes Transactions annually. Institutions for the care
of unfortunates, demanded by enlightened humanity, have been established.
The following medical journals have been published : American Medical News, 1876;
American Medical Weekly, 1874; American Practitioner, 1869; Kentucky Medical Re-
corder, 1853; Louisville Journal of Medicine and Surgery, 1838; Louisville Medical Jour-
nal, 1860: Louisville Medical Gazette, 1859; Louisville Review, 1856; Richmond and
Louisville Medical Journal, 1868; Transylvania Medical Journal, 1849; Transylvania
Journal of Medicine and Science, 1828; Western Journal of Medicine and Surgery, 1840
Western Lancet, 1842; Western and Southern Medical Recorder, 1841.
A D D R E S S ON ME DIC A. L. B I O G. R. A. P. H. Y. 107
vania University. Through life he devoted himself strictly to the duties
of his profession. He remained connected with Transylvania University
till 1850, when he retired from practice, and lived in quiet on his farm.
He was a bold surgeon and successful operator. He performed lithotomy
225 times, and did not lose a patient until after he had operated more than
100 times. He had a genius for originating new operations and devices.
He contributed many articles of great value to medical journals, chiefly
on surgery, but wrote no large work. (b. 1785; d. Jan. 20, 1870.) Dr.
Charles W. Short, of Lexington, was a learned botanist, and an accom-
plished physician and teacher. He held the chair of Botany and Materia
Medica in the Transylvania University. He published but little. His
best known writings are his contributions to the Flora of Kentucky. Dr.
Ephraim McDowell, a native of Virginia, originated the surgical opera-
tion of ovariotomy, which at first was severely condemned, but which is
fully justified by the success attending the proceeding. (b. November 11,
1771; d. July 25, 1830.) Dr. Henry Miller, a native of Kentucky, was an
obstetrician, writer, and teacher of ability. In 1835 he was appointed to
the chair of Obstetrics in the Medical Institute at Louisville. He was
the first physician in the West to use the speculum, and to practise local
applications in diseases of the uterus. He was in many respects one of
the most original and skilful physicians that Kentucky has produced.
(b. Nov. 1, 1800; d. Feb. 8, 1874.) Dr. Samuel Brown, a native of Vir-
ginia, introduced vaccination in Lexington, as early as 1802. Iſe was a
man of decided ability, but exhibited a restless disposition, removing to
New Orleans, then to Natchez, Miss., then to Huntsville, Ala., and
finally returning to Lexington. He held the chair of Theory and Prac-
tice in Transylvania University. He was very entertaining as a lecturer.
Contributions from his pen were published by the American Philosophical
Society, and in the New York Medical Repository and other medical
journals. As early as 1820 he suggested the formation of an American
Medical Association. (b. Jan. 30, 1769; d. July 12, 1830.)
Dr. James Bush, of Lexington, filled with ability the chair of Surgery
in Transylvania University from 1839 to the time of his death. (b. 1808;
d. Feb. 9, 1875.) Dr. Wm. H. Richardson was a physician of high cul-
ture, and Professor of Obstetrics in the Transylvania University. He
was a man of superior education and address, and enjoyed a large prac-
tice. Dr. Joshua Barker Flint, a native of Massachusetts, practised for
Some years in Boston, but removed to Louisville, where he held the chair
of Surgery in the Louisville Medical College from 1837 to 1849, and,
from this time to his death, the same chair in the Kentucky School of
Medicine. In 1868 he published a work on Practice. He was the first
surgeon in Kentucky who administered ether to produce insensibility
for surgical operations, which he did in 1847. Dr. Charles Caldwell was
an eminent physician, author, and teacher. As early as 1810 he filled
the chair of Natural History in the University of Pennsylvania. In
1818 he was elected to the chair of Theory and Practice in the Tran-
sylvania University, which he held till 1837. He was a ready and volu-
minous writer. (b. May 14, 1772; d. July 9, 1853.) Dr. John Esten Cooke
was a physician, author, and teacher of ability, and practised with suc-
cess in the Shenandoah Valley of Virginia, and assisted in establishing
the Winchester school, before removing to Kentucky. In 1827 he was
elected to the chair of Theory and Practice in the Transylvania Uni-
versity. In connection with Prof. Short he founded the following year
“The Transylvania Journal of Medicine.” In 1828 he published a work
108 - TO NER,
entitled “Pathology and Therapeutics.” Dr. Lewis Rogers fairly won
his high reputation by his intelligence and devotion to professional
duties. From 1849 he filled a chair in the University of Louisville.
He was President of the State Medical Society in 1873, and gave in his
opening address an admirable history of medicine in Kentucky. (b. Oct.
12, 1812; d. June 17, 1875.) Dr. J. D. Jackson, of Danville, was, for his
age, one of the most accomplished physicians and surgeons of Kentucky.
He originated the movement for the erection of a monument to Ephraim
McDowell. He performed with success many capital operations, includ-
ing ovariotomy and tracheotomy. (b. Dec. 12, 1834; d. Feb. 8, 1874.)
Beside the physicians named, I will mention Drs. Joseph Buchanan,
Daniel L. Metcalf, Ethelbert L. Dudley, Robert Breckenridge, W. A.
McDowell, James Fishback, Elisha Warfield, T. L. McLary, Walter
Brashiers, Charles McCreary, and Frederick Ridgley.
ToUIsIANA.”—Dr. Rouanet was a native of France, but in 1844 settled
in New Orleans, where he soon acquired a leading position in the profes-
sion. He won high encomiums for his studies of the diseases of the heart
in Paris, and contributed a number of papers to the French Academy on
the physiological and pathological sounds of the heart. In New Orleans
he gave office instruction to medical men and advanced students, but
was not a teacher in any medical college. His practice for years was
large and responsible, and he was recognized by the profession every-
where as a leading authority on diseases of the heart. (d. 1865.) Dr.
Warren Stone, a native of Vermont, settled in New Orleans in 1832, and
rapidly acquired business and professional reputation. In 1836 he was
chosen to lecture on Anatomy in the University of Louisiana, and in 1837
was elected Professor of Anatomy and Surgery, continuing to hold this
chair until he resigned in 1872. Throughout the South he was without
a rival as a surgeon. In 1870 he was Vice-President of the American
Medical Association. (b. 1808; d. Dec. 6, 1872.) Dr. John Hoffman Har-
rison, a native of Washington, D.C., was surgeon to Charity Hospital from
1833 to 1836. He originated and edited the New Orleans Medical and
Surgical Journal. He contributed a number of papers on yellow fever,
and wrote a work on the Nervous System. (b. Aug. 30, 1808; d. March
19, 1849.) Dr. Thomas Hunt, a native of South Carolina, settled in New
Orleans in 1833. He was one of the founders of the Louisiana Medical
College, was popular as a teacher, and a good writer. He was esteemed
| Louisiana was admitted to the Union in 1812. Settlements were made at Biloxi as
early as 1699, but the earliest successful settlement was at New Orleans in 1712. Louisiana
was purchased by the United States from France in 1803. It included all the territory west
of the Mississippi, east of Mexico, and south of the British possessions. In 1810 the
United States Census gave a population of 76,576. The population in 1870 was 726,915,
with about one-fourth of her people living in cities and towns of over five thousand
inhabitants. There were at this time 936 physicians. The soil of the State is alluvial
and exceedingly rich, but much of it is rendered unfit for cultivation by overflow,
checking agricultural production and the increase of population. The situation of New
Orleans, at the mouth of the largest river in the world, gives it great commercial impor-
tance. A large and well-conducted hospital, known as “Charity Hospital,” was rebuilt
in 1815. Two medical colleges are now giving instruction. For many years a State
Board of Health, having also cognizance of the health of the city of New Orleans, has
existed, which reports to the Legislature and publishes a volume of Transactions annually.
There is no State medical society, though medical organizations exist in the large cities.
The following medical journals have been published : New Orleans Journal of Medicine,
1868; New Orleans Medical Journal, 1844; New Orleans Medical News and Hospital
Gazette, 1854; New Orleans Medical Record, 1866; New Orleans Medical and Surgical
Journal, 1844; New Orleans Medical Times, 1861; New Orleans Monthly Medical Regis-
ter, 1851; Union Medicale de la Louisiane, 1852.
A D D R E SS O N M E D I C A L B I O G R A PHY. 109
specially successful in the treatment of yellow fever. (b. May 18, 1808;
d. March 20, 1867.) Dr. Edward Barton, a native of Virginia, practised
with success in New Orleans. He filled the chair of Materia Medica and
Therapeutics in the University of Louisiana from 1835 to 1840. His
writings on Meteorology, on Hygiene, and on Yellow Fever, show much
research and professional experience. In addition I will name Drs. John
Leonard Riddell, the inventor of the binocular microscope, J. Jones,
Wm. M. Carpenter, Charles A. Luzenburg, and Frank Hawthorn.
MAINE."—Dr. Stephen Cummings, of Portland, was a leading physi-
cian in extensive practice as early as 1800, and continued actively en-
gaged in his profession for over 50 years. (b. 1773; d. 1854.) Dr. James
C. Bradbury, a native of Maine, settled in practice at Oldtown, and for
35 years enjoyed the confidence of the community. Although not a sur-
geon, he performed such operations as became necessary in his practice,
and on Oct. 11, 1851, amputated at the hip-joint with success. This was
the fourth operation of the kind in America. (b. 1806; d. Oct. 3, 1865.)
Dr. Amos Nourse, a native of New IIampshire, a physician of Belfast,
Maine, and a surgeon of ability, although advanced in years, served
in the late war as surgeon of the 20th Maine Regiment. He had been
honored by the Presidency of the State Medical Society. Dr. Job
Holmes, a native of Maine, settled in Paris, where he enjoyed a large
practice. In a few years he removed to Calais, where he passed the
remainder of his life in the active duties of his profession. Dr. Hosea
Rich, a native of Massachusetts, was a practitioner of note in Bangor.
His professional career began as early as 1805, and was continued till
1865. During the war of 1812, he was the surgeon of the 4th Maine
Regiment. I will also name Dr. James l’arker, who was a physician of
ability, and in active practice for over 50 years. He served two terms in
Congress.
MARYLAND.”—Dr. John Beale Davidge was a fine classical scholar and
an extensive reader of the early masters in medicine. As early as 1798,
he published an essay on autumnal and intermittent fevers. IIe was
conspicuous and influential in the founding of the Medical Department
| Maine was admitted into the Union in 1820. From its settlement, in 1607, it was a
part of Massachusetts, and remained under her control till admitted as an independent
State. The population in 1870 was 626,915, about one-third of the people living in
cities and towns of over five thousand inhabitants. The number of physicians was 818. ,
One medical college, a department of Bowdoin College, is giving instruction. There is a
State Medical Society, formed in 1834, that publishes Transactions annually. Institutions
for the care of unfortunates have been founded, sufficient for the wants of the people.
The following medical journals have been published in Maine : Journal of the Medical
Society of Maine, 1834; Maine Medical and Surgical Reporter, 1858.
* Maryland is one of the thirteen original States. Its earliest settlement was in 1634.
The population in 1870 was 780,892, one-third of her people living in cities and towns
of over five thousand inhabitants. The number of physicians was 1251. The State has
great advantages for ocean commerce, owing to its situation on the Chesapeake Bay. It
is rapidly increasing in wealth and population. There are three medical colleges giving
instruction. Institutions for the relief of the insane and other unfortunates, have been
established. There are also a State Medical Society, formed in 1789 under the name of
The Medical and Chirurgical Faculty of Maryland, and a State Board of Health.
The following medical journals have been published in Maryland: Baltimore Journal
of Medicine, 1861; Baltimore Medical Journal. 1870; Baltimore Medical and Philo-
sophical Lyceum, 1811; Baltimore Medical and Physical Recorder, 1808; Baltimore
Medical and Surgical Journal, 1833; Baltimore Monthly Journal of Medicine and Sur-
gery. 1830; Baltimore Philosophical Journal and Review, 1823; Baltimore Physician
and Surgeon, 1872; Maryland Medical Recorder, 1829 : Medical Bulletin. 1868; North
American Archives of Medical and Surgical Science, 1834; Vaccine Inquirer, 1822.
110 T ONER,
of the University of Maryland. In 1813, he published a new classifica-
tion and nomenclature of diseases, in Latin. From 1814 to 1816, he
published a work in parts, entitled “Physical. Sketches,” and was a con-
tributor to Medical Journals. (d. 1829, aet. 60.) Dr. Horatio Jameson,
of Baltimore, was a native of Maryland, and Professor of Surgery in
the University of Maryland. In 1829 he started and edited with ability
the Maryland Medical Recorder, which he continued until 1832.
One of his best known works is on cholera. He published a pamphlet
on the parts concerned in lithotomy. He was fond of the study of the
natural sciences, and was a good geologist. In 1830, he attended a meet-
ing of naturalists and physicians, in Hamburg, Germany. Dr. Nathaniel
Potter was one of the original founders of, and filled for over thirty
years, with distinguished ability, a chair in, the University of Maryland.
IIis writings show much erudition as well as original observation. In
1805, he published a paper on the medical and deleterious properties of
arsenic. The best known work from his pen is one on contagion and
yellow fever, published in 1817. (b. 1770; d. July 2, 1843.) Dr. Tris-
tram Thomas was a physician of large practice and great influence, on
the Eastern Shore of Maryland. He was actively engaged in practice for
Over 50 years, and was an ardent lover of his profession, studious and
observing, and an occasional contributor to the medical journals. IIis
best known paper was one on Bilious and Remittent Fevers, which is
referred to favorably in Eberle's Practice. (b. Dec. 25, 1769; d. Aug. 5,
1847.)
Drs. John and Thomas H. Buckler, brothers, were men of fine intellect,
and good practitioners. For many years, they held the very front rank
as skilful and able physicians. Dr. Philip Thomas, a native of Maryland,
practised in Frederick, from 1769 to 1815. He attended the second
course of lectures delivered in Philadelphia, under Morgan and Shippen.
He was a good scholar, a man of correct habits, and of large influence in
the profession of the State. (b. June 11, 1747; d. April 25, 1815.) Dr.
John Archer, a native of Maryland, was noted as having introduced the
use of Senega in croup, and enjoyed the distinction of having been the
first person that received a diploma from an American Medical College,
which he did in Philadelphia, in 1768. He served in the State Legisla-
ture, and as a member of Congress, from 1801 to 1807. I will also men-
tion Drs. Charles Frick, Samuel Baker, Frederick Dorsey, Ennals Martin,
Miles Littlejohn, John Tyler, the two Murrays, of Annapolis, Samuel
R. Jennings, John Baltzell, Gustavus Brown, Elisha Butts, and R. S.
Stewart.
MASSACHUSETTS.'—Dr. Edward Augustus Holyoke, a native of Massa-
* Massachusetts was one of the thirteen original States, and the first to raise troops and
to inaugurate the measures that led to armed resistance to the claims of Great Britain,
and to American Independence. Settlements were made in her territory as early as 1620.
She soon aſter began a system of public education, which has been developed and adopted
in all the States. Her population in 1870 was 1,457,351, nearly one-half of her people living
in cities of over five thousand inhabitants. She had 2047 physicians. One medical col-
lege, a department of Harvard University, has existed since 1782. Institutions on the
most approved plans, for the care of unfortunates of all classes, have been established on a
liberal scale. A State Medical Society, formed in 1781, publishes Transactions, and a sys-
tematic registration of vital statistics has been in successful operation for many years.
The following medical journals have been published in Massachusetts: Berkshire
Medical Journal, 1861; Boston Journal of Chemistry, 1866; Boston Medical Intelligencer,
1823; Boston Medical and Surgical Journal, 1828; Journal of the Gynaecological Society,
1869; Medical and Agricultural Register, 1806; Medical Magazine, 1832; Monthly
Journal of Medical Literature, 1832; New England Journal of Medicine and Surgery and
Collateral Sciences, 1812; Worcester Journal of Medicine, 1845.
A D D R E SS O N M E I) IC A. L. B I O G. R. A. P. H. Y. 111
chusetts, was a man of learning and accurate observation, and an indus-
trious and skilful practitioner. He died at the age of 100 years and 8
months. He was one of the principal founders of the Massachusetts
Medical Society, and its first President. He published Astronomical
observations, and articles in the Transactions of the Massachusetts
Medical Society, and in the New York Medical Repository. (b. Aug. 1,
1728 (O. S.); d. 1829.) Dr. James Lloyd was the first surgeon in
America to use ligatures, instead of searing wounds with the actual
cautery, and to use the double flap in amputation. He also performed
lithotomy. For nearly 60 years, he was the great physician and surgeon
of New England. He was a warm advocate of inoculation for the small-
pox. (b. April, 1728; d. March, 1810.) Dr. John Warren acquired much
reputation as a hospital surgeon in the Revolutionary army. He was the
head of a family of eminent physicians and surgeons of Massachusetts,
and the brother of the patriot, Dr. and Gen. Joseph Warren. Dr. War-
ren was the earliest systematic teacher of Anatomy in Massachusetts,
and the founder of the Medical Department of Harvard University, in
which he held a chair up to the time of his death. He was President of
the Massachusetts Medical Society, and a member of nearly all the learned
Societies of his time. He published observations on the “Mercurial
practice,” and contributed articles to the Transactions of the Massachu-
setts Medical Society, and of the American Academy of Arts and Sciences.
(b. July 27, 1753; d. April 4, 1815.) Dr. J. Collins Warren, his son,
was not inferior to his father. He was the first surgeon to use ether as
an anaesthetic in surgical operations, and aided much to promote its use.
He was also an author and teacher of great ability. (b. Aug. 1, 1778; d.
May 4, 1815.) Dr. Benjamin Waterhouse, a native of Rhode Island, was,
in 1799, the introducer of vaccination in America. He was a zealous
and able defender of the practice of vaccination, and published two works
upon the subject. He held the chair of Theory and Practice of Medicine,
in Harvard College, from 1783 to 1812. He was a man of very active
intellect and varied information, fond of study, and a voluminous writer.
(b. March 4, 1754; d. Oct. 2, 1846.)
Dr. James Jackson, a native of Massachusetts, commenced practice in
the year 1800. In 1810, with Warren and others, he initiated measures
which led to the establishment of the McLean Asylum for the Insane,
and also for the founding of the Massachusetts General Hospital. He
was physician to the latter institution until 1835. In 1810, he was ap-
pointed clinical lecturer to Harvard College, and in 1812, to the chair of
Theory and Practice. His contributions to the literature of medicine
were numerous and valuable. (b. Oct. 3, 1777; d. Aug. 26, 1867.) Dr.
John Ware, a native of Massachusetts, was from 1832 to 1858 Professor
of Theory and Practice in Harvard College. He was a most admirable
teacher, a close reasoner and original observer, and a beautiful and cor-
rect writer. (b. Aug. 1, 1778; d. May 4, 1854.) Dr. James Thacher, a
native of Massachusetts, settled in practice in Plymouth, after having
served as a surgeon in the Revolutionary army. During his military
life, he kept a journal, which he subsequently published, and which has
become a most valuable contribution to the history of the times. He
was the author of the work entitled “The New Dispensatory,” and of a
number of other publications. His best known work is entitled “Ame-
rican Medical Biography,” and is a great storehouse for information per-
taining to the early profession in America. (b. 1754; d. May 24, 1844.)
Dr. Elisha Bartlett, a native of Rhode Island, was a leading physician,
112 T ONER,
and the first Mayor of the city of Lowell. He was a close student and
fine classical scholar. Tſe was a sufferer from lead poisoning, but held
professorships in quite a number of colleges. Although he wrote numer-
ous works, his most popular one is on the fevers of the United States, pub-
lished in 1842. (b. 1805; d. 1855.) Dr. Luther W. Bell, a native of New
Hampshire, gained the Boylston Prize when about 30 years of age. By
his ability in the treatment of the insane, he attracted the special atten-
tion of his contemporaries, and was placed in charge of the McLean Asy-
lum, which continued under his control from 1837 to 1856. In 1857, he
was President of the Massachusetts Medical Society. He wrote on many
subjects of interest to the medical profession. During the late war, he
went out as a surgeon and lost his life in the service of his country. (b.
Dec. 1806; d. 1862.)
The following also deserve mention: Drs. John Brooks, Jeffries Wyman,
H. H. Childs, A. A. Gould, George Hayward, Oliver Prescott, Lemuel
Danforth, S. G. Howe, G. Darby, A. L. Peirson, C. T. Jackson, T. W.
Harris, Enoch Hale, Winslow Lewis, and W. T. G. Morton, dentist and
discoverer of the use of ether as an anaesthetic.
MICHIGAN.”—Dr. Zina Pitcher, a native of New York, entered the
army in 1822 as an assistant surgeon; was promoted to be full surgeon in
1832, and resigned in 1836, when he settled in Detroit. He was not only
a good physician and surgeon, but an emergetic and successful business
man. He was mayor of the city, a faithful and intelligent manager of
the school fund, and one of the founders of the State Insane Asylum.
In 1856 he was honored with the presidency of the American Medical
Association. (b. April 12, 1797; d. April 5, 1872.) Dr. Richard Inglis
was a good classical scholar, full of information and energy, cheerful in the
sick-room, and an agreeable companion in society. With the profession
of the State he was exceedingly popular, and in 1869 was elected Presi-
dent of the State Medical Society. Mention should also be made of Drs.
E. M. Clark and Porter, of Detroit; Robinson, of Palmyra ; Robert
Clark, of Monroe; Isaac C. Paddock, of Pontiac, and Denton and Brig-
ham, of Ann Arbor.
MINNESOTA.”—Dr. Samuel Willey, a native of Massachusetts, after
| Michigan was admitted as a State in the Union in 1837. The earliest settlements
within her territory were by the French, in the vicinity of Detroit, in the latter part of the
seventeenth century. The lands are generally good and heavily timbered. The population
as given by the census in 1870 was 1,187,234, about one-sixth of the people residing in
towns and cities of over five thousand inhabitants. The same authority gives the number
of physicians as 1034. Population and wealth have rapidly flowed into this State. From
land grants by the United States a large educational fund has been established both for
general education and colleges of a high grade. There are two medical colleges, a State
Medical Society, formed in 1819, and publishing Transactions, and an efficient State Board
of Health.
The following medical journals have been published in Michigan : Detroit Review of
Medicine and Pharmacy, 1866; Michigan University Medical Journal, 1870; Peninsular
Independent Medical Journal, 1858; Peninsular Journal of Medicine, 1873; Peninsular
Journal of Medicine and Collateral Sciences, 1858.
* Minnesota was a part of the Louisiana purchase. This region was visited as early as
1650, the French having had posts in different parts along the Lakes. The United States
government established, in 1819, a military post at Fort Snelling. In 1845 settlements
began to be made, and immigration set in actively, and in 1859 a territorial form of gov-
ernment was organized. In 1853 Minnesota was admitted into the Union. The population
as given by the United States Census of 1870 was 446,056, with about one-tenth living in
towns of over five thousand inhabitants. There were then in the State 402 physicians.
The population and wealth of Minnesota are steadily increasing. The State is fertile and
well timbered, and is well situated as to commercial lines, by lakes, rivers, and railroads. A
A D D RESS O N M E DIC A. L. B I O G. R. A. P. H. Y. 113
graduating was for two years assistant physician in the State Lunatic
Asylum, at Columbus, Ohio. In 1852 he settled in practice in St. Paul,
and soon acquired a full business. In the fall of 1862 he was appointed
pension surgeon and medical referee for the State. The organization of
the State Medical Society was largely due to his efforts, as was that of
the State Board of Health. He was twice elected president of the State
Society, and in 1870 was one of the Vice-Presidents of the American
Medical Association. (b. 1828; d. Nov. 21, 1872.) Dr. E. Herman
Smith, a native of Connecticut, after serving a year as surgeon on the
French steamer “Arago,” settled at St. Paul, and soon acquired a fair
business. He was accurate in diagnosis, and an expert in the use of
the microscope. Dr. H. C. Hand, a native of New Jersey, settled in
St. Paul in 1871, and formed a business relation with his brother, Dr. D.
W. Hand, then in practice in that place. In 1872 he became editor and
publisher of the Northwestern Medical and Surgical Journal, which he
conducted with ability. He was one of the physicians to the St. Paul's
City IIospital. (b. March 17, 1849; d. March 2, 1876.) Dr. Josiah S.
Weiser, a native of Pennsylvania, located in 1855 at Shakopee, a settle-
ment chiefly made up of Germans. IIe was induced to join Gen. Sib-
ley’s military expedition, as surgeon, in June, 1863, and was murdered
by the Indians while holding a parley with them. The following de-
serve mention: Drs. N. B. Hill, A. E. Ames, J. K. Reiner, J. C. Jones,
J. D. Ford, L. B. Smith, and G. T. Turner.
MISSISSIPPI."—Dr. Samuel A. Cartwright, a native of Virginia, settled
at Natchez, Miss., and was particularly successful in the treatment of fever,
and of cholera, during the epidemic of 1832. He wrote a number of
valuable papers. (b. Nov. 30, 1793; d. May 3, 1863.) Dr. Erasmus D.
Fenner, a native of North Carolina, settled in 1832 at Clinton, where
his ability obtained for him a good practice. In 1840 he removed to
New Orleans, and in 1844, in connection with Dr. A. Heister, estab-
lished the New Orleans Medical Journal. He was one of the original
members of the American Medical Association, and a Professor in the
New Orleans School of Medicine. In 1849 he commenced the publi-
cation of the Southern Medical Reports, which extended to two
volumes. He also edited the New Orleans Medical News and Hos-
pital Gazette. (b. 1807; d. May 4, 1866.) Dr. Allen Gillespie, a
native of Tennessee, after graduating in medicine, served as an as-
sistant surgeon in the army of the Southwest. In 1824 he removed to
Mississippi, and in 1834 settled at Granada, where he spent his life in
the active duties of his profession. He possessed in a high degree the
qualities that go to make the successful physician. It is claimed that to
him is due the credit of introducing the practice of giving large doses of
quinia as an anti-pyretic in miasmatic fevers. After treating fevers in
State Medical Society, organized in 1855, publishes Transactions, and a State Board of
Health is also in successful operation.
The following medical journal has been published in Minnesota: Northwestern Medical
and Surgical Journal, 1870.
* Mississippi was admitted into the Union in 1817, having been erected into a territory
with Alabama in 1798. It had been visited by De Soto in 1540, and by La Salle in 1682,
but the first successful settlement by Europeans was at Natchez, in 1716, under Bienville.
According to the United States Census in 1870 the population was 827,922, about one-tenth
of the people living in cities of over five thousand inhabitants. There were at the same
time 1511 physicians. The lands are generally low, alluvial, and subject along the water-
courses to overflow. A State Medical Association. organized in 1856, publishes Transac-
tions annually, and institutions for the care of unfortunates have been established.
8
114 TO NER,
this way for years, he made his views public in 1835. The use of quinia
in large doses has been recommended by others, but only during the
remission. (b. Aug. 18, 1801; d. 1869.) In addition to the above-
named, I will mention Drs. Samuel B. Malone and Elvis McCrory.
Missouri."—Dr. Wm. Beaumont, a native of Connecticut, entered the
army as assistant surgeon in July, 1812, and resigned in 1839, and settled
in the city of St. Louis. In 1825, while stationed at the military post
Michilimackinac, he met the Canadian, St. Martin, who had received a
wound which left an opening into the stomach, exposing in a measure
the operation of that organ. The Doctor made a series of experiments
upon the process of digestion, which he published in 1838. This is one
of the most complete series of observations ever made on the living
stomach. (b. 1785; d. April 25, 1853.) Dr. Charles A. Pope, a native of
Alabama, settled in St. Louis in 1841. He was studious, energetic, and
anbitious in his profession, and soon acquired a leading practice. He
was elected to the chair of Anatomy and then to that of Surgery in the
St. Louis University. His preference in practice was for surgery, and in
this he was very successful. He was a fluent lecturer, and familiar with
the history of the various surgical operations and procedures. He was
surgeon to the St. Louis City Hospital. He identified himself with all
movements calculated to advance the medical profession, and was Presi-
dent of the American Medical Association in 1854. (b. March 15,
1818; d. July 6, 1872.) Dr. M. L. Linton, a native of Kentucky, set-
tled in practice in St. Louis in 1842. He was elected to the chair of
Obstetrics in the St. Louis Medical College, and in 1844, was trans-
ferred to the chair of Theory and Practice. In 1843 he founded and
edited the St. Louis Medical and Surgical Journal, the first medical
periodical published west of the Mississippi River. He possessed high
intellectual endowments and scientific culture, and wrote well, and on a
great variety of subjects—medical, literary, religious, and scientific. IIe
was a member of the Academy of Sciences, and contributed many papers
to it. He had an extensive practice, and was widely known in the
Southwest. (b. 1808; d. June 1, 1872.) Dr. B. F. Shumard, a native
of Pennsylvania, commenced to practise in Kentucky, but became con-
nected with one of the U. S. Government Pacific R. R. surveys and
explorations. His scientific acquirements led him to be much em-
ployed in such pursuits. He removed to St. Louis in 1853. In 1860
he was engaged in a geological survey of the State of Texas, which
was interrupted by the war, when he returned to St. Louis, and re-
sumed the duties of his profession. He was elected to the chair of
Obstetrics in the University of Missouri. He was President of the
Academy of Sciences at the time of his death. (b. Nov. 24, 1820;
| Missouri, a part of the Louisiana purchase of 1803, was admitted as a State in the
Union in 1821. Its earliest settlers were the French, who built a fort on the present site
of the city of St. Louis as early as 1719. Another point of early settlement was at St.
Genevieve. The population of Missouri in 1870 was 1,721.295, about one-fifth of the
people living in towns and cities of over five thousand inhabitants. There were then in the
State 3560 physicians. Missouri has a large school fund, and a successful system of free
schools. There are four medical colleges. A State Medical Society, formed in 1850,
publishes Transactions. Institutions for the care of unfortunates, sufficient for the wants
of the people, have been established. -
The following medical journals have been published in Missouri : Humboldt Medical
Archives, 1867; Kansas City Medical Journal. 1871; Kansas City Medical and Surgical
Review, 1860; St. Joseph Journal of Medicine and Surgery, 1859; St. Louis Medical
Reporter, 1866; St. Louis Medical and Surgical Journal, 1845; St. Louis Probe, 1850.
A DDRESS ON ME DICAL BIOGRAPHY. 115
d. April 14, 1868.) Dr. Lewis F. Linn, a native of Kentucky, settled in
Genevieve in 1819. He served in the war of 1812, and after this took
an active part in public affairs. He was a fluent and eloquent speaker.
In 1827 he was elected to the Legislature, and in 1833 to the U. S.
Senate, which office he held to the time of his death. (b. 1795; d. 1843.)
I will also mention Dr. John H. Watters, of St. Louis, who was one of
the earliest to write upon the theory of the Correlation and Conserva-
tion of Forces, Drs. J. N. McDowell, John A. Chambers, and John
Edwards.
NEW HAMPSHIRE.”—Dr. Nathan Smith, a native of Massachusetts, first
practised in Cornish, New Hampshire. He suggested the establishment
of a Medical Department in connection with Dartmouth College, and in
1797 gave there a course of lectures. In 1798 he was appointed Professor
in the Medical Department. He taught all the branches, and furnished
all the apparatus needed in teaching until 1810, when he was joined by
another professor. In a few years, by his genius and indomitable perse-
verance, fair classes attended this institution. In 1813 he was invited to
the chair of Surgery in Yale College, which he accepted. He continued,
however, to lecture at Dartmouth, at the Vermont University, and at
Bowdoin College. His reputation as a surgeon had by this time become
national. The credit of having first pointed out that dislocations of the
hip and other joints should be reduced by manipulation, is due to Dr.
Smith. In 1824 he published a particularly valuable essay on typhoid
fever, in which he made a distinction between typhoid and malarial
fevers. (b. 1762; d. 1829.) Dr. Amos Twitchell, a native of New Hamp-
shire, was a close observer, and an indefatigable student. It seems to be
well authenticated that he was the first to place a ligature on the com-
mon carotid artery, which he did six months before the occurrence of the
case reported by Sir Astley Cooper. I can discover no publications of
Dr. Twitchell, but he was in the habit of taking part in the discussions
of the New Hampshire Medical Society. (b. 1781; d. 1850.) Dr. Josiah
Bartlett, a native of Massachusetts, commenced to practise in Kingston,
N. H., in 1750. His intelligence, high moral character, and ability, soon
brought him a full share of professional business. From 1765 to the
time of the Revolution he was annually chosen to the Legislature, and
was a Lieutenant-Colonel in the State militia. In 1775 he was elected to
Congress, and in 1776 was the first on the roll call to vote for the Declara-
tion of Independence. He served as a Justice of the Supreme Court of
the State, and was one of the originators and first President of the New
Hampshire Medical Society. (b. 1729; d. 1795.)
Dr. Ammi R. Cutter, a native of Maine, served as surgeon in the
Revolutionary war, and part of the time was Physician General to the
Middle Department of the army. After the war he settled at Ports-
mouth, where he acquired a large practice, and was greatly esteemed
throughout the State. For many years he was president of the State
Medical Society. (b. 1735; d. 1820.) Dr. Matthew Thornton was a
native of Ireland, and settled at Londonderry. He was a surgeon in
the expedition in 1745 against Louisburg. In 1775 he was president of
| New Hampshire was one of the thirteen original States; its first settlement having
been near Portsmouth, in 1623. Its population in 1870 was 318,300, nearly one-fifth living
in cities and towns of over five thousand inhabitants. The number of physicians was 565.
There is a State Medical Society, formed in 1791, which publishes Transactions annually,
and one medical college. There are also institutions for the care of unfortunates, sufficient
for the wants of the people.
116 TO NER,
the convention which assumed the government of New Hampshire in
the name of the people. He was a delegate to Congress, and signed the
Declaration of Independence, though not present to vote for it. (d. June
24, 1803, aged 88.) Dr. Lyman Spalding, a native of New Hampshire,
began practice at Portsmouth in 1799. He was a good anatomist and
a learned physician. He published in 1799 a new momenclature of
chemistry. In 1813 he removed to the city of New York. He con-
ceived the idea of publishing a United States Pharmacopoeia, and for
years advocated the project, and called the convention which formed it
in 1820, being also one of the committee of publication. (b. June 5,
1775; d. Oct. 31, 1821.) Dr. Dixi Crosby, a native of New Iſampshire,
commenced practice at Gilmanton, where he acquired a large business,
and established his reputation as a surgeon. In 1836 he removed the
scapula, humerus, and two-thirds of the clavicle at one operation, the
patient recovering. In 1838 he was elected to the chair of Surgery and
Obstetrics, in Dartmouth College, which position he held till 1868,
when he resigned the branch of Surgery in favor of his son, lecturing for
two years longer on Obstetrics. He contributed a number of able arti-
cles to the medical journals, and was President of the New IIampshire
State Medical Society, and a member of the American Medical Associa-
tion. (b. Feb. 9, 1800; d. Sept. 26, 1873.) I will also name Drs. Ma-
thias Spaulding, Josiah Crosby, Charles P. Gage, W. Graves, Daniel
Oliver, George B. Twitchell, and A. Smalley.
NEw JERSEY."—Dr. William Burnett, a native of New Jersey, settled
in practice at Newark, and, during the Revolution, took a conspicuous
part in the events of the day. IIe was a member of the “Committee of
Safety,” in 1776, and was one of the commissioners for issuing State bills
of credit. He was physician of the hospitals, and Chief Surgeon of the
State troops; and was a member of Congress from 1780 to 1781. In the
latter year he was again elected to Congress, but resigned, and was
appointed Chief Physician and Surgeon in the Eastern Department,
serving till the close of the war. After peace was established he returned
to private practice, and engaged to some extent in agriculture. He was
Judge of the Court of Common Pleas and President of the State Medical
Society, and throughout a long life was greatly beloved and esteemed.
(b. 1730; d. 1791.) Dr. Moses Scott was a native of Pennsylvania, and
on the outbreak of the Revolutionary war, took part with the patriots.
He had been in military service with Braddock's expedition. In July,
1776, he was appointed physician and surgeon of the State troops, and in
1777, when Congress took entire control of the hospital department, was
appointed Assistant Director General. He was present at all the battles
fought in New Jersey. After the war he was esteemed one of the most
experienced and learned physicians in the State. (b. 1738; d. 1821.)
Dr. Jonathan Elmer, a native of New Jersey, was a surgeon in the
* New Jersey is one of the thirteen original States. The Dutch made two settlements
at Bergen between 1614 and 1624, and a Swedish colony settled near the Delaware River
in 1627. Some of the most stirring events of the Revolutionary war took place within the
territory of New Jersey. Her position between the two great cities of New York and
Philadelphia gives her great commercial advantages. Her population, as given by the
census of 1870, was 906,096, a little over one-third of her people living in cities of over five
thousand inhabitants. She had at the same time 1208 physicians. She has a State Medi-
cal Society, organized in 1766, which publishes Transactions annually. She has also a
number of institutions for the care of unfortunates.
The following medical journal has been published in New Jersey: New Jersey Medical
Reporter, 1847.
A D DRESS ON ME DICAL BIO G R A PHY. 117
Revolutionary war, as was his brother Ebenezer. He was a man of
extensive information, with great power of detail, and executive ability.
He was elected to Congress in 1776, serving till 1778; again in 1781,
serving till 1784; again in 1787, serving till 1788, and was United
States Senator from 1789 until 1791. He was a member of the Ameri-
can Philosophical Society, and held many offices of trust in his native
State. (b. 1745; d. 1817.) Dr. Nicholas Belleville, a native of France,
settled in Trenton in 1791. He had a very extensive practice, and was
physician to Joseph Bonaparte, ex-King of Spain, while he resided in
New Jersey. His office was the resort of many students who subse-
quently rose to eminence in their profession. Dr. John N. Woodhull,
a native of New Jersey, was a man of superior education. He settled
at Princeton, and enjoyed the reputation through life of being a most
skilful physician. He endowed a professorship in Princeton College.
His whole life reflects honor upon himself, as a man, as well as upon
the medical profession. (b. 1752; d. 1831.) Dr. L. A. Smith, a native
of New Hampshire, was a physician of superior ability. He settled at
Newark, and had the esteem of the profession, and was popular with
the community. He was one of the early movers for, and an able advo-
cate of, the establishment of the New Jersey Lunatic Asylum. He was
devoted to his profession, and was an earnest promoter of medical organi-
zations. He was President of the New Jersey State Medical Society, in
1837, and throughout his life was an active worker for the advancement
of medicine and the elevation of the profession. (b. Nov. 11, 1795;
d. Dec. 15, 1865.) The following names are also deserving of mention :
Drs. John Beatty, W. Johnson, Isaac Ogden, Samuel Hayes, J. Ward,
Isaac P. Coleman, Silas Condit, Isaac Pierson, and J. Lilley.
NEW YORK.”—Dr. Valentine Mott, a native of New York, and an
| New York is one of the thirteen original States. Its earliest known mention was in
1609, from the visit of Henry Hudson, who gave his name to the Hudson River. This is
now the most populous and wealthy State in the Union. The population in 1870 was
4,387,464, nearly one-half living in cities of over five thousand inhabitants. The number
of physicians in the same year was 6810. New York has nine medical colleges, distributed
as follows, viz.: Albany, Brooklyn, Buffalo, and Syracuse, each one, and New York City
five. A State Medical Society was organized in 1807, and has published Transactions
almost continuously since. Institutions for the care and treatment of unfortunates have
been provided in different parts of the State, sufficient for the wants of the people.
The following medical journals have been published in New York: Albany Journal of
Neurology, 1843; American Chemist, 1870; American Journal of Indigenous Materia
Medica and Repertory of Med. Science, 1860; American Journal of Insanity, 1844;
American Journal of Medicine, 1852; American Journal of Obstetrics and Diseases of
Women and Children, 1868; American Journal of Ophthalmology, 1862; American
Journal of Syphilography and Dermatology, 1870; American Lancet, 1831; American
Medical Monthly, 1854; American Medical and Philosophical Register, 1810; American
Medical and Surgical Journal, 1851; American Medical Times, 1860; Annalist, 1847 ;
Archives of Ophthalmology and Otology, 1869; Archives of Scientific and Practical
Medicine, 1873; Buffalo Medical Journal, 1845; Buffalo Med. and Surgical Reporter,
1861; Medical Gazette, 1867; Medical Record, 1866; Medical and Surgical Register,
1818; Nelson's American Lancet; New York Journal of Medicine, 1839; New York
Journal of Medicine and Collateral Sciences, 1843; New York Journal of Pharmacy,
1852; New York Lancet. 1842; New York Medical Gazette, 1841; New York Medical
Gazette and Journal of Health, 1850; New York Medical Independent and Pharmaceu-
tical Reporter, 1864; New York Medical Inquirer and Domestic Magazine, 1830; New
York Medical Journal, 1831; New York Medical Journal, 1865; New York Medical
Magazine, 1814; New York Medical and Pathological Journal, 1858; New York Medi-
cal and Philosophical Journal and Review, 1809; New York Medical and Physical
Journal, 1822; New York Medical Press, 1860; New York Medical Repository, 1797;
New York Medical Review, 1873; New York Medical and Surgical Reporter, 1845; New
York Medical Times, 1851; New York Medico-Chirurgical Bulletin, 1851; New York
118 . to NER,
eminent surgeon and teacher, settled in New York City in 1809, and
was appointed to the chair of Surgery in Columbia College. He was
elected to fill the same chair in Rutgers College, and also in the College
of Physicians and Surgeons. In 1818 he passed a ligature around the
brachio-cephalic artery, about two inches above the heart, for aneurism.
He excised the entire clavicle, and was the first in America to ligate the
iliac artery, and to remove the lower jaw. Sir Astley Cooper says of him,
that he performed more of the great operations than any other surgeon,
living or dead. It would be impossible to enumerate here all his great
achievements. In 1814, in connection with Dr. Onderdonk, he started
and published the “New York Medical Magazine,” which only extended
to two parts. He translated Velpeau's work on Surgery, and contributed
articles to the medical journals, and to the Transactions of the New
York Academy of Medicine. (b. Aug. 20, 1785; d. April 26, 1865.) Dr.
Samuel Bard commenced practice in 1767 in the city of New York. He
was one of the projectors of the first Medical College organized in New
York, and held the chair of Theory and Practice. He acted as examining
surgeon for the admission of surgeons to the Medical Department of the
Army during the Revolutionary war. In 1774, he was influential in
founding the New York Hospital, in which he gave a course of clinical
lectures. In 1791, when the public hospital was opened, he was appointed
one of the visiting physicians. In 1798, he had retired to his country
seat, but on the outbreak of the yellow fever returned to the city, and
resumed practice. He was finally taken down with the fever, but re-
covered. He was General Washington’s physician, when in New York,
after the war. He published a compendium of Midwifery, and con-
tributed to the Philosophical Transactions and to medical journals. (b.
April 1, 1742; d. May 24, 1821.)
Dr. David Hosack, a native of New York, settled in practice in the
city of New York in 1794. The following year he was appointed Pro-
fessor of Botany in Columbia College, and shortly afterwards published
a syllabus of the lectures. In 1796, he formed a partnership with Dr.
Bard, which continued till 1800. In 1797 he was elected to the chair of
Materia Medica, but in 1811, on the re-organization of the Faculty, was
assigned to the chair of Theory and Practice, and afterwards held that
of Obstetrics and Diseases of Women and Children, until 1826. He was
visiting physician to the Almshouse and to the Insane Asylum. He
wrote on ſevers, and other medical topics, and was elected a member of
the Royal Society of London. His paper on the causes of contagion was
able, and received a wide appreciation. In 1810, with Dr. Francis, he
started the American Medical and Philosophical Register, which was
conducted with ability. (b. August 31, 1769; d. Dec. 22, 1835.) Dr.
Theodoric Romeyn Beck, a native of New York, began practice in
Albany in 1811. In 1813 he wrote a paper on the minerals of the United
States. In 1815 he was appointed Lecturer on the Institutes of Medi-
cine, and Professor of Medical Jurisprudence in the College of Physicians
and Surgeons. He also held a professorship in the Fairfield Medical Col-
lege from 1826 to 1836. In 1836 he was elected to the chair of Materia
Monthly Chronicle of Med. and Surg., 1824; New York Monthly Review of Med. Science
and Buffalo Medical Journal ; New York Register of Medicine and Pharmacy, 1850;
North American Medical Reporter, 1858; Northern Lancet and Gazette of Legal Medicine,
1850; Opal, 1851; Quarterly Journal of Psychological Medicine, 1867; Sanitarian,
1873; Syracuse Medical and Surgical Journal, 1854; United States Medical and Surgical
Journal, 1834.
A L) D R E S S O N M E DIC A. L. B I O G. R. A. P. H. Y. 119
Medica in the Albany Medical College. From 1840 to 1850 he was
President of the Albany Academy, and was the originator of the Albany
Institute. He was President of the New York State Medical Society,
and was one of the managers of the State Lunatic Asylum. In 1823
he published the first edition of his great work on “Medical Jurispru-
dence.” He edited for some years the “American Journal of Insanity.”
(b. Aug. 11, 1791; d. Nov. 19, 1855.) Dr. J. W. Francis, a native of .
New York, commenced to practise in 1811, and formed a partnership with
Dr. Hosack. They together published the American Philosophical
Register. In 1813 he was lecturer in the Institute of Medicine, and
Professor of Materia Medica in the College of Physicians and Surgeons.
About this time he visited Europe, and on his return was elected to the
chair of Medical Jurisprudence, and in 1819 filled that of Obstetrics, in
Rutgers College. In 1822 he was one of the editors of the New York
Medical and Physical Journal. He was an accomplished writer, and
took an active part in promoting the objects of the New York Academy
of Medicine, the Historical Society, the Woman's Hospital, etc. (b. Nov.
17, 1789; d. Feb. 8, 1861.)
Dr. A. H. Stevens, a native of New York, commenced practice in the
city of New York in 1812. In 1814, he was invited to the chair of
Surgery in Queen's, afterwards Rutgers College. He was one of the
visiting surgeons to the New York Hospital. In 1817, he was assigned
to a chair in the College of Physicians and Surgeons. In 1848, he was
President of the New York State Medical Society, and also President of
the American Medical Association. His general as well as his surgical
practice was very large. His contributions to the literature of medicine
are found in Journals, Reports, and Addresses. (b. 1789; d. March 30,
1869.) Dr. Wright Post, a native of New York, commenced practice in
1786. The chair of Surgery in Columbia College was tendered him in
1792, but in 1793 he was transferred to the chair of Anatomy, which he
continued to hold for twenty years. He was also a member of the
Faculty of the College of Physicians and Surgeons, and its president
from 1821 to 1826. He was for thirty years consulting physician of the
New York Hospital. He was a bold, original, and successful operator.
He tied the subclavian artery, and also the carotid. (b. Feb. 19, 1766;
d. June 14, 1828.) Dr. John Torrey, a native of New York, although a
learned physician, never acquired a large practice, and being greatly
interested in botany and the collateral sciences, his time became occupied
by them. In 1817, he published a catalogue of plants growing within
thirty miles of New York city, and in 1831 published the first volume
of the Flora of North America. In 1824 he was appointed Professor of
Botany in the Military Academy at West Point, and from 1827 to 1850
was Professor of Chemistry in the College of Physicians and Surgeons
of New York. He was subsequently appointed director of the New
York Assay Office. The Doctor was one of the most accomplished
botanists of our country, and did much to elevate the science by his life
and teachings. (b. 1798; d. March 10, 1873.)
Dr. Samuel L. Mitchell, a native of New York, commenced practice
in New York city, and, with Dr. E. Miller and Dr. E. H. Smith, started,
in 1797, the “New York Medical Repository.” He was connected with
it as editor for sixteen years, and survived both of his associates. He was
a member of the State Legislature, and for a number of years a member
of Congress, and also U. S. Senator. He was a man of very extensive
scientific acquirements, and of a remarkably retentive memory. He
120 TO NER,
wrote on a variety of topics, making substantial additions to scientific
literature. (b. Aug. 20, 1764; d. Sept. 7, 1831.) Dr. Joseph M. Smith,
a native of New York, commenced practice in 1811. He was one of the
original members of the Medico-Philosophical Society, which published
its first volume in 1817. He was Professor of Theory and Practice in the
College of Physicians and Surgeons for thirty years. His most noted
work is perhaps his “Elements of Etiology, and Philosophy of Epi-
demics.” IIe was a frequent and valued contributor to medical serial
literature. (b. March 14, 1789; d. April 22, 1866.) As of almost equal
merit, I will name Drs. John Watson, J. Kearney Rodgers, J. Stearns,
Joseph White, Richard Bayley, W. W. Reid, John A. Smith, Charles
A. Lee, Alden March, John B. Beck, James Stuart, Elisha Smith, H.
D. Bulkley, John A. Swett, Amasa Trowbridge, Amariah Brigham,
George T. Elliot, James McNaughton, H. Green, J. H. Armsby, Alban
Goldsmith, R. S. Rissam, and H. M. Onderdonk.
NoFTH CAROLINA.”—Dr. Charles Harris, a native of North Carolina,
served in the Revolutionary war before he had completed his medical
education. IIe first practised with success at Salisbury, but removed
to Favonia, the name of his plantation in Cabaries County, where he
remained actively engaged in practice to the close of his life. Ninety-
three physicians studied with him, his reputation being such as to make
him a desirable preceptor. His professional life extended over forty years.
(b. 1763; d. Sept. 21, 1825.) Dr. James Norcom, a native of North
Carolina, commenced practice at Edenton in 1799. He acquired a large
but laborious business, often visiting patients at a distance of 100 miles,
on horseback. His practice was chiefly that of a physician, although
performing such surgical operations as usually fall to the lot of rural
practitioners. His obstetrical practice was large. In 1812, he was com-
missioned Assistant Surgeon in the U. S. Army, but resigned in January,
1813. He wrote a paper on the Winter Epidemic of 1816, and made a
number of contributions to medical journals. (b. 1788; d. Nov. 9,
1850.) Dr. James Dickson, a native of North Carolina, having prac-
tised for a couple of years in South Washington, removed to Fayette-
ville, where his practice became large. In 1835, he performed successfully
the operation of transfusion of blood. In 1828, 1831, and 1833, he per-
formed urethrotomy. In 1835, he divided the tendo Achillis, for the re-
lief of club-foot. About this time he ligated the external iliac artery.
He was everywhere recognized as a skilful and successful surgeon. Dr.
Benjamin Robinson, a native of Vermont, commenced practice in his
native place, but removed to North Carolina in 1804, and settled at Fay-
etteville, where he spent the remainder of his life, laboriously engaged in
| North Carolina is one of the thirteen original States. Sir Walter Raleigh attempted
to establish a colony in it in 1585, but failed. The earliest point successfully settled was
on the Roanoke and Chowan Rivers, by emigrants from Virginia, in 1653. In 1693, North
and South Carolina were separated. This State took an early and active part to secure
American Independence. Ephraim Brevard, at a meeting of the citizens at Charlotte, on
May 20, 1775, prepared what is known as the “Mecklenburg Declaration of Independence.”
This embodied many of the sentiments of the Declaration adopted more than a year later,
at Philadelphia. The population of the State, as given by the census of 1870, was 1,071,362.
There are no large cities or towns, and but about one in forty of the population live in
towns of over five thousand inhabitants. There were, in 1870, 1143 physicians. A medical
college has been projected, but is not yet organized. There is a State Medical Society,
formed in 1850, which publishes Transactions. Institutions for the care of unfortunates,
sufficient for the wants of the people, have been provided.
The following medical journal has been published: Medical Journal of North Carolina,
1858.
A ID ID RESS ON ME DIC A. L BIO G R A PHY. 121
his profession. While a student of medicine, he performed an operation
for the relief of strangulated hernia, with success. . He was distinguished
through life for his untiring assiduity and sound common sense. His
memory is still cherished by the descendants of the community in which
he passed his useful life. (d. March 8, 1857, aged 82.) Tyr, Charles E.
Johnson, a native of North Carolina, settled in practice at Edenton, and
thence removed to Raleigh in 1835. He was especially interested in ner-
vous diseases and physiological studies. He wrote a paper on the Medico-
Legal Relations of Insanity. (b. March 15, 1812; d. April 1, 1876.) Dr.
Arnand John De Rosset was a native of North Carolina, and a graduate
of Princeton College. His immediate ancestors, father, grandfather, and
great grandfather, were physicians. The duration of his practice ex-
tended to 69 years. He was a good classical scholar, and a cultivator of
the sciences, which he applied to the practical and every-day requirements
of his profession. (d. April 1, 1859, aet. 92.) I will also mention Drs.
James J. Philips, of Edgecombe Co.; James Furgus McRee, of Wilming-
ton; R. H. Shield, of Winton; Wm. H. McKee, of Raleigh; Wm. Perry,
of Franklin Co.; Elisha Battle, of Edgecombe Co.; Henry M. Shaw, of
ICurrituck Co.; Joel B. IIouston, of Columbia; Matthias E. Sayer, of
Edenton; Simon J. Baker, of Raleigh; and Pinckney Caldwell.
OHIO.'—Dr. Daniel Drake, a native of New Jersey, but reared in Ken-
tucky, began to practise in Cincinnati in 1804. He rapidly rose to be
recognized as a leading physician, and as one of very extensive know-
ledge and scientific attainments. In 1810 he published “Notes” con-
cerning Cincinnati, and in 1815 a work entitled “A Picture of Cincin-
nati.” In 1817 he was elected a professor in the Transylvania Univer-
sity, at Lexington, Ky. The following year he obtained a charter and
founded the Medical College of Ohio, at Cincinnati, and in 1819 he es-
tablished the Commercial Hospital. From 1827 to 1839 he edited the
“Western Journal of American Medical Sciences.” Its publication was
transferred to Louisville, Ky., and the name changed to “Western Jour-
nal of Medicine and Surgery.” He continued as one of the editors till
1848. In 1832 he published an essay on Medical Education and Medical
Men of the United States, and the same year a pamphlet on Cholera.
His great work, which contained the observations of nearly half a cen-
tury, was published in 1850, entitled “Diseases of the Interior Valley of
* No European settlement prior to the Revolution is known to have been made in Ohio.
The first emigration to this State was in 1788, from New England to a point known as
Marietta, on the Ohio River, it having been included in 1781 in the general territorial
legislation pertaining to the territory northwest of that stream. The population in 1870,
as given by the U. S. Census, was 2.605,260, nearly one-fourth of the population living in
towns of over five thousand inhabitants. There were at that time 4638 physicians. Popu-
lation and wealth are still rapidly accumulating in this State. It has seven medical colleges,
three at Cincinnati, two at Cleveland, and two at Columbus. A State Medical Society
was established in 1846, and publishes reports annually. Institutions for the care of
unfortunates have been provided, sufficient for the wants of the people.
The following medical journals have been published in Ohio; Annals of Science, 1853;
Cincinnati Journal of Health, 1844: Cincinnati Journal of Medicine, 1869; Cincinnati
Lancet and Observer, 1858; Cincinnati Medical News. 1858: Cincinnati Medical News,
1872; Cincinnati Medical Observer, 1856; Cincinnati Medical Repertory, 1868; Cincin-
nati Medical and Surgical News, 1860; Cleveland Medical Gazette, 1859; Clinic. 1871;
Columbus Review of Medicine and Surgery. 1860; Critic. 1853; Northern Ohio Medical
and Scientific Examiner, 1848; Ohio Medical Recorder, 1876; Ohio Medical Repository of
Original and Selected Essays and Intelligence, 1826; Ohio Medical and Surgical Journal,
1848; Ditto, 1876; Western Journal of Medical and Physical Sciences, 1828; Western
Journal of Medicine, 1840; Western Lancet, 1842; Western Medical Gazette, 1832;
Western Quarterly Reporter of Medical, Surgical, and Natural Science, 1822.
122 TONER,
North America.” A second volume of this series, in preparation at the
time of his death, was published subsequently. This great work de-
serves to be better known. (b. Oct. 20, 1785; d. Nov. 6, 1852.) Dr.
Reuben D. Mussey, a native of New Hampshire, commenced practice in
Essex Co., Massachusetts, in 1805, after having received the degree of
Bachelor of Medicine from Dartmouth College. In 1807 he attended
lectures at the University of Pennsylvania, and wrote a thesis on Cuta-
neous Absorption, based upon original observations, his experiments
proving certain facts, while an opposite doctrine was being taught in
the colleges. He made many other experiments upon this subject, which
have not been published. Fresh from the college at Philadelphia, he
settled at Salem, Mass., where he obtained a good practice, and where
he resided for six years, devoting much time to the surgery of the eye.
In 1814 he was elected to the chair of Theory and Practice in Dartmouth
College, and in 1819 to the chair of Anatomy and Surgery in the same
institution, holding the latter position till 1838. He also gave lectures
on chemistry at Middlebury College, and at Fairfield College, New York.
In 1829 the doctor visited Paris, to study medical institutions abroad.
During the year 1837 he was tendered three professorships, at Nashville,
New York, and Cincinnati, and accepted the latter. His fame as a sur-
geon preceded him, and in a few years he was one of the best known sur-
geons in the Valley of the Mississippi. He possessed much mechanical
skill, and had a genius for original operations. He performed many capi-
tal and heroic operations, tying on the same patient within twelve days
both carotid arteries, and saving his patient’s life. His whole professional
life was one of eminent success, and sheds lustre upon the profession. He
was President of the American Medical Association in 1850. (b. 1780;
d. 1866.)
Dr. John Delemater, a native of New York, commenced practice in
1809, in the city of New York. He subsequently practised in Pittsfield,
Mass., and was connected with the Medical College there. In 1843 he
removed to Cleveland, Ohio, and was elected to the chair of General
Pathology and Midwifery in the Western Reserve College at that place.
(d. April, 1867, aged 80.) Dr. George Mendenhall, a native of Pennsyl-
vania, commenced practice in Cleveland, but in 1843 removed to Cincin-
nati, where by great devotion to his profession he acquired a large
business. In 1852 he was elected to the chair of Obstetrics in the Miami
Medical College, and, on the consolidation of that college with the
Medical College of Ohio, was re-elected and continued to serve till his
death. He published a “Wade Mecum,” which passed through several edi-
tions. He was one of the editors of the “Western Irancet,” and afterwards
of the “Lancet and Observer.” The journals contained many articles
from his pen. He was President of the American Medical Association in
1870. (b. 1814; d. 1874.) Dr. Jesse P. Judkins, besides having a large
practice, was Demonstrator of Anatomy in the Ohio Medical College, and
Professor of Anatomy in Starling Medical College, at Columbus. After-
wards he held the chair of Special Pathology in the Miami Medical
College, filling the latter position with ability up to the time of his death.
He wrote a number of excellent papers which were published in the
Cincinnati Medical Journal. (d. Dec. 6, 1867, aged 52.) Dr. Horace
Ackley settled in practice at Akron. He was elected professor in
Willoughby College in 1837. In 1843 he was elected Professor of Surgery
in the College then at Cleveland. He was an early and efficient member
of the Ohio State Medical Society, and for some years its president. He
A DI) RESS ON ME DIC A. L BIO G R A PHY. 123
was physician to the Marine Hospital at Cleveland, and one of the
trustees for the Central and Southern Lunatic Asylums. His surgical.
practice was for years quite large, and he was esteemed a safe and skilful
operator. (d. April 22, 1859, aet. 47.)
Dr. Leonidas M. Lawson, a native of Kentucky, first practised in
Madison, and started the “Western Lancet;” and in 1844, commenced
the reprint of Hooper's Pathological Anatomy. The same year he was
invited to a chair in the Transylvania University. In 1845 he visited
England and France, to study medical institutions abroad. In 1847 he
was offered the chair of Materia Medica and Special Pathology in the
Medical College of Ohio. He also at this time held chairs in the
Kentucky School of Medicine and in the University of Louisiana. (d.
Jan. 21, 1864, aet. 51.) Dr. John Dawson, a native of Virginia, after
practising for some time in Green County, removed in 1851 to Columbus,
and in 1853 was elected to the chair of Anatomy in the Starling Medical
College. As a teacher he gave great satisfaction to his associates and
to the students. About this time he became editor of the Ohio Medical
and Surgical Journal. He was an original observer and forcible writer.
(d. Sept. 1866, aet. 55.) Dr. G. W. Boerstler, a native of Maryland, settled
in practice in Lancaster, 1853. All the sympathies and all the energies
of his nature were directed to the discharge of his duties as a physician.
His practice was very large. (d. Oct. 19, 1871, aet. 78.) Dr. George C.
Blackman, a native of Connecticut, commenced to practise in the State of
New York, where he acquired reputation as a surgeon. In 1854 he was
elected to the chair of Surgery in the Medical College of Ohio. He was
surgeon to the Cincinnati Hospital, and also to the Good Samaritan
Hospital. On the breaking out of the war he entered the medical service
of the army as a Surgeon of Volunteers. He was a man of fine presence,
and had an air of resolution. (d. July 19, 1871.) I will name in addi-
tion, Drs. Edward Tiffin, John P. Harrison, John Butterfield, G. F.
Mitchell, R. L. Howard, Daniel Tilden, Philip J. Buckner, John T. Shot-
well, J. W. Russell, and S. M. Smith.
PENNSYLVANIA."—Dr. Benjamin Rush commenced practice in Phila-
delphia in 1769, and the same year was elected to the chair of Chemistry
* Pennsylvania is one of the thirteen original States, and was settled by the benevolent
William Penn in 1682. This State took an active part in the measures that ushered in the
struggle for American Independence, and was, during the war, the chief seat of Congress.
On her territory were fought several of the important battles of the Revolution. The popu-
lation in 1870, according to the U. S. Census, was 3,522,050, nearly one-third living in towns
of over five thousand inhabitants. The number of physicians at the same time was 4843.
There are three medical colleges, all in Philadelphia. There is a State Medical Society,
formed in 1848, which publishes a volume annually. Institutions for the insane and other
unfortunates have been provided in different parts of the State. Pennsylvania has from
the settlement of our country taken the lead in matters relating to medical publication
and medical education, and, as a consequence, we find, as would be expected, a larger pro-
portion than usual of eminent medical men resident within her borders.
The following medical journals have been published : AEsculapian Register, 1824; Ame-
rican Journal of the Medical Sciences, 1827; American Journal of Pharmacy, 1825; Ame-
rican Library and Intelligencer, 1836; American Medical Intelligencer, 1837; American
Medical Recorder, 1818; Barrington & Haswell's Medical Bulletin, 1849; Bulletin of
Medical Science, 1843; Cholera Gazette, 1832; Compendium of Medical Science, 1868;
Hospital Register, 1863; Journal of the Philadelphia College of Medicine, 1829; Medical
Examiner, 1838; Medical Reporter, 1853; Medical Review and Analectic Journal, 1826;
Medical and Surgical Reporter, 1856; Medical Times, 1870; North American Medical
and Surgical Journal, 1826; Philadelphia Journal of Medicine and Physical Sciences,
1820; Philadelphia Medical Museum, 1805; Philadelphia Medical and Physical Journal,
1804: Philadelphia Medical and Surgical Journal, 1853; Philadelphia Monthly Journal
of Medicine aud Surgery, 1828.
124 TO NER,
in the Philadelphia College. In 1787 he was assigned to the chair of
Theory and Practice. He possessed a remarkably well trained and observ-
ing mind, and, in addition to his professional duties, took an active part in
all public affairs. He was for many years physician to the T'ennsylvania
Hospital and other benevolent institutions. In the State convention he
moved that the colony should express its sentiments on the subject of
separation from the mother country. He was shortly afterwards elected
to Congress, and signed the Declaration of Independence. His writings
embrace many topics in medicine, and are everywhere characterized by
originality and ability. II is conduct through life as a citizen and phy-
sician was such as to make him a marked man. (b. Dec. 24, 1745; d.
April 19, 1813.) Dr. Philip Syng Physick, a native of Pennsylvania,
commenced to practise in Philadelphia in 1793, after having spent a
number of years in visiting the hospitals of Europe. This was the year
of the great yellow fever epidemic in Philadelphia. Dr. Physick was
placed in charge of Bush Hill Hospital, and discharged his duties with
marked ability. In 1794 he was appointed one of the surgeons of the
Pennsylvania Hospital, and from 1801 to 1816 he was one of the consult-
ing surgeons of the Philadelphia Almshouse Infirmary. In 1815 he
was appointed Professor of Surgery in the University of Pennsylvania,
in which he afterwards filled the chair of Anatomy. In 1825 he was
elected a member of the Royal Academy of Medicine of France, and in
1836 a member of the Royal Medical and Chirurgical Society of Dondon.
(b. 1768; d. Dec. 15, 1837.) Dr. John Morgan, a native of Pennsylvania,
after serving as surgeon to the Militia in the French war in 1759, resigned
in 1760, and went to Europe to further perfect his knowledge of medical
science. He returned to Philadelphia in 1765, and was then perhaps the
most learned physician in America. The same year he delivered an
address at the commencement of the Philadelphia College, and the open-
ing of the first medical college in America, established through his own
and Dr. William Shippen's influence, and in which he was appointed
Professor of Theory and Practice. In 1775 Dr. Morgan was appointed
Director General and Physician in Chief of the Hospital Department
of the American Army, but political cabals and the exigencies of the
times caused his removal in 1777. A report by Congress shows him to
have been an efficient officer. In his thesis he proposed the theory that
pus was formed by a secretory process. He was one of the founders of
the American Philosophical Society, and a member of the Royal Philo-
sophical Society of London. (b. 1735; d. Oct. 15, 1789.)
Dr. Benjamin Smith Barton, a native of Pennsylvania, settled in
practice in Philadelphia in 1789. He was the same year appointed
Professor of Natural History and Botany, and in 1813 Professor of
Materia Medica in the University of Pennsylvania. He contributed
papers to the American Philosophical Society, and in 1804, started the
“Medical and Physical Journal.” He was an indefatigable worker,
and all his writings were practical contributions to medicine. (b. Feb.
10, 1766; d. Dec. 19, 1815.) Dr. Caspar Wistar, a native of Penn-
sylvania, commenced practice in Philadelphia in 1787. In 1789 he
was elected Professor of Chemistry and Physiology in the University of
Pennsylvania. In 1792 he was elected physician to the Philadelphia Dis-
pensary, and to the Pennsylvania Hospital, and the same year was
appointed Adjunct Professor of Anatomy, which position he filled until
the time of his death. His abilities as a physician secured him a large
practice, and assisted in popularizing the school. He was a member of
ADDRESS ON MEDICAL BIOGRAPHY. 125
many learned societies, and President of the American Philosophical
Society. His best known work is his “Anatomy,” in two volumes, the
first of its kind contributed by an American. (b. Sept. 13, 1761; d. July
22, 1818.) Dr. Wm. P. Dewees, a native of Pennsylvania, commenced
practice in the interior of the State, but removed to Philadelphia in 1793.
He devoted his time chiefly to Obstetrics, but, his health failing in 1812,
he retired to his farm at Phillipsburg, where he remained for five years,
when, having recovered, he returned and resumed practice, which he
continued with increasing popularity. In 1825 he was chosen assistant
professor of Midwifery in the University of Pennsylvania, and in 1834
was elected to the full chair. But his health had gradually failed, and
the following year he resigned and was elected emeritus professor.
(b. May 5, 1768; d. May 20, 1841.) Dr. Nathaniel Chapman, a native
of Virginia, commenced practice in Philadelphia in 1804. By his
assiduity in professional duties, and by a fortunate marriage, he speedily
acquired a large business. About this time he commenced a course of
lectures on Obstetrics to medical students, and in 1808 associated himself
with Professor James in a summer course of lectures. From 1813 to
1816 he was Professor of Materia Medica in the University of Pennsyl-
vania, and from 1816 to 1850, Professor of Theory and Practice and of
Clinical Medicine. In 1817 he founded the Medical Institute, and
lectured in it during every summer for twenty-five years. He was Pre-
sident of the American Philosophical Society from 1846 to 1848, and
President of the American Medical Association in 1847. (b. May 28,
1780; d. Jan. 1, 1853.) Dr. Wm. E. Horner, a native of Virginia, having
resigned his commission in the U. S. Navy, commenced practice in the
city of Philadelphia. His abilities soon attracted the attention of the
leading physicians, and he shortly after received the appointment of
Demonstrator of Anatomy in the University of Pennsylvania. In 1819
he was made adjunct, and in 1831 full Professor of Anatomy. In 1824
he discovered the “Musculus Horneri,” which had escaped the observa-
tion of previous anatomists. His whole life was a continuous struggle
of mind and duty over physical suffering. In 1847 he founded St. Joseph’s
Hospital, to which he bequeathed his library and instruments. About
this time he published a treatise on Pathological Anatomy, which was
shortly afterwards followed by other important publications. (b. Jan. 3,
1793; d. March 13, 1853.)
Dr. John K. Mitchell, a native of Virginia, settled in practice in Phila-
delphia in 1822, and soon acquired a large practice. After taking
his medical degree he made three voyages to China as surgeon in a
merchant ship. In 1824 he delivered a course of lectures on the Insti-
tutes of Medicine and Pathology before the Philadelphia Institute, and
in 1826 was appointed to the chair of Chemistry and Applied Arts in
the Franklin Institute. He was a ready writer, and frequently con-
tributed to the medical journals. In 1841 he was elected to the chair
of Theory and Practice in Jefferson Medical College, a position he filled
with rare ability till the time of his death. IIe was a gifted lecturer,
and occasionally introduced experiments with good effect, as he was an
expert manipulator. His writings were numerous, and always contained
important additions to medical knowledge. (b. March 12, 1796; d. April
4, 1858.) Dr. George McClellan, a native of Connecticut, shortly after
graduation commenced practice in the city of Philadelphia. . In 1825,
with a few able associates, he founded the Jefferson Medical College, in
which he was a professor till 1838. In 1839 he organized the Medical
126 TO NER,
Department of Pennsylvania College, from which he retired in 1844,
and devoted his time to private practice. He was a fluent and agree-
able lecturer. For a time he edited a medical journal in connection
with Dr. John Eberle, and was a frequent contributor to the columns of
periodical medical literature. (b. Feb. 22, 1796; d. May 9, 1847.) Dr.
Robley Dunglison, a native of Scotland, was invited to the United States
in 1824, and elected Professor of Medicine in the University of Virginia,
where he continued till 1833. From 1833 to 1836 he was Professor of
Materia Medica and Therapeutics in the University of Maryland, and
from 1836 to 1868 was Professor of the Institutes of Medicine and Medical
Jurisprudence in the Jefferson Medical College. His Medical Dictionary
is by far the most convenient work of the kind known to the profession.
(b. June 4, 1798; d. April 1, 1869.) Dr. T. D. Mütter commenced prac-
tice in Philadelphia about 1831, and shortly afterwards established a
“Quiz class,” and soon became a teacher of surgery in what was known
as “Chapman’s Medical Institute.” He was made Adjunct Professor of
Operative Surgery in Jefferson Medical College to assist Dr. Randolph, and
on the resignation of the latter, was elected to the full chair of Surgery.
It was in this field that he acquired his great reputation as a teacher and
as an operator in rhinoplastic surgery. He has left an enduring monu-
ment to his name in the establishment of the “Mütter lectureship” and
the “Mütter Museum” of the College of Physicians. Besides the names
already given, I will mention Drs. William Shippen, Samuel Jackson,
Franklin Bache, T. S. James, P. S. Dorsey, H. L. Hodge, C. D. Meigs, J.
D. Godman, Adam Kuhn, J. Redman Coxe, Robert Hare, Samuel G.
Morton, Réné La Roche, W. Darlington, John S. Parry, Samuel Jackson
(of Northumberland), Peter Mowry, Nathaniel Bedford, James Agnew,
Joseph Gazzam, B. R. Reese, W. W. Gerhard, Jacob Randolph, David
Gilbert, G. W. Norris, Thomas T. Harrison, Joseph Parrish, Thomas
Harris, and P. B. Goddard.
RHODE ISLAND.'-Dr. Isaac Senter, a native of New Hampshire, served
as a surgeon in the Revolutionary war, and in 1779 settled in practice in
Pawtucket. In 1780 he was appointed Surgeon and Physician-General
to the State troops, and removed to Newport, where he passed the re-
mainder of his life actively engaged in the practice of his profession.
IHe contributed articles on medical subjects to the journals, and was an
honorary member of the Massachusetts Medical Society, of the Medical
Society of London, and of the College of Physicians of Philadelphia. He
was for some years President of the Rhode Island State Medical Society.
(b. 1735; d. Dec. 20, 1799.) Dr. Pardon Bowen, a native of Rhode Island,
served during the Revolutionary war as a surgeon on a privateer, and in
1779 was taken prisoner, and after being exchanged re-entered the service.
He settled in practice in his native town, and gradually acquired a large
business. He was an active and efficient member of the Rhode Island
State Medical Society, and for some years its president. He was also a
member of the Board of Trustees of Brown University. His profes-
| Rhode Island is one of the thirteen original States. Its first settlement was in 1636 by
Roger Williams, at the present site of Providence. Other settlements were soon made at
Newport and at Warwick. The population in 1870, according to the United States Census,
was 317,353. Nearly one-half of the people live in cities and towns of over five thousand
inhabitants. The number of physicians in 1870 was 260. One medical college, a depart-
ment of Brown University, is giving instruction. Rhode Island has a State Medical Society,
formed in 1812, which publishes Transactions annually, and a good system of registration
of vital statistics. Institutions for the care of the insane and other unfortunates have
been established, sufficient for the wants of the people.
A D D R E SS O N M E I) I C A L BIO G. R. A. P. H. Y. 127
sional life extended to nearly half a century. (b. 1757; d. Oct. 25, 1826.)
Dr. Usher Parsons, a native of Maine, became on graduating a surgeon
in the navy during the war of 1812, and was in the battle of Lake Erie.
After ten years’ service he resigned, and settled in practice in Providence.
He held a professorship in Brown, Jefferson, and other medical colleges,
and was President of the Rhode Island Medical Society, and Vice-Presi-
dent of the American Medical Association. He wrote a number of
medical works, and took four Boylston prizes. He was an influential
promoter of the establishment of the Rhode Island Hospital, and a most
agreeable and witty writer. (b. Aug. 18, 1788; d. Dec. 19, 1868.)
Dr. Solomon Drowne, a native of Rhode Island, served as a surgeon's
mate in the Revolutionary war, and on the restoration of peace settled
in Providence. In 1788 he joined a party going to the new settlement
in the West, at Marietta, on the Ohio River. He attended, during his
last illness, General Varnum, one of the Ohio Land Company, and, at the
request of the community, pronounced his funeral eulogy. He resided
for a time at Morgantown, Va., and for seven years at Uniontown, Fay-
ette County, Pa. Here he delivered four orations commemorative of
American independence, and a eulogy on General Washington. In 1801
he returned to Providence and engaged in private practice. In 1811 he
was Professor of Materia Medica and Botany in Brown University. The
Rhode Island Medical Society, in 1819, appointed him a delegate to the
convention that formed the National Pharmacopoeia. He possessed a
fine classical education, and was a beautiful writer and an interesting
lecturer. (b. March 11, 1753; d. Feb. 5, 1834.) Dr. Wm. Bowen studied
medicine with his father, then a leading physician, and speedily acquired
a large practice for himself. He avoided surgery, whenever practicable,
and was deemed specially skilful in diseases of women and children.
His instruction was much sought by pupils who were preparing to enter
the medical profession. His reputation in the treatment of fevers was
unequalled by any physician in his section. (d. 1832, aet. 86.) Dr. Caleb
Fiske, a native of Rhode Island, served as a surgeon in the Revolutionary
war, then settled in practice in Scituate, and passed a long and successful
professional life, residing all the time in the house in which he had been
born. He was one of the original members of the Rhode Island Medical
Society, and in 1823 its president. At one time he was Judge of the
Court of Common Pleas. He has perpetuated his name by endowing
the Fiske fund for the promotion of medicine. (d. Sept. 1835, aet. 82.)
To the names already mentioned I will add those of Drs. Levi Wheaton,
Joseph Mauran, L. L. Miller, and David King—the first to introduce
vaccination in Rhode Island.
SOUTH CAROLINA.”—Dr. James Moultrie, a native of South Carolina,
| South Carolina was one of the thirteen original States. The first settlement was at
Port Royal by the English, in 1670. The government was a proprietary one till 1719, when
South Carolina became a colony under the crown. During the Revolution the State was
very active, and suffered much from the depredations of the British troops. The popula-
tion in 1870, according to the U. S. Census, was 705,606, with about one in thirteen living
in towns and cities of over five thousand inhabitants. The number of physicians was 798.
There are two medical colleges, one at Charleston, and the other at Columbia. A State
Medical Society was formed in 1789, and a State Medical Association in 1848; the latter
publishes annually a volume of Transactions. Institutions for the care of unfortunates
have been established.
The following medical journals have been published in South Carolina: Carolina Journal
of Medicine, Surgery, and Agriculture, 1825; Charleston Medical Journal and Review,
1848; Charleston Medical Journal and Review, 1873; Southern Journal of Medicine and
Pharmacy, 1846.
128 TO NER,
commenced practice in Charleston in 1813, and was soon afterwards ap-
pointed physician to the fort and jail. He took an active part in public
health matters, and was soon recognized as the leading sanitarian of the
city. In 1819 he was elected by the Medical Society of South Carolina
a delegate to the first convention for forming the National Pharma-
copoeia. In 1822, lie, with other influential medical men, memorialized
the Legislature for a charter to establish a medical college, which was
granted in 1823. He was elected to a chair in the college, but declined.
In 1832, however, he accepted the chair of Physiology, and here devel-
oped the high powers of his well-stored and vigorous mind. He was
President of the American Medical Association in 1851, and had pre-
viously been President of the Medical Society of South Carolina. (b.
1793; d. 1869.) Dr. Tucker Harris, a native of South Carolina, commenced
practice in Charleston in 1771, in partnership with his preceptor Dr. Lionel
Chalmers, and served as a hospital surgeon in the Revolution. Immedi-
ately after the restoration of peace, he resumed his practice. From 1783
to 1786 he had a business partnership with Dr. Oliphant. He was one of
the earliest members, and an ardent friend, of the Medical Society of
South Carolina, and from 1796 to 1799 was chosen its president. (b. 1747;
d. July 6, 1821, aet. 74.) Dr. J. L. E. W. Shecut, a native of South Caro-
lina, commenced practice in Charleston in 1791. He was attentive to
business and a close student. In 1806 he exhibited an ingenious electrical
machine of his own construction, and the same year published a work
entitled “Flora Caroliniana.” His publications were quite numerous.
(b. 1770; d. 1836.) Dr. Alexander Baron, a native of Scotland, settled in
practice in the city of Charleston in 1769. His fund of general informa-
tion was great, and his ability equal to any position in professional or
civil life. He was one of the founders of the South Carolina Medical
Society, and its vice-president in 1790. In 1770 he joined the St. An-
drew’s Society, and was shortly after elected its president, an office
which he held for twenty-eight years. (d. July 9, 1819.) Dr. J. Edwards
|Holbrook, a native of South Carolina, established himself in Charleston
in 1822. In 1824 he was elected Professor of Anatomy in the Medical
College of South Carolina. He was universally recognized as a learned
scientist, and as a popular and successful physician. He avoided sur-
gery, and was particularly noted for his sympathy for suffering patients.
Pſe was a successful medical teacher, and particularly popular with his
class. Although contributing valuable articles to medical journals, his
greatest works, and those on which his reputation as an author will rest,
are his “American Herpetology” and “The Fishes of South Carolina.”
(b. Dec. 30, 1794; d. Sept. 8, 1871.)
Dr. John Bellinger, a native of South Carolina, commenced practice
in Charleston, where his eminent abilities soon carried him, through
all difficulties, to a full recognition of his professional abilities. His
high reputation pointed him out as a proper occupant for the chair of
Surgery in the Charleston Medical College, to which he was elected.
His skill in surgery was only equalled by his acuteness as a physician.
IHe was a thorough pathologist, and, although a busy practitioner, kept
pace with the progress of the profession, and with the latest and best
literature. (d. Aug. 13, 1860, aet. 56.)
Dr. Samuel H. Dickson, the physician, author, and teacher, commenced
practice in Charleston in 1820. In 1823 he delivered a course of lectures
on Physiology and Pathology before a medical class. He was influential
in the establishment of the medical college at Charleston, and, in 1824,
.A. T) D RESS ON ME DIC A. L. B [O G. R. A. P. H. Y. 129
was called to the chair of Institutes and Practice of Medicine. He was
Professor of the Practice of Medicine in the University of New York
from 1847 to 1850, when he returned to Charleston ; but in 1858 was
elected to the chair of Practice of Medicine in the Jefferson Medical
College at Philadelphia, which he held nearly to the time of his death.
He contributed many able papers to medical journals, and wrote a work
entitled “Manual of Pathology,” etc. (b. 1798; d. 1872.) Dr. B. B.
Simons was a native of South Carolina. In 1801 he commenced prac-
tice in Charleston, and soon acquired business and reputation. His
abilities were recognized by his appointment as Lecturer on Chemistry
in the College of South Carolina. He was a thorough anatomist, and
of rare skill and boldness in surgery, in which he acquired an extensive
reputation and practice. (b. 1766; d. 1844.) Dr. Richard Evans Wylie,
a native of Charleston, settled in 1832 in Lancaster Co., where he ac-
quired distinction in his profession. He was a fine anatomist, and made
many post-mortem examinations, and was a good pathologist. He was
of a charitable and generous disposition, and was well versed in medical
literature. (b. 1810; d. 1875.) Dr. Robert Wilson Gibbes was assistant
and afterwards Professor of Chemistry, Geology, and Mineralogy in the
South Carolina College, which position he filled with ability. He com-
menced practice in Columbia, where he acquired a good professional
business. He was for several years sent as a delegate to the American
Medical Association, and was President of the Medical Society of South
Carolina. During the late war he was Surgeon-General of the State
troops, and was the originator of the “wayside hospital system.” Dr.
Gibbes was an ardent student of the sciences, and the author of several
valuable contributions to the Academy of Sciences and to the Smithso-
nian Institution. He was the author of Gibbes's History of South Caro-
lina, and made a large collection of autographs, coins, and specimens in
palaeontology, geology, etc., as also a collection of the fossils of South
Carolina. He was a member of the Royal Societies of England, France,
Germany, and Denmark. (b. 1809; d. 1866.) I will add the names of
Dr. David Ramsay, Dr. Geddings, and Dr. Peter Fayssoux.
TENNESSEE.'—Dr. Wm. H. Deadrick, a native of Virginia, having
acquired his professional education, settled in East Tennessee. His
operation for the removal of the inferior maxillary bone, in 1810, and
other capital operations performed at that early date, have won for him
an enduring name in the literature of the profession. (b. 1785; d. 1857.)
| Tennessee was the first State west of the Alleghany Mountains, settled by emigrants
from the colonies, anterior to the Revolutionary war. The settlers were chiefly from North
Carolina, to which State the territory belonged. Fort Loudon, in West Tennessee, was built
as early as 1757. An attempt was made to found a State out of this territory under the
name of “Franklin,” but after three or four years' trial the effort was abandoned. Tennessee
was admitted as a State in the Union in 1796. It has no very large cities. The population,
according to the census in 1870, was 1,158,520, with about one in fifteen living in towns of
over five thousand inhabitants. The number of physicians at that time was 2220. One
medical college, organized in 1850 at Nashville, is well supported, and there is another, a
department of Vanderbilt University. The profession of the State has a Medical Society,
formed in 1830, which publishes Transactions annually. Institutions for the care of un-
fortunates have been organized in different parts of the State, sufficient for the wants of the
eople.
p #. following Medical Journals have been published in Tennessee : Memphis Journal of
Medicine, 1853; Memphis Medical Journal of the Progressive Medical and Physical
Sciences, 1851; Memphis Medical Recorder, 1852; Nashville Journal of Medicine and
Surgery, 1851; Nashville Medical Recorder, 1860; Record of Medicine and Surgery, 1852;
Southern Journal of Medical and Physical Sciences, 1853.
9
130 TO NER,
Dr. Felix Robertson, a native of Tennessee, wrote, for graduation in 1805,
a thesis entitled “Chorea Sancti Viti,” giving in it a history of the dancing
mania which had exhibited itself in Tennessee, Kentucky, and Ohio about
1802. He was well read in his profession, and possessed strong common
sense and original powers of observation. IIe was twice Mayor of the city
of Nashville, and a member of the Board of Trustees of the University ;
and through a long life maintained the dignity and character of an able
physician. (b. 1781; d. 1865.) Dr. Wilson Yandell, a native of North
Carolina, settled in 1804 in Hartsville, Rutherford Co. He was a man
of mental vigor, untiring industry, and had a love for the acquisition of
knowledge. IIis devotion to his profession rapidly advanced him to the
front rank of practitioners in the State. IIe received from the University
of Maryland the honorary degree of M.D. in 1823. He was the imme-
diate ancestor of the physicians of the same name in Kentucky. (b. Dec.
17, 1774; d. Oct. 1, 1827.) T)r. A. H. Buchanan, a native of Virginia,
commenced practice in East Tennessee, then removed to Columbia, and
finally to Nashville where lie became a professor in the Medical School
on its organization. He was a man of learning and high character. (b.
1808; d. June 20, 1863.) Dr. John McClaran Watson, a native of North
Carolina, settled in Murfreesboro, Tenn., but on the organization of the
Medical Department of the University of Nashville, was induced to take
the chair of Obstetrics and Diseases of Women and Children. He was a
minister of the Gospel, as well as a successful practitioner, and a promoter
of medical education. (b. 1796; d. 1866.) Dr. A. P. Merrill, a native of
Massachusetts, served as a volunteer surgeon with General Jackson's
Army in the War of 1812, and in 1819 was appointed surgeon in the
U. S. Military service. In 1823 he resigned, and settled in practice at
Natchez. In 1850 he removed to Memphis, Tenn., and assisted in organ-
izing the Medical College at that place, taking the chair of Theory and
Practice. He originated and edited the Memphis Medical Recorder.
He was an able practitioner and an original writer, his contributions to
medical literature being varied and valuable. (b. April 1793; d. Nov.
1873.) In addition to these I will name Drs. T. R. Jennings, James
Roane, W. Walker, R. Porter, J. L. Armstrong, and Samuel IIogg.
TEXAs.”—Dr. Benjamin Briggs Goodrich, a native of Virginia, practised
for some time after graduating in Alabama and Mississippi, finally
locating in Washington, Texas. IIe was a member of the State Legis-
lature, and on Texas resolving upon independence, was one of the signers
of its declaration. (b. 1800; d. 1860.) Dr. Anson Jones, a native of Mas-
sachusetts, a patriot of Texas, commenced his career as a practitioner of
medicine at Brazoria. He entered the Texan army as a surgeon, and was
Texas until 1836 was a part of Mexico. In 1821, emigration to it from the United
States became considerable. In 1830, it demanded admission to the Mexican confederation,
as a separate State, but being refused, declared its independence, and conquered in a con-
test of arms, in 1836, maintaining its independence as a republic till it was admitted as one
of the United States, in 1846. Its area is the largest of any of the States. There are no
large cities in Texas; but it has a fertile soil, navigable rivers, and rich minerals. The
population in 1870, according to the U. S. Census, was 818,899, with about one in twenty-
five living in towns of over five thousand inhabitants. At the same time there were 1906
physicians. Population is increasing, and wealth accumulating. One medical college is
located at Galveston, and is giving instruction. A State Medical Society was formed in
1869, and publishes Transactions annually. Institutions for the care of unfortunates have
been established.
The following medical journals have been published in Texas: Galveston Medical
Journal, 1866; Texas Medical Journal, 1873. -
A. I.) I) RESS O N M E DIC AI, BIO G R A PEI Y. 131
at the battle of San Jacinto. In 1837–8, he was a representative in the
Texan Congress. In 1838, he was Minister to the United States, where
he made an unsuccessful endeavor to secure the annexation of his country.
On his return, he was made Senator from Brazoria to the Texan Congress.
He was Secretary of State of Texas in 1841, and in September, 1844, was
elected President of the Republic, and held this office up to the time of
the annexation of Texas to the United States. (b. 1798; d. 1858.) Dr.
Edward A. Pye, a native of Maryland, was a physician of eminence. He
had a good practice at Hearne, in Robertson Co. When the yellow fever
at Calvert had exhausted the medical men of that place, he offered his
services, which were gladly accepted by the authorities. But this heroic
act cost him his life. IIe contracted the disease, and died. During the
war, he served as surgeon at Beaumont. (b. July 9, 1818; d. Nov. 9,
1873.). Dr. John A. Pettus, a native of Virginia, settled at Fort Bend,
Texas, where he acquired a large practice. During the late war, he was
Medical Director of the Corps of Surgeons of U. S. Volunteers. After
the war, he returned to practice, and was elected Professor of Physiology
and Medical Jurisprudence in the Galveston Medical College. (d. Sept.
26, 1870, aged 52.) Dr. E. L. Massie was a skilful and benevolent phy-
sician of Houston. During the war, he served as a surgeon in the Con-
federate army, and was afterwards Medical Purveyor of Texas. He was
one of the leading physicians of Houston. I will name in addition, Drs.
E. T. Bonney, Alva Connell, W. Riddell, George W. Peete, W. D. Rob-
inson, Wm. Richardson, W. R. Smith, and Wm. McCraven.
VERMONT."—T)r. Joseph Adams Gallup, a native of Connecticut, settled
in practice at Woodstock, Vermont, in 1800. He possessed a vigorous
mind, and was a close observer and correct reasoner. By skill in his pro-
fession, and by force of character, he acquired a leading business. He
was Professor in the Castleton Medical College, and in the Medical College
of the University of Vermont. In 1827 he founded the medical school
of Woodstock. His best known writings are entitled “Sketches on Epi-
demic Diseases in Vermont,” published in 1815, and “Outlines of Insti-
tutes of Medicine,” published subsequently. (b. Mar. 30, 1769; d. Oct.
12, 1849.) Dr. Noadiah Swift, a native of New York, commenced practice
in Burlington about 1802, and enjoyed a large practice for nearly fifty
years. He was a man of great energy of character, and of correct habits,
and possessed rare skill in his profession. His reputation extended far
beyond the community in which he resided. He was elected at differ-
ent times to the State Senate. (b. Nov. 24, 1776; d. Mar. 21, 1860.)
I)r. Benjamin R. Palmer commenced practice in Woodstock, Vermont,
where he acquired much popularity, and a good professional business.
Iſe possessed decided talents as a teacher of anatomy and physiology.
He was elected to the chair of Anatomy in the Vermont Medical College,
where he taught for many years with success. He also held the same
| Vermont was settled by emigrants from Massachusetts, New Hampshire, and New
York, each of which States claimed her territory. In 1791 Vermont was admitted as the
first new member of the Union. The population in 1870, according to the United States
Census, was 330,531. She has no large cities, and about one in twenty-three of her popula-
tion live in towns of over five thousand inhabitants. She had at the time mentioned 569
physicians. Vermont has one medical college, a department of the University of Burling-
ton. A State Medical Society was organized in 1814, and publishes Transactions annually.
A registration of vital statistics has also been established. Institutions for the care of
unfortunates have been founded, sufficient for the wants of the people. g
The following Medical Journal has been published in Vermont : Vermont Medical
Journal, 1874.
132 TO NER,
chair in the Berkshire Medical College of Massachusetts. Iſis reputation
as a teacher gained him the election to the chair of Anatomy in the Louis-
ville Medical College, when he removed to Kentucky, where he enjoyed
an extensive practice up to the time of his death. Dr. Benjamin Chandler,
a native of Connecticut, commenced practice in 1792 in Rutland, Vermont,
where he acquired reputation, and whence he removed to St. Albans in
1807. As a successful operator in surgery, he had no equal in that section
of the country. IIe was one of the founders of the Vermont State Medical
Society, and of the Franklin County Medical Society. (b. 1772; d. 1818.)
T)r. John Pomeroy, a native of Massachusetts, was a physician of ability.
He settled in Cambridge, Vermont, in 1787, and in 1792 removed to Bur-
lington, where he remained actively engaged in practice for over forty
years. He was a man of vigorous intellect, and was characterized by
simplicity of manner, directness of purpose, and strong common sense.
Although he could not claim superior education, he was an ardent
supporter of it. IIe was a member of the Corporation of the University
of Vermont, and a professor in the Medical Department. (b. April 9,
1764; d. Feb. 19, 1844.) Dr. Jonathan Adams Allen, a native of Massa-
chusetts, commenced practice at Windham, in 1814. In 1820 he com-
menced to give lectures on Chemistry, at Middlebury College, and con-
tinued till 1826. In 1822 he removed to Middlebury, where he became
extensively engaged as a physician. He was an active member of the
State and County Medical Societies. (b. Nov. 17, 1787; d. Feb. 2, 1848.)
Dr. Horace Eaton, a native of Vermont, commenced practice in Enosburgh
about 1824, and soon became popular as a physician. He was a man of
great energy, and fully qualified in the duties of physician and surgeon.
He was elected to the Legislature of the State, and was six years in the
State Senate. IIe was also Lieutenant Governor and Governor of the
State for two years. He was greatly interested in education, and was
for years State Superintendent of Schools. In 1848 he was elected Pro-
fessor of Natural History and Chemistry in Middlebury College, a posi-
tion which he filled with credit to himself and the Institution till the
time of his death. (b. June 22, 1804; d. July 4, 1855.) To these names
may be added those of Dr. Theodore Woodward, of Castleton; Dr. David
Palmer, of Woodstock; Dr. Ezekiel Porter, of Rutland; the Drs. Tudor,
of Middlebury, and Dr. Danforth.
VIRGINIA."—Dr. Wm. Baynham, a native of Virginia, studied medi-
cine with his father, and then with the celebrated Hunters of London.
He was an excellent anatomist, and was held in high esteem by his
London preceptors, and by Mr. Cline and Mr. Else. He made some deli-
! Virginia was, in 1607, the seat of the first permanent settlement by the English in Ame-
rica, at Jamestown. Her first charter was annulled in 1677, and a new one, less liberal,
granted. She took an early and decided stand in favor of American Independence. Her
territory at that time was very large, and in 1781 she ceded the whole northwestern part to
the U. S. government. In 1861 the western part of the State was formed into a separate
State, under the name of West Virginia. Her geographical position gives her great commer-
cial advantages. The population of Virginia, according to the U. S. Census in 1870, was
1,225,163, about one in ten living in cities of over five thousand inhabitants. The number
of physicians was 2226. There are two medical colleges, one at Richmond and the other
at the University, at Charlottesville. The State Medical Society, formed in 1821, pub-
lishes Transactions annually. Institutions sufficient for the care of unfortunates have been
organized in different parts of the State. The first Insane Asylum in this country, under
State authority, was established at Williamsburg in 1773.
The following medical journals have been published in Virginia: Monthly Stethoscope
and Medical Reporter, 1856; Richmond Medical Journal, 1866; Virginia Clinical Record,
1871; Virginia Medical Monthly, 1874; Virginia Medical and Surgical Journal, 1856.
A D D RESS ON ME DIC A. L BIO G R A PHY. 133
cate dissections and minute injections, which are still on the list of
preparations at St. Thomas’s Hospital. He practised for some years in
London, but returned to Virginia, and settled in Essex Co. He was,
without question, the most celebrated anatomist and surgeon in his day
in America. Although being in a sparsely settled region, he was con-
sulted by many persons from a distance, and frequently made long visits
to perform surgical operations. (b. Dec. 7, 1749; d. Dec. 8, 1814.) Dr.
James McClurg, a native of Virginia, served during the Revolutionary
war as a surgeon, and part of the time as Medical Director. He com-
menced practice at Williamsburg in 1773, and soon won his way to
recognition as a physician of high culture and skill. He had published
in London, in 1772, a thesis on the Bile, which attracted the attention
of the profession. On the removal of the State government from Wil-
liamsburg to Richmond in 1793, the doctor took up his residence in the
latter city. By virtue of his decided skill, he was for nearly fifty years
at the head of the profession of Virginia. (b. 1746; d. July, 1823.) Dr.
Wm. B. Selden, a native of Virginia, settled in practice in Norfolk in
1799, and was fully employed for half a century. He was an elegant
scholar, retaining his love for the classics to the close of his life. He was
a careful reader of the best medical literature, and a close observer of
disease. In 1799 he obtained from Dr. Jenner some vaccine virus, with
which he continued to vaccinate, and with which he kept up a con-
tinuous supply for fifty years. He declared that he could see no varia-
tion in the appearance of the vesicle, nor any failure in its power of
protection in all this time. (b. Aug. 31, 1773; d. 1849.) Dr. Beverly
R. Welford, a native of Virginia, settled in practice in Fredericksburg
in 1816, when he was scarce twenty-one years of age, and soon won the
confidence and affection of a large circle of friends and patients. He
was a man of liberal studies, and enthusiastically devoted to the advance.
ment of the medical profession. In 1854 he was elected to the chair of
Materia Medica and Therapeutics in the College of Virginia, and re-
moved to Richmond. His courteous manners, ripe experience, and pro-
fessional knowledge soon made him the popular physician of that city.
In 1852 he was President of the American Medical Association. (b. July
29, 1797; d. Dec. 20, 1870.)
Dr. Hugh Holmes McGuire, a native of Virginia, commenced his career
as a medical man in Winchester, Va., and soon developed a preference
for surgery. His first operation was for cataract, which he successfully
performed with a needle made under his direction by a mechanic in Win.
chester. In 1827, with other physicians, he established the Winchester
Medical School, in which he was Professor of Anatomy and Surgery.
In 1847 this instituton obtained a charter, and continued in successful
operation till the beginning of the war. In 1862 the buildings were
burned by soldiers under Gen. Banks. In the same year the Doctor was
commissioned as surgeon in the Confederate Army, and served till the
close of the war. He was tendered a professorship in a medical school
at Philadelphia, and also at New Orleans. In 1850, he was elected one
of the Vice-Presidents of the American Medical Association. He was a
man of great industry, and had wonderful success as a surgeon. He
performed lithotomy thirty times without losing a case. (b. 1801; d. ,
1875.) Dr. James Craik, a native of Scotland, was a surgeon in Brad-
dock's expedition against Fort Duquesne, and also a surgeon in the Revo-
lutionary Army. After peace was established, he settled in practice near
Mt. Vernon, in Virginia. He was a warm personal friend of Gen. Wash-
134 TO NER,
ington, who mentioned him in his will, as his “old and intimate friend.”
The Doctor was one of the three physicians who attended Gen. Wash-
ington in his last illness. He was a thoroughly educated physician and
surgeon, and a man of great probity of character. (b. 1731; d. Feb. 6,
1814.) Dr. George Cabell, a native of Virginia, practised for years with
success and reputation at Lynchburg. He was a man of superior endow-
ments and much culture. His practice extended for many miles along
the valley of the James River. (d. 1823.)
Dr. J. P. Mettauer, a native of Virginia, practised in Prince Edward
County. He was in many respects one of the boldest and most successful
surgeons in the State. He commenced practice in this sparsely settled
region about 1809, and during a long life maintained the character of a
learned and skilful physician and surgeon. No medical man in the South
was better known for his success, and for his valuable and numerous
contributions to medical literature. Even when past eighty years of age,
he was active and energetic in practice, and performed important surgical
operations with success. (d. Nov. 22, 1875, aged 88.) Dr. Francis T. Strib-
ling settled in Staunton, Va., where he soon acquired a large practice by
devotion to professional duties. In 1836 he was elected physician to the
Western Lunatic Asylum, and in 1840 was appointed Superintendent,
which position he filled with great success to the time of his death. He
possessed a strong intellect, and introduced many improvements in the
management of the insane. (b. Jan. 20, 1810; d. July 23, 1874.) In addi-
tion I will mention Drs. Charles B. Gibson, James Henderson, John
Minson Galt, Thomas Massey, Goodridge Wilson, Thomas Robinson, P.
C. Spencer, Micajah Clark, James Bolton, John Cullen, James Currie, R.
W. Haxall, B. H. May, A. L. Warner, H. Selden, G. N. Upsher, J. B.
Strachan, J. S. Giliaim, J. B. McCaw, A. G. Strachan, John Field, John
F. Peebles, T. R. Atkinson, D. J. Claiborn, R. B. Butt, besides the
forty-five martyrs who died of yellow fever at Norfolk in 1855.”
* I believe that a complete record of the names of the physicians who died during the
great epidemic of yellow fever in Norfolk, in 1855, has not found a place in medical litera-
ture. The list given here is taken from the Virginia Medical and Surgical Journal for Oct.
1855, p. 338, from the Portsmouth Relief Association's report, from Forrest’s “Great Pes-
tilence in Virginia,” and from other sources. It will be observed that in some cases no first
names are given. In the midst of the terrible panic and distress that existed, these noble
men were buried without any special ceremony, but were conveyed silently to their graves.
We honor their courage and devotion to professional duty, which was equal to that which,
in the church, purchased the title of Saint. Over one hundred physicians volunteered their
services, and actually went to Norfolk and Portsmouth during the epidemic. Forty-five
medical men are known to have died of yellow fever in these cities, and, so malignant was
the disease at one time, that seven physicians died upon one day, and five on another. A
majority of the deaths of physicians took place among those who came from other places to
render assistance to their medical brethren and the citizens in their great distress. While
it is probable that I have not obtained the names of all, it is possible that some in the list
may have been druggists and not graduates in medicine. The following are the names in
alphabetical order, with the place of residence when known :-
Bache, Berry, J. L. (Memphis, Tenn.), Berry, R. B. (Tenn.), Blow, Richard (Sussex, Va.),
Booth, T. (Baltimore, Md.), Briggs, J. A. (Norfolk, Va.), Burns, Capri (a Hungarian),
Cole, C. (Philada., Pa.), Collins, Wm., Constable, T. F. (Norfolk, Va.), Craycroft, T. H.
(Philada. Pa.), Crowe, N. J. (l{ichmond, Va.), Dabershe (Dist. of Columbia), De Berane,
Dillard (Montgomery, Ala.), Fliess (Baltimore, Md.), Gilbardt, Leon (Richmond, Va.),
Gooch, P. C. (Richmond, Va.), Halson, G. I. (Norfolk, Va.), Handy, T. W. (Philada., Pa.),
Higgins. F. L. (Norfolk, Va.), Howe (Baltimore, Md.), Howle, Thos. P. (Richmond, Va.),
Hunter, Edwin (Brooklyn, N.Y.), Jackson (Dist. of Col.), Lovett, M. P. (Portsmouth,
Va.), Marshall (Baltimore, Md.), Mierson, T. (Philada., Pa.), Morse, Nash, Thos. (Nor-
folk, Va.), Nicholson, L. P. (Portsmouth, Va.), Obermulier (Georgia), Parker, R. H.
(Portsmouth, Va.), Rizer (Penn.), Schell (N. Y.), Selden, Henry (Norfolk, Va.), Sil-
A D D RESS ON ME DIC A. L. B I O G R A PHY. 135
WEST VIRGINIA.--Dr. James W. Clemens, a native of Pennsylvania,
commenced practice in Wheeling in 1819. He was not only solicitous
for business, but ambitious for knowledge, and a constant reader of the
best medical literature. He had a private chemical and pathological
laboratory attached to his office, in which he was constantly experiment-
ing. He was a ready writer and a fluent speaker, and enjoyed through
life the reputation of a successful physician. (b. May 26, 1795; d. Nov.
21, 1841.) Dr. Martin L. Todd, a native of New York, commenced
practice in Wheeling in 1810, and soon acquired reputation in the treat-
ment of a then prevalent low grade of fever, popularly called the “Cold
Plague.” He served as a surgeon with the State troops in the war of
1812. He was remarkable for his acuteness in diagnosis, as well as for
his choice of efficient remedies. (b. 1782; d. March 8, 1866.) Dr. S. P.
Hullihen, a native of Pennsylvania, commenced practice as a surgeon
and dentist in 1832, and the same year received the degree of Doctor of
Medicine from Washington Medical College, Baltimore. He was a man
of genius, gifted with original conceptions, and with ability to overcome
difficulties in surgical operations, and to make efficient appliances. He
never was a general practitioner. To him belongs the credit of originat-
ing the movement for the establishment of the Wheeling Hospital. He
contributed some valuable articles to Medical Journals, the result of
observation and experience. His death was regretted by all classes, and
at a public meeting a spontaneous subscription was made to erect a
monument to his memory. (b. Dec. 10, 1810; d. March 27, 1857.) Dr.
R. H. Cummings, a native of Pennsylvania, commenced practice in
Wheeling. IIis professional qualifications were of the first order. He
was a ready writer, and a close observer of all the conditions that affect
health. He occasionally contributed to medical literature, and was Pre-
sident of the State Medical Society in 1872. (b. Feb. 17, 1817; d. April
12, 1873.) In addition to the foregoing, I will name Drs. Samuel Mc-
JKeehan, John W. Moss, II. D. Chapman, and James Tanner.
WISCONSIN.”—Dr. Mason C. Darling, a native of Massachusetts, settled
in 1830 in Fond-du-Lac, Wisconsin, the pioneer physician of that place.
He had formerly practised for about thirteen years in Greenwich, Mass.,
where he had acquired experience and reputation. In addition to being
a good physician, he was an emergetic far-seeing business man. These
qualities caused him to be put forward in politics, and he was elected to
vester, Richard J., and Silvester, R. W. (Norfolk, Va.), Smith, J. C. (Columbia, Pa.),
Thompson, Robt. (Baltimore, Md.), Trugien, J. W. H. (Portsmouth, Va.), Tunstall, R. B.
(Norfolk, Va.), Upsher, G. L. (Norfolk, Va.), Walters, Charles (Baltimore, Md.).
| West Virginia formed a part of Virginia until 1861, when a convention at Wheeling
formed it into a new State; and it was admitted into the Union Dec. 31, 1862. The popu-
lation in 1870, according to the U. S. Census, was 442,014, about one in twenty living in
cities and towns of over five thousand inhabitants. The number of physicians was 612.
A State Medical Society, organized in 1867, prints annually a volume of Transactions. In-
stitutions for the care of the insane and other unfortunates have been established.
The following medical journal is published in West Virginia: West Virginia Medical
Student, 1875.
* Wisconsin was early visited by the French missionaries, and permanent settlements
were made in the latter part of the 17th century. It was erected into a territory in 1836,
and admitted as a State in the Union in 1848. Population and wealth are rapidly moving
to it. The U. S. Census of 1870, assigns to it a population of 1,064,985, with about one in
eight living in towns of over five thousand inhabitants. The same authority gives 915
physicians. The agricultural resources are of the first order. A State Medical Society
and a State Board of Health have been organized; the first, formed in 1842, has for years
published Transactions.
136 TO NER,
the Legislature and also to the State Senate, where he took a prominent
part in favor of educational projects. He was one of the originators and
first President of the State Historical Society. (b. May 18, 1801; d. March
12, 1856.) Dr. John B. Donsman, a native of Michigan, commenced
practice in 1826 with his preceptor Dr. Twitchell, of New Hampshire.
In 1840 he came to Wisconsin, and settled in Milwaukee, where he prac-
tised with success up to the time of his death. IIe was a man of clear
perceptions, great stability of character, and devotion to his profession.
He was a member of the State Medical Society and of the American
Medical Association. (b. 1807; d. 1868.) Dr. Clark G. Pease, a native
of New Hampshire, commenced practice in IIolyoke, Mass., in 1849, but
in 1850 removed to Janesville, Wisconsin. II is agreeable address and
skill as a physician soon won him a numerous class of patrons. IIe was
an influential member of, and one of the best workers in, the State Med-
ical Association, acted on nearly every committee of importance, and
was elected President in 1857. He contributed papers to the State
Society, and also to the American Medical Association. He served as a
surgeon in the late war, and lost his life from a dissection wound.
(b. Dec. 31, 1821; d. June 27, 1864.) Dr. Alexander McDill, a native of
Pennsylvania, after practising for fifteen years in his native State,
removed in 1856 to Wisconsin, and settled in Plover, Portage Co., where
he became fully employed. In 1862–3 he was sent to the Legislature,
and the following year to the Senate. In 1868 he was chosen Super-
intendent of the State Hospital for the Insane. In 1872 he was elected
to Congress, but at the expiration of his term of office, resumed his
place as Superintendent of the Asylum. (d. Nov. 12, 1875.) In addition
to the foregoing, I will name Drs. Henry M. Lilly, Moses Barrett, H. O.
Crone, A. Blanchard, B. F. White, and Corydon Farr,
My task here ends. A century of American Medical Biography has
been traversed. Of necessity, the memoirs are very brief. The claims of
every part of our country have however been considered. The retrospect
is finished: I would it were worthier of the occasion. And in conclu-
sion I wish to bear testimony to the fact that the study of the lives of the
physicians of America, for the Centennial period, has produced in me,
as I trust it will in others, a profound conviction that eminence and hon-
orable distinction in the profession, are the legitimate results of good
education and professional knowledge, conjoined with high moral cha-
racter and devotion to duty. These qualities, with a desire to do good
and an active sympathy for our race, stand out so prominently in the
lives of all truly eminent physicians, as to appear to be essential traits
of professional character. So unifornly are love of man and devotion to
duty characteristic of the true physician, that it is not arrogant to claim
for him a higher approbation, as in the vision of Abou Ben Adhem,
who saw that the name of him who loved his fellow men “led all the
rest,” on the roll “of those whom love of God had blest.”
When in the course of time another century of American Independ-
ence shall have been concluded, the professional men then occupying our
places may perchance choose to meet as we have done, and, casting a retro-
spective glance across the second century, contrast their position and the
progress then attained with that which marks our era. And while
I trust that they may have abundant reason to congratulate themselves
upon the advance which medicine shall have made, I doubt not they will
have an honest pride in the monuments, legacies, and records left by
A D D R E S S ON ME DIC A. L. B I O G. R. A. P. H. Y. 137
the profession during the century just closed. These have in part been
referred to in the addresses and papers read before this Congress. Per-
mit me to indulge the hope that the biographer of the next Centennial
may have as great pleasure and satisfaction in the study of the lives of
the medical men of the second century of our country, as I have enjoyed
in the preparation of this address. I am persuaded that the temple of
fame holds no more honored tablets than those on which are inscribed
the names and deeds of the worthy members of the Medical Profession.
That the members of this Congress may deserve to have their names
perpetuated to fame through all succeeding ages, is my earnest prayer.
To have my own there enrolled, I may not hope, since this is granted to
but the immortal few.
138
ADDRESS ON OBSTETRICS.
BY
THEOPHILUS PARVIN, M.D.,
PROFEssor of OBSTETRICS AND THE MEDICAL AND su RCICAL DISEASEs OF WOMEN, colled E
OF PHYSICIANS AND SURGEONS OF INDIAN A.
“There is no department of medicine or surgery, superior to midwifery in
dignity and utility.”—Mauriceaw.
OF American Obstetrics, with its associate branches, Gynaecology and
Paediatrics, we commemorate the centennial.
What have Americans done, in the century just closed, to advance
these great departments of Medicine : How easy the question and how
difficult the answer | Contemporaneous discoveries and successes are
found in these as well as in other fields of human effort, and who, then,
shall be primus inter pares / Sometimes, too, that which is supposed to
be new" is really old, and the discoverer has unconsciously trodden in
the footsteps of another.
Beside this, much of medical knowledge is merely provisional, the
best expression of the truth for the time being, and serves only a present
utility—a mere ladder by which we ascend to higher platforms and larger
planes, and which is then cast aside. Nor does everything claimed as
valuable by him who first points it out, prove to be such when thoroughly
tested. Alas, for the many Ixions who mistake a cloud for a goddess!
Alas, for the fool's gold that so often delights, so surely disappoints'
Change is not synonymous with improvement; so far from change always
being progress, it may be retrogression.” -
Nor are these the only difficulties. Add to them the limitation of
individual knowledge, and the infirmities of human judgment, so liable
to error in estimating the value of things present, no matter how deter-
mined and desirous one may be suum cuique tribuere. And surmounting
all these, there stands in bold relief the fact that the very work of this
occasion has been largely anticipated by an able paper in the American
Journal of the Medical Sciences,’ from the pen of one who has himself
contributed so much to the glory of American Medicine. Confronted by
such difficulties, and addressing such auditors, one even of ample qualifi-
cations might well shrink from attempting the duty assigned me.
However, strengthened by your recognition of these impediments, and
! Professor Blackie, Horae Hellenicae, observes: “Even in the free exercise of poetical
talent in the case of individual poets of highly potentiated imagination, we constantly
stumble on comparisons which have been made independently by other poets at other times
or in distant countries, and which superficial critics are sometimes eager to fasten on as
plagiarism.” Quite similar facts are observed in the history of medicine.
* Baudelocque, Vol. II, pp. 34, of L’Art des Accouchemens, Paris, 1781, in referring to
the obstetrical forceps remarks: “ . . car si plusieurs ont travaillé à sa perfection,
les autres me l’on rendu que plus imparfait.”
* July, 1876. A Century of American Medicine. III—Obstetrics and Gynaecology.
By T. Gaillard Thomas, M.D. -
A D DIRESS O N O B STE TRIC S. 139
confiding in your earnest sympathies with this work, I address myself
to it with zealous desire to honor justly both the dead and the living of
our country, who have added useful knowledge in obstetrics, and in
diseases of women or of children, and to help exalt their fame in all
they have thus done to lift or lighten the cross of human suffering.
In this proposed exposition, the subject of Obstetrics will, for obvious
reasons, be presented first. After some brief allusions to the condition
of obstetric art and science in the last century, and the sources from which
the first American practitioners of this art derived their knowledge,
suitable topics will be found in works on Obstetrics, and in special con-
tributions to obstetric pathology and therapeutics.
The eighteenth century was marked by great advances in obstetric
knowledge and improvements in practice, though history has shown
the mistake of a distinguished physician of South Carolina, Dr. David
Ramsey, who, in an address before the Medical Society of his State, on
the first day of the present century, asserted “that the art of obstetrics
had been brought to such perfection, further improvements were scarcely
to be expected.”
Standing at the commencement of the eighteenth century is the famous
Hollander, Deventer, who declared theory as essential to practice as body
to shadow—surely a very doubtful compliment to practice—who asserted
that those' ignorant of the obliquities of the uterus were equally blind
with him that saw trees as men walking, but who, despite these and similar
exaggerations, despite plain, palpable errors, advocated cephalic version,
and taught the genu-pectoral position as part of the treatment in one
variety of prolapse” of the cord, and in some cases of transverse” presen-
tation. gº
Near its close we have the illustrious Baudelocque, to whom so many
of our obstetric authors acknowledge their obligations, and whose fame,
notwithstanding his twenty-three presentations and ninety-four positions,
has suffered only partial eclipse in the revolutions of more than four-
score years. And interposed we have Chapman coming from the country
to London once a year to give lectures on obstetrics, the first,” and the
first ever given in that city, being in 1730, and revealing the beneficent
instrument which the Chamberlens had kept secret with cruel cupidity,
the obstetric forceps; we have Sir Fielding Oulde, the wit’s “Lord deliver
* . . quicunque obliqui situs uteri sunt ignari, in artibus obstetricantium aeque cecu-
tiant, ac ille, qui homines instar arborum videbat ambulantes. Henrici à Deventer, Medi-
cinae Doctoris, Operationes Chirurgica: Novum Lumen exhibentes Obstetricantibus, etc.,
Leyden, 1701.
* Similiter accidit sed rarius, ut funiculus à capite retrorsum vertebris vel ossi sacro
apprimatur: tunc caput alterutra manu removendum, prout Scilicet plus minus in alterutrum
latus vergit; parturienti (si vires suppetant) in genua provolutae à tergo manum Sospitam
admoveat obstetriac: aut, si infirmior fuerit, in alterutrum latus declinetur, umo pede ad
ventrem attracto, ut plus spatii suppetat, etc., Ibid., cap. xxxviii. De partu difficili, ab
infante praevia vena umbilicali prodeunte.
3 . ideoque parturientem, tali situ disponat, quo uteri spatium Suppetat, nec
ille cum infante in manum obstetricis delabatur; nimirum utero propendulo convenit
parturientem procumbere genibus, aut in deact rum latus inclinare, posteriore corpore
aliquatenus elevato, et ut plurimum prono, etc., Ibid., cap. xl. De infantibus transversim
positis.
* My authority is Dr. Thyme. Wide MSS. Lectures. 1794, Surgeon-General's Library,
Washington. Dr. T. remarks, “ Chapman had no machines, nor were his students allowed
to attend midwifery cases. To Smellie we owe those improvements.” Denman, however,
credits Dr. Maubray, 1724, with the first lectures.
140 PAR VIN,
us,” giving a glimpse at the mechanism of labor, that mechanism soon to
be much more fully and clearly expounded by Smellie and Solayres; we
have Smellie and William Hunter, representing opposite but concordant
elements of obstetrics, mechanism and physiology, the one writing a work
upon obstetrics, the fruit of forty, years’ study, which for nearly three-
quarters of a century was the best English text-book, and enduring the
harmless criticism of Dr. Burton, who probably had his reward in being
made the Dr. Slop of Tristram Shandy ; the other preparing those plates
of the human gravid uterus, which can never become obsolete ; we have
Levret, the geometric obstetrician, explaining the mechanism of labor
before the Paris Academy of Surgery, using in his demonstrations the
egg of an ostrich and a “mattrice mechanique,” and dividing with
Smellie" the honor of an important improvement in the forceps. With
these two men, using the words of Baudelocque, commenced the most
brilliant epoch of obstetric art.
I3ut it is not my purpose to mention further the famous obstetricians
of the eighteenth century, and allude to any of their special contribu-
tions. Enough to add that the two first American obstetric practitioners
had been instructed by two of the most eminent of London teachers, for
Iloyd,” in Boston, and Shippen,” in Philadelphia, were pupils of Smellie
and Wm. Hunter. Thus we see that the germ of American Obstetrics
was British rather than French, in so far giving probable contradiction
to the assertion of Dr. Tyler Smith when he states, “notwithstanding
the blood relation between the United States and this country, American
Midwifery is far more the child of France than of England.” So, too,
probable contradiction is given by these other facts, that Dr. Samuel Bard,
the author of the first American work on obstetrics, had received his pro-
fessional training largely in Edinburgh; and that there, too, after having
previously been a house-pupil in London under Drs. Osborne and John
Clarke, was instructed Dr. T. C. James, the first professor of obstetrics in
the University of Pennsylvania. And the famous Dewees, who bears
the same paternal relation to American Obstetrics that Physick does to
American Surgery, or Rush to American Practice, and who “ has the
high honor of first attempting a full course of lectures on obstetrics in
America,” was too independent a thinker and original investigator to
be unduly swayed by the teachings of any man or of any school.” And
finally, the obstetric books of the American profession have been British
or American much more than French.
Seventy or eighty years ago, the practice of obstetrics was almost
exclusively in the hands of women, even in the long settled parts of the
United States, and, as the tide of population passed westward, the female
midwife was still the trust of the matrons among the early settlers who
| Possibly, according to the recent researches of Dr. McClintock, each of them was anti-
cipated by Dr. Pugh (see Dublin Journal, June, 1876), so that there is an end to the con-
test in this matter between France and England.
* Dr. Bartlett, of Massachusetts, states that Dr. James Lloyd, of Boston, was the first
systematic practitioner of midwifery in that section of the country, 1754.
* In 1756 Dr. William Shippen engaged in the same practice at Philadelphia, and sub-
sequently was Professor of Anatomy, Surgery, and Midwifery in the University of Penn-
sylvania.
y; Eulogium upon William P. Dewees, by Prof. Hugh L. Hodge. These lectures were
first delivered in 1797.
5 “Drs. James and Dewees should be regarded as the fathers of obstetric science in
America: the former, erudite and polished, gave currency to the teachings of the British
schools; the latter, more vigorous and energetic, exemplifying theoretically and practically
the doctrines of the French obstetricians.”—Preface to Hodge's Obstetrics.
A. D. D. R. ESS ON OB STE TRIC S. 141
swept away the forests and founded an empire beyond the Alleghanies.
Dr. J. G. F. Holston' has given a most graphic description of early mid-
wifery in Ohio; but the compensation of these practitioners, as stated
by him, seems so meagre that none could have had a lucrative practice,
no matter how large it was—one dollar, and in cities not more than
three dollars, and in the country the midwife was also nurse the first
week or until the ninth day.
Nor had the American midwife any of the posthumous honors which
were once the fortune of her sisters in France. That famous Sage:femme,
Touise Bourgeois—whose picture” Dr. Goodell has with such perfect
art recently exhibited to the profession—in her Instructions to her
daughter, Paris, 1617, states, “There are now very few women who have
such an affectionate regard for their midwives as prevailed formerly,
when it was the custom, if a midwife died, for her friends to put on deep
mourning for her, and they prayed God not to send them any more
children,” etc.
However the fact remains that the general practice of obstetrics in
this country has been but for little more than half a century chiefly
devolved upon medical men, and even to this day, in most of Our large
cities, a considerable portion of this practice, more especially among the
foreign population, is attended to by females.
The first American work on obstetrics was the Compendium of Mid-
wifery, by Dr. Samuel Bard, of New York, the first edition being issued
in 1808, the fourth and last in 1817. Using the phrase of the present
day, this book is remarkable for its amount of padding, page after page
being filled with extracts from Smellie, Perfect, Clarke, and various
writers in the Medical and Physical Journal. But it also contains
many judicious thoughts and directions well expressed by Dr. Bard, and
from the very number and variety of important cases quoted, is really
an excellent compend of clinical obstetrics. In meeting that modus obste-
tricus——why labor occurs at nine months, Dr. Bard does not shelter him-
self with Avicenna behind the grace of God, but assails the question
with a brace of questions, Why do strawberries ripen in June and
peaches in August 7 -
In reference to the delivery of the placenta, he certainly was greatly
in advance of many obstetric authors of recent days, advising almost
essentially Crédé's method before Crédé was born, as the following passage
clearly shows. “While this is about,” i. e. attention to the new-born
child, “let an assistant or the woman herself, place her hand on the ab-
domen, a little above the fundus uteri, so as in some measure to grasp it
in the palm, and make a moderate pressure upon it. This can possibly
do no harm ; it has been my general practice; and I think I have found
a manifest advantage from it in promoting the contraction of the uterus
and in disengaging the placenta.”
And in the management of women after parturition the following
instructions seem wise, though even at this day they are too generally
neglected. “After one or two days, women should rise from their beds,
and sit up for a longer or shorter time every day, according to their
| Transactions of the Ohio State Medical Society, 1857.
* A Sketch of the Life and Writings of Louyse Bourgeois—The Annual Address of the
Retiring President before the Philadelphia County Medical Society, by William Goodell,
A.M., M.D. Delivered June 5th, 1876.
* Dr. John Moultrie, for forty years at the head of the profession in Charleston, died
about 1773; and several of the ladies of the city bedeved his grave with their tears, and
went into mourning for him.—Thacher's Medical Biography.
142 - PAR VIN,
strength and inclination.” “The lochia require no other attention than
sitting up a short time every day to promote their evacuation.”
Of wider scope, of more originality, and destined to a much larger
fame, was the Compendious System of Midwifery, by Dr. Dewees, first
issued in 1826, of which no less than twelvel editions have been pub-
lished. Dewees himself had some years before, 1807, published an
abridgment of Heath's translation of Baudelocque, with annotations,
and it passed through at least three editions. Burns's Principles of Mid-
wifery was republished in 1810, with notes by Dr. Chapman, and several
subsequent editions edited by Dr. James; in 1821, Denman's Introduction
to the Practice of Midwifery, with very valuable notes by Dr. John W.
Francis, was issued in New York. Dut not Baudelocque, nor Burns, nor
Denman was to be the first great obstetric teacher of the American pro-
fession. He who was to have this honor was no favored child of fortune,
but one early in youth left fatherless and poor, with no heritage but a
good name, with few facilities for acquiring a complete literary education
amid the desolations of the Revolution, yet bravely struggling up against
rude adversities. His first professional labors were those of a country
practitioner in one of the pleasantest” of yillages—once hidden away,
surrounded by farms or forests—now almost lying within reach of the
outstretched arms of this great city. There he acquired those habits of
close observation and reflection which were the foundation of his future.
greatness and fame. Then, after four years’ experience casting his lot in
Philadelphia, and without fortune, without family influence, without
professional friends save as they were attracted to him by the recognition
of his abilities—no adventitious aids—he succeeded by his own inherent
power and perseverance. The name of William Potts Dewees should
live forever in the memory of the American profession.
Dr. Hodge, in speaking of Dr. Dewees in 1842, observed: “He is our
representative to other nations on the science of obstetrics, and as such
is continually quoted by European authorities, as if he constituted one
of their own number.” As to the merits of Dewees’s Midwifery, let me
again quote the opinions of Dr. Hodge. Iſe considered it, twenty years
after its publication, as “probably the best practical book in our pro-
fession.” “It takes a stand decidedly in advance of Denman, Osborne,
I3urns, and other English authorities in general use in our country at
that period, and even of Baudelocque himself,” etc. Without acceding
to the truth of Pope's couplet—
“Authors, like coins, grow dear as they grow old ;
It is the rust we value, not the gold,”
| “An honor rarely, if ever, bestowed on any similar work.”—History of American Medi-
cal [iterature. By Professor S. D. Gross.
* Abington, Penna.
8 “Dr. John Ramsbotham, of London, dedicated the second part of his ‘Practical Obser-
vations on Midwifery’ to Dr. Dewees, in connection with Sir C. Mansfield Clark. Dr. Edward
Rigby, of London, and author of a most excellent work on Obstetrics, which has lately
been republished in this country, writes to Dr. Dewees in August, 1834, in the following
manner:——“I trust you will pardon the liberty I have taken in writing to you, as well as
the motives which have induced me to do so. I have been accustomed, for some years, to
hold such frequent intercourse with you in reading your admirable system of Midwifery,
and work on children, that I cannot refrain from requesting a more direct intercourse
between us,” etc. The July number of the British and Foreign Medical Review, for 1839,
contains the following handsome compliment: – The Philadelphia school of Midwifery has
for many years been looked upon with great respect by the obstetricians on this side of the
Atlantic. The high name and professional standing of Dr. Dewees, his great experience,
and, above all, his inestimable, compendious system of Midwifery and other valuable pub-
lications, have mainly contributed to this result.’”
A D D R ESS O N O B STE TRIC S. 143
let me predict that as with pious care and grateful appreciation one of
the most celebrated of the Dublin school is bringing the “Treatise” of
Smellie before this generation, so this or a succeeding generation will
See the avatar of the “Compendium” of Dewees in like modern form.
To Dr. Dewees, probably, we are more indebted than to any one else,
for the general preference on the part of the American profession for the
long forceps." Dr. Dewees” accomplished great good in exposing the
errors of Denman in his aphorisms as to the use of this instrument, and
the practice of the former is much more in accordance with that of
to-day, than is that of the latter: an apparent timidity and conservatism
ruled Denman's teachings in this regard, which conduced to the interests
of neither mother nor child—he was a representative of that physiological
school of obstetrics, originating with William Hunter, in opposition to
what Tyler Smith has termed the mechanical school of Smellie——but our
American obstetrician represented both in harmonious union.
To Dr. Dewees belongs the honor of pointing out the value of
venesection not only in overcoming rigidity of the os uteri, but also
in diminishing the resistance of vaginal cicatrices—the utility of his
teaching and practice in this regard being recognized by foreign obste-
tricians.
It is sad to recall the fact that this famous man, with whom the history
of American obstetrics really begins, should ever have been an unsuc-
cessful candidate for the chair of midwifery in the University of Penn-
sylvania:” sadder still to know that when, twenty-four years later, the
honor came by unanimous voice of the trustees, failing health permitted
him to hold it but a year—the infirmities of age are upon him, almost
the shadow of the grave is in his path before he reaches the noble goal of
his life, and grasps the coveted prize. How true it is that his
—“ laurel crown
Rustled most when the leaves turned brown.”
The next American work on Obstetrics was “The Philadelphia Prac-
tice of Midwifery,” by Dr. Charles D. Meigs," published in 1838; it was
brief and elementary; a second edition was issued in 1842. Three
years subsequently Dr. Meigs was elected a professor in Jefferson Medi-
cal College, and became famous as one of the best of teachers and one
of the most brilliant of lecturers, while his genial manners in social life
won all hearts. Almost equally fascinating with his uttered are his
printed words, so that one can now read page after page until hours
pass away without weariness. Fluency and force, strength and beauty,
characterized his literary composition in a remarkable degree; not only
! It is stated by Hutchinson (Biographia Medica, London, 1799), that Smellie for a time
endeavored to substitute wooden for steel forceps.
* In referring to Dr. Denman, Dr. Dewees remarks: . . “there was a time in my life
when I looked upon Dr. Denman to be the highest authority in midwifery.”
* The election of Dr. James seems really to have been effected by a combination between
him and Dr. Chapman—there were only three candidates—the latter to have half the emolu
ments, and to succeed to the next vacant chair in the University (see Hodge's eulogium
upon Dewees)—a sort of bargain and sale which at this distance does not seem quite im-
maculate.
* A very interesting memoir of Dr. Charles D. Meigs, by his son, Dr. J. Forsyth Meigs,
has been published, but unfortunately did not come into the writer's possession until he
was correcting the proof sheets of this Address. In the memoir the author states that his
father wished to call his home in the country “Paraclete,” the Comforter. Was not this
in imitation of Abelard, who, when his admiring students, following him to his desert
retreat, built him a new oratory, called it the Paraclete?
144 PARVIN,
the treasures of his favorite department were his, but he was at home
in general literature and familiar with classic story, while a Gallic
vivacity, if not a poetic genius, flashed out as he moved on his brilliant
path, like the phosphorescent spray from a ship's prow as she ploughs
the tropic seas.
In 1849, Dr. Meigs re-issued his work on obstetrics in a much en-
larged and improved form ; since that date four editions have been
published, this fact indicating the great favor with which the Ame-
rican profession regarded it. The most valuable discovery in obstetric
pathology made by Dr. Meigs is the usual cause of sudden death after
delivery, which he announced in 1849. Before and since, various other
explanations of this terrible accident have been given, such as the entrance
of air by the uterine veins, nervous exhaustion, shock, puerperal poison-
ing, etc., but to-day the theory of Meigs has general professional accept-
ance, even if the heart clot, or pulmonary thrombosis, the immediate
cause of fatality, should be proved to be itself a result of myo-cardiac"
degeneration.
As we read how earnestly Dr. Meigs declares against Caesarean section,
save in the interests of the mother, we shall find additional reasons for
questioning Dr. Smith's allegation as to American obstetrics being so
much more nearly a product of French than of English teaching—the
chief alleged characteristic of the French school being the proneness to
sacrifice the mother's rather than the infant’s life whenever the rights of
the two are brought in conflict.
T}r. Meigs's views as to puerperal fever were boldly expressed, and no
concealment of them is now required. The painter in the Sacrifice of
Iphigenia simply drew a veil over the face of Agamemnon: Would that
a veil had forever hidden, not the views of Dr. Meigs only, but of other
teachers of the Philadelphia school, and many sacrifices, blinder, more
terrible, might have been averted He who held the non-contagiousness
of measles, of scarlet fever, even, might also hold to the non-communica-
bility of puerperal fever under all circumstances. To-day, at least, the
American profession are generally agreed that while the disease is fre-
quently auto-genetic, it sometimes at least, and in its most terrible forms,
is hetero-genetic, and it is the merest petitio principii to allege, as Dr.
Meigs did, that, because he did not know of his having communicated it,
either by conveyance of the poison from one patient to another, or from
autopsies, therefore this never happened to others.
In 1849, “A Theoretical and Practical Treatise on Human Parturition,”
by Professor Henry Miller, of the University of Louisville, was published.
In 1858, a republication of this work, much enlarged and improved, was
made. From Dubois, Dr. Miller took his anatomy, and from Dugès, his
classification of presentations and positions, while his principles of practice
were essentially the same as those of Burns and Hamilton. Dr. Miller’s
views in reference to the importance of inflammation of the lining mem-
brane of the uterus as a frequent cause of abortion, were certainly in
advance of obstetric writers of his day. So, too, the higher honor must
be given of being the first American obstetric author who advocated
anaesthesia in labor.
Dr. Miller was a man of vigorous mind; he was clear and original in
thought, concise in expression, severe almost to bitterness in controversy.
* De la Myocardite Puerpérale, comme cause la plus fréquente des Morts Subites apres
l'Accouchement. Par Maurice Coste. Paris, 1876.
A DI) R. ESS O N O B STE TRIC S. 145
Like Dr. Dewees, he had few early advantages in education, but he
learned to use his pen with more ease and force than the latter, and pro-
bably was a man of better original endowments. His work on obstet-
rics was declared by the late Dr. Condie" to be a most able one, confer-
ring the utmost credit upon the author.
The Principles and Practice of Obstetrics, by Gunning S. Bedford,
M.D., Professor of Obstetrics in the University of New York, was pub-
lished in 1861; and five subsequent editions have been issued. Dr.
Bedford’s volume, which is probably the most learned of American
works on obstetrics, is in the form of lectures, and with here and there
Some extravagances in rhetoric, is written clearly, plainly, indeed some-
times assuming a colloquial style. It is evidently “the result of much
labor and research.” From its long list of authors quoted, and from its
full and carefully prepared index, it is admirable as a book of reference.
We find this author arraying himself on the side of the contagionists
as to puerperal fever, but a rejector of anaesthesia in normal labor. His
teaching as to the choice between craniotomy and the Caesarean section
is almost directly the opposite of that of Dr. Meigs and most other
American obstetricians, and while he protests against craniotomy, he
does not fully recognize that podalic version may be the true alternative,
and not the Caesarean operation.
In 1864, the most original and elaborate of American Obstetrical
works was issued in Philadelphia, the admirable treatise of the late Dr.
IIugh L. Hodge, the honored successor of Dewees in the University of
Pennsylvania. After thirty-one years of obstetric teaching, he prepared
this rich legacy for the profession.”
Dr. Hodge was the first to illustrate the peculiarities of the female
pelvis, its axes and its planes, by taking a plaster cast of it, and making
sections of the cast. He was the first to use photography,” to exhibit
with perfect accuracy the relations of the foetal head to the mother’s
pelvis, in the various presentations and positions, and in the different
stages of simple and of complicated labor, and also the applications of
the forceps in different positions. He contributed materially to restore
the vectis to use in the remedying of malpositions. The application
of the obstetrical forceps to steady and isolate the head, in craniotomy,
then after the operation the use of the instrument for compression
and extraction, must be regarded as a most valuable improvement, for
which the profession is indebted to Dr. Hodge. He also improved the
operation of cephalotripsy by devising a simple and efficient instrument
—his compressor cranii. He taught the doctrine of synclitism, or
parallelism of the plane of the child’s head, in cases of natural presenta-
tion, to the planes of the pelvis and vagina, as early as the year 1832,
and from that time until his death presented this doctrine with more
precision and detail than has any other author. He was among the first
to recommend the induction of premature labor, in cases where labor had
previously terminated fatally to the child in consequence of its great size
and the complete Ossification of its head. His obstetric forceps is the one
| American Journal of the Medical Sciences, Jan. 1857.
* British and Foreign Medico-Chirurgical Review, July, 1862.
* “Dr. Hodge's treatise is, nevertheless, full of much valuable information, and although
its price alone will prevent its ever becoming popular amongst students in this country,
still we strongly recommend that it should have a place in the library of every obstetric
physician.”—British and Foreign Medico-Chirurgical Review, October, 1865.
* This was done at the suggestion of his son, Dr. H. Lenox Hodge.
10
146 P A R V IN,
held in most favor by the American profession. Few men have studied
the mechanism of labor more thoroughly, none have expounded it more
clearly. Generations may come and depart, until another century pours
its treasures upon the race, but it is doubtful if among these will be found
another work on obstetrics of greater relative merit and of more enduring
value than the treatise of Dr. Hodge.
In the year 1870, a Treatise on the Theory and Practice of Obstetrics,
by Dr. W. H. Byford, was published, a second edition appearing in
1873. The design of Dr. Byford was to furnish the student, and busy
practitioner with a more concise work than any in general use, and
yet embodying all the necessary practical information. No one can
question how well its able and industrious author has succeeded in this
design.
A work entitled Elements of the Principles and Practice of Midwifery,
by Dr. David H. Tucker, was issued in 1848. The Obstetric Catechism
of Dr. Warrington was, in Philadelphia, held in high esteem twenty or
more years ago, especially by those who were fortunate enough to avail
themselves of the practical instructions of this excellent teacher. Dr.
Cock's Manual of Obstetrics, 1853, was held in like favor in New York.
IIaving devoted so much space to the consideration of treatises upon
obstetrics, the topics of obstetric pathology" and therapeutics must neces-
sarily be briefly considered.
The present century has been marked by some of the most important
advances in obstetrics ; and “it is not going too far to assert that, not-
withstanding the brilliant improvements in surgery, and the solid and
wise modifications in medicine, the changes in our art have preserved
more lives, and relieved more human suffering and misery.” In pro-
moting these advances, and in effecting these changes, our country has
borne her part. Few obstetricians of the present day would accept the
statement of William Hunter, that upon the whole the forceps had “done
more harm than good,” or participate in the “doubt” of Denman
“whether it would not have been happy for the world if no instrument
of any kind had ever been contrived for, or recommended in, the practice
of midwifery,” or believe—and we quote again from Denman”—that
“the doctrine of applying forceps before the bulk of the head has passed
the superior aperture of the pelvis, carries great danger and insurmount-
able difficulties with it;” nor again, does the obstetrician now wait until
he can “feel an ear,’’ or until “the head has rested six hours upon the
perineum,” before resorting to an instrument that is at once for the good
of both child and mother.
Anaesthesia in obstetricy must be counted one of the greatest glories
of the century—nay, the brightest, broadest beam of perennial light that
has ever fallen upon woman’s pathway, darkened by the primeval curse.
In 1846, the great discovery of anaesthesia by inhalation of ether vapor,
with which the names of Wells and Morton are so inextricably inter-
* The topics of obstetric anatomy and physiology would be appropriate could their history
be made really complete. Under the former head would be mentioned in detail Dr. Hodge's
studies as to the female pelvis, already referred to; Dr. John Neill's, as to the shape of the
thyroid foramen, and numerous similar investigations; and under the latter, studies such
as Dr. Dalton's, of the corpus luteum; Dr. Geo. J. Englemann's recent, patient, thorough,
and interesting researches as to the mucous membrane of the uterus; Dr. Isaac E. Taylor's
demonstration of the non-shortening of the cervix in the latter months of pregnancy; and
Dr. J. R. Beck’s observations upon the entrance of the spermatozoa into the uterus.
* Dr. Thomas Edward Beatty's address before the Dublin Obstetrical Society, 1862.
* Criticism of Leake.
ADDRESS ON OBSTETRICS. 147
woven, was made; in January, 1847, the illustrious Simpson, of Edin-
burgh, proved the value of ether in child-birth. The discovery found
Walter Channing, the first professor of obstetrics' in Harvard, past his
three-score years; but he entered heartily into the study of this question,
and the next year he presented a volume upon Etherization in Child-bed,
in which the records of nearly six hundred cases were given, and which
greatly contributed to the frequent—I wish at this day one could say
general—use of anaesthetics in labor. Other names deserving of recogni-
tion in this connection are those of Drs. F. Barker, of New York ; H. R.
Storer, of Boston ; J. C. Reeve, of Dayton, Ohio; and H. Miller and L.
P. Yandell, of Louisville, Kentucky.
The administration of chloral is another of the beneficent means of
recent times for the relief of the sufferings of parturition, which has had
many advocates in this country.
The opium treatment of peritonitis is one of the most important ad
vances in therapeutics. It may be now true, as asserted by Dr. Spender.”
that “the bare mention of that terrible disease, peritonitis, is suggestive
of the siren lullabies of opium.” But this treatment was the suggestion
and practice of Dr. Alonzo Clark, as early as 1841, though it was not
until 1848 that he had an opportunity of demonstrating its value in the
puerperal form of peritoneal inflammation. Opium alone, is the treat-
ment of phlegmasia dolens advocated by Dr. Clark," of Oswego, and he
claims that the remedy is as efficient as quinia in ague.
A marked advance has been made in the more liberal diet and rational
hygiene of women after labor. That former horror of the lying-in room,
| This position Dr. Channing held for nearly forty years, and only a few weeks since
passed away from earth, having lived to be upwards of ninety years of age.
* Therapeutic Means for the Relief of Pain. London, 1874.
* The following recent note from Dr. Clark will be read with interest:-
DEAR Doctor : I continue to use opium in the treatment of simple peritonitis and puer-
peral peritonitis, and peritomitis after perforation, with the fullest confidence that it will
cure a much larger proportion of cases than any other treatment yet proposed. It is ac-
cepted by all the physicians of this city and State, I think ; at least I hear of no other, not
only for peritonitis in its different forms, but in all operations, injuries, and wounds that
are likely to be followed by this inflammation. I do not know how far it is approved
abroad, but infer that it has received little attention in England, from the fact that Dr.
Barker, of this city, made it the topic of an address at a meeting of English physicians a
year or so ago.
Dr. Graves, it is said, used opium in large doses for the cure of peritonitis after perfora-
tion of the intestine. When he began that treatment I do not know; but I do not find
any reference to it in his lectures published in 1843. Watson's Lectures, one of the later
editions, refers to a Mr. Bates, who treated peritonitis with opium ; but when he began,
does not appear. Still the English physicians generally seem to know little of the power
of opium in the different forms of peritonitis. In the Am. Journ. of Med. Sci., July, 1876,
p. 144, you may find a statement of the origin of this treatment in my own mind, in 1841;
and before 1843 cases of intestinal perforation had been successfully treated on this plan.
Regarding the rules, I begin with two grains of opium, or its equivalent opiate, and in
two hours give the same, or more, or less, according to the effects produced. Patients re-
sist or yield to the narcotic effects of the drug very differently. In some cases, twenty-four
grains of opium a day is all that is required ; in a few. twelve or sixteen grains is sufficient.
In most, two to four grains at a dose are needed; in a few, more than this. The aim is to
get and maintain the symptoms of safe narcotism, or, as I sometimes call it, semi-narcot-
ism, indicated by subsidence of the pain; contracted pupils; itching of nose and skin; a
continuous sleep, from which, however, the patient is easily aroused; reduced frequency of
respiration, followed by reduced frequency of pulse; and absolute quiet of the bowels.
Regarding the respiration, the aim is to reduce its frequency to twelve in the minute,
and in the attempt to do this it is often found to fall as low as seven, without danger, if
the opium is then withheld for a few hours, till it rises to ten, when a smaller dose is given,
to be increased or not afterwards. Yours truly, A. CLARK.
* New York Medical Record, June, 1870.
148 P A R VIN,
the very existence of which is cast in doubt—milk fever—which was to
be averted by a liberal use of the canonical caudles of Smellie's day, and
the prophylactic panadas of more modern times, and by poisoned air, no
longer governs practice; and the recent parturient is given cold water
as she desires, inhales pure air, and is fed with wholesome food, that is,
such as will best repair her exhausted powers and furnish suitable mate-
rial for making good milk. How early any publications were made
advocating this course, I cannot ascertain, but certainly it has been pur-
sued for some years, and possibly it may not have been at the instance
of any professional leader, but simply a general tendency of physicians
themselves. The names of Drs. F. Barker, William Goodell, and Wil-
liam B. Atkinson, are among the more prominent of those who have ad-
vocated it.
During the present year a most able volume on Extra-uterine Preg-
nancy, by the late Dr. John S. Parry, has been published. In it the
talented author, removed too early for the honors that surely awaited
him, and for a career of great usefulness not half accomplished, has col-
lected five hundred cases of this accident, and from a careful study of
them has deduced most important practical rules. Such works are at
once permanent contributions to medicine, and indices of its higher de-
velopment and more scientific character.
Some of the most remarkable cases of operation for extra-uterine preg-
nancy are those by Dr. William Baynham, of Virginia, who operated
twice, 1791 and 1799, successfully by abdominal incision; one by Dr.
John King, of South Carolina, 1813, who incised the vagina at full term,
saving both mother and child, and one by Dr. T. G. Thomas, the preg-
nancy having advanced to three months, who also incised the vagina,
but with the galvano-caustic knife. So, too, the case reported by Clarke,
in 1806, where he passed his hand into the bowel, and with his finger in
the child’s mouth exerted such traction that he withdrew the head per
anum, should not be forgotten among the extraordinary cases, especially
as he thus showed the feasibility of the method of abdominal explora-
tion recently proposed by Simon. Dr. Easley,” of Little Rock, Ark., has
quite recently reported an interesting and successful case of abdominal
section for the removal of a dead foetus. gº
The Induction of Premature Labor was first resorted to in this coun-
try, in 1810, by Dr. Thomas C. James"—the cause, contracted pelvis, and
the result fortunate to both mother and child. Since that time a much
larger range has been given this operation. We have already stated Dr.
Hodge's views as to its being indicated in cases where the head is large
and completely Ossified at full term. Dr. Thomas' has enumerated ten
other conditions indicating it, the most important being placenta praevia
and aggravated uraemia. The teaching and experience of Dr. Thomas have
contributed much towards the recognition of the propriety of inducing
premature labor, in the interest of both the mother and the child, in
cases where the placenta is praevia. A distinguished British obstetricianº
observes: “We have arrived at a very generally admitted conclusion as to
| Dr. William Baynham was long considered the most eminent surgeon in the Southern
States, and was particularly distinguished for his accurate knowledge of anatomy.—
Thacher's Medical Biography.
2 American Practitioner, September, 1876.
* Memoir of Dr. Thomas C. James. By Professor Hugh L. Hodge, Philadelphia, 1853.
* New York Medical Journal, February, 1870.
* Dr. Playfair. British Medical Journal, May 4th, 1872.
A D D R ESS O N O B STE TRIC S. 149
the danger of temporizing, and as to the advisability of artificially in-
ducing labor as soon as the existence of placenta praevia has been fully
determined.” It is true Dr. Thomas's publication was in some measure
anticipated some six years by a paper from Dr. Greenhalgh," advocating
this practice; but he himself was partially anticipated by Dr. A. S.
Donkin,” who proposed to expedite labor and check the flooding in pla-
centa prævia by inserting into the OS uteri a sponge-tent prepared for the
purpose. Dr. S. C. Busey,” of Washington, has presented an able argu-
ment for the induction of labor in uraemia. -
Placenta Praevia has been the subject of special study by Dr. J. D.
Trask,” and by Dr. Wm. Read." Dr. Read was regarded by the highest"
critical authority in Great Britain as having rendered valuable service
to his profession, and considerably enlarged and strengthened the founda-
tions of obstetric science; and it is declared that the impartial and philo-
sophic manner in which he has used statistics for the purpose of deciding
grave practical problems is worthy of all praise and imitation.
Dr. Trask, whose prize essay on placenta praevia has been alluded to,
has also laid the profession under obligations by quite a thorough study
of rupture" of the uterus; four hundred and seventeen cases of this
accident are tabulated, and important lessons deduced. This mono-
graph ranks by the side of the one by Crosse on uterine inversion.
Dr. John Stearns,” of New York, in a letter to Dr. Akerly, published
in the Medical Repository, 1807, announced that ergot" was capable of
exerting a specific action upon the uterus; that it greatly augmented
the power of that organ during the efforts of parturition ; and that, in
lingering and protracted cases, it speedily induced forcible pains, and
greatly expedited delivery. And in June, 1813, Dr. Oliver Prescott, in a
communication made to the Massachusetts Medical Society, pointed out
the value of this agent in post-partum hemorrhage. Thus the two most
important obstetric uses of ergot were first made known by American
physicians. An able paper, by Dr. William Goodell, on Concealed Acci-
dental Hemorrhage," was published in 1869. This paper contained an
analysis of one hundred and six cases, and presented the symptomatology
more clearly and definitely than had been done before. TXiphtheria of
Puerperal Wounds has been made the subject of important contributions
by Drs. Lusk and Parry.
We now make some brief references to operative obstetrics, including
both manual and instrumental.
One of the most valuable contributions to obstetric art ever made was
| Transactions of the London Obstetrical Society, vol. vi.
* Edinburgh Medical Journal, 1859.
* American Journal of Obstetrics.
* Prize Essay. Transactions American Medical Association, vol. viii.
* Library of Practical Medicine. Published by order of the Massachusetts Medical So-
ciety. Vol. xxii. Philadelphia, 1861.
* British and Foreign Medico-Chirurgical Review, 1862.
7 American Journal of the Medical Sciences, 1848 and 1856.
* The American Dispensatory. By Dr. James Thacher. Boston, 1817.
* Pulvis ad partum was the name soon appropriated to the powdered ergot. Hosack,
however, shortly substituted for it, Pulvis ad mortem. This is suggestive of Guy Patin's
remark in regard to an antimonial preparation which was in great favor in his day, known
as the Vinum vitae. In one of those letters, first published at Geneva, 1683, of which
Voltaire has observed. “they were read with eagerness, because they contained anecdotes
of such things as every body loves, and satires, which are liked still more,” Patin writes
that the Vºn win vitae should be called Vinum mortis.
10 American Journal of Obstetrics, August 1869.
150 P A R VIN,
that of Dr. M. B. Wright, of Cincinnati, in the year 1854. To him is
justly due the credit of originality in the method of such bimanual
operation as will in shoulder-presentation succeed in converting it into
a presentation of the head. Even if the method of Wright were pre-
cisely the same as that of Hicks,” still it was published six years before.
But the essential of each is in the use of both hands—the external hand,
not as by former operators merely to steady the uterus, but to assist the
action of the other. True, Dr. Wright applied the method only to what
is called cephalic version; Dr. Hicks gave greater prominence to the
accomplishment of podalic version.
Next among important manual Operations must be placed the postural
treatment of prolapsed cord and of shoulder presentations, known in its
first application as the method of Thomas, in its second as that of Maxon.
In foot-notes I have given extracts from the original work of Deventer,
conclusively showing that this treatment was advised by him, though it
was pressed with no urgency, and seems to have been theoretical rather
than supported by clinical facts. Dr. Bard, in considering podalic ver-
sion in presentations of the breast, belly, and back, says expressly: “And
in all cases of particular difficulty, we may facilitate the operation by a
judicious choice of the posture of the woman ; or by changing it from the
side to the back, or from the back to the knees and elbows. Deventer par-
ticularly recommends this position.” No one in the face of these testi-
monies can doubt the priority of the Hollander in the suggestion of
postural treatment in these labor-complications. So, too, in Dr. Wright's
essay, already referred to, the suggestion of the knee-elbow position is
made. Nevertheless, to Dr. Thomas, of New York, and to Dr. Maxon,
of Syracuse, is due the credit of having demonstrated by abundant
clinical facts the great value of this method in prolapse” of the cord,
and in transverse presentation, and of establishing it in professional
confidence.
A passing notice is due Dr. Goodell’s “Management of Head-Last
Labors,” in which constant supra-pubic pressure conjoined with con-
tinuous traction may so expedite delivery as to greatly diminish foetal
mortality; and Dr. Parry’s" method of correcting with the hand faulty
presentations and positions. e
In obstetric surgery no country can claim more brilliant operations
than those of the late Dr. William Gibson, Caesarean section twice suc-
cessfully performed upon the same subject, the children also saved, and
the gastro-elytrotomies of Thomas and Skene.
Of course it is impossible to refer to even a tithe of all the valuable
American contributions to obstetrics and puerperal diseases in the limits
of this Address—a simple bibliography would consume more than the
time allotted it ; and a dictionary of dates, with a catalogue of cases,
would illy meet the requirements of the occasion. Nevertheless, three
contributions in this department demand special notice.
In the year 1843, Dr. Oliver W. Holmes published, in the New England
| Prize Essay. Ohio State Medical Society. “Difficult Labors and their Treatment.”
* Dr. Hicks published his method in the Lancet in 1860, giving five cases of placenta
praevia in which he had resorted to bimanual version, and in 1863 (London Obstetrical
Society's Transactions, vol. v.), presented a fuller account of it.
* Prolapse of the cord has been made the subject of an elaborate monograph by Dr.
George J. Englemann, American Journal of Obstetrics, 1873–4.
* Philadelphia Medical Times, March 20, 1875.
* American Journal of Obstetries, vol. viii. p. 138.
A D D R ESS ON O B STE TRIC S. 151
Quarterly Journal of Medicine and Surgery, a paper afterwards issued in
book form, in reference to the contagiousness of puerperal fever. Emped-
Ocles combined in one, poet, priest, politician, and physician ; and history
records that he rescued a city from desolation by blocking up a mountain
gorge through which pestilential winds were sweeping. In like manner
an American, whom the world so knows as poet, essayist, and philosopher,
that, arrayed in these glories, crowned with these honors, we almost for-
get that he is a physician and medical teacher, once by his bold, decisive
utterances, his startling array of facts, his invincible logic, greatly con-
tributed to destroy a pernicious doctrine taught by some of our leading
obstetric authors—a doctrine which was more certainly laden with death
than the foul wind that was destroying the citizens of Agrigentum.
In 1868, the Obstetric Clinic, a Practical Contribution to the Study of
Obstetrics and the Diseases of Women, by Dr. George T. Elliot, was pub-
lished. Its author, whose talents and culture were admirable, and who,
alas, was taken away in the prime of life and power, utters these noble
and just words explaining his motives in writing this book, words which
ought to be well pondered by all who have similar opportunities. “The
work is presented as a partial discharge of the debt due to the profession
by all who enjoy hospital advantages; and in grateful recognition of the
benefits which the author has derived from the experience of others.”
Elliot's Obstetric Clinic has taken its place among the classics of our
profession, and cannot fail to be of value to any one who consults its
pages.
In 1874, the first edition of Dr. F. Barker's Lectures on the Puerperal
Diseases was issued, and the second edition the present year. This, too,
is a clinical work, and eminently practical. It filled a gap in medical
literature, met an urgent need of the practitioner, and was received
with great favor, both at home and abroad.
In considering the second division of the subject, an order similar to
that observed in the first will be pursued, and accordingly American
treatises on Diseases of Women will first be referred to. These works
have had the following authors: Dewees, Meigs, Hodge, Byford, Chap-
man, and Thomas. The first edition of Dewees's work was issued in
1826, the ninth and last in 1847; this contains the revisions and addi-
tions made by the author a short time before his death, and may be
regarded, therefore, as embracing Dr. Dewees’s best utterances upon the
subjects discussed in it. To say that the book is badly written, would
be a mild way of stating that there are therein frequent instances of
violations of the simplest rules of grammar and the plainest laws of
rhetoric. But what of the matter? More than one-third of the five
hundred and odd pages are occupied with the disorders of pregnancy,
puerperal fever, phlegmasia dolens, milk abscess, and hysteria; diseases
of the ovaries are discussed in a little more than a page, and the moder-
ately well-behaved irritable uterus of Gooch, becomes a monster of
inflammation for the conquering of which general depletion is some-
times, and local depletion is always, necessary. On pages 256 and 257,
there is given the history of one of the most strangely managed cases, as
seen by the light of to-day, that ever was recorded. In brief, nature
tried to extrude from the vagina a uterine fibrous polypus as large as a
child’s head, and the doctor with might and main resisted, but vainly,
the extrusion; and then, instead of dividing the short, thick pedicle, he
tried to push the tumor back because the womb was inverted ; but the
152 PAR VIN,
tenderness of the parts prevented, the tumor became black and offensive,
and the next day the patient died.
However, Dr. Dewees did advance the knowledge of the profession in
regard to the symptoms of uterine displacements, and the means for
relieving them ; he taught when and how to use tincture of cantharides
in amenorrhoea, and his name will not be forgotten as long as dysmemor-
rhoea ever suggests the ammoniated tincture of guaiacum. Dut Dr.
Dewees’s great fame is that of an obstetrician, not a gynaecologist.
Woman, Her Diseases and Remedies—the work of Dr. Charles T).
Meigs—was issued in 1847, and the fourth edition in 1859. The volume
is in the form of letters, and, of course, less dignity of style and greater
freedom of expression are permitted than in a purely didactic treatise.
Here are not only sketches of disease, but also lessons of high morality,
of professional honor, and of tender sympathy; here are odd words and
odd forms of expression; sometimes ludicrous dialogues, in which refine-
ment and dignity are thrust in the background by realism; a fluent
stream, apparently wandering at its own sweet will—now rippling with
music and sparkling with sunshine, here narrow and strong, there diffuse
and almost wearisome in its slow progress—but still always advancing,
and strengthening in the advance; or a picture-gallery (and the aesthetic
element in his nature was so strong that, possibly, Dr. Meigs might have
been a great poet, or a great painter, had he not been a great physician),
in which various representations, persons and scenes are collected, some
altogether mean, and given with painful minuteness of sketch and color,
others noble in conception and expression, but each filling a destined
place, all real, vivid, and combining in a common design and purpose——
such are these Letters that never lose their charm. Dr. Condie, who
had no patience with anything but the plainest English, severely criti-
cized in the American Journal of the Medical Sciences the style of these
letters. But the style was the man; the letters are not less his teach-
ings than they are Dr. Meigs himself.
Undoubtedly the instructions of Meigs were very much in advance of
those of Dewees. Was he not, too, the first American at least to describe
vaginismus under his horrible designation of sphincterismus’. He hated
abdominal surgery, and so rejected ovariotomy ; cervical surgery, too,
and so in stenosis adhered to Mackintosh rather than to Simpson ; he
clung with devout faith to Gooch's canula in the removal of uterine
polypi, and regarded complete perineal ruptures as incurable.
Clinical Lectures on the Diseases of Women and Children, by Dr.
Gunning S. Bedford, were published in 1855, the seventh edition in 1862.
To this work was paid the high compliment of translation into French
and German. With much that is valuable even to-day, and impressively
given, there are some things that would be utterly rejected as rules of
practice. For example, who would now think of salivating a patient
because she had ovarian dropsy, or expect such dropsy to disappear under
the magnetic influence of “patting the tumour with the ends of the
fingers several times during the day, together with pressure, and the in-
termal administration of muriate of lime.” The author's utterances, too,
as far as manner is concerned, are at times either simply grandiloquent,
or degenerate into tedious and undignified dialogues, or trite common-
places. -
A far better book than any of those yet referred to is the Practice of
Medicine and Surgery applied to the Diseases and Accidents incident to
Women, by Dr. William H. Byford, published in 1865. Its great merit
A D D R ESS O N O B STE TRIC S. 153
is its evidence of faithful observation and reflection ; it was the work of
a painstaking, conscientious man with large experience, and it has con-
tributed much to the promotion of a knowledge of diseases of women
among the American profession. Dr. Byford (p. 348) has proposed and
practised an original method of treating uterine fibroids, which is pro-
bably deserving of more professional attention than it has received, and
he also first made use of tents of slippery elm. T)r. Byford speaks of the
“ philosophy” of uterine displacements, and in the misuse of this term'
has been imitated by some others: would it not be quite as correct to speak
of the philosophy of boot-blacking or of coat-cutting?
Diseases Peculiar to Women, by Dr. Hugh L. Hodge, the first edition
in 1860, the second edition revised and enlarged in 1868, and Hysterology,
by Dr. E. N. Chapman, New York, 1872, are two works diametrieally
opposed to each other, or at least presenting entirely different theories of
uterine disease. Dr. Chapman’s pathology is congestion, and his local
therapeutics are chiefly scarification and nitrate of silver; where pessa-
ries are required, preference is given for those that are globular, and appro-
priate constitutional treatment is directed. His work is largely clinical,
though unfortunately most of his reports of cases are too brief to be of
great utility. Dr. Hodge, on the other hand, taught that the condition
of uterus characterized by tenderness, congestion, increase of secretion and
of size, was not inflammation, and should not be so treated. Here was
the irritable uterus rescued from the inflammation of Dewees which was
devouring it, and restored to the position which Gooch and Addison meant
to assign it; nay, given an importance and extent in uterine pathology
which they could hardly have anticipated. According to Dr. Hodge,
“displacements of the uterus are the most frequent cause, original or
secondary, of irritable uterus;” and “the mechanical treatment of ute-
rine displacements by intra-vaginal supports is essential, a sine quá mon
for their perfect relief.”
Whether accepting in full, or only in part, the views of Dr. Hodge upon
uterine pathology, no one can deny the great service that he rendered
uterine therapeutics in the device of his lever pessary, an instrument in
such common use in all lands where diseases of women are studied. His
pessary was no happy accident, but the result of much thought and of
many experiments; as he himself once expressed it, he had hundreds of
abortions before producing it. “Great poetry, great philosophy, great
scientific discovery, every intellectual production which has genius, work,
and permanence in it, is the fruit of long thought, and patient and pain-
ful elaboration.” Not only with the form of the pessary, but with the
material, is Dr. Hodge to be credited. No man ever accomplished as much
with these instruments, or explained their modes of application and their
utilities more clearly and completely. He showed their value not only in
relieving the ordinary results of uterine displacement, but also in curing
sterility, and in the prevention of abortions when these, too, were conse-
quences of such mal-positions. So, too, he demonstrated their value as
repositors, gradually replacing the uterus when in mal-position. He
| Sir William Hamilton, Discussions on Philosophy and Literature, remarks upon the
vague universality which is given to the terms philosophy and philosophical in common
English—an “indefinitude” limited especially to Great Britain : “Mathematics and physics
may here be called philosophical sciences; whereas, on the Continent, they are excluded
from philosophy, philosophy being there applied emphatically to those sciences which are
immediately or mediately mental.”
? Froude's Address to the Students of St. Andrews, March 19, 1869.
154 P A R V IN,
showed how useful they were, too, in relieving some of the urgent
symptoms of uterine fibroids.
I3ut the American work on diseases of women most widely known is
the Practical Treatise of Dr. T. G. Thomas, published in 1868, and pass-
ing to its fourth edition in 1874. As a clear, concise, and practical expo-
sition of gynaecology, it has no superior. At home, its merits have been
so fully appreciated by the profession that nearly twenty-five thousand
copies are now in their hands, helping them in their daily work—a suc-
cess which, when we compare it with that of even popular" literary pro-
ductions, is simply astonishing. Abroad, its great merits have been fully
acknowledged by the leading journals of the profession, and it has been
translated into French, German, Spanish, and Italian. Some of Dr.
Thomas’s views as to uterine diseases, and some of his special contribu-
tions to gynaecology, will be referred to in the next topics presented.
Laying aside the briefer mongraphs, whether appearing in the form of
reports in the Transactions of Medical Societies, lectures, addresses, etc.,
the libelli of our literature, and contributions to our medical journals—all
these numbering not merely hundreds but thousands, and of course an
analysis of which, even if it might be instructive, would be impossible
—four works relating to diseases of women, demand especial attention.
These are Clinical Notes on Uterine Surgery, by Dr. Sims (New York,
1869); Vesico-Vaginal Fistula, by Dr. Emmet (New York, 1868); Gene-
ral and Differential Diagnosis of Ovarian Tumors, by Dr. Washington
L. Atlee (Philadelphia, 1873); and Ovarian Tumors, their Pathology,
Diagnosis and Treatment, especially by Ovariotomy, by Dr. E. Randolph
Peaslee (New York, 1872).
The Uterine Surgery was published not only in New York, but also
in London, and a French translation appeared in Paris. It met, as it
deserved, with much favor at the hands of the profession, although some
parts of it did not escape” severe criticism. One of the leading British
journals' spoke in these terms of the book: “It is a collection of bedside
studies of the uterine diseases of which it treats, notable for their accu-
racy, and continually challenging our admiration for the sagacity and
originality of their author, the fertility of resource, the unfailing patience,
the successful adaptation to new purposes of simple means, the exact
perception and clear statement of the vital points of every case.” “For
the first time in the history of medicine, the sterile condition is here
subjected to a full and philosophical analysis, complete as far as the
advanced knowledge of our time permits.”
Dr. Emmet's work on Vesico-Vaginal Fistula was essentially clinical
in character, the history and treatment of the seventy-five cases given,
representing the author's own invaluable experience. “The results of
the numerous cases related are in the highest degree honorable to Dr.
Emmet's skill as an operator, and also to American surgery.”
Of the two admirable volumes upon Ovarian Tumors referred to, one
embodies the thirty years’ experience of a surgeon who ranks as one of
the world’s most celebrated ovariotomists, and is a treatise upon the
general and differential diagnosis of these tumors. The other is more
ambitious in design, and wider in scope. More largely a work of com-
1 Mark Twain's Innocents Abroad, for example, has reached a sale of two hundred
thousand.
* London Medical Times and Gazette, 1866. British and Foreign Medico-Chirurgical
Review, January, 1867.
* Lancet, February 3, 1866. * Lancet, February 20, 1869.
A D D RESS ON OBSTE TRIC S. 155
pilation and of analysis, than a record of personal experience, it exhibits
the indefatigable research, the patient investigation, and the accurate
judgment of its scholarly and erudite author. Without being encum-
bered, or possibly for some enriched, with so many details, it has much
of the encyclopedic character of Gallez's volume, and not only is a most
useful guide in the diagnosis and treatment of ovarian tumors, but is
valuable for reference.
Special contributions to gynaecology, other than those just referred to,
can be better considered under the heads of particular disorders. But
before entering upon this division of our subject, two or three prelimi-
nary observations may be permitted.
The first is, that while in this country specialism in other departments
of medicine has made rapid progress, in gynaecology few, and until quite
recently only two, specialties are found. And this arises from the fact
that the diseases of women must, in the nature of things, be chiefly
under the charge of the general practitioner. What is the numerical
relation between those diseases that are constitutional in their origin
and amenable to general treatment, and those that are local and re-
quire local treatment, is a question that would have different answers,
according as addressed to the general or the special practitioners. That
there were extreme surgical tendencies of uterine pathologists, was the
complaint a few years since of one” of the most eminent of British
gynaecologists; and that this is true to-day, in this country, will be very
generally admitted. There is something so fascinating in surgery, so
demonstrative and demonstrable—that which the eye can see and the
fingers touch—as to inspire the operator with ambition and the patient
with hope.
Undoubtedly the danger of specialism is an undue exaltation of local
disease and of local therapeutics. The general practitioner, on the other
hand, is liable to depreciate the former, and then of course the latter. IIe
does not extend himself, as Mill said of Jeremy Bentham, infinitely in
one direction, but must be many-sided, undergoing a more general and
complete development. Thus, other things being equal, he will be better
able to detect the relations between local and general disorder, what in a
given case is the antecedent and what the consequent, what may be cause
or effect, unless indeed the specialist, as I believe is true of all who are
devoted to gynaecology in this country, has chosen his department after
large experience in general practice. The pine in our Southern forests
grows stately and tall, lifting its tufted head far up to the clouds, but it
is almost bare of boughs, and barren of foliage and fruit. “The un-
wedgeable and gnarled oak” is knit together with a stronger fibre.
More firmly rooted, it spreads broadly on every side great branches, with
dense foliage, ample shade, and abounding fruit.
The American development of gynaecology has been largely due to the
labors of men engaged in general practice. Considering now that devel-
opment, brief reference will be made first to the treatment of some of the
positional disorders of the uterus. -
The pessary of Hodge has already been spoken of; an instrument
which, both as to form and material, has received the general and grate-
ful acceptance of the profession everywhere. Modifications or additions,
more or less valuable, of the lever pessary have been made by Drs. Albert
| Histoire des Kystes de l'Ovaire, etc. Brussels, 1872.
* Dr. E. J. Tilt. Transactions of the London Obstetrical Society.
156 PARVIN,
II. Smith, Cutter, Thomas, and others. Nor must we omit, in this con-
nection, a passing reference to the very interesting observations of Dr. H.
F. Campbell, of Georgia, upon pneumatic pressure in the treatment of
uterine displacement.
Turning to the greatest of all the positional disorders of the uterus—
inversion—we will find that American operators may challenge com-
parison with those of any country in regard to ingenuity, skill, and
success in its cure. -
Inversion of the uterus, an accident first noticed by Celsus,” was, until
quite recently, an opprobrium of the profession, since replacement of
the organ, unless efforts were made almost immediately after the acci-
dent, was regarded as impossible. The few instances where a chronic in-
version was reduced, were regarded as happy accidents rather than as
indicating a rule of practice. On April 13, 1858, Dr. Tyler Smith ob-
served, in reporting to the Medico-Chirurgical Society” a case of uterine
inversion of nearly twelve years, which he had reduced : “IIitherto
inversion of the uterus has been treated either with styptics and astrin-
gents, or the inverted organ has been removed by ligature or excision.
The instances in which reinversion has been accomplished have been few
in number, and chiefly limited to cases of recent origin.” On the 12th
of March of the same year, Dr. J. P. White,” of Buffalo, reduced an in-
version of nearly six months’ duration. The one used elastic pressure
and taxis; the other taxis and pressure" with a bougie. These success-
ful cases were the heralds and guides of numerous similar successes at
home" and abroad.
In this country the most important new methods of accomplishing
reduction were that of Noeggerath, indenting one or other or both of the
cornua, and thus starting the movement of restoration ; that of Emmet,
using silver sutures to hold in place a partial reduction ; and those of
Thomas, consisting, the one of mediate dilatation with a boxwood cone
pressed down from the abdomen into the constriction, the other of abdo-
minal section, and then immediate dilatation; and the repositor of Dr.
White. Abdominal section, with immediate dilatation, has been twice
performed—once with complete success, and once with a fatal result—
but fails of professional endorsement. The repositor of Dr. White is
an admirable instrument, as any one who has ever used it faithfully will
testify : no one comparing it with the “drum-stick” repositor of Depaul
* Dr. Isaac E. Taylor has proposed and ably sustained the view that spontaneous inver-
sion of the uterus sometimes commences at the os; a view which is strengthened by the
cases of spontaneous reduction, the most extraordinary of which has recently been reported
(American Practitioner) by Dr. Chesnut, of Lafayette, Ind. In Dr. Chesnut's case the
restoration was twelve years after the accident.
* I am indebted to Dr. J. S. Billings for the following reference: Celsus, A. Cor., Medi-
cinae Libri Octo; Ed. by A. Lee, London, 1831. Lib. I. Praefatio, p. 15. “Cum aetate
nostra quaedam, ex naturalibus partibus carne prolapsa et arente, intra paucas horas exspi-
raverit; sic ut nobilissimi medici neque genus mali, neque remedium invenerint. Quos ego
nihil tentasse judico, quia memo in splendida persona periclitari conjectura sua voluerit; ne
occidisse, nisi servasset, videretur,” etc. I find that several have commented on this pass-
age, and especially Morgagni, who decides it to be a case of inversion of the uterus. Re-
spectfully and truly yours, J. S. BILLINGs.
° Medico-Chirurgical Transactions, vol. xli.
* American Journal of the Medical Sciences, July, 1858.
* Dr. Thomas is in error when he states (Diseases of Women) that taxis alone was used
by Dr. White, as can be seen by reference to the original account of the operation.
° Dr. White has been successful in twelve cases, and in one of the twelve the inversion
had existed for twenty-two years.
A D D R ESS O N O B STE TRIC S. 157
would hesitate to give a decided preference to the former. Its value
will become more and more appreciated as its use becomes more general.
Two of the most useful therapeutic agents in uterine disease, the one
suggested by Dr. Sims, the other by Dr. Emmet, are among the simplest,
viz.: glycerine' and hot water.” Dr. Emmet began the use of hot water
injections in 1859, and observes, “I have been so thoroughly identified
with this mode of practice, that it seems scarcely necessary to claim the
priority. Certainly, no one in this country is on record as an advocate
for the practice previous to myself; and so far as I have been able to
ascertain, the same is true in regard to the practice of gynaecologists
abroad.” Confirmatory of Dr. Emmet's views as to the action of hot
water injections in producing contraction of blood vessels, and therefore
useful not only in uterine, but also in pelvic, congestion, and in threatened
cellulitis, was the practice of Trousseau” in memorrhagia—frequently
directing two or three very hot injections daily. If Dr. Emmet had done
nothing beside this, his name would deserve to be one of the most hon-
ored of the century in medicine.
Since the invention of the hysterotome by the illustrious Sir James
Y. Simpson, and of its many modifications or substitutes by others, the
cervix uteri, relieved from the potash-persecutions which, carried on by
the ultra followers of Dr. Henry Bennet, a few years ago, threatened its
integrity, has been made the subject of numerous cutting operations for
the relief of dysmemorrhoea, or of sterility. Those who have contributed
most to the practical study of these operations are Drs. Sims, Emmet,
Pallen, Peaslee, and Worster, of New York, and Reamy of Cincinnati.
There is something wonderfully fascinating both for surgeon and patient,
when the former can carry salvation from dysmenorrhoea, and also a
baby, upon the sharp edge of a bistoury, or between the blades of scis-
sors! Unfortunately a conflict exists, both in theories and in experi-
ences, as to the utility, the modes of, and the cases for, operation. It is
to be hoped that since the recent publication of Dr. Peaslee, so conserva-
tive in its character, there will be elicited such discussion as will fully
present the truth in this matter, and firmly establish practical rules for
general professional guidance.
In amputation of the cervix uteri the flap method of Dr. Sims, and
the use of the galvano-cautery of Dr. Byrne, are worthy of remembrance.
Fluid applications to the lining membrane of the uterus are regarded by
the profession everywhere as of great utility; and the safest and most
common way of making such applications is simply one in close imita-
tion of that originally devised and practised by the late Dr. Henry Mil-
ler,” of Louisville, Ky., more than a score of years ago.
Uterine fibroids in their frequency, in their exacting symptoms, in
their sometimes apparently capricious history, and in the utter uncer-
tainty of therapeutic means pursued for their relief, have long presented
to the gynaecologist a field at once inviting and repellant. Electrolysis,
studied in this relation by Neftel, Sims, Cutter, Kimball, and some others,
cannot yet be said to have been admitted to professional confidence. Dr.
Byford has ably collected most of the experience of the profession of this
| Sims's Uterine Surgery, pp. 21, 72.
2 New York Medical Journal. June, 1874.
8 Nouveau Dictionnaire de Médecine et de Chirurgie Pratiques, vol. xxii. p. 452.
* Others whose names might be mentioned in connection with the study of means for
-v-
t
making such applications are Emmet, Lente, Nott, and Reamy.
158 P A R V IN,
country in the hypodermic use of ergot of Hildebrandt. But this treat-
ment frequently fails, and the knife is occasionally required.
Those whose names in this country are especially identified with ope-
rations for the removal of these tumors, are Dr. Atlee,' Dr. Sims, and
Dr. Emmet. The most valuable original observation belonging to the
last is the pedunculization of a fibroid which can be effected by traction.
The important operations performed by the others, and the ingenious in-
struments devised for this by Dr. Sims, almost as prolific of instruments
as Hudibras” of tropes, we pass by with this brief reference.
Removal of the uterus by abdominal section has been performed seve-
ral times in this country, but most of these operations have not been suc-
cessful. Probably the first case in this country, certainly one of the first,
was that of Dr. Thomas G. Prioleau,” of Charleston, S. C., in the year
1819. The tumor, prior to the operation regarded as malignant, was
very large, its removal with the uterus attended with much hemorrhage,
and the patient died in twenty-four hours. On the 16th of April, 1850,
Dr. Paul F. Eve removed the uterus for malignant disease, and the pa-
tient lived for between three and four months. The operation has, how-
ever, been done on account of fibroid disease, with permanent recovery,
by the Atlees, Burnham, Kimball, H. R. Storer, Thomas Wood," and
some others.
Removal of the prolapsed uterus—the vaginal operation—has several
times been successfully performed. One of the most interesting of these
cases is that of Dr. S. Choppin, of New Orleans. The doctor, in 1861,
removed not only the uterus, but with it the left ovary and Fallopian
tube, which were also prolapsed, and the patient rapidly recovered.
Many other topics in this division are suggested, but only two can be
considered as the greatest glories of American gynaecology, the operation
for genito-urinary fistula, and that for the removal of ovarian tumors.
Holding up these to the world, she may, with just pride, exclaim: These
are my offerings to Humanity and to Medicine ! Yea, these are MY
offerings
But is not the operation for genito-urinary fistula a triumph of Ameri-
can surgery 7 Up to less than a quarter of a century ago, how deplorable
the condition of the unfortunate woman suffering from such a lesion
She had entered upon all the remaining sad and weary years of her life,
through a portal over which surgeon and obstetrician alike had, time
and again, witten: Let her who enters here dismiss hope. If here and
there, now and then, a case was cured, the result was the exception,
failure the rule. If Jobert, for example, cured some, his operation always
failed in the hands of others. Now, how changed An operation, known
abroad as the American method, rescues these unfortunates from their
infirmity, and restores them to society. Failure is now as rare as success
was formerly.
Of course surgeons had come to apprehend the principles, before they
had attained the method of cure.
* Transactions of the American Medical Association, 1853.
* “For rhetoric, he could not ope
His mouth, but out there flew a trope.”
* Dr. Prioleau graduated in Philadelphia in 1808. Drs. Samuel Jackson and W. P. C.
Barton were classmates. At the organization of the Medical College of the State of South
Carolina, in 1824, he became Professor of Obstetrics, and filled the chair for many years.
I am indebted to Prof. J. Ford Prioleau, the present occupant of the chair, for the state-
ments given.
* Dr. Wood's cases are seven, with three recoveries.
A D D RESS ON OB STE TRIC S. 159
For the closure of these fistulous openings two things were necessary.
First, their margins must be thoroughly and uniformly freshened.
Second, this vivification accomplished, the freshened surfaces must be
brought and retained in accurate apposition until union took place. But
how should these edges be pared so completely and accurately : The
first step for the accomplishment of this end was their thorough expo-
sure. This step was taken in the position and speculum of Marion Sims.
Here we have the very foundation of the operation. This fixed, knives
of various angles, forms, and sizes, or curiously curved scissors, became
mere minor matters, resting with the individual operator, or determined
by the exigencies of each individual case.
But how are the prepared fistulous margins to be brought and kept in
contact until nature binds them fast : Here again we hear, in 1852, the
voice of Marion Sims crying, and crying aloud and on, until the whole
world has heard Silver Sutures. Am I told that a British surgeon, in
1834, using silver gilt sutures, cured a case of vesico-vaginal fistula 2 He
did not follow up this one success, and confirm it by others. He estab-
lished no rules of practice, he instituted no method, and his report was
unnoticed, it was as the voice of one crying in the wilderness. That
one success, too, was it any more than an American, Mettauer, of
Virginia, had gained in 1830, with lead sutures : Was it as much as
Hayward, of Boston, accomplished with silk sutures? But are the
brilliant results which Simon obtains, adduced to disparage the Ameri-
can method 7 Simon’s operation has become the property and the prac-
tice of the profession scarcely more than Jobert's. We gratefully record
the statement of one of the most eminent of French gynaecologists,
Courty,’ that the American school has no higher claims to future cele-
brity than the operation for vesico-vaginal fistula.
It is needless to mention the various modifications made by Dr. Sims
in his original operation, or the valuable improvements introduced by
Dr. Emmet, or the peculiarities of the method of Dr. Bozeman, who has
labored with such signal zeal and ability, both at home and abroad, in
this department of surgery, or the additions made by Dr. Mastin, of
Alabama; or by Dr. Schuppert, of New Orleans; or by Dr. Battey, of
Georgia; for the American method remains essentially that of Dr. Sims.
Nor is it necessary to speak of Dr. Sims's early trials, patient persever-
ance, and triumphant success in working out the great problem to which,
more than thirty years ago, he devoted himself with all that he had.
The world knows them, and he has received honors such as have been
accorded to few representatives of American Medicine.
A beautiful fable of the old Greeks made Apollo, the god of healing,
give to the laurel tree its evergreen leaves, and consecrate them as crowns
for the brows of victors. And surely who so worthy of the present of
these crowns as a son of Apollo, who, after years of bitter struggles, has
gained a victory which has brought blessings to thousands, and will
bring them to tens of thousands more?
Is not ovariotomy one of the rightful glories of American gynaecology 7
What are the facts? In the year 1809 a village doctor of Kentucky suc-
cessfully removed an ovarian tumor, and from that time until his death in
1830, operated in all thirteen times with eight recoveries”—a success, by
| Traité Pratique des Maladies de l’Uterus.
* For the collection of Dr. McDowell's cases, the profession is indebted to Prof. S. D.
Gross.
160 PARVIN,
the way, which, compared with the first thirteen cases of Baker Brown,
or Spencer Wells, is most extraordinary. Spencer Wells, whose opera-
tions began in 1857, lost four out of the first thirteen, and Baker Brown
lost eight out of his first thirteen.
Is the priority of Ephraim McDowell as the first surgeon to remove
the diseased ovary invalidated by the case of IIouston, of Glasgow, in
1701 : All other claims to priority have been swept away as blunders or
shams, and this, too, would need no notice, had not Dr. Washington L.
Atlee republished it as a proof that ovariotomy “originated with Eng-
lish surgery,” and had not Spencer Wells asserted that it “undoubtedly
strengthens the claims of British surgery to the honor of originally prac-
tising ovariotomy.” It is strange that this case, rejected by Boinet and
Clay,” should be now adduced. The operator simply incised a cyst and
evacuated its contents. He no more performed ovariotomy than he who
lances a suppurating parotid has extirpated the gland. The claim of
British surgery to the honor of originating ovariotomy is weak beyond
expression if it rests upon this case.
Again we are told, “Put the operation was suggested by William
Hunter; its practicability and the mode of performing it were taught by
John Bell.” William Hunter said: “I am of opinion that excision can
hardly be attempted.” He adds, however: “If we could beforehand know
that the circumstances would admit of such treatment, the incision should
admit of only two or three fingers, and the cyst be tapped and drawn
out, that the surgeon may cut the pedicle without introducing his hand.”
But Tozzetti,” in 1752, Vanderhaar and Delaporte, in 1752, and Morgagni,
in 1761, gave more encouragement to ovariotomy than did William IIun-
ter; some of them as much, indeed, as John IIunter did, in 1786. The sug-
gestions of Hunter and the instructions of Bell doubtless had an import-
ant influence upon McDowell’s mind, but this detracts nothing from the
glory of his achievement. The fame of Columbus is not dimmed by the
fact that others before him, others in his time, believed with him that by
sailing westward a sea-way to the Indies would be found. No matter
what surgeons may have believed and suggested as to removal of diseased
ovaries, no matter though John Bell taught the mode of operating, their
faith without works was utterly dead, and the new Columbus started
upon his exploration without pilot or chart.
But then, declares Nélaton, McDowell’s first patients were negresses,
and Gallez follows him, adding that his effort was to save the lives of
slaves, who at that time commanded a high price, so that surgery owes
this brilliant conquest to the cupidity of planters. How strange that
historical facts of the present century can be so misrepresented. The
truth is, that Dr. McDowell's first patient" was not a colored woman, but
one of his own race and Social position.
i Diseases of the Ovaries.
* Comme le fait judicieusement remarquer Boinet, après J. Clay, il y a eu simple incision
du kyste, qui n'a €té lié, ni excisé : on me peut donc voir lä une opération d’ovariotomie
proprement dite. Gallez, op. cit.
* Gallez, op.cit. p. 404.
* This was Mrs. Crawford, who, after the operation, resided for a time at Madison, Ind.
From the late Dr. Speer, of Hanover, Ind., who, when a young man, was for a time a
member of her family, I received some years since a statement as to the efforts made by Dr.
Ephraim McDowell's nephew to wrest the honors of the operation from the uncle. A law-
yer from Lexington, Ky., visited Mrs. C., urging her to sign a paper stating that the
nephew was the operator. Her reply was that she was blindfolded, and could not posi-
tively assert that Dr. Ephraim McDowell was the operator, but that she never would have
consented to the young man’s operating.
A D ID RESS O N O B STE TRIC S. 161
Surely British surgery has glory enough in the splendid successes of
Spencer Wells and Keith, and the French in those of Péan, without either
abating one jot or tittle of the fame of Ephraim McDowell.
Only sixty-five years since the performance of his first ovariotomy,
only fifty-eight since its publication, and then many years before general
professional recognition of the operation as legitimate, and probably it is
not extravagant to assert that more than two thousand women have been
by it rescued from impending death ! Dr. Peaslee, writing in 1872,
concluded, from a careful calculation, that ovariotomy had, in the
United States and Great Britain, within the last thirty years, added
more than thirty thousand years to the active life of woman. We may,
indeed, assert most unequivocally that the name of the father of ovari-
Otomy, is worthy of being recorded with those of the best benefactors of
the race.
Dr. McDowell's third ovariotomy was in 1816. In that year, or in the
one preceding, Dr. Thomas G. Prioleau, whose extirpation of the uterus
has already been referred to, assisted by his nephew, Dr. Philip Prioleau,
and Dr. Frost, attempted ovariotomy, but was compelled by extensive
adhesions to abandon the attempt ; he therefore simply evacuated the
cyst, and excised a portion of it. The patient died. Dr. Nathan Smith, of
Connecticut, Dr. Alban G. Smith, of Kentucky, Dr. David L. Rogers, of
New York, and Dr. Billinger, of South Carolina, are among the early
American ovariotomists. To give a list of those who have operated
since, including as it would numbers of the profession in almost every
State in the Union, and in some more than a score of them, is impossible.
Those who have operated most frequently are Atlee, Kimball, Dunlap,
Burnham, Peaslee, Thomas, White, Sims, and Bradford. The last named,
the late Dr. J. T. Bradford, of Augusta, Ky., had a higher percentage, no
less than ninety per cent., of recoveries than any other operator in the
world. Those who have contributed most, by the publication of statistics
of the operation, or arguments in its behalf, to its proper appreciation, are
the late Dr. Pope, of St. Louis, Dr. Lyman, of Boston, Dr. Atlee, the late
Dr. Miller, of Louisville, Ky., Dr. Peaslee, and Drs. Hamilton and Reeve,
of Ohio. In regard to the diagnosis of cystic diseases of the ovary, no
more important addition has been made than the examination with the
microscope of the contained fluid by Dr. Drysdale.' Dr. Atlee has estab-
lished important rules of diagnosis from the coagulability of the fluids
obtained from uterine or ovarian cysts, or from the abdominal cavity.”
| DEAR SIR : Since reading the paper at St. Louis, in 1873, “On the Granular Celt
found in Ovarian Fluid,” I have continued the investigation of these and other dropsical
fluids, and have now examined over a thousand specimens of them. These examinations
enable me to emphasize the opinion which I then expressed, that the ovarian granular cell
is pathognomonic of cystic disease of the ovary. Yours, very truly, T. M. I.) RYSDALE.
* (1) Fluids, drawn from the peritoneal cavity, or from ovarian or broad ligament cysts,
do not coagulate on mere exposure to air. (2) Fluids, drawn from non-inflammatory accu-
mulations in the peritoneal cavity, will coagulate more or less under the influence of heat
and nitric acid. (3) Fluids, drawn from inflammatory accumulations, will coagulate by
heat and nitric acid; and will also, by standing, produce a fibrinoid deposit in small quan-
tities without heat and nitric acid. (4) Fluids of ovarian cysts proper, will coagulate to a
greater or less extent by heat and nitric acid. Certain fluids, however, may collect in the
parenchymatous structure of an ovarian tumor, which will neither coagulate by heat or
nitric acid, nor on mere exposure to air. (5) Fluids of cysts of the broad ligament will not
coagulate by any means. (6) Fluids, drawn from fibro-cystic tumors of the uterus, are dis-
tinguishable from all others taken from the abdominal cavity by coagulating rapidly on ex-
posure to air, and, after standing, by separating into clot and serum. This fluid, when not
stained with red blood, is very transparent and of a yellowish color, and is really blood, or
liquor sanguinis mºnus the red corpuscles. . WASHINGTON L. ATLEE.
162 P A R V IN,
In the operation itself the most important advance is the enucleation
of the cyst according to the method of Dr. Miner, of Buffalo. This
method is not of general, but of particular, application, and permits the safe
removal of tumors that otherwise could not be dealt with in consequence
of adhesions. Clamps, instruments used probably by only a minority of
American operators, have been devised by Atlee, Storer, Dawson of New
York, and Mears of Philadelphia. Peritoneal drainage after operation
has been practically studied by Kimball, Atlee, Sims, and Thomas. Dr.
Peaslee has shown the utility of intra-peritoneal injections in septi-
caemia, regarding them as more valuable than any other and all other
IIlê8, Il S.
Vaginal ovariotomy originated with Dr. Thomas, in 1870. The same
operation has since also been successfully performed by Dr. Davis, of
Pennsylvania, Dr. Gilmore, of Alabama, and Dr. Battey, of Georgia.
Ovariocentesis Vaginalis has been greatly improved by Noeggerath,
and the results he has had are remarkably favorable.
Removal of the ovaries in order to determine the menopause in certain
cases where menstruation is attended with great suffering, and otherwise
incurable disease, was the proposition of Dr. Battey. The operation has
been performed sixteen times, with three deaths, the operators being Dr.
T}attey, Dr. Sims, and Dr. Thomas. Its propriety is hardly established
in the face of such statistics.
Did time permit, many other contributions to operative gynaecology
might be alluded to, such as that of Nott,” extirpation of the coccyx for
coccygeal neuralgia, in 1844; Schuppert’sº operation for obliteration of
the vagina, in 1858, “the first case of vulvar occlusion by elytro-
episiorraphy without ulterior accidents;” and Emmet's method of securing
the restoration of the anal sphincter in operation for ruptured perineum,
a method which has recently been successfully followed by a surgeon of
Rouen." So, too, we might mention the peculiarities of Dr. Bozeman’s
operation for vesico-vaginal fistula — his knee-chest support, his self-
retaining speculum, his button sutures, his method of auto-plasty by
gradual approaches," and, above all, his past successes at home, his present
abroad, might be mentioned. The merit of a method will be at once
conceded when it has won the approval of such men as Simon, Braun,
and Dolbeau.
One of the minor, but by no means insignificant advantages of the
establishment of a method of cure for vesico-vaginal fistula, that must
not be omitted, is that in consequence thereof the operation of vaginal
lithotomy is relieved of its most serious objection—the resulting fistula.
Now surgeons, following the example of Dr. Sims, in 1850, remove the
calculus by vagimo-vesical incision, and immediately close the opening
with silver sutures. This operation is growing in favor; in this country
forty-one cases have been collected by Dr. Mastin: “the operation,” says
Dr. Warren, “seems to have been done more frequently in this country
* Dr. Trenholme, of Montreal, and Dr. Peaslee, have reported cases of the operation since
the delivery of this address.
* American Journal of the Medical Sciences, October, 1844.
* A Treatise on Vesico-Vaginal Fistula, New Orleans, 1866.
* Le Double, Du Kleisis Génital, et principalement de l'Occlusion Vaginale et Vulvaire
dans les Fistules Uro-Génitales. Paris, 1876.
* Annales de Gynécologie, July, 1876.
* New York Medical Record, August 26, 1876.
* Boston Medical and Surgical Journal, July 20, 1876.
A D DIRESS O N O B STE TRIC S. 163
than in any other.” IIybord, in considering the relative advantages of
lithotrity, dilatation and lithotomy, observes that the latter, especially
vesico-vaginal, with immediate suture, is preferable if the calculus is hard,
large, or encysted.
But turning from these and many other topics, and concluding this
division of the subject, we cannot refrain from a remark or two concern-
ing the surgical development of American Gynaecology. Of course in
this country, as in others, the advance has been much greater in the
surgical than in the medical department of so-called uterine therapeutics.
In explanation of this fact, as it is observed here, two peculiar causes
have been in operation, in addition to those which are common. One of
these is in the characteristics of the American mind—its tendency is to
action rather than to reflection; quick and fertile in expedients, it seeks
immediate results, rather than exercises the patience for recondite inves-
tigation. And again, most of those who have made themselves espe-
cially famous, and therefore have become leaders of sentiment and of
action, have acquired their celebrity and influence by brilliant operations.
An inspiration comes from the graves of the dead and from the deeds of
the living, kindling hope and ambition, to emulate their fame, and to do
their works, or even greater works. American Gynaecology has proved
its power, and recorded triumphs that cannot perish. The past is secure.
The future is the child of the past, and its glories may be more numerous
and grander.
“Men, my brothers, men the workers, ever reaping something new ;
That which they have done but earnest of the things that they shall do.”
Let us hope that, as Uterine Surgery has in this country made such
great progress, and accomplished so much, the future historian will
record similar progress and a corresponding development of Uterine
Medicine.
The first American work on Diseases of Children, entitled, “A Treatise
on the Physical and Medical Management of Children,” was by Dr.
Dewees, and published in 1825. Up to 1842 no less than seven editions
had been issued. “To Dr. Dewees we are greatly indebted,” said Dr.
Hodge, “simply for fixing attention on the physical management of
children, independently of the high value of his directions; for, prior to
this period, the profession in this country left the details almost exclu-
sively in the hands of nurses and midwives, with all their tormenting
ignorance and officiousness.” Dr. John Eberle, one of the first professors
in Jefferson Medical College, then a professor in the Medical College of
Ohio, and finally in the Transylvania School at Lexington, Ky., where
he died in 1838, was author of a Treatise on the Diseases and Physical
Management of Children, which was published in 1837. A third edition
appeared in 1845. Dr. Eberle was a compiler, but was always judicious
in his compilations.
In 1841, the Practical Treatise on Diseases of Children of Dr. James
Stewart was published. This was, according to Dr. Condie, “ certainly
superior, in many points of view, to those heretofore accessible to the
great body of our profession in this country.” The author refers to the
fact that opium is of admirable benefit in many of the inflammatory com-
plaints ºf children, especially after bleeding, and was much in use by the
older Am grican practitioners. The practitioner of to-day would use the
| Des Calcules de la Vessie chez la Femme et les Petites Filles. Paris, 1872.
164 P A R V IN,
opium much oftener than he would the bleeding. The year 1844 brought
another Practical Treatise on Diseases of Children, the well-known vol-
ume of Dr. D. Francis Condie. The sixth edition of it was issued in
1868.
Dr. Condie was, according to Prof. Stillé, by long and extensive ex-
perience, accurate observation and diligent study, not only of English
writers, but also of the Continental, and especially of the German, well
qualified to prepare such a work. The volume grew with each new edi-
tion, especially in accretions from foreign sources, and one who reads it
now will, without the greatest care, occasionally get lost in conflicting
pathological opinions and theories. But no one can mistake the two
important characteristics of the therapeutics—great caution in the use of
opium, great faith in the power of mercurials. Few American physicians
have equalled Condie in medical learning, and the hundreds, possibly I
might say thousands, of pages of criticism he has contributed to the
American Journal of the Medical Sciences, constitute an important feature
of our national medical literature. He was remarkably fluent in compo-
sition, yet no one could say—
“His talk was like a stream which runs
With rapid course from rocks to roses.”
Rocks, big, solid rocks, enough there were in his writing, but roses
fared as ill at his hands, as the poppy-heads that fell before Tarquin's
angry cane.
In 1848, A Practical Treatise on Diseases of Children, by Dr. J. Forsyth
Meigs, was issued by Lindsay and Blakiston. This was the third of the
series of manuals which this well-known firm engaged in publishing, the
first being the work on Obstetrics, by Dr. Tucker, to which reference
was made in a former part of this address. Meigs on Diseases of Child-
ren has been and still is held in much esteem by the American profession.
It has passed to the fifth edition, and in the preparation of the two last
editions Dr. Wm. Pepper has been associated with Dr. Meigs.
A Treatise on the Diseases of Infancy and Childhood, by Dr. J. Lewis
Smith, was issued in 1869; the third and latest edition appeared in 1876.
“Smith’ is a book of fewer pages than “Meigs and Pepper,” but clearly
and concisely written. As a guide for the practitioner, and as a text-
book for students, it hardly has a superior.
In 1849, Dr. John B. Beck, one of the first professors in the College of
Physicians and Surgeons, New York, published his work on Infant
Therapeutics, which Dr. Gross' recently pronounced “a perfect gem in its
way.” The late Dr. C. R. Gilman” states that “it was received with the
greatest favor, both at liome and abroad. Few medical books of its size
contain an equal amount of sound learning and practical good sense.”
Observations on certain of the Diseases of Young Children, by Dr.
Charles D. Meigs, was issued in 1850. Here we have, in the midst of
excellent and most useful instruction as to the management of several of
the diseases of children, some of the author's peculiar pathological views,
views which were always ingenious, and, if not always true, never failed
of the semblance of truth. Here we are taught the efficacy of a wool-
len cap in coryza, the “right-side treatment” of cyanosis, and are brought
face to face with that “eudangium” which played so important a part in
his theories of disease.
History of American Medical Literature. * American Medical Biography.
A D D R E S S O N O B STE TRIC S. 165
In Dr. Bedford’s valuable Clinical Tectures, already referred to, some
of the diseases of children are treated of plainly, practically, and wisely,
but there is by no means a complete course given. Indeed, in reading
this volume, and finding here and there these diseases considered, while
the great body of the work is occupied with diseases of women, one is
reminded of a street-car or omnibus crowded with adults, and then here
and there a child interposed or superposed.
Having thus briefly noticed these different volumes, we shall next refer
to a few special American contributions to Paediatrics. Among the
earlier, must be placed the letters on Angina Trachealis, by Dr. Richard
Bayley, of New York, 1781, to Dr. William Hunter. Dr. John W.
Francis' speaks highly of these letters, and states, “we are justified in
giving to Dr. Bayley the merit of being the first writer who understood
the nature and treatment of croup.” In a letter written to Dr. Fother-
gill by Cadwallader Colden, New York, October 1, 1753, the writer
describes diphtheria and its treatment, chiefly as observed by Dr. Doug-
lass, of Boston. In 1736, Dr. Douglass published a pamphlet” entitled,
The Practical History of a new Epidemical Eruptive Miliary Fever, with
an Angina Ulcusculosa which prevailed in New England in the years
1735 and 1736. “The first full description of this affection published in
this country,” says Dr. J. F. Meigs, “was by Dr. Bard, and based on an
epidemic which occurred in 1771. The views advanced in his paper have
been universally recognized, even to the present day, as most clear and
just.” Dr. Bard's account of the disease has been recently very favorably
referred to and quoted by Loraine & Lépine.”
Shall we mention one of the first applications of electricity as a thera-
peutic agent, in this country; its successful use in 1752 by the illustrious
Franklin in a case of convulsions, in a patient of Dr. Cadwallader Evans,
of Philadelphia, a girl of fourteen, who had been afflicted for ten years?
In regard to the treatment of croup, four important therapeutic agents
have been introduced by American physicians. The mercurial treatment
is attributed to Dr. George Monroe, of Delaware, who graduated at the
University of Edinburgh in 1786. Dr. Hubbard, of Maine, is to be credited
with first using and advising the yellow sulphate of mercury, a remedy
which has received from Dr. Fordyce Barker, after using it twenty-eight
years, the highest possible praise. The late Dr. Charles D. Meigs was
the first to advise the common alum as an emetic, while more recently
the treatment by cold has been ably advocated by Dr. Jacobi.
The most valuable contributions to the subject of umbilical hemorrhage
have been by three American physicians, Drs. Minot, Stephen Smith, and
J. Foster Jenkins.
The subjects of masturbation and hysteria in young children have been
elaborately presented by Jacobi, whose many and valuable contributions
to Paediatrics are so well known to the profession, not only at home but
abroad
Dr. R. W. Taylor" has produced a monograph upon. Syphilitic Lesions
of the Osseous System in Infants and Young Children, which has at-
tracted much attention, both in this country and in Europe.
Dr. Busey" has given a faithful study of the action of certain drugs in
1 Anniversary Discourse before the New York Academy of Medicine, 1847.
* An abstract of this paper will be found in the Medical Recorder, Philadelphia, 1825.
* Nouveau Dictionnaire de Médecine et de Chirurgie Pratiques, vol. xi.
* American Journal of Obstetrics.
* Columbia Hospital Report.
166 PARVIN, ADDRESS ON OBSTETRICS.
bronchitis. And thus, name after name might be mentioned, paper after
paper referred to, showing how active the American profession has been
in the department of diseases of children. But this address has already
transcended the time assigned it, and I must conclude.
Did time permit, I might mention the organization of societies devoted
to the especial study of obstetrics, and of diseases of women and of child-
ren, in Louisville, Boston, New York, and Philadelphia, as at once the
signs and means of advance. So too, the American Gynaecological So-
ciety, born this Centennial year, gives promise of high honor and great
usefulness. The establishment of hospitals devoted to diseases of women,
is another evidence of progress. The Woman’s Iſospital of New York,
founded and built chiefly by the labors of Sims and Emmet, and which
has been of such incalculable benefit to thousands of suffering women,
and to the profession, has been the noble pioneer. May the day speedily
come when every State shall have a similar institution -
The American Journal of Obstetrics, founded by Dr. Dawson, and
conducted with such signal ability, the demand for the reprint of the
Obstetrical Journal of Great Britain and Ireland, and the valuable addi-
tions made to it by American writers, are evidences of progress.
And now, in conclusion, have we brought the names of those who, in
this country, have been prominent in advancing the knowledge of Obstet-
rics, Gynaecology, and Paediatrics, for apotheosis in some new Olympus?
Nay, rather, for inscription in our memorial window of the Temple of
Medicine. There let them be written, Samuel Bard, William P. Dewees,
Thomas C. James, Ephraim McDowell, Charles D. Meigs, Gunning S.
Bedford, Hugh L. Hodge, D. Francis Condie, Henry Miller, Walter
Channing—but I cannot repeat the long list." There let them all be
recorded, and there forever abide. It is done. To the Orient sun of
the Republic's second century is pouring its light upon them, is kin-
dling in our hearts gratitude and joy, and evoking more than MEMNONIAN
music, TE DEUMS and JUBILATES, from a multitude whom no man can
number, who lived because they lived, who suffered and who were saved
from their sufferings and from the sorrows of death by the interposition
of their Divine Art. When that sun is sinking behind the flood of years,
may its departing rays gild those names with a new glory, shining too
on others still more illustrious.
! Is it presumptive to interpret the presence with us to-day of two eminent obstetric
teachers from abroad, as a cheerful tribute to the value of American work in this depart-
ment of Medicine 2 To those teachers, one of them the honored occupant of a chair made
illustrious by the names of the Hamiltons and of Sir James Y. Simpson, and the other
whose fame has gone out into all the earth, and whose imperial authority the professional
world acknowledges, every American physician gives hearty thanks.
167
ADDRESS ON MEDICAL JURISPRUDENCE.
WITH
N O T E S A N D A B IIB L I O G R A PHI C A L A PPEN DI X.
BY
STANFORD E. CHAILLE, A.M., M.D.,
PROFESSOR OF PHYSIOLOGY AND PATHOLOGICAL AN ATOMY IN THE MEDICAL DEPARTMENT
OF THE UNIVERSITY OF LOUISIAN A.
MEDICAL JURISPRUDENCE owes its power to knowledge derived from
every branch of medicine, but the law determines how far this power
shall be utilized in the administration of justice. Hence, the develop-
ment of Medical Jurisprudence has varied in different nations with the
progress of medical science, and with the extent of its application to the
protection of property, reputation, and life. Efficiency in this legal
application varies with the appreciation of medical knowledge by the
rulers of a nation ; and (since an adequate appreciation is limited to the
educated few, and is not yet disseminated among the mass of any people),
it results, that laws more favorable to the culture of legal medicine are
to be found in nations ruled by the educated few, than in those governed
by the people. The unequal development of Medical Jurisprudence in
different nations finds in these facts an explanation, in large part at least,
and recalls the political axiom that “arbitrary powers well executed, are
the most convenient,” while “delays and inconveniences in the forms of
justice are the price that all free nations must pay for their liberty in
more substantial matters.”
The papal canon-laws,” originating many medico-legal questions, sowed
in 1620 by the hand of Zacchias,” a pope's physician, the first sound seed
of Medical Jurisprudence in the land of Columbus, then the home of
Science and the Arts.”
' Blackstone, iv. p. 350. Blackstone’s “Commentaries on the Laws of England” (four
books) were published a century ago, viz. 1765 to 1769, and, hence, are frequently
referred to.
* The “Corpus Juris Canonici,” a compend of the canon-laws, is dated 1580.
* B. 2. This and all succeeding references to “B,” refer to the Bibliography, with the
numbers therein.
* From many facts which might be cited to prove this statement, as also that the
development of medical jurisprudence in different nations has varied with their culture of
medical science, the following quotation is selected from p. 142 of Russell’s “History and
Heroes of Medicine,” London, 1861 : “If we survey the social and political state of Europe
from the twelfth to the sixteenth century, in its relation to the development of medical
art, our attention is at once arrested by Italy, which at this period was far ahead of the
rest of the world. Taking the number of Universities as an index of civilization, we find
that before the year 1500, there were sixteen in Italy, while in France there were but six :
in Germany . . . there were eight; and in Great Britain two ; making sixteen in all–
the exact number which existed in Italy alone. The Italian Universities were likewise no
less superior in fame than in number to those of the North.” Italy maintained this supe-
riority during, and even after, the sixteenth century.
168 CHAILLE,
The new-born shoot, languishing in Italy, was transplanted in German
soil, where it received such culture as nourished its growth, developed its
fruit, and reproduced seed to germinate in other lands. To favoring
legislation from 1532 to the present day, the fatherland owes its pre-
eminence in Medical Jurisprudence. Germany, for two centuries, has
had an organization of medico-legal officials, to whom alone it intrusts
the duty, both to procure the medical facts needed by the courts, and to
estimate the weight due such facts from whatever source obtained ; it
alone requires that these experts shall be especially educated, and
provides medico-legal clinics” for their practical instruction. In 1650,
Michiaelis' delivered the very first lectures on Legal Medicine, and as early
as 1720 professorships of the same were founded by the state. By 1725, the
celebrated works of Valentini, Teichmeyer, and Albertus,” had supplanted
that of Zacchias; and since then a medico-legal literature more abundant
than in all other languages has nourished the science of Medical Juris-
prudence both at home and abroad. In fine, Germany, specially excelling
in the Art, has consequently excelled in the culture of the Science.
France, from 1570 to 1692, enacted laws which, like those of Germany,
favored the culture of Legal Medicine; but in 1692, medico-legal offices
became hereditary and venal, and Legal Medicine languished until after
the French Revolution. Since 1790, no nation has surpassed France in
the culture of medical science; in addition, the judges appoint medical
experts, who, since 1803, must be graduates in medicine, and must have
attended one course of lectures, and have passed an examination on Legal
Medicine, professional chairs of which were established by the state in
1794.” IIowever, French authorities denounce their didactic instruction
as insufficient for the education of experts, and declare the appointment
of these by the judges, and the lack of skilled medico-legal officials to
procure medical evidence, to be most unsatisfactory, and their whole
system to be much inferior to the German. Still, France has at least a
system, and meanly as this does apply the art, it has served to greatly
stimulate the culture of the science, as has been notably illustrated since
1796" by French medico-legal literature. A critical appreciation of how
much of this literature has been derived from Germany, and how much
of medico-legal science without the art has been transported from Ger-
many and France to Great Britain, and the United States, would, I fear,
prove offensive to Gallie, and still more to Anglo-American, vanity.
Great Britain transmitted to this nation laws, barbarously conspicuous
for the absence of provisions to apply medical knowledge to the admi-
nistration of justice, and Anglo-American law continues to be, in large
measure, hostile to Medical Jurisprudence. However, British laws have
done something for the science, and a little for the art. For Great
Britain has fostered medical education ; did in 1803 found a chair of
1 The Constitutio Criminalis of Charles V, 1532, (published in 1553) rendered it
obligatory on the Courts to take the evidence of medical men in medico-legal cases.
* The first one established was at Vienna, about 1830; a second at Berlin, 1833;
a third at Munich, 1865; and probably a fourth since 1870 at Strasbourg, where France
had its only medico-legal clinic, 1840 to 1870. In France, Great Britain, and the United
States, Medical Jurisprudence cannot be said to be practically taught, except as to
Toxicology.
* University of Leipzig; Michiaelis was succeeded by Bohn.
4 B. 29, 30, 31.
* Chaussier, in 1790, was the first lecturer, and Mahon, in 1795, (B. 115) the first
professor. Foderé says the state enacted the first laws favorable to Legal Medicine in 1792.
* The date of the first French general treatise (B. 114). .
A DI) RESS O N M E DIC A. L J U R IS PR U D E N C E . 169
Forensic Medicine in one University, and now has such chairs in all its
medical colleges (some of these conferring a special degree in State
Medicine);” has by the Registration Act and other laws' greatly
strengthened the medical profession ; and has compelled its courts to
accept expert evidence only from registered, and therefore educated,
medical men. Still, “the crowned republic” remains destitute, as does
its democratic American offspring, of popular, and hence of governmental,
appreciation of the legal importance of medical knowledge, as is proved
by the same lack of any system to secure the medical evidence of com-
petent experts that characterized its laws when surgeons were barbers,”
and when physicians were astrologers, sorcerers, and interpreters of
dreams. What wonder that Germany and France began the study
earlier, and have prosecuted it more successfully 7
The States of this Union have, for the most part, left the culture of
medical science to individual enterprise which supplies solely that which
the private citizen demands—practitioners of medicine to heal the sick.
The States have as yet made no demand for competent medical experts
to aid the administration of justice, and have done nothing designedly
for the culture of Medical Jurisprudence. What growth can this branch
of State Medicine have as long as a State does not recognize even its
existence 2 Before attempting to answer this question, it will be well—
having now briefly examined the causes—to present as briefly some illus-
trations of the extent of the general progress of Legal Medicine.
To appreciate progress during any period, it is necessary to keep in
mind the empire of the dead over the living; to recall some of the victo-
ries gained over superstition and ignorance during the preceding century,
as well as during that now closing.
From 1620 to 1722, the authority of the father" of medico-legal science
was supreme. Iſe devoted chapters to Torture, Sorcery, Prophecy, Mir-
acle, and Immaculate Conception. Admitting one hundred and fifty
births at a labor, he skeptically doubted the three hundred and sixty-
five brought forth by the prolific Countess of Henneberg . During this
period doctors gravely discussed whether a woman could be got with
child by the devil, or by a dream; and French judges legitimized an
infant in a case where the husband had been separated four years from
the mother, on the ground that the child owed its paternity to a dream.
Doctors taught that grossly deformed infants had a bestial parentage;
judges, even in 1769, declared that they had “no inheritable blood” for
| University of Edinburgh : Dr. Duncan, Sr., in 1801, was the first English speaking
lecturer on Forensic Medicine, and his son the first professor, in 1803. In this same
University (chartered in 1582) was established, in 1726, the first English-speaking Medical
Faculty, which conferred degrees on less than 300 graduates from 1726 to 1776. From
1705 to 1726 twenty-one medical degrees, which would now be deemed irregular, perhaps
honorary, were conferred. Institutions for medical education were established in Italy,
Germany, and France, long prior to 1705 or 1726.
* Each of the twenty-three medical colleges reported in England and Scotland in 1875,
had a regular teacher devoted to Forensic Medicine; and some of these, at least those at
Cambridge, Oxford, Edinburgh, and Dublin, confer a special degree in State Medicine on
those applicants only who have already graduated in medicine, and have thereafter
satisfactorily pursued this special study.
* The Registration Act was passed in 1858. “ Glenn's Mannal of the Laws affecting
Medical Men,” London, 1871, gives a list of 36 such laws from 1800 to 1870, and of these
25 from 1850 to 1870.
* Surgeons were barbers in England until 1745. 5 B. 2.
170 CHAILLE,
a “reason too obvious and too shocking to bear a minute discussion,”
and the priest, encouraging doctor and judge, cried “Si tu es homo, te
baptizo.”
Until 1726 (Albertus), it was taught that, in presence of the murderer,
his victim’s wounds did “Open their congeal’d mouths and bleed afresh,”
and courts accepted the testimony of medical experts to this miraculous
bleeding of the corpse.” The effect upon a suspected homicide of touching
the dead body of his supposed victim, continued to be a legal expedient
within the nineteenth century.”
Unearthed bones served to convict men of murder, and yet these
accusing bones, since not even human, were not those of missing men.
A cranial foramen devised by nature, yet perverted by ignorance into
an assassinating awl-hole, would have hung Thomas Bowman, but for
accident. -
Superstition, denouncing medico-legal autopsies even more fiercely
than it now does cremation, did not permit these to become frequent
until about 1750; and the work of the father of morbid anatomy,” a
foundation stone of Legal Medicine, was not published until 1761. By
superstition, and by ignorance of normal and morbid anatomy, of the
causes of sudden death, of diagnostics, and of chemistry, Legal Medicine
was powerless, when compared with its present state. So great was
its helplessness, that a horrible atmosphere of suspicion encompassed
the fear of death by poison. On those even suspected, the grossest legal
abuses were every where inflicted ; while those convicted were long boiled'
alive by English law, and burned (as late as 1780) by the French
“Chambre Ardente,” which was not abolished until 1791.
The highest medico-legal authorities" taught belief in ghosts, witches,
and possession by the devil; and united with the clergy until 1752 in
denouncing all disbelievers thereof as heretics and atheists. They found
demoniacs for the jailor and the stake, where we find patients for the
doctor and the asylum. The distinguished medico-legist, Hoffman, com-
mended to the barbarity of the law those who “ vomited nails, hair, wax,
glass, or leather,” as indisputable witches." The “great and good” Dord
Chief Justice Hale, prompted by the medico-legal testimony of the learned
physician Sir Thos. Browne,” illuminated the stake with witches—exem-
plifying in 1664 the practice of Anglo-American witch-laws till 1727, laws
not repealed until 1736.” Thus did the legal medicine of our ancestors,
only five generations removed, persecute, drown, and burn thousands of
the insane, as “fire-brands of hell,” who were “moved and seduced by
instigation of the devil.”
| Blackstone, II. pp. 246-7.
* See plea of the great scholar and lawyer, Sir George McKenzie, in the “State Trial,”
1688, of Sir Philip Stansfield, executed for the murder of his father.
* The latest American case was in New York in 1824. (See B. 349, I. p. 807.)
* Morgagni, B. 18.
* Instituted at the close of 17th century as a special remedy for poisoning, which had
become a very frequent crime in Paris.
* Paré, Zacchias, Hoffman, Storck, Boerner, &c., (B. 100, 2, 34, 39).
7 “De diaboli potentiá in corpora.” Hoffman died in 1742.
* Author of “Religio Medici,” and also of “Pseudoxia Epidemica,” or Vulgar Errors.
* The “witch-mania” originated with a papal edict in 1484. The last judicial execu-
tions for witchcraft were in England, in 1716; Scotland, 1722; Würzburg (Germany),
1749; Glarus (Switzerland), 1780. The witch-mania prevailed in New England, 1692 to
1727. Although the witch-laws were repealed in Great Britain in 1736, yet as late as
1760 supposed witches were murdered by mobs, and there were “witch-doctors” in 1838.
In France there was a legal trial for witchcraft as late as 1818.
A D D R E SS O N M E DIC A. L J U R IS PR U D E N C F. . 171
These few examples must suffice to recall the parentage of the Medical
Jurisprudence of our century, and the facts that, with the impotence of
science to aid the law, it adopted miracles as explanations, suspicion as
proof, confession as evidence of guilt, and “ torture as the chief witness,”
summoning the medical expert to sustain the accused until the rack
forced confession.”
During the hundred years now closing, the progress of medicine has
been greater than in all preceding time. To detail the means acquired
to aid the law, would require the record of every medical discovery ; for
what one of these may not contribute to the administration of justice?
This occasion precludes more than bare suggestions illustrative of the
general progress of medico-legal science.
(1) Innumerable precious facts have been contributed by every branch
of Anatomy, and especially by Pathological Anatomy. The study of
putrefaction, fractures, burns, scars, marks, stains—in fine of every
change and injury to be found on the living or dead body—has given
the skilled expert a power (miraculous to the ignorant) to identify the
body, to distinguish real from apparent death, to approximate the date
of death, to decide whether it be due to morbid, accidental, or criminal
causes, and often to point unerringly to the criminal.” So great is this
power that medico-legal autopsies have become indispensable to justice;
and, since 1837, the Microscope, strengthening notably Anatomy as also
Toxicology, has repeatedly released the innocent from the jailor's clutch,
and delivered the culprit to the hangman.
(2) Diagnostics, aided by stethoscope, thermometer, and many other
instruments" invented or newly applied since 1776, have stripped the
malingerer of power to feign disease, become the corner-stone of Life
Insurance, and aided the law in many other particulars.
| Montesquieu, 1748.
* It is true that in our motherland, England, torture was abolished in 1640 (a century
and a half earlier than in continental Europe); but, to such extent did suspicion replace
proof, and the single penalty of death overtake every species and grade of crime, that the
law had much less need than now of medical experts. Prisoners accused of a capital crime
were not permitted any witnesses until 1702 (Blackstone, IV, p. 360); an accusation of
infanticide sufficed for conviction, unless there was one eye-witness to the birth, until 1802
(B. 153, p. 309); and “prisoners were first allowed the assistance of counsel ” about 1830
(“Science of Law'' by S. Amos, p. 312). Even in 1769 there was “a dreadful list of 160
capital offences,” and, not content with this liberal supply of the halter, English laws
provided for criminals horrible mutilations, as branding, castration, slitting the nostrils,
cropping the ears, and cutting off the hand, with a medical expert to sear the stump;
death by exposure and starvation (“Peine fort et dure”), till 1772, by beheading, by
drawing and quartering, and by burning alive; and brutal persecution of widow and
orphan by corruption of blood and confiscation. Yet Blackstone asserts (1769), with
evident pride, that this “disgusting catalogue" when compared with the criminal codes of
other European nations did “honor to the English law.” It is calculated to soften
impatient indignation to remember that “it cannot be justly regarded as a fault in
[legislators] courts or juries not to be in advance of the age in which they live”; and it is
encouraging to recall that many of these barbarous laws were repealed because courts and
juries did get so much in advance of them, that they could not be executed.
* Among errors credited by the profession and corrected within the 19th century may
be mentioned here : the beliefs that the human hair could grow after death; that the wind
of a canon-ball could destroy life; and that violent and fatal injuries, which at times do
fail to leave any visible signs externally, might also fail to present any lesions internally.
* Schwann and Schleiden.
* Spirometer, Pneumatometer, Galvanic and Electric Batteries, Ophthalmoscope,
Laryngoscope, Endoscope, Spectroscope, Sphygmograph, Cardiograph, Dynamometer,
AEsthesiometer, etc.
172 CHAILLE,
(3) Obstetrics, until 1750 in the hands of ignorant midwives, conse-
quently remained a special nursery of mystery and credulity. During
the present century, Obstetrical Jurisprudence has rescued from igno-
rant superstition monsters, retarded births, superfootation, and hermaph-
rodism ; has discovered new signs of pregnancy, and the significance of
uterine moles” and hydatids; has appreciated the evidences of impotence,
sterility, and “live-birth,” and has discarded the hydrostatic test” as con-
clusive proof of the latter. In vindication of chastity, the signs of
virginity" have been duly estimated, false have been distinguished from
true corpora lutea," and it has been proved that sexual connection “with-
out consent” may be fruitful. Finally, the “jury of matrons” has been
slowly despoiled of its authority to decide a question of pregnancy. It
is mortifying to record that, in criminal cases, the laws of some of our
States continue to regard “quickening” as proof of the very dawn of
life; and yet add to this barbarism the inconsistency of admitting, in
civil cases, the vitality of the embryo from the date of conception. More
than a century ago, medico-legists," abandoning a belief long universal,
taught that life began months prior to, and was as sacred before as after,
maternal sensation ; but, to the encouragement of foeticide, this ancestral
superstition" still prevails among a free people, and lingers in their laws.
(4) Chemistry, since 1789, when Lavoisier gave it a firm foundation,
has enriched every science, bestowing such services on State Medicine as
to necessitate the distinct department of Legal Chemistry. Two of
many services may be mentioned : the murderer has been deprived of
one refuge, which even professional credulity supplied—Spontaneous
Combustion"—a mode of death yet to be witnessed by a skilled expert;
but this interesting service is insignificant when compared with that
rendered toxicology. Though poisons have become much more procur-
able and numerous, yet the skill of the medical chemist has so increased,
that criminal poisoning has become, largely through this power, one of
the most certainly detected, relatively infrequent, and least dreaded
modes of death.
(5) Py the knowledge acquired of the nervous system, medical science
has influenced society and law to an extent difficult to over-estimate.
* A man-midwife was first employed with the greatest secrecy, in 1663. In England,
men-midwives did not secure respectable professional position until 1783. Prof. T. G.
Thomas writes that in the United States the subject of obstetrics has “been recognized as
one of paramount importance and dignity " since 1767.
* The French Parliament decided in 1781 that virgins and nuns discharged moles (i. e.
“blighted ova”) without having had sexual connection. (B. 114, 2d Ed. I. p. 477.)
* The hydrostatic test was first practically used in legal medicine by Jan Schreyer in
1682, and was long accepted as conclusive proof of live-birth.
* Buffon, as also Foderé (B. 114, in the 1st Ed. of 1796, not in the 2d Ed. of 1813),
Mahon (B. 115) and many others taught that there was no such thing as the Hymen.
* In the trial of Chas. Angus (Lancaster, England), for the murder of Miss Burns, in
1808, all the medical witnesses testified (to her dishonor) that all corpora lutea without
distinction proved previous conception.
6 Faselius, 1767; Haller, 1782; Farr, 1788, etc.
7 “Absurd ecclesiastical canons handed this error down from one criminal code to an-
other.” B. 349, II. pp. 9 and 1076; Foderé, etc.
* This debt is due chiefly to Liebig and Bischoff (Case of the Countess of Goerlitz, 1850).
Casper wrote: “It is afflicting to be obliged in a serious scientific work in 1861 to still
speak of the fable, spontaneous combustion.” A human body reduced in a few moments
to a cup of ashes . To the credulous in this matter, one is prompted to recall Velpeau's
attitude in reference to the “vagitus uterinus,” or capacity of the foetus (inclosed in its
membranes) to cry in utero—a belief long firmly attested and universally credited. Said
Velpeau : “Since earned and credible men have heard it, I will believe it; but I should
not believe it if I had heard it myself "
A DI) RESS ON ME DIC A. L J U R IS PR U D E N C E . 173
In 1774, England enacted the first law evincing one touch of pity for the
insane; in 1792, Pinell adopted the first humane treatment of their dis-
ease. Since then, civilization has been slowly taught that those upon
whom our grandfathers inflicted “the pains of Hell” in order to thus
drive the devil out of bodies “accursed by God,” are the most pitiably
diseased of all our fellow creatures, and we are enabled to point with
pride to the palatial asylums with which our laws have replaced the
garrets, cellars, stables, and dungeons, where starved and tortured insanity
once writhed in filth and chains.” The history of the Medical Jurispru-
dence of Insanity is eloquent with the increasing number and efficiency
of the laws designed to protect both society and the sufferer; and with
assurances of the extension of these laws from insanity to habitual
intemperance. .
Is it too much to claim that the progress of Psychological Medicine
has strengthened the conviction that not only mental disease, but also
hereditary organization, defective education, and circumstances for which
society is more accountable than any of its units, do modify criminal
responsibility in fact, and therefore should do so in law 2 IIas not this
special knowledge broadened man’s charity, encouraged society’s efforts
to redeem its outcasts, and influenced the law's amelioration of its
criminal code? Is it not forcing to the front that most important social
question, the problem of heredity ; thus disclosing an immeasurable
field for the medical research and legislative labor of our descendants :
In fine, is it not true that science, stripping nature of providential
caprice and disheartening chance, divinely adorning her with eternal Order
and omnipotent law, has gradually established that the diseases and de-
formities of the mind are as much as those of the body subject to nature's
laws; and that the lunatic, the drunkard, the criminal, the Sage, and the
fool are not the products of chance, but of laws as comprehensible,
though not yet as well comprehended, as those governing that thunderbolt
which, once in the hand of Jove, now traverses even the depths of the
sea at man's command 3
The part this nation has taken in the general progress of Medical
Jurisprudence must now be considered, and to test our progress five
inquiries will be instituted.
I. What have our Laws dome to apply medical knowledge to the Administra-
tion of Justice?–In the United States there are probably forty-five
thousand medico-legal autopsies made annually. The service of a skilled
expert at these “coroner's inquests,” which have exceptional opportunity
and power to detect crime, is of inestimable importance; the opportuni-
ties there presented, if once lost, can never be regained. Further, our
courts have annually from twenty-five hundred to treble this number of
criminal trials necessitating medical testimony; and of these a large
part originate from the coroner's inquests. If to these criminal be added
all the medico-legal civil trials, it would be found, I doubt not, that our
courts require medical evidence in not less than twenty thousand cases
annually.” Whatever the number may be, it would indicate inade-
1 B. 129.
2 In New England, say “Wharton and Stillé,” the insane were sold out to the lowest
bidder, who starved them, and when violent chained them in stables.
3 I have sought in vain for full and reliable statistics to illustrate numerically the im-
portance of legal medicine. The numbers given are only approximative estimates based
partly on some meagre British statistics cited by Guy and by Taylor, and partly on the
174 CHAILLE,
quately the number of citizens whose welfare is involved, and the extent
to which society is interested in the efficient application of medical
knowledge to the administration of justice.
Now, what are the methods which Anglo-American law adopts to
secure in practice that “best attainable evidence” which in theory it
demands : It entrusts medico-legal autopsies, which require special
medical and some legal knowledge, to those having neither the one nor
the other, except by accident; for, these coroners (whose inexperience
our law insures by constant “rotation in office”) owe their position
wholly to political popularity, a qualification which a competent expert
is most unlikely to possess. Are these unqualified officials supplied with
efficient aid : If so, again by accident, since the law leaves it to chance,
or the coroner, or to his still less qualified jury, to provide a medical
expert ; and, as is usual, accident and ignorance provide inexperience and
incompetence. Could ingenuity devise for medico-legal autopsies any
methods more inefficient than these, which Anglo-American laws,
franed before the birth of Medical Jurisprudence, have barbarously per-
petuated 7"
On this Pelion of inefficiency our legislative giants have piled an Ossa
of absurdity; for, besides these fatal defects in the primary legal pro-
ceedings, Anglo-American law, in order to secure “the best attainable
evidence” for its courts, where poverty and dishonor as well as the halter
are administered to the free citizen, clings to a method as Sadly ludicrous
as it is antiquated. To plaintiff and defendant the law gives full license
to summon such medical witnesses as each has already found reason to
following facts as to New Orleans, La., for the year 1875. The total number of coroner's
views and inquests was 1026; of these there were 268 inquests, and out of these grew 47
trials. Giving New Orleans 210,000 and the United States 40,000,000 population, the
New Orleans statistics would indicate for the United States annually 8952 medico-legal
criminal trials, growing out of 51,047 medico-legal autopsies, or coroner's inquests.
| Convincing reasons could be given in proof that the duties of coroners are discharged
even worse in the United States than in England. The following facts indicate how the
Anglo-American method works in the latter country. An Englishman writes (1876) :
“The coroner is elected for life by the rate-payers of his district [a superiority over the
American method], and he is paid a good salary out of the county rates. In most cases he
is a medical man who has studied the arts of popularity with more success than those of
medicine, or he is a small country attorney who has failed in the higher paths of his profes-
sion.” Dr. Wm. Farr officially reported as to England in 1868: When all the verdicts of
coroners “for the first time came under review [another great superiority over the American
lack of any such system], they were not at all creditable to the intelligence of the country.
They conveyed the least possible information in the vaguest possible words.” Prof. A. S.
Taylor wrote in 1873: “The coroner's inquest affords no certainty for the detection of
crime. It, in some instances, tends to screen a criminal.” “In the course of thirty years'
practice, at least fifteen cases of the exhumation of dead bodies were referred to me. On
some of these inquests had been held, but no inspections were made. Verdicts of death
from cholera or natural causes had been returned, and at intervals of from one to twenty-
two months the bodies have been disinterred, and it was then proved that the deceased per-
sons had died from poison.” (See B. 358, I. p. 12.) The British Medical Journal (Jan.
1876) reports a glaring case of poisoning, undetected by the incompetent coroner. National
attention was recently attracted to the same monstrous evil in the inquest of a Mr. Bravo.
An English writer asserts that “almost every day, from all parts of England tales come up
of the inadequacy and absurdity of the institution. Notice has been given to-day [May
23d, 1876] in the House of Commons, by an independent member on the ministerial side,
that he will call attention to the office of coroner at an early day.” Other facts indicate
that England recognizes this evil better than does the United States, and therefore will
probably correct it sooner. July, 1876, it was reported that “the practice of electing coro-
ners has been condemned in the House of Commons by a unanimous vote. A bill for the
reform of the office of coroner is soon to be brought in.” See also B. 259, 274, and 330.
A L) D RESS O N M E DIC A. L J U R IS PR U I) E N C E . 175
believe entertain opinions the most contradictory.' Who are these partisan
witnesses thus summoned by the law to apply the power of medical
knowledge to the administration of justice 2 "Surely these legal represen-
tatives of science must be competent experts 2 No.—Well, experienced
and educated physicians of repute 7 No.—Then, of course graduates, at
least some fledgling hatched in nine months, and fully feathered with
the plumes of every branch of medicine, Medical Jurisprudence included ?
No, not indispensable, since “as a general rule” it has been adjudged
that any practitioner of medicine (that is, any man who dubs himself
Doctor) has sufficient knowledge of medical science to furnish justice
with its “best attainable evidence.” “O, [this] offence is rank, it smells
to Heaven l’’
Common sense would presume that laws, so prodigal to ignorance and
pretension, would provide means to test the value of scientific opinions
by eliciting the facts upon which, if valid, they must be founded. Not
so ; since these opinions are replies to questions, which often by their
very structure comically prove entire ignorance of the facts involved ;
for they are propounded by lawyers to whom these facts are unknown.
Finally, it would be presumed that the decision as to the weight due
such opinions would be left to a judge or jury specially chosen. No,
even this last poor boon is denied by the law
With the power of medical science thus crippled at the coroner's
inquest, then prostituted by the partisan opinions of incompetent experts,
then perverted by advocates, and at last when emasculated of all vigor
submitted for decision to those unable to estimate its weight; what
wonder that such gross misapplication of medical knowledge brings
upon it that public contempt which belongs justly to methods so mon-
strous, and to which true medical knowledge is a helpless, pitiable, and
disgusted victim'
But these legal defects, so paralyzing to the past, so discouraging to
! Reference is often made to the well-known facts that the sound expert-evidence of the
illustrious John Hunter was in 1781 overborne by the evidence of three ignoramuses, and
that the testimony of the famous Denman was in 1806 set aside by the Court in favor of
one male and two female quacks. The same system is continued, and therefore the same
evils persist. Prof. A. S. Taylor reports now, as to England, that a good search and good
pay can always find, in abundance, the witnesses needed on either side of any medico-legal
issue. This is certainly true as to the United States. Some facts may be cited in illus-
tration. I have personal experience in a suit (unsoundness of a slave) in which the medical
experts were selected by one side because of their well-known ignorance of the special
knowledge (auscultation) which the issue involved; and the judge decided that the whole
medical testimony must be set aside, because the negative evidence of the incompetent suf-
ficed to counterbalance the very positive affirmative testimony of the competent experts.
Death, with a post-mortem examination, soon after the decision, conclusively proved that
the ignoramuses deserved no consideration in justice, though they did receive equiponderant
consideration in law. Whenever a notorious trial attracts public attention, the results of
our defective laws become disgracefully apparent, as has been illustrated in recent years by
the Steinecke-Schoeppe (1868), the Wharton-Ketchum (1872), and the Stokes-Fisk (1874)
trials (B. 363, 344, 370). If the medico-legal proceedings are so discreditable in cases like
these, exciting great public interest and engaging the best legal and medical talent, what
robably are they in ordinary trials lacking these advantages 2
* The text will be found fully sustained by reference to B. 317, pp. 131–2, B, 349, I. pp.
283–5, and B. 363, p. 406. However, Elwell (B. 330, p. 589) refers to eight decisions to
the effect that “special knowledge must be fully established before a witness can be ex-
amined as an expert;” but had he stated by what slight proofs, and by what incompetent
judges, this “special knowledge must be fully established,” the apparent discrepancy would
have practically disappeared. An eminent lawyer assures me that in the courts of my
native State (Mississippi) the competency of a medical expert rests solely on his own oath;
and that, when his own interests and reputation prompt such an oath !
176 - CHAILLE,
the future of Anglo-American Medical Jurisprudence, are not the only
disadvantages against which this nation has had to contend. It in-
herited from Great Britain not even a page of the literature, in fact
nothing of Medical Jurisprudence except laws hostile to it. So desti-
tute was it of those indispensable promoters of science, well endowed
institutions, with libraries, laboratories, and museums; so exhausted by
the war for independence; so closely occupied by the pressing demands
of daily life; and so profitably absorbed by glorious efforts to present to
civilization a savage continent, that every science seems to have required
half our century to secure the conditions necessary to fairly begin its
culture." Another potent, yet ill-appreciated friend to science, pressure
of population, now wanting in many, was long wanting in every State.
Tinally, while a European nation requires but one legislative body to
reform its laws, our political system now necessitates the action of thirty-
eight State-legislatures to embrace the entire nation.
Just consideration of all these impediments should incline other
nations not to condemn, if we have done little for Medical Jurisprudence,
but rather to wonder that we have done anything at all ; and to con-
gratulate us that, so great has been the diffusion of knowledge, so ardent
the love of justice, we have in the main kept pace with, and in some
particulars have even Outstripped, our mother-land. Fairly we can claim
no more ; reasonably no more should be expected.
II. What have our Medical Colleges dome to cultivate and to disseminate a
knowledge of Medical Jurisprudence 2—The first chair of Medical Juris-
prudence was established by the “College of Physicians and Surgeons”
of New York City, and filled by Prof. Stringham,” in 1813. In 1815
two other Colleges' had chairs devoted to the usual branches with
Medical Jurisprudence attached to some one of these. In 1825 there
were about twenty-two medical colleges; of these only one had a full
chair, and only five others had even the fraction of a chair devoted
to the subject.” At present (1875–6) there are sixty-four regular
medical colleges (four of these for women). A report" as to forty-six of
| To illustrate this as to medicine, and also the practical difficulty encountered by the
courts in securing, under our laws, the evidence of competent experts, the following facts
are stated: Prof. S. D. Gross reports that in 1776 the United States had about 3000 prac-
tising physicians, of whom the great majority had never received a medical education, and
those who had, were educated abroad. Prof. Austin Flint, Sr., reports that in 1776 our
two medical colleges (one founded in Philadelphia in 1768, the other in New York City in
1770) had not graduated even fifty doctors of medicine, and that up to 1800 the five colleges
then existing had graduated only about two hundred. Thacher’s “History of Medical
Science in the United States” reports that it was computed that in 1826 the United States
had 10,000 “ very easily graduated” doctors of medicine, and more than 15,000 practitioners
without diplomas. Prof. John B. Beck wrote that, “at no period in the history of this
country, it may safely be asserted, has empiricism flourished to the same fearful extent as
at the present time [1845], notwithstanding our boasted improvements in other respects.”
In 1870, the United States had 62,383 practitioners of medicine; of these there were per-
haps 47,000 “very easily graduated” doctors, and at least 15,000 quacks outside of profes-
sional ranks.
* Dr. Stringham was also the first lecturer on Medical Jurisprudence in the United
States, viz., in New York City in 1804.
* In 1815, “The College of Physicians and Surgeons of the Western District of New
York” appointed Dr. T. R. Beck “Professor of the Institutes of Medicine, and Lecturer on
Medical Jurisprudence;” and the Medical Department of Harvard University (Cambridge,
Mass.) appointed Dr. Walter Channing “Professor of Midwifery and of Medical Juris-
prudence.” -
* See “Thacher's History of Medical Science in the United States, 1828.”
* Due to the courtesy of (my colleague on this occasion) Prof. N. S. Davis, M.D., of
Chicago, Ill. The forty-six graduate more than nine-tenths of all our annual graduates.
The twenty-five graduate fully one-half of the whole number.
A D D RESS ON ME DIC A. L J U R IS PR U D E N C E. 177
the most noted, shows that twenty-one do not profess to teach the subject;
of the remaining twenty-five, only fourteen (and these not the best known
and attended) have professorships devoted exclusively to Medical Juris-
prudence, and, by five of these fourteen, students are taught to become
medical experts by lawyers ; while the other eleven have Medical Juris:
prudence “tacked on as a caudal appendage” to some one of the usual
branches. In fine, only about one-half of even our best colleges profess
to pay any special attention to the subject; and many facts could be
cited to prove that the true significance of the whole matter, from 1813
to the present day, is correctly represented by the following quotations
from one of the most prominent of our living medico-legists:–%
“There are very few of the medical colleges in which it is taught, and
still fewer in which it takes rank as a distinct and independent branch
along with the other departments. Usually when it professedly receives
any attention at all, it is tacked on, as a sort of appendix, to some other
branch with which it has no natural affinity whatever, as, e.g., Obstetrics
or Materia Medica. This is of course done to make a show on the pro-
gramme, while the subject itself is not taught systematically to the
student, if taught at all.” “I very much doubt whether Medical Juris-
prudence is ever made a qualification for graduation, even in those
colleges where it is professedly taught as one of the regular branches.”
From these facts it is manifest that, since 1813, our colleges (the off.
spring of the enterprise of individuals, and not of the State) have made
ineffectual efforts to cultivate that special knowledge which, while
highly beneficial to the State, would not benefit the individual members
of our profession any more directly than any other citizens. In fact, the
States through these citizens have failed to provide honorable and profit-
able employment for medico-legal experts, and, therefore, the profession
has not furnished them ; and, however enlightened the colleges, however
praiseworthy their efforts, they will continue to contend in vain against
the obstinate “demand and supply law” of political economy.
The profession recognizes the absurdity of the popular and legal pre-
sumption that every practitioner is a medical expert; but the profession
does not yet recognize sufficiently that even the most skilful healers of
disease are neither necessarily nor generally medico-legists; and that the
experience of other nations has fully proved that merely didactic lectures
can never render medical graduates competent experts. Were this feasi-
ble, any such ideal education is now impracticable; for who will deny
(1) that our two short courses of lectures are insufficient for proper
instruction even in the fundamental facts indispensable to the education
of practitioners of medicine; (2) that the fundamental facts for the prac-
titioner are the same as for the medical expert; and (3) that Society
remunerates the one, while the State finds no use for the other? Finally,
there is reason to fear that, until the State demands medical experts, the
colleges, dependent on the student and not on the State for their exist-
ence, will be forced by these practical students to realize continually the
| Casper insists, with good reason, that the medico-legist should remain a physician;
and become neither a lawyer, jurisconsult, nor judge, but simply an expert witness, who
does need from the law thorough instruction in the “rules of evidence.”
* John J. Reese, M.D., Professor of Medical Jurisprudence in the University of Penn-
sylvania. (See B. 247 and 362.)
* Some only of our Law Schools have professorships of Medical Jurisprudence; and there
is good reason to believe that the general facts as to the Medical are fully applicable to
the Law Schools, as far as instruction in Legal Medicine is concerned.
a-l
178 CHAILL É,
force of the homely adage, “you may take a horse to the water, but you
cannot force him to drink.”
III. What new Facts have Americans added, by original research, to the com-
mon stock of Medico-legal Science?—Restricting the list to researches design-
edly and specially medico-legal, it must be borne in mind that the sum
total of these in all nations has not been very large, and that few should be
expected in this country for reasons already stated. Prof. John C. Dalton
(though to some extent anticipated by Coste (1849) whose researches were
unknown to Dalton) was the first (1851) to make a rigid comparison
between the corpus luteum of menstruation and that of pregnancy ; and
to distinctly indicate the differences which, during a certain period,
enable the expert to determine from an inspection of the ovaries whether
pregnancy has or has not existed." T)r. Joseph G. Richardson announced
in 1869 the important medico-legal discovery that, by the proper appli-
cation of high powers of the microscope, human blood-corpuscles could
with certainty be discriminated from those of certain animals;” thereby
enabling the expert to refute such statements as criminals have often
offered to explain the presence of condemnatory stains of blood. Though
the justice of this claim has been questioned, yet some of the highest
authorities emphatically sustain it; and this discovery has been usefully
applied in several criminal trials.” Dr. Richardson deserves the additional
credit of having called attention in 1875° to a simple method of so treat-
ing a blood-stain, of even microscopic size, that it can be successfully
examined by the spectroscope and guaiacum test,” as well as by the
microscope.
Researches by which error is exposed, or truth more firmly established,
are often as important to science as those which discover new facts.
Among such researches may be mentioned those of John B. Beck, on
Ploucquet's" and on the hydrostatic test," in 1817 and subsequently ; of
Horner, on the mucous membranes of the stomach and intestines, in
1827; of Gross, on strangling, in 1833; of Wetherill, on adipocere,” in
1855; and of Fleming, on blood-stains, in 1859.”
Contributions by my countrymen to the progress of Medical Jurispru-
| See B. 257; also, Coste's second livraison, “Histoire du Développement,” 1849; and
the adoption of Coste's views in Longet’s “Traité de Physiologie,” II. p. 88, 1850.
* “An objective 2'; to go inch distinguishes human blood-corpuscles in stains (but not in
dried masses of blood) from those of the ox, pig, sheep, cat, horse, deer, and goat.” (See
B. 320, 373, 374,376, 377.)
* Since the delivery of this address, eminent microscopists have made on the pre-
ceding periods two criticisms. First, that the word “discovery” is misused—since it has
long been known that the blood-corpuscles of the “certain animals” are much smaller
than those of man, as also that high powers render this difference in size more appa-
rent. Second, that the words “with certainty” demand a modifying explanation, since
able observers declare that cases do occur wherein human corpuscles in dried stains
shrink, so as to be as small as those of the “certain animals”: hence, that the expert
when confronted with such small corpuscles cannot swear “with certainty” whether
these be human ; but if the specimen of corpuscles approximate those of man in size,
then the expert can swear “ with certainty” that they are not those of any one of the
“certain animals,” inasmuch as corpuscles in dried stains do shrink, but do not enlarge.
The issue thus raised is as to the amount of shrinkage of human red blood-corpuscles in
dried stains; Dr. Richardson asserts that this does not exceed ten per cent. ; while others
assert that this may be thirty per cent., the corpuscle shrinking in size to rºad, or
even to # 66 m inch.
4 B. 375. * Van Deen, 1862, and A. S. Taylor, 1868.
6 1782. 7 Jan Schreyer, 1682. * Fourcroy, 1785–7.
* See B. 205, 215, 225, 267, 287. To this list might be added Brown-Séquard's experi-
ments in 1851 on Cadaveric Rigidity. (Am. Journ. Med. Sci., Oct. 1851.)
A DT) RESS O N M E DIC A. L J U R IS PR U D E N C E . 179
dence during a century, present a field for investigation so extensive,
that some of these contributions may have escaped my search, or may
have been inadequately appreciated. To rectify, at least in some mea-
sure, any such defects, I present, with this address, a Bibliography of
American Medical Jurisprudence, to which attention is invited. The
next inquiry is:—
IV. What culture of Medico-legal Science is evinced by our Literature ?'.
1. GENERAL TREATISES.—The embryonic stage of medico-legal litera-
ture in our mother-tongue is attested by the following “footprints on
the sands of time.” Farr’s “Elements of Medical Jurisprudence,” an
abridged translation of Faselius, was the first general treatise in the
English language, and the only one from 1788 to 1815, when another
worse little duodecimo was added by Bartley.” In 1816 Male contributed
an insignificant “Epitome of Forensic Medicine,” borrowed from
Plenck,” and in 1821 John Gordon Smith, M.D., published a small book,
which was the first original and meritorious treatise in our language.”
In 1823 appeared, in two large octavo volumes, the American, Theo-
dric Romeyn Beck’s “Elements of Medical Jurisprudence,” which, in
spite of the merit of Smith's book, and of the greater merit of Paris's and
Fonblanque's English treatise," also published in 1823, quickly sup-
planted these wherever the English language was spoken. From the
date of its publication, which may be deemed the origin, in fact, of
Anglo-American medico-legal science, its twelve successive editions have
ably kept pace with the progress of legal medicine. Filling many offices
of trust and honor, a member of twenty American and seven foreign
scientific societies, Prof. Beck” lived to witness the issue of ten editions
of his treatise; of these, several were published in England, and even the
prolific mother of medico-legal literature issued in 1828 a translated
German edition. But to Beck’s merit no testimony can be more con–
vincing or pleasing than that gracefully given by the three eminent
authors whose works eventually succeeded in largely supplanting his
treatise in Great Britain. Traill, the distinguished Scotch professor and
author, eulogizes it as “the best work on the general subject which has
appeared in the English language;” Guy “acknowledges his obliga-
tions in a special manner to Beck’s learned and elaborate Elements of
Medical Jurisprudence;” and Taylor, than whom there is no higher
living authority, testifies that he, when a student, was stimulated by
Beck’s work to study medical jurisprudence in 1825, when no lectures
were delivered in England on the subject, and this book was the leading
authority for both lawyers and physicians; and that it “will carry
down” the author’s “name to future years as one of the most erudite and
distinguished writers on medical jurisprudence.”
To these testimonials from abroad may be added the eloquent eulogy
of that son of America whom its medical profession delights to honor as
one of its noblest representatives, and as its President on this occasion.
His voice, generous to all, even loving to worth, declares that “this
grand book” “was in its day the most comprehensive, able, and erudite
production on the subject of which it treats in any language,” and that
it “constitutes a lasting monument to the genius, industry, judgment,
| B. 150, also 207. 2 B. 151. * B. 152, also 207.
4 B. 47. 5 B. 153. 6 B. 209. 7 B. 154.
8 Born in 1791; died in 1855. For the biographies of Drs. T. R. Beck, John B. Beck,
and Moreton Stillé, see Gross's “American Medical Biography,” 1861.
9 B. 158, 2d Ed. 19 B. 161, 2d Ed. 11 B. 359.
180 CHAILLE,
and learning of its lamented author.” It is pleasing to learn from the
same source that, in honoring this famous author, we are honoring the
memory of a good and noble man; and this pleasure is enhanced by re-
calling the humble estimate which he himself accorded to his “world-
renowned book.” For his own statements were that his “highest ambi-
tion would be gratified” if his “collection of detached essays” should “ in
some tolerable degree” “prove useful.” Knowing that these modest
words will find a generous echo in the hearts of all noble men, to them
is commended the fame of America’s first and greatest medico-legal
author.
In 1850, Prof. Amos Dean, a lawyer, published his brief but excellent
text-book, the “Principles of Medical Jurisprudence,” which has passed
through three editions.
A lawyer and a physician united to produce in 1855 the voluminous
and admirable general treatise, “Wharton and Stillé's Medical Jurispru-
dence.” After completion, but prior to its publication, profession and
country had cause to mourn the death of the young and gifted Moreton
Stillé.” His legal associate, deriving from other able pens indispensable
medical aid, has lived to issue three editions of a work which both pro-
fessions accept as one of the highest standard authorities.
Evidence of our increasing appreciation of legal medicine, as also of
our obligations to foreign sources, is found in the republication, since
1819, of nine books by British authors on the general subject, viz.,
Cooper's collection of the earliest English tracts (1819), and the nume-
rouš valuable articles in the “Cyclopædia of Practical Medicine” (1845),
which deserve mention with the general treatises of Ryan (1832), Chitty
(1836), Traill (1841), Guy (1845), and Woodman and Tidy (1876); and
of still greater value Taylor’s “Manual,” as also his “Principles and
Practice of Medical Jurisprudence” (1845 to 1873).”
2. TREATISES, ESSAYs, ETC., ON SPECIAL SUBJECTS.–Desides the excellent
books of Ray, Elwell, Ordronaux, Wormley, Reese, and the New York
“Medico-Legal Society,” the essays and articles on special topics have
been too numerous to permit full examination, or more than a partial
sketch of this important branch of my subject.
Infanticide and foeticide received from Prof. John B. Beck attention in
1817;” and this thesis, enlarged and improved for the various editions of
his brother’s “great work,” displays a combination of erudition, original
research, sound sense, and rhetorical excellence, which render it one of the
most classical essays in the medical literature of the English language.
Abortion has been further illustrated by the essays of Hodge (1839,
1873), Storer (1866, 1867), Heard (1868), and others; as also by numerous
valuable articles in our periodical literature.” Apparently increasing
with the pressure of population, this stain on modern civilization has
become one of the most serious and hopeless problems within the province
of Legal Medicine, and demands the grave consideration of every enlight-
ened citizen. .
! See pp. 39, 65, “History of American Medical Literature” (1776–1876), by S. D.
Gross, 1876.
2 J3. 254. - 8 B. 264. * Born 1822; died 1855.
* B. 207, 245, 223, 231, 239, 246, 390, 247, 358. 6 B. 205.
7 B. 236, 279, 305, 309, 314, 310, 315, 325, 341.
* In the “Specimen Fasciculus of a Catalogue of the National Medical Library,” 1876,
pp. 24–5, are reported from our medical journals thirty-nine articles on this subject, since
1825, by Americans; of these, twenty-three have been published in the last ten years.
A D D R E SS O N M E DIC AI, J U R IS PR U D E N C E . 181
Elwell’s “Malpractice and Medical Evidence” (1860, 1871) and Ordro-
naux’s “Jurisprudence of Medicine” (1869) are very valuable works—
legal rather than medical—and unique, it is believed, in medico-legal litera-
ture. In connection with malpractice, IIamilton’s noted essay on “De-
formities after Fractures” (1855) and his standard treatise on “Fractures
and Dislocations” (1860–1875) deserve mention, since more than half of
all trials in the United States for malpractice have originated from the
results of these injuries.”
Supplied with domestic editions of Orfila (1819, 1826), Christison
(1845), and Taylor (1848–1875), on Poisons, and with Naquet's Legal
Chemistry (1876)," native authors have produced two meritorious works
on Toxicology. Wormley’s “Micro-Chemistry of Poisons” (1867) has
received the most flattering commendation from the highest authorities,
who report this book to be the result of original researches which enrich
it with the treasures most valuable to science. No more will be said,
because the author is not only living but present, and no praise from me can
enhance the reputation of his work. The same considerations prohibit
more than reference to Reese's excellent “Manual of Toxicology” (1874),
which has been republished in London.
On the most important specialty, America has produced one treatise,
Ray’s “Medical Jurisprudence of Insanity.” In 1838, when first pub-
lished, there were few such treatises extant,” and it at once assumed, and
throughout an English, a Scotch, and five American editions, has
deservedly maintained, the first rank in Anglo-American medical litera-
ture. An able advocate of “moral mania”—the present battle ground
in the Medical Jurisprudence of Insanity—Dr. Ray does not forget,
while urging a larger charity for disease, to demand ample and better
legal means to protect society. Besides this treatise, essays of value
have been published by Hammond (1866, 1873), Fisher (1872), and
Cowperthwait (1876)," and numerous meritorious reports and articles
have richly adorned our periodical literature." It would require a volume
to do justice to the medico-legal labors of the Superintendents of our
Insane Asylums, and to record the evidences of progress presented solely
in the “American Journal of Insanity;” while some of the most valua-
ble essays on this and other special subjects are to be found in the pub-
lications of the New York Medico-Legal Society.”
There are four other works which, treating incidentally of the Medical
Jurisprudence of Insanity, deserve mention: the notable “Diseases of
the Mind” (1812–1835), by Benj. Rush, a father of this republic and “the
father of its medical literature;” Seguin’s “Idiocy” (1866); Echeverria’s
“Epilepsy” (1870); and Hammond’s “Diseases of the Nervous System”
(1871–1876).”
Fourteen foreign books on insanity have been republished in the
United States. Five treat specially of its legal relations, viz., those by
1 B. 290. 2 B. 317. 3 B. 266.
* B. 330, pp. 55 and 587; and B. 213. 5 B. 206. 212, 244, 252, 389.
6 B. 307. 7 B. 362. 8 B. 234. wº
* Viz.: Haslam's. 1807; Hoffbauer's, 1809; Georget's, 1827; Conolly's, 1830.
10 B. 304, 338, 348, 385.
11 B. 216. 265. 275, 278, 282. 283, 284, 285, 295, 296, 302. 304, 311, 316, 322, 323, 324,
327, 331, 332, 347, 353, 354, 357. 365. 366, 368, 369. 379.
In addition to the above, Dr. John S. Billings, U. S. A. (Surgeon-General's Library) has
kindly furnished a selected list of 88 medico-legal articles by Americans on unsoundness of
mind ; of these, the first was in 1827 : 79 since 1850; and 41 of the 88 since 1865.
12 B. 363. * B. 203, 303, 321, 326.
182 CHAILLE,
Highmore (1822), Blandford (1871), Maudsley (1874), Sheppard (1875),
and Browne (1876); and nine treat of these relations incidentally, viz.,
those by Combe (1834), Prichard (1837), Esquirol (1845), Brierre de Bois-
mont (1855), Bucknill and Tuke (1858), Winslow (1860, 1866), Maudsley
(1867, 1871), Tuke (1873), and Wynter (1873).”
This incomplete sketch of our medico-legal literature attests that it has
since its origin progressively increased, and that a very large proportion
has been furnished during the last ten years; thus indicating a diffusion
of this knowledge to an extent which encourages the hope that such
appreciation of its importance is in growth as will insure its proper use.
That our progress in this literature may be properly estimated, as far
at least as increase of quantity is concerned, it is indispensable to com-
pare it with that of other nations. As concerns general treatises, this
nation, beginning in 1823, has produced three " Germany, beginning a
century earlier, published at least forty before, and more than twenty
since 1823; France beginning in 1796 published nine before, and seven
since;" and Great Britain, making its first creditable effort in 1821, pub-
lished its second in 1823, and has issued eight since." If a comparison
as to special treatises be instituted, a like result ensues, and a search into
periodical literature proves even more unfavorable. Since 1782, Germany
alone has had, and now has, several journals of great merit devoted ex-
clusively to Legal Medicine, from which flow, to the benefit of all nations,
a constant stream of medico-legal knowledge. France has had, only
since 1829, one of the ablest journals' in the world devoted to State
Medicine, but not one to Medical Jurisprudence exclusively. Great
Britain has no such journal, nor has this nation except in so far as repre-
sented, since 1874, by the valuable “Psychological and Medico-Legal
Journal” of Prof. Hammond.
These facts tend to prove that the culture of medico-legal literature
is proportionate to the use made of it by the law ; and prompt the com-
ment that, however valuable compilations may be, these and the pro-
gress of every science depend ultimately on original research, and the
labor of practical workers. Germany has produced many, France several,
and Great Britain one or two, practical medico-legal experts of wide-
spread fame. This people has never had, nor is it likely to have, one,
until it provides for him honorable and lucrative employment.
V. What illustrations of medico-legal progress are to be found in the Insti-
tutions, Laws, and Judicial Decisions of our States?—Originated by vital
statistics, nourished by medical selection, protected by medical evidence,
Life Insurance, the wondrous child of Medicine and Finance, encourages
the hope that it will repay our science the debt it owes. Causing
numerous medico-legal suits, its vast interests are deeply involved in the
legal reforms indispensable to the progress of Medical Jurisprudence;
for these interests are often sacrificed by the negligence of coroners,” the
incompetence of experts, and the inefficiency of our medico-legal methods.
While Life Insurance suits have most frequently grown out of intem-
perance and suicide, yet there would seem to be few medical issues on
which they may not depend, even on whether death was due to consump-
I B. 208, 334, 371, 382, 388, * B. 226, 232,243, 270, 286, 297, 313, 335, 360, 361.
* B. 209, 254, 264. * B. 29 to 94. * B. 114 to 128.
8 B. 153 to 164. 7 Annales d’Hygiène et de Médecine Légale, Paris.
* The issue has recently been raised, in reference to a case, the subject of a coroner's
inquest, whether death was due to intemperance or to heart-disease. A medico-legal
autopsy would have probably prevented any such issue, but this was totally neglected.
A D D R E S S O N M E DIC A. L J U R IS PR U D E N C E . 183
tion or to diphtheria. To illustrate the progress and extent of the
medico-legal interests involved, it deserves record that, in 1840, there
were in the United States only three or four companies having an insig-
nificant amount of business; that in 1874 there were seventy-seven
companies insuring $2,226,000,000 upon 910,000 policies; and that the
annual average number of lives insured during the past three years has
exceeded 200,000.”
The growth of Life Insurance is one of many examples which illustrate
the fact that the importance of Medical Jurisprudence has constantly
increased with the progress of medicine, and the requirements of civili-
zation. None the less, there are instances where, through legal and
other causes, the bounds of Legal Medicine have been restricted.
When suicide ceased to be a felony,” it ceased to concern Legal Medicine,
except when the suicide's life was insured; feigned diseases have under
our laws little importance; and, with the abolition of imprisonment for
debt, and of slavery, there disappeared from the courts many medico-legal
questions. To education,” Forensic Medicine owes a diminution of its
duties in deciding the degree of criminal responsibility of the deaf and
dumb ; all of whom, long held as “legal idiots” under the “perpetual
pupillage of the law,” were disabled from making a contract, will, or
valid marriage. Possessing no institutions for their education until
1817,” the United States had, in 1875, forty-eight institutions, with 5309
pupils, so that “nearly all the deaf mutes of school-age within the country
are now receiving instruction”; and, since “all pupils on leaving school
take their places as responsible members of society, in possession of full
civil rights,” they cease to be of special medico-legal interest." t;
In this, as in every civilized nation, the best examples of medico-legal
progress are furnished by the institutions, laws, and decisions benefiting
* I have been summoned (1876), as a medical expert, to testify to my opinion as to
whether a death was due to consumption, as the main issue, and, secondarily, whether due
to consumption or to diphtheria.
* For these statistical facts I am indebted to Mr. C. C. Hine, Editor of the Insurance
Monitor, No. 176 Broadway, New York City. Mr. Cornelius Walford, of London, the
highest authority on this subject, has kindly furnished, for comparison with the United
States, the following among other interesting facts: Life Insurance was begun in the
United Kingdom (Great Britain) on a scientific basis in 1762, and reached its maximum in
1865–1868; in 1874 there were 120 companies, which issued 47,516 policies, and had in
force an unstated number of total policies insuring £362,238,534. In France it was first
legalized in 1787, and fettered with many legal restrictions which were removed in 1819;
in 1870 there were 166,474 Life Policies, insuring £66,312,000, and 58,572 annuity con-
tracts, securing annual annuities amounting to £1,528,600; and in 1874 there were 72
companies, having in force an unstated number of total policies insuring £49,906,400. In
Germany (including German Austria and German Switzerland) Life Insurance was begun
in 1827 ; in 1874 there were 51 companies, having in force 645,989 policies insuring a little
under £100,000,000; and the new policies issued in one year (1873) were 98,692.
* By English law the suicide was required to be buried in a highway “with a stake
driven through the body” (repealed in 1823), and his property confiscated. Juries, more
humane than the law, generally decided that suicides were insane, and therefore irre-
sponsible. Beck in 1823 (B. 209, 1st Ed.) congratulates the United States that “we do
not war on the dead body in this country.”
* The Abbé de l'Epée published in 1759 the first modern method to teach mutes, by
sign-language. To him and to his disciple, the Abbé Sicard, civilization owes the initiation
of the education of mutes. The first educational institution was established in France in
1760. Europe had about thirty of these institutions in 1817.
* The first institution founded in the United States was the American Asylum, Hartford,
Conn., 1817. * >
* I am greatly indebted for the above statistical and other interesting facts to Mr. I. L.
Peet, Superintendent of the New York Institution, the second one founded in the United
States, viz., in 1818. (See B. 340.)
184 CHAILLE,
all who, no longer possessed or seduced by a legalized devil, are in fact
afflicted with “unsoundness of mind,” from mental disease, deformity,
or debility." By legislation many measures (still very incomplete in
most, and not complete in any, of Our States) have been adopted for the
counter-protection of both the insane and the same. The corner-stone of
these measures has been the establishment of Insane Asylums. Deginning
our national existence with two of these, having only eleven in 1830, we
now possess about eighty public asylums, accommodating more than 30,000
of our 45,000 insane population.” The knowledge derived from these
schools for scientific observation, is destined to benefit those without,
even more than those within, their walls. Stimulated by this knowl-
edge, the law is extending its protection, from insanity, to all who by
intenperance “ have lost the power of self-control.” In this reform,
New York, in 1854, pioneered the way with the first legislation pro-
viding for the restraint in a public asylum of habitual drunkards. In
1858, this State, as also Massachusetts, supplied the asylums indispensable
for the execution of the law. With an origin thus recent, there are now
at least seven asylums in five States, and four additional States have
legislated to accomplish the same end.” The best interests of society
require that this progress shall continue until the laws of every State
provide for every person, whose abuse of his own liberty outrages the
rights of others, ample protection both for himself and for society.”
Maine and New York illustrate additional progress in the jurisprudence
of insanity. It is conceded that, within this century, unfortunates have
been legally murdered for illegal acts, the product of disease and not of
a “vicious will.” To prevent these “bitter mockeries of justice,” Anglo-
American law, so jealous of the “liberty of the subject,” fails not only
to provide him, when his life is imperiled through brain-disease, with
competent experts, but also to provide these with proper time and oppor-
tunity to decide a question so difficult as doubtful sanity. It is not
strange that decisions reached through such defective means should
cause constant dissatisfaction, nor that this should have been more
serious prior to the establishment of State Lunatic Asylums; for it then
occurred that he who might be acquitted of homicide, because of insanity,
was freed by the law, and permitted to live a constant danger to society.”
Maine, in 1847, wisely enacted that “when any person is indicted for
a criminal Offence, or is committed to jail on a charge thereof, . . .
' This progress has been especially notable since 1830.
* For these statistics I am indebted to Dr. John P. Gray (my colleague on this occasion),
who reports 54 State Asylums in 1875, accommodating 21,542 patients; 9 State Asylums
in process of erection to accommodate 4600; 18 other public asylums accommodating
6064; and 10 private asylums accommodating 254 insane.
° Our effective Inebriate Asylums are: the Washingtonian Home, Boston, Mass., since
1858; the State Inebriate Asylum, Binghamton, N. Y., since 1858; the Inebriates'
Home, King's Co., N. Y., since 1867; the Washingtonian Home, Chicago, Ill., since 1864;
the Sanitarium, Media, Pa., since 1867; the Harlem Asylum for Inebriates, Baltimore,
Md., which was opened in 1871; and the Franklin Reformatory Home for Inebriates, in
Philadelphia, Pa., opened in 1872. California enacted the requisite laws in 1870, and
Connecticut in 1874. It is believed that Texas and Kentucky have legislated on the
subject. For the facts stated I am indebted to Dr. Albert Day, Sup’t of the Washingtonian
Home, Boston; to Dr. D. H. Dodge, Sup’t of the Binghamton Asylum ; and to the
Annual Reports (since 1871) of the “American Association for the Cure of Inebriates.”
* In connection with intemperance, it deserves record that only within the present
century have Anglo-American Judges inclined to admit drunkenness in extenuation of
crime, ºriying it of premeditation. (See B. 329, p. 567.)
* B. 349, I. p?759. An eminent lawyer asserts that this still occurs in some of the States,
notwithstanding the State Lunatic Asylums.
A D D RESS ON ME DIC A. L J U R IS PR U D E N C E . 185
any judge of the court before which he is to be tried, when a plea of
insanity is made in court, or he is notified that it will be made, may
§ order such person into the care of the superintendent of the in-
same hospital, to be detained and observed by him till the further order
of the court, that the truth or falsity of the plea may be ascertained.”
New York, in 1874, enacted laws which provide for “an investigation
of the sanity or insanity of the accused, as a separate and independent
proceeding from the trial of the indictment,” and, after such preliminary
investigation, “leave the question of the guilt or innocence of the accused
to be tried by itself.” Thus have Maine and New York lessened the
frequent difficulty of choosing between “inhumanity to disease, and in-
dulgence to crime.” *
Five States” have aided the solution of this problem by progress in
another direction. For, by the abolition of capital punishment, the cruel
alternative between the asylum and the gallows has been obviated, and
no shocking injustice can be perpetrated by confining in a penitentiary,
rather than in an asylum, him proved dangerous to society. It was a
great advance in civilization when the victor ceased to slaughter, and by
enslaving utilized the lives of the vanquished. Will it not be proof of
like progress when society has fully learned how best to utilize the lives
of all its criminals 33
Notwithstanding that there is still great lack of uniformity in the de-
cisions of our courts as to what are the proper tests of insanity, there has
been decided progress. Until Pinel’s day (1792), insanity had never been
properly studied, hence physicians were little less ignorant and superstitious
in regard to it than the public. In the absence of medical knowledge,
what could the law do other than establish tests for itself? Until 1800,
the savage test of Anglo-American criminal law was that he alone should
be adjudged insane, who was “totally deprived of his understanding
and memory, and did not know what he was doing any more than an
infant, than a brute, or wild beast.” In 1800, it was, for the first time,
mercifully decided that those whose crimes were due to an “insane de-
lusion,” should not be hung, even though not yet wild beasts.” In 1812,
it was decided that the correct test was whether the criminal alleged
insane had, as to matters generally, “the power of distinguishing right
from wrong;” and since 1843, in England, and to a large extent in this
country, the judges’ test has been, whether such criminal had, as to his
special crime and at the moment it was committed, “a sufficient degree
of reason to know that he was doing an act which was wrong.”
But, since 1800, alienists have taught, in constantly increasing number,
that a capacity to distinguish right from wrong is an inadequate test,
! B. 364.
* Michigan in 1846; Rhode Island in 1852; Wisconsin in 1853; Iowa in 1872; and
Maine in 1876. Blackstone, referring in 1769 to England’s “dreadful list of 160 capital
offences,” hoped for “such a gradual scale of punishment to be affixed to all gradations of
guilt, as may in time supersede the necessity of capital punishment, except for very
atrocious crimes.” (Book IV. p. 371.) In the various States, other than the above, capital
punishment is now inflicted for only from three to eight “very atrocious crimes.”
* My brief allusions to the “abolition of capital punishment” and to “moral mania,”
intimate convictions which may cause misapprehension. For until our present defects in
the administration of justice, in the constitution of our juries, and in the means needed to
fully protect society, be remedied, I shall believe that our courts have gone generally as far
as, and often much further than, the best interests of society require.
* In 1800, Lord Erskine initiated the first enlightened legal discussion of insanity; and
the Attorney-General of England then declared that the “wild beast theory’ of Lord
Hale had never been contradicted, but had always been adopted.
186 CHAILLE,
and that, not infrequently, while the reason is apparently able to make
this distinction, the will may be so enfeebled, and the morals so perverted
by disease, as to deprive the sufferer of that “vicious will” necessary to
constitute a crime. The first Anglo-American judges to adopt these
lessons of medical science, were Shaw, of Massachusetts, in 1843, and
Edmonds, of New York, in 1845. They ruled that insanity was proved
if the homicide “ had no power of control;” “if his moral or intellectual
powers were so deficient that he had not sufficient will ;” and “if he did
the act from an irresistible and uncontrollable impulse.” The learned
Edmonds took occasion to observe that “the law in its slow and cau-
tious progress still lags far behind the advance of true knowledge,” and
the history of the progress of Legal Medicine proves the truth of this
observation as to every medico-legal topic. How can this be otherwise
while, as another legal authority asserts, our “legislatures are much
better versed in the miserable tactics of party, than in the . . . laws
of physiology,” and while judges, as well as legislators, mindful as they
should be of precedent, that friend to uniformity and stability of the law,
do, in their superstitious reverence, often forget, not only that “the law
of nature, being coeval with mankind and dictated by God himself, is of
course superior in obligation to any other,” but also that science is con-
stantly engaged in revising and adding to our knowledge of this supreme
law, thus increasing man’s power to “think the thoughts of God!”
Improving on Shaw and Edmonds, Judges Bell, Perley, Ladd, and
Doe, of the Supreme Court of New Hampshire, have, since 1864,
announced the only principles worthy of both legal and medical science.”
and have thereby merited the profound gratitude of the medical profes-
sion, and lasting commemoration in the annals of Anglo-American
Medical Jurisprudence. None announced the true principles of the law
more clearly than Judge Doe, who (in 1869) charged that “at present,
precedents require the jury to be instructed by experts in new medical
theories, and by judges in old medical theories;” and that, in this, “the
legal profession were invading the province of medicine, and attempting
to install old exploded medical theories in the place of facts established
in the progress of scientific knowledge.” But, he adds, “that cannot
be a fact in law which is not a fact in science ; that cannot be health in
law which is disease in fact; and it is unfortunate that courts should
maintain a contest with science and the laws of nature upon a question
of fact, which is within the province of science, and outside the domain
of the law.” “The legal principle, however much it may formerly have
been obscured by pathological darkness and confusion, is, that a product
of mental disease is not a contract, a will, or a crime. It is often diffi-
cult to ascertain whether an individual has a mental disease, and whether
an act was the product of that disease, but these difficulties arise from
the nature of the facts to be investigated, and not from the law ; they
are practical difficulties to be solved by the jury, and not legal difficulties
| In the record of progress in the legal tests of insanity, it deserves notice that Drs.
Gooch and Combe, about 1830 (B. 226), “first announced the great principle that the
mind of one supposed insane should be compared with his own mind when in its natural,
habitual state,” and not with some ideal average mind of health. This principle has been
extended by the laws of New York to homicide in self-defence, etc., modifying the inter-
pretation of “apparency of danger,” “cooling time,” “intent,” and “premeditation.”
(See Homicide; by F. Wharton, 2d Ed., 1875.)
* Blackstone, I. p. 41.
* State v. Wier, State v. Pike, State v. Jones, Boardman v. Woodman, 1864, 1869, 1870.
A D D R E SS O N M E DIC A. L J U R IS P R U D E N C E . 187
for the court.” “If the tests of insanity are matters of law, the practice
of allowing experts to testify what they are, should be discontinued; if
they are matters of fact, the judge should no longer testify without being
sworn as a witness, and showing himself qualified to testify as an ex-
pert.” In fine, all symptoms and all tests of mental disease are purely
matters of fact to be determined by the jury from the evidence of com-
petent witnesses; and since “legal precedent was one way, legal principle
the other,” precedent should be abandoned, and principle be followed.
Side by side with the enlightened views of these American judges, will
be recorded, for the instruction of astonished posterity, that as late as
1862 the Lord Chancellor of England did, in referring to insanity,
declare in the House of Lords that “the introduction of medical opinions
and medical theories into this subject has proceeded upon the vicious
principle of considering insanity as a disease,” and that he condemned
“the evil habit which had grown up of assuming that it was a physical
disease” '' Can this fail to revive the recollection that ninety-three years
anterior to this Lord Chancellor, Blackstone, an abler lawyer than he,
thus fulminated (1769): “to deny the possibility, nay, actual existence
of witchcraft and sorcery is at once to flatly contradict the revealed word
of God,” . . . “ and the thing itself is a truth to which every nation
in the world hath in its turn borne testimony” ” This Dord Chancellor
affords, however, a psychological lesson much needed even now ; for his
opinions illustrate what profound furrows the ancestral bigotry and
superstition of centuries can plough into even the best endowed brains
of the descendants—as we all are—of uneducated barbarians.”
One more hopeful example must close my record of our progress. In
1867, Medicine and Law, uniting for the first time in history for such a
purpose, founded “The Medico-Legal Society of New York;” now
numbering among its members more than four hundred physicians and
lawyers of influence and distinction, its brief life has been adorned with
good deeds. It has established a medico-legal library, which promises
to become, if it is not already, the best in existence ; it is about to issue
a second volume of valuable essays, the first having been published in
1874; it has, by critical vigilance, elevated the standard of medical
experts, and in one noted, conviction its criticisms instigated a second
trial with acquittal; wisely imitating its junior, “La Société de Méde-
cine Légale de France,” in its efforts to furnish a substitute for the
negligence of the State, it has (May, 1876) appointed three medical and
three legal experts as a permanent commission to investigate any medico-
legal issue referred to it; it has called attention to the condition and
criminal responsibility of uneducated mutes, and to the laws necessary
for their protection; and it has influenced the legislation of New York
as to abortion, as to robbery under the influence of chloroform, and as
to the trial and punishment of all homicides, whether same or insane.
Thus instructing the public, and inaugurating reforms, it seems destined
! Hansard, CLXV. 1297. * Blackstone, IV. p. 60.
* It deserves record, in connection with the progress of judicial decisions, that, at the
present day, Anglo-American law does not regard the killing of an infant prior to its
complete expulsion from the vagina (i. e. to its being “fully born alive ’’) as infanticide.
An English Judge recently charged a jury that, “if of opinion that the prisoner had
strangled her child before wholly born, she must be acquitted of murder.” (See B. 292,
I. p. 542; and B. 358, II. pp. 359-61.) Ellwell (B. 290, p. 555) says, “Infanticide may
be committed upon an unborn live child.”
* Organized February, 1868, and formally recognized by a decree of the French govern-
ment, January, 1874.
188 CHAILLE,
to render New York the pioneer of all the States in medico-legal progress;
and finally, in promoting scientific intercourse and discussion between
the two professions, it has forcibly taught that the invidious bigotry of
the one is as misplaced as that of the other, and that the common weal
loudly demands the united efforts of the best minds of both."
What labor so god-like as the dispensation of justice; what efforts in
its behalf can be more important than those designed to enable the law
to reap promptly the full benefits of science—of that knowledge which,
having done so much for human development, now proffers unappre-
ciated boons, and by incessant progress assures mankind a higher destiny 7
Shall medicine and law, standing aloof, not only endure but even blindly
honor ancestral evils : Is it needful in 1876 to remind two learned profes-
sions that the author of our imperishable Declaration of 1776 declared :
“The Gothic idea that we are to look backwards instead of forwards for
the improvement of the human mind, and to recur to the annals of our
ancestors for what is most perfect in government, in religion, and learning,
is worthy of those bigots in religion and government by whom it has
been recommended, and whose purposes it would answer. But it is not
an idea which this country will endure” 7
This historical sketch requires for its completion a record of the
measures proposed to correct our medico-legal evils, which, often de-
nounced since 1823 by the medical profession, continue unappreciated
by the people. To test the value of these proposed measures it is indis-
pensable to understand the following premises, accepted by the highest
medical and legal authorities.
While one would suffice to maim, our law adopts two methods to
murder, Medical Jurisprudence; both so result that it is a vulgar mockery
of medical knowledge and of justice to term such medical evidence as
is attained, “the best attainable.” In one case, the law neglects to
secure competent experts to testify, as “ordinary witnesses,” to facts
obtained by them from inquests and all medico-legal examinations. In
the other case, the law fails to provide such experts to testify, as “skilled
witnesses,” not to facts they have personally witnessed in the case, but
to their “opinions,” as to what conclusions are deducible from the
medical facts sworn to by ordinary witnesses; for this marked difference
between the ordinary and the skilled witness, Anglo-American law
deplorably fails to make any provision, while German and French law
wisely recognize that the skilled witness is not an ordinary witness, but
an arbitrator. Further, it is manifest that the experts thus needed,
for two distinct purposes, can never be supplied except by the State; that
the competency of these experts can never be secured except by special
and practical instruction; that the chief instruction must be given by
medical men; and that the instructors alone are competent to attest the
competency of their pupils.
These premises cannot be refuted, and force the general conclusions that
no measures could fully correct our evils except such as, in the first place,
would reform altogether the office of coroner, and supply competent
experts for its duties, and, in the second place, would provide a legal
status for skilled witnesses, and secure their skill ; and that these two
indispensable ends can never be gained except through an organized
system of medico-legal officials, specially trained as medical experts, and
| B. 356, 363, 364, 380, 387.
A D D RESS O N M E DIC A. L J U R IS PR U D E N C E. 189
attested as competent by competent judges. Alas! these irrefutable conclu-
sions are most discouraging, for no American can fail to appreciate how
difficult and distant is their realization. But when the remedies are not
forth with at hand to cure a disease, should we cease its study, and our
efforts both to discover and to obtain all the remedies necessary 7 A full
understanding of the indispensable remedies, will at least enable us to
test the value of the seven which have been proposed. Their introduc-
tion requires two comments: first, there is no one of them which would
not prove decidedly beneficial, since, fortunately in this regard, there is
no change of our law which could possibly aggravate our present evils;
and second, the first four to be mentioned apply to only one of our
two great evils. -
One proposal is that special juries be provided for special cases, and
another is that a medical assessor be appointed to advise and assist the
courts; either would provide better judges of medical testimony, but
neither makes any attempt to supply “the best attainable evidence.”
A third measure proposes a commission of experts chosen either by
mutual consent,” or one by each party and a third by the judge.” This
great improvement could probably be adopted more readily than any
other measure suggested ; but none of those thus authorized to appoint
have the knowledge necessary to enable them to select competent experts,
and therefore this measure would certainly not secure “the best attain-
able evidence.” A fourth proposal is the adoption of the French law
which empowers the judge to appoint a medical commission.” French
authorities, while urging the adoption of the German system, denounce
their own with even contemptuous bitterness," asserting that their judges
rarely appoint competent experts, but generally their own family-physi-
cians and practitioners of merely popular repute." A fifth proposal,
which would require all graduates in medicine to be competent experts,
as well as practitioners,” has long been, and is daily becoming so much
more impracticable, as to deserve no notice except as illustrating how
inadequately is estimated the extent and character of the special know-
ledge necessary to a medico-legist.
Prof. Gross' urged, in 1868, that the Judges of the Supreme Court of
each State should appoint a commissioner in every judicial district, to
elicit and estimate medical evidence; and that he should be provided
with two or more medical experts as assistants, to make all medico-legal
examinations. This is the only measure, thus far considered, which aims
a practical blow at both our evils. But, if French experience be appli-
cable to us, then judges of law are not good judges of experts, and should
not be authorized to appoint them, except from those whose competency
has been attested by competent judges of experts; and, if German experi-
ence be applicable to us, then a medical commissioner, long ago tried
J. Fitz Stephen’s “Criminal Law of England, London, 1863;” and Dr. I. Ray (B. 234).
* A. S. Taylor and many others. * Beck (B. 209) and others.
* Ordronaux (B. 318), etc. * Urged by many.
* See Foderé, Orfila, Devergie (B. 114, 121, 124); and especially the Preface to Vol. I.
4th ed. of Orfila. Some at least of the French courts have made the improvement of ap-
pointing a permanent commission of experts for all medico-legal cases, instead of a special
commission for each case. -
7 If the French system be satisfactory, if the State provide, as it should, “the best at-
tainable evidence,” then why should there be in Paris, as in New York City, an unofficial
and gratuitous commission of volunteer experts 2
* Chitty (B. 231), and very many others.
* President's Address, Trans. Am. Med. Assoc. 1868.
190 CHAILLſ,
and abandoned in Germany, is superfluous, provided the law supplies
a proper system and competent experts to present to the courts “the best
attainable evidence.”
Finally, others advocate some such modification, as may be practicable
under our form of government, of that German system which, the growth
of two centuries of experience, alone gives satisfaction at home, and at
the same time commands the admiration of the medico-legists of every
civilized nation.” The Prussian system has four grades of medico-legal
officials. (1) To a specially educated official expert is submitted every
medico-legal case.” His examinations, made in presence of the judge
(in some cases), and of medical men and students, insure by their publi-
city thoroughness and impartiality, and are the foundation of Germany's
medico-legal clinics which provide the practical instruction indispensable
to the education of competent experts. All the facts and proofs derived
from the examination, and essential to a conclusion, are made parts of a
written report, and these reports, with subsequent action thereon, are
preserved in official archives, and have been the source of Germany’s
fruitful medico-legal literature. (2) If prosecution or defence be dissatis-
fied, the expert's report, with all proofs preserved, is forwarded to a
Medical Court of Appeal, which, consisting of from four to six members,
exists in each province. (3) If this second decision prove unsatisfactory,
there is a final appeal to a Scientific Deputation, composed of experts of
national reputation.” (4) Finally, one of the highest officers of the gov-
ernment, the Minister of Medical Affairs, presides over an educational and
a sanitary, as well as over this medico-legal organization, and in fact
rules a department of State Medicine. -
Has State Medicine become necessary to a nation’s progress in civili-
zation ? Can services essential to the welfare of a people be rendered by
other than medical officers? Who will deny that no well-governed State
can dispense with medical instructors; with physicians in charge of its
hospitals and asylums; with medico-legal experts; with inspectors to
watch over the execution of proper laws for prohibiting quackery and
the sale of quack, foeticidal, poisonous, and adulterated drugs and food,
and also to certify to every death with its cause, after personal examina-
tion ;" with registrars of vital statistics to record not only marriages,
! See Preface to the French edition of Casper (B. 88).
” Sheldon Amos, Esq., Prof. of Jurisprudence, University College, London (see “Science
of the Law,” New York, 1874), in discussing the expert problem, says: “Almost all the
solutions point to the public organization of bodies of skilled witnesses in each of the im-
portant departments in which they are constantly demanded, and to a special preference
being given to their evidence in the administration of justice.” Francis Wharton, Esq.,
(B. 264, II. p. 1120) urges that the German system is the only one worth imitating. In
these views I thoroughly concur, notwithstanding the serious objections urged by such high
authorities as J. Fitz Stephen, Esq., and I. Ray, M.D.
* There are circumstances, says Casper, where any doctor may be called on, as an expert,
in Prussia. -
* Formerly in Prussia (probably still in parts of Germany) the collegiate medical facul-
ties were appealed to, whenever the primary reports of the official experts were not satis-
factory to both litigants. -
* The English system of determining and certifying to death and its cause is certainly
not inferior to any such system (or lack of system) existing in the United States; and yet
so inefficient is this superior system that Prof. A. S. Taylor reports that a man registered
his own death, and then based a fraudulent claim on the certificate of his death and on the
fact of his burial, which he himself had supervised; and he further asserts that “all that is
requisite for future murderers by poison to do, is to use small doses, combine the use of
various drugs, and subpoena the proper medical witnesses for the defence.” (See B. 358,
I. pp. 167–8 and 196.) -
ADDRESS ON MEDICAL JURISPR U DENCE. 191
births, and deaths, but also prevailing diseases with their causes; and,
finally, with sanitary officers to guard the public health by vaccination,
quarantine, seclusion, disinfection, and all known means?
While such services to the State would now confer incalculable benefits,
these are not a tithe of those which the progress of medical science
assures the future. But a patchwork of ill-digested laws cannot secure
these benefits, nor mere practitioners of medicine render these services.
To this end a well-organized system of State Medicine, administered by
specially educated medical men, is indispensable ; and however dis-
couraging the difficulties, educational, legal, and political, in our path,
these must be eventually overcome, or our country prove a laggard in
the triumphant march which civilization, led by the hand of science, is
now treading. One of these difficulties, an increase of officials, dangerous
to a republic, repugnant to the people, is more serious in appearance than
in reality ; for our present posts for coroners, and for sanitary and other
medical officers, would suffice for, at least, the initiation of an organized
system of State Medicine. Far more serious difficulties are presented by
those causes which now so often fill these posts with unqualified men,
by the continual elections and “rotations in office,” through which the
people, with suicidal folly, eliminate from public service responsible and
efficient servants. If the demoralizing political principle, “to the victors
belong the spoils,” is to continue its mastery over the virtue and intelli-
gence of a great people, then all hope of efficiency in any system of State
Medicine, as well as in every public service which requires special skill
and experience, must be abandoned. But, if the cardinal maxim of our
political faith be well founded, if it be true that a republican govern-
ment is better adapted than . other to secure the greatest good to the
greatest number, then, though public enlightenment develop slowly,
the day must come at last when all impediments will be overthrown, and
an efficient system of State Medicine be organized by our laws. This
progress, as all others, must pass through stages of evolution, and expe-
diency force the acceptance, as now, of mere make-shifts; but this con-
viction should not deter the attempt to measure the full extent of our
defects and of our needs, nor prevent us, while conscious that we are but
scratching the surface of great evils, from striving to direct our efforts
to their very root.
Honored Members of this International Medical Congress : Laboring on
the task now completed, professional instinct prompted as sedulous a
search for the symptoms of disease which skill might alleviate, as for the
evidences of health which need no aid ; for the instruction of my suc-
cessor of 1976 (the one man who, should there be no other, will study
this Address), I have deemed it as needful to record that which has
been left undone, as that which has been done ; and, while mindful of
gratitude's debt to the honored living and illustrious dead, I have en-
deavored to keep in mind that the chief object of history is to teach
wherein and why we have failed, that we may do better in future.
Actuated by these motives, I have thought no time more appropriate
to note our failures than this Centennial Year, which gathers from far
beyond our own vast domain, conclusive evidences of the might and
fame of this nation. To its colossal power, how harmless is the voice of
malice; to its dignity, how offensive should be the voice of flattery; to
its honor, how unwelcome aught save the voice of truth ! What higher
evidence of true greatness, what better pledge of continued prosperity,
192 CHAILLE,
can this people give, than by proofs that now, in the day of its supreme
vigor and renown, it is intent upon its own shortcomings; and that,
beneath a flimsy veil of national vanity, there sturdily stands “the pith
o’ sense, and pride o' worth”! If I have dwelt unduly on my country’s
faults, it has not been from lack either of devotion to its form of govern-
ment, or of just pride in its many noble deeds in humanity’s behalf; but
that I would have our Republic foremost in every good work, its pro-
gress endless, and its glory deathless.
BIBLIOGRAPHICAL APPENDIX.
ExPLANATIONS AND ABBREVIATIONs.
To economize space, the titles and places of publication of the general treatises in foreign
languages have been omitted, except in a few instances of those of great note. For the
same purpose, each author has been numbered, and is referred to by number in the notes to
the Address, and in the final indices to this bibliographical appendix. Dates separated by
a hyphen, e.g. 1621–58, indicate that the publication of the book in different parts was
begun in 1621, and completed in 1658; dates separated by a comma, e.g. 1598, 1602, 1671,
indicate the dates of the publication of different editions; and dates repeated, or closely
approximating, indicate the publication of different editions in different places.
This contribution to the bibliography of American Medical Jurisprudence is
preceded by a bibliographical record of the medico-legal literature of Italy,
Germany, France, and Great Britain; and the whole has been arranged chrono-
logically to illustrate the Origin and progress of medico-legal science.
Wildberg’s “Bibliotheca Medicinae Forensis, 1819,” records 2980 treatises,
essays, etc., published from the origin of medico-legal literature (about A. D.
1600) to 1818. Orfila's Médecine Légale, 4th ed., furnishes a list of 168 treatises
(to 1848), on poisons generally; of these 100 were German, 33 French, and 19
English. An English authority, the New Sydenham Society’s “Year Books”
for 1859 and 1860, reports the chief literary contributions of all nations to
Medical Jurisprudence and Toxicology during the two years 1858 and 1859;
the total number was 498, viz., 250 for Legal Medicine and 248 for Toxicology:
and of the former, Germany contributed 201, and of the latter, 118. These, with
other facts, indicate that Germany continues to contribute more to medico-legal
literature than all other nations combined ; and that a complete bibliography
of the Medical Jurisprudence of all languages must report many thousands of
books, essays, and articles. Hence the bibliographical sketch of foreign litera-
ture attempts no more than the record of treatises and manuals on the general
subject ; preceding these with a list of the books on special subjects which were
published prior to the first general treatise; and following these with a reference
to a few authorities of great repute on special subjects. It deserves note that
in every language the number of publications on special subjects, after the issue
of the first general treatise, has been very great, and proportionate to the
number of general treatises.
The contribution to the bibliography of American Medical Jurisprudence
attempts to report all the treatises, books, essays, and pamphlets, by native
and foreign authors, published in the United States; the republication of foreign
works being indicated by a f. Only a few articles from Journals are cited,
and these for a special purpose. The bibliography of Medical Jurisprudence,
as represented by “articles in journals, transactions, and collections,” giving
“the results of the examination of about 5000 volumes of such publications,”
will constitute a part of the “Catalogue of the National Medical Library,”
now in course of preparation by Dr. John S. Billings, Asst. Surgeon U. S. A.,
and Librarian ; and will probably be published in 1877. Further, the New
A D D R E SS O N M E DIC A. L J U R IS P R U D E N C E . 193
York Medico-Legal Society is preparing for publication an extensive bibli.
ography of Medical Jurisprudence. These two sources will no doubt supply
all defects and omissions in this contribution.
For articles and reports of merit, the reader is referred especially to the
American Jurist and Law Magazine, Boston, 1829 to 1843; American Journal
of Insanity, Utica, N. Y., since 1844; Reports of the Association of Medical
Superintendents of Hospitals for the Insane in North America, since 1844;
Transactions of the Medical Society of the State of New York, prior to 1845;
Transactions of the American Medical Association, since 1848; Albany Law
Journal, since 1870; Annual Reports of the American Association for the Cure
of Inebriates, since 1871; the Psychological and Medico-Legal Journal, N.Y.,
and the Series of Papers by the N. Y. Medico-Legal Society, both since 1874.
ITALY.
General Treatises.—1. Fidelis, Fortunatus, De Relationibus Medicorum,
1598, 1602, 1671. 2. Zacchias, Paulus, Questiones Medico-legales, &c., Books
I. to X., 1621–58, 1651, 1655–61, 1657, 1666, 1688, 1674–1701; Nuremberg, 3
vs. 1720; Venise, 1737. 3. Tortosa, “best book to its date,” 2 vs. 1802, 1809.
4. Sidoti, 1806. 5. Barzelotti, “very excellent,” 2 vs. 1818, 1823–4, 1839.
6. Martini, 3 vs. 1825. 7. Taurini, 4 vs. 1832, 1841–4. 8. Speranza, 1833.
9. Grotanelli, 1834. 10. Clédillot, 1836. 11. Riscica, 1836. 12. Gianelli,
1836. 13. Perrone, 2d ed. 1840. 14. Presutti, 1841–4. 15. Treschi, 3 vs.
1846. 16. Lazzaretti, 1859. 17. Gandolfi, 1854, 1863.
Special Treatises.—18. Morgagni, De Sedibus et Causis Morborum, 1761.
19. Beccaria, Scriptura Medico-Legalis, 1764; and “Crimes and Punishments;”
republished in Italian, 1821; French, 1821; English, 5th ed. 1804; Phila-
delphia, 1778 and 1793.
GERMANY.
Earliest Treatises on Special Subjects.-20. Condronchus, Methodus Testifi-
candi, 1597. 21. Libavius, De Cruentatione Cadaverum, 1599. 22. Ammann,
Irenicum, &c., 1619, and Medicina Critica, 1677. 23. Behrens, Medicus Legalis,
1696. 24. Wolf, Cogitat. Med.-Leg. 1697. 25. Valentini, Pandectae Med.-Leg.
1701, and Novellae Med.-Leg. 1718. 26. Fischer, Consilia Medic., &c., 1703–6,
and Responsa Pract. et Forens. Select. 1719. 27. Bohn, De Officio Medici,
1704, and De Renunciatione Vulnerum, 1689, 1710 (both of note). 28. Zittman,
Medicina Forensis, 1706.
General Treatises.—29. Valentini, Corpus Juris. Med.-Leg (“best book to
its date”), 2 vs. 1722. 30. Teichmeyer, Institutiones Med.-Leg., &c. (“long
the Manual of Students”), 1722, 1731, 1740, 1762, 1769. 31. Albertus, Systema
Jurisp. Medicae, &c. (“very excellent”), 1725, 1733–47, 1756. 32. Goelicke,
1723. 33. Loew, 1725. 34. Storck, 1730. 35. Tropanneger, 1733. 36. Eschen-
bach, 1746, 1775. 37. Hebenstreit, Anthropologia Forensis, &c. (“much valued
by lawyers”), 1751. 38. Furstenau, 1752. 39. Boerner, 1756. 40. Bernhold,
1760. 41. Ludwig, 1765, 1774. 42. Faselius, Elementa Medicinae Forensis,
1767, 1775 (“foundation” of Farr's Elements of Med. Jurisp., 1788, the first
treatise in the English language). 43. Braendel, 1768, 1789. 44. Kannegiesser,
1768, 1772, 1777, 1778. 45. Baumer, 1778. 46. Sikora, 1780, 1792. 47. Plenck,
Elementa Med. et Chir. Forensis, 1781, 1786, 1802 (foundation of Male's
Epitome of Forensic Medicine, London, 1816). 48. Haller, 1782–4. 49.
Schlegel, Collect. Opusc. Select. ad Med. For. Spect., 6 vs. 1785–90 (“best
book to its date”). 49. Loder, 1793. 50. Metzger, System. der gerichtl.
Arzney. (“best book to its date”), 1793, 1794, 1798, 1803, 1814, 1820, and two
French editions: Autun, 1812; Paris, 1813. 51. John, 1795. 52. Fahner,
13
194 CHAILL É,
3 vs. 1795–1800. 53. Müller, 4 vs. 1796–1802. 54. Erhard, 1800. 55. Schraud,
1802. 56. Schmidtmuller, 1804. 57. Masius, 1810, 1812, 1821–3. 58. Bene,
1811. 59. Wildberg, 1812, 1824. 60. Henke, Lehrb. der gerichtl. Med., 1812,
and Bergmann’s 13th ed., 1859. 61. Niemann, 2 vs. 1813. 62. Bernt, 1813,
and 5th ed. 1846. 63. Dorn, 1813. 64. Klose, 1814. 65. Sprengel, 1816.
66. Mende, Handb. der gerichtl. Med. (“a remarkable book”), 6 vs. 1819–32.
67. Meckel, 1821. 68. Platner, 1824. 69. Niemann, 3 vs. 1827–9. 70. Wagner,
1833–40. 71. Sporer, 1837. 72. Siebenhaar, 2 vs. 1838. 73. Freidreich, 2 vs.
1839, 1843, 1848, 1855. 74. Rolff, 1840. 75. Nicolai, 1841. 76. Ney, 1845.
77. Bergmann, 1846. 78. Brach, 1846, 1850. 79. Siebold, 1847. 80. Meckel,
1848–53. 81. Schürmayer, Lehrbuch der gerichtl. Med., 1848, 4th ed., 1874.
82. Quentner, 1851. 83. Güntner, 1851. 84. Krahmer, Handb. der gerichtl.
Med., 1851, 1857; and 85. Handb. der Staatsarzneik., 1874. 86. Böcker, 2d
ed., 1857. 87. Hauska, 1857–69. 88. Casper, Handb. der gerichtl. Med., 1857,
1858; 3d was the first complete ed., 1860, 1864; Liman's 5th ed., 1871; French
ed., 2 vs. 1862; English ed., 4 vs. 1861–5; and translated into several other
languages. 89. Hofman, 1860. 90. Pichler, 1861, 1867. 91. Lion, 1861, 1867.
92. Schauenstein, 1867. 93. Büchner, 1867; 2d ed., 1872. 94. Kraus und
Pichler, Encyc. Wörterbuch d. Staatsarzneik., 2 vs. 1873.
N. B.-Five of the above sixty-five German general treatises have been
published since 1870, viz.: Casper (Liman's 5th ed.), 1871; Büchner, 2d ed.,
1872; Kraus & Pichler, 1873; Krahmer, 1874; Schürmayer, 4th ed., 1874.
Special Treatises. – Among the most distinguished German authors on
special subjects have been : 95. Roose, Grund. Med.-gericht Vorles., 1798, 1800,
1802; translated into French by Marc, Manuel d’Autops. Cadav. Méd.-Lég.,
Paris, 8vo. 1808. 96. Hoffbauer, 1802, 1807, 1809; translated into French,
Méd. Lég. relative aux Aliénés, &c., Paris, 1827. 97. Heinroth, 1812, 1825.
98. Mittermaier, 1856, 1858, 1865. 99. Krafft-Ebing, 1868, 1872, 1875. All
of these in reference to the Medical Jurisprudence of Insanity or Medico-Legal
Psychology.
FRANCE.
Earliest Treatises on Special Subjects. – 100. Paré, Ambroise, Medical
Reports, Monstrous Births, Feigned Diseases, 1575, 1582, and CEuvres Com-
plètes, Paris, 3 vs. 1840. 101. Pineau, Integ. et Corrup. Virgin., 1598. 102.
Riolan, Les Monstres, 1605. 103. Tagereau, L’Impuissance, 1611. 104. Duval,
L'Hermaphrodisme, 1612. 105. Sebitz, La Virginité et L'Hymen, 1630, 1638.
106. Gendri, Moyens de bien rapporter a justice, 1650. 107. Blegni, La Doct.
des Rapports de Chirurgie, 1684. 108. Devaux, L’Art de faire des Rapports
en Chirurgie, 1693, 1701, 1730, 1746. 109. Bruhier, L’Incertitude des Signes
de la Mort, &c. (180 cases of living, treated as if dead), 1742. 110. Verdier,
La Jurisp. de la Méd., &c., 1752. 111. Prévost, Principes de Jurisp., &c.,
Méd.-Lég., 1763. 112. Louis, A. Signes de la Mort, &c.; Exps. Sur les Noyes;
Recueil d’Observations, &c.; Causes Celebres (first 43 vols.), 1752–88. 113.
Chaussier, Obs. Chirur-Légales, &c., 1790, 1824, 1838.
N. B.-The most noted of these were Paré, Generi, Blegni, Devaux, Louis,
and Chaussier.
General Treatises.—114. Foderé, Traité de Méd. Lég. et d’Hyg. Pub., 3 vs.
1796; 2d ed., 6 vs. 1813. 115. Mahon, 1801, 1807, 1811. 116. Belloc, 1801,
1811, 1819. 117. Wigné, 1805. 118. Bertrand, 1817. 119. Lecieux, &c., 1805.
120. Biessy, 1821. 121. Orfila, Leçons de Médecine Légale, 3 vs. 1821–5, 1828,
1839; 4th ed., 1848. 122. Briand, Manuel de Médecine Légale, 1821, 1828;
Briand et Bresson, 3d ed., 1830; Briand et Chaudé, 1846, 1852, 1858, 1864,
1869; Paris, 9th ed., pp. 1102, 8vo. fort., 1874. 123. Sédillot, 1830, 1833.
124. Trinquier, 1836–8. 124a. Devergie, Médecine Légale, 3 vs. 1837, 1840,
1852. 125. Bayard, 1844. 126. Legrand du Saulle, Ortolan, et Naquez, 1870.
ADDRESS ON MEDICAL JURISPRUDEN CE. 195
127. Legrand du Saulle, Traité de Médecine Légale et de Jurisp. Méd., Paris,
pp. 1268, 1874. 128. Bergeron, 1876.
Special Treatises.—Among the most distinguished French authors on
special subjects may be mentioned : 129. Pinel, Ph., 1800, 1805, 1809. 130.
Georget, 1820, 1826, 1828. 131. Esquirol, 1832, 1838. 132. Marc, 1840.
133. Brierre de Boismont, 1827–1860. (All on Medico-Legal Psychology.)
134. Capuron, Obstetrical Medical Jurisprudence, 1821. 135. Trebuchet,
Jurisp. de la Médecine, &c., 1834. 136. Poil.roux, Manuel de Méd.-Lég.
Criminelle, 1834, 1837. 137. Tardieu, A., numerous experimental and literary
contributions, entitling him to the first rank among the medico-legists of the
present time, 1845 to 1876.
GREAT BRITAIN, ETC.
Earliest Treatises on Special Subjects.-138. Percival, Thos., Essays Med.
and Exp., &c., 1778–90. 139. Wm. Hunter, Uncertainty of Signs of Murder
in Bastard Children, 1783. 140. Goodwyn, Submersion, Strangulation, &c.,
1788. 141. Crichton, Mental Derangements, 1798. 142. Haslam, Insanity,
and Medical Jurisp. of Insanity, 1798, 1809, 1817, 1819. 143. Johnstone,
Madness, Med. Jurisp. of 1800. 144. Perfect, Insanity, 2d ed., 1801. 145.
Collinson, Lunacy, Law of Idiots, Lunatics, &c., 1812. 146. Johnson, C., Signs
of Murder in New-Born Children (from the French of Mahon), 1813. 147. Hill,
Insanity, 1814. 148. Hutchinson, Infanticide, 1820. 149. Burrows, Insanity,
1820, 1828. *
General Treatises.—150. Farr, Saml., Elements of Medical Jurisprudence
(founded on the German of Faselius, 1767, see 42), London, 12mo, 1788; 2d ed.,
pp. 139, 12mo. 1814. 151. Bartley, Treatise on Forensic Med. (said to be very
insignificant), Bristol, 12mo. 1815. 152. Male, Epitome of Forensic Medicine
(largely from the German of Plenck, see 47), London, 12mo. 1816; 2d ed., 1818.
153. Smith, John Gordon, Principles of Forensic Medicine (the first book in
the English language of any original merit), London, pp. 503, 8vo. 1821; 2d ed.,
1824; 3d ed., 1827. 154. Paris and Fonblanque, Medical Jurisprudence (best
book to its date), London, 3 vs. 1823. 155. Forsyth, Synopsis of Modern
Medical Jurisprudence (denounced by Beck as a wholesale plagiarism), London,
pp. 600, 1829. 156. Ryan, Manual of Med. Jurisp., London, pp. 309, 8vo.
1831; 2d ed., 1836. 157. Chitty, Med. Jurisp. (never completed), London,
Part I. 8vo. 1834. 158. Traill, Outlines of Med. Jurisp., Edinb. 12mo. 1836;
2d ed., 1840. 159. Brady, Med. Jurisp., Dublin, 1839. 160. Taylor, A. S.,
Elements of Med. Jurisp., Vol. I., pp. 511, 8vo., London, 1836 (a second volume
never published). Manual of Med. Jurisp., 1st ed., 1844; 8th ed., 1866; 9th
ed., London, pp. 772, 8vo. 1874. N. B.—Seven American and one German ed.,
1858. 161. Guy, W. A., Principles of Forensic Medicine, London, 1843; 2d
ed., pp. 534, 1861 ; 3d ed., 1868. 162. Taylor, A. S., Principles and Practice
of Medical Jurisprudence, London, 1865; 2d ed., 2 vols. pp. 723, 672, 8vo. 1873.
163. Husband, Forensic Medicine and Med. Police, Edinb. 1873. 164. Wood-
man and Tidy, Handy-book of For. Med. and Toxicology, London, 1875.
Special Treatises.—Among the most distinguished British authors on special
subjects, and whose books have not been republished in America (see 201 to
390), may be mentioned—165. Conolly, 1830. 166. Pagan, 1839, 1843—both
on the Med. Jurisp. of Insanity. 167. Watson, Alex., Homicide, 1837; 2d ed.,
1842. 168. Gavin, H., Feigned and Factitious Diseases, 1843.
196
CHAILLE,
CONTRIBUTION TO THE BIBLIOGRAPHY OF AMERICAN
MEDICAL JURISPRUDENCE.
Republications of foreign works are indicated by a f, and pamphlets by a *; the latter are
for the most part reprints from Journals, etc. Some works not strictly medico-legal are
given, because often referred to by medico-legists.
201.
202.
203.
204.
205.
206.
207.
208.
209.
210.
211.
212.
213.
214.
215.
216.
217.
218.
. 219.
# Cox, J. M. Observations on Insanity, Med. Jurisp. of, from the 2d Lon-
don ed. Phila., 1811.
Rush, Benj. Introductory Lectures (16th). 8vo. Phila., 1811.
Rush, Benj. Diseases of the Mind. 8vo. pp. 367. Phila., 1812. 2d and
3d ed.’ 4th ed. 1830, 5th ed. 1835.
*Ducachet. Dissertation on Action of Poisons. New York, 1817.
*Beck, John B. Infanticide. 8vo. pp. 95. New York, 1817. (Republished
with additions, etc., in the various editions of “Beck's Med. Jurisp.”)
+Orfila. Poisons, by R. H. Black. 12mo. pp. 240. Baltimore, 1819.
i Cooper, Thos. Tracts on Med. Jurisp., viz., of Farr, Dease, Male, and
Haslam (British). 8vo. pp. 456. Phila., 1819.
+Highmore. Law of Idiocy and Lunacy. 8vo. Exeter, N. H., 1822.
(1st Am. from last English ed.)
Beck, T. R. Elements of Medical Jurisprudence, with the Chapters on
Infanticide and Abortion, by J. B. Beck. (First American General
Treatise.) 2 vols., 8vo. pp. 418, 471. Albany, N. Y., 1823.
2d ed. with notes by Dr. W. Dunlop. London, 1825.
3d and 4th eds. dates unknown. One at least was a London ed. with notes
by Dunlop and Darwell. -
German edition (translated). Weimar, 1828.
5th ed. (2d American ed.) by T. R. and J. B. Beck. 2 vols., pp. 661, 694.
Albany, 1835. 5th ed. London, 1836.
6th ed. (3d American) pp. 670, 743. Phila., 1838. -
7th ed., with notes by Dunlop and Darwell. pp. 1138. London, 1842.
8th and 9th editions, dates and places of publication unknown.
10th ed. 2 vols. Albany, 1850–51.
11th ed., revised by Dr. C. R. Gilman, with Drs. D. T. Brown, R. H. Coo-
lidge, A. Flint, Sr., B. W. McCready, S. St. John, Jno. Watson, and J. P.
White, as Collaborators. 8vo. 2 vols., pp. 884, 1003. Phila., 1860.
12th ed. Same Editor and Collaborators. 8vo. 2 vols., pp. 894, 995.
Phila., 1863. -
*Webster, J. Essay on Med. Jurisp. 8vo. pp. 52. Phila., 1824.
#Morgagni. Seats and Causes of Disease. (Cooke's English Translation.)
8vo. 2 vols. Boston and Phila., 1824.
+Orfila. Poisons (translated by J. G. Stevenson). 12mo. Boston, 1826.
Warren, J. C. Dislocations of Hip-Joint (Malpractice). 8vo. pp. 142.
Cambridge, Mass., 1826.
*Dunglison, R. Syllabus of Lectures on Med. Jurisp. 8vo. pp. 142.
Univ. Va., 1827. -
Horner, W. E. Healthy and Diseased Appearances of the Mucous Mem-
branes of the Stomach and Intestines. [With experiments.] Am. Journ.
Med. Sci., pp. 1–40, Nov. 1827.
*Simons, T. Y. Mental Alienation, Med. Jurisp. of 8vo. Charleston,
S. C., 1828. *
Horner, W. E. Pathological Anatomy. 8vo. pp. 460. Phila., 1829.
Lobstein, J. F. D. Semeiology of Countenance, etc., in Med. Jurisp.
8vo. pp. 150. N. Y., 1830.
*Hance, W. Appeal to Citizens of Ohio. . . . Medical Law, etc. 8vo.
pp. 20. Columbus, O., 1830.
A D D RESS ON ME DIC A. L J U R IS P R U D E N C E . 197
229.
. Rush, B. Diseases of the Mind. (See 203.) 5th ed. 1835.
231.
232.
233.
234.
239.
240.
241.
242.
243.
244.
. Rush, B. Diseases of the Mind. (See 203.) 4th ed. 1830.
. Dubois, W. E. Trial of Lucretia Chapman (Poison). 8vo. pp. 213.
Phila., 1832.
. Coley, H. (of London). Treatise on Med. Jurisp. Part I. Poisons and
Asphyxia. (Never completed.) 8vo. pp. 72. N. Y., 1832.
. #Fyan. Manual of Med. Jurisp., with notes, etc., by Dr. R. E. Griffith.
1st Am. ed. 8vo. pp. 327. Phila., 1832.
. Ducatel. Toxicology (from Christison, and for practitioners rather than
for medico-legists). 12mo. Balt., 1833.
. Gross, S. D. Experiments on Strangling. Western Journ. Med. and
Surg. Vol. 9, 1833.
. f Combe, And. Mental Derangements (1st Am. ed). 8vo. pp. 336. Bos-
ton, 1834.
. Beck, J. B. Researches in Medicine and Med. Jurisp. 8vo., 2d ed.,
pp. 258. N. Y., 1835.
. Williams, S. W. Catechism of Med. Jurisp. (Very severely criticized.)
18mo. pp. 205. Northampton, Mass., 1835.
Beck, T. R. and J. B. Med. Jurisp. (See 209.) 5th ed., 1835.
† Chitty. Med. Jurisp. Part I. Am. ed. 8vo. pp. 509. (Never com-
pleted.) Phila., 1836.
† Prichard, J. C. Insanity. A m. ed. 8vo. pp. 111, Phila., 1837.
†Taylor, A. S. Observations and Experiments on Lungs of New-Born
Children. Phila., 1838.
Ray, Isaac. Medical Jurisprudence of Insanity. (“Best book in Eng-
lish language to date,” reprinted in England and Scotland.) 8vo. Bos-
ton, 1838.
2d ed., pp. 490, 1844; 3d ed., 1853; 4th ed., 1860; 5th ed., pp. 658, 1871.
. Beck, T. R. & J. B. Med. Jurisp. (See 209.) 6th ed., 1838.
. *Hodge, H. L. Criminal Abortion. Phila., 1839; Phila., 1854; 12mo.
pp. 44, Phila., 1869; 4th ed., 1873.
. Gross, S. D. Pathological Anatomy. 2 vols., 1839. 2d ed., 8vo. pp.
822, Phila., 1845; 3d ed., pp. 771, 1857.
. fMontgomery. Signs and Symptoms of Pregnancy. pp. 220, Phila.,
1839; from London ed., 1837. 2d Am. from 20 London ed., 8vo. pp.
568, Phila., 1857.
#Traill. Outlines of Med. Jurisp.; (from 2d Edinb. ed.) 8vo. pp. 234.
Phila., 1841.
† Winslow, F. Plea of Insanity in Criminal Cases. 8vo. pp. 111. Boston,
1843.
Ray, I. Med. Jurisp. of Insanity. (See 234.) 2d ed., 1844.
Gross, S. D. Path. Anatomy. (See 237.) 2d ed., 1845.
† Esquirol. Mental Maladies. Notes, etc., by E. K. Hunt. 8vo. pp. 496.
Phila., 1845.
+Christison. Poisons. Edited by Jno. Bell. 8vo. pp. 756. Phila., 1845.
(Reprint 4th Edinb. ed.)
. f Porbes, Tweedie, and Conolly. Cyclopædia of Practical Medicine, with
additions, etc., by R. Dunglison. (Contains many valuable articles on
Med. Jurisp.) 4 vols. 8vo. Phila., 1845.
. f6+uy, W. A. Forensic Medicine, with Notes, etc., by Chas. A. Lee.
8vo. pp. 771. New York, 1845.
. #Taylor, A. S. Manual of Med. Jurisp., with Notes, etc., by R. E. Griffith,
M.D. 8vo. pp. 539. Phila., 1845.
Same by Griffith. 2d Am. from 3d London ed., 1850.
Same by E. Hartshorne, M.D. 3d Am. from 4th London ed., 1853.
Same by Hartshorne. 4th Am. from 5th London ed., 1856.
Same by Hartshorne. 5th Am. from 7th London ed., 1861.
Same by C. C. Penrose, Esq. 6th Am. from 8th London ed., 1866.
Same by Jno. J. Reese, M.D. 7th Am. from 9th London ed., 1873.
CHAILLE,
253.
254.
255.
256.
257.
258.
259.
260.
261.
262.
263.
264.
. Crozier. Life and Trial of Dr. Abner Baker. 8vo. pp. 152. Louisville, Ky.,
1846.
. *Purple, S. S. Corpus Luteum. (Med.-Legal, from N. Y. Jour. Med.)
8vo. pp. 13. N. Y., 1846.
. Hall, B. F., Esq. Freeman Trial (Van Nest Murder). 1847.
. Costill, O. H. Pract. Treatise on Poisons. 12mo. pp. 160. Phila., 1848.
. *Taylor, A. S. Poisons, with Notes, etc., by R. E. Griffith. 8vo. pp. 687.
Phila., 1848. 2d Am. from 2d London ed., 1859; 3d Am. from 3d
London ed., pp. 788, Phila., 1875.
Beck, T. R. & J. B. Medical Jurisp. (See 209.) 10th ed., 1850.
Dean, Amos, Esq., Prof. Med. Jurisp., etc. Medical Jurisprudence. 8vo.
pp. 664. Albany, N. Y., 1850. 2d ed., 1854; 3d ed., 1873.
Bemis, G., Esq. Parkman-Webster Murder. Boston, 1850.
+Taylor, A. S. Manl. of Med. Jurisp. (See 247.) 2d Am. ed., 1850.
*Dalton, J. C. Corpus Luteum. Trans. Am. Med. Asso., vol. 4, 1851.
*Storer, D. H. Address on Med. Jurisp. Boston, 1851. -
*Binney, H., Esq. Coroner, Jurisdict. of Phila., 1853.
Ray, I. Med. Jurisp. of Insanity. (See 234.) 3d ed., 1853.
*Taylor, A. S. Manl. Med. Jurisp. (See 247.) 3d ed., 1853.
Dean, Amos, Esq. Medical Jurisp. (See 254.) 24 ed., 1854.
Hodge, H. L. Criminal Abortion. (See 236.) 2d ed., 1854.
Wharton, Francis, Esq., and Stillé, Moreton, M.D. Medical Jurisprudence.
8vo. pp. 815. Phila., 1855. 2d ed., “Wharton and Stillé,” and Prof.
Alfred Stillé, M.D., pp. 1031, 1860; 3d ed., “Wharton and Stillé,” and
Drs. S. Ashburst, Sinkler, and Amory, two vols. in three, Phila., 1873.
. Wharton, F., Esq. Mental Unsoundness. Phila., 1855.
. Hamilton, F. H. Deformities after Fractures (Malpractice). 8vo. pp.99,
Phila., 1855, and Tr. Am. Med. Asso., vols. 8, 9, 10. Treatise on Frac-
tures and Dislocations, 8vo. pp. 757, Phila., 1860; 5th ed., 1875.
. *Wetherill. A dipocere and its Formation. Folio, pp. 25. Phila., 1855,
and in Tr. Am. Philosoph. Society, vol. 11, Phila.
. *Lee, C. A. Case of John Hendrickson, Jr., for Wife-murder (Poison).
8vo. pp. 41. N. Y., 1855.
. Purple, S. S. Wounds of Heart, and their Relations to For. Med., with
42 Cases. N. Y. Med. Times, May, 1855.
. #13rierre de Boismont. Hallucinations. (Am. from 2d Paris ed.) 8vo.
pp. 553. Phila., 1855.
. *Gilman, C. R. Relations of Medical to Legal Profession. 8vo. pp. 26.
N. Y., 1856.
. #Taylor, A. S. Manual Med. Jurisp. (See 247.) 4th Am. ed., 1856.
. Gross, S. D. Path. A nat. (See 237.) 3d ed., 1857.
. *Semmes, A. J. Med.-Legal Duties of Coroners. 8vo. pp. 16, and Tr.
Am. Med. Asso. Phila., 1857.
75. *Jarvis, E. Criminal Insane. 8vo. pp. 39. Utica, N. Y., 1857.
. *Earle, P. Parish Will Case (Apoplexy and Paralysis). 8vo. pp. 50.
N. Y., 1857.
. *Watson, Browne, etc. Parish Will Case. N. Y., 1857.
. *Gilman, C. R. Case of C. B. Huntington (Insanity). 8vo. pp. 24.
N. Y., 1857.
. *Suffolk Dist. Med. Society. Criminal Abortion. 8vo. pp. 13. Boston,
1857.
. #Otto, J. Poisons, by W. Elderhorst. N. Y., 1857.
. fMontgomery. Signs and Symptoms of Pregnancy. (See 238.) 2d Am.
ed., 1857.
. *Reese, D. M. Moral Insanity, Med. Jurisp. of 8vo. pp. 26, and Tr.
Am. Med. Asso. Phila., 1858.
. *Coventry, C. B. Med. Jurisp. of Insanity. 8vo. pp. 56, and Tr. Am.
Med. Asso. Phila., 1858.
A D DRESS ON ME DICAL JURIS PRUDEN CE. 199
284.
286.
287.
2.88.
289.
290.
291.
292.
2.93.
2.94.
295.
296.
297.
N. B.
298.
299.
300.
301.
302.
302
304.
312.
313.
*Perkins, R. G. Insanity in its Legal Relations. 8vo. pp. 24. N. Y.,
1858.
. *Davis, T. G. C. Plea of Insanity in Case of R. C. Sloo. 8vo. pp. 53.
St. Louis, Mo., 1858.
+Bucknill and Tuke. Manual of Psycholog. Med. Phila., 1858.
*Fleming, A. Blood Stains. Pittsburg, Pa., 1861, and Am. Journ.
Med. Sci., 1859.
*Wright, M.D. Drunkenness and Inebriate Asylums. 8vo. pp. 22. Co-
lumbus, O., 1859.
+Taylor, A. S. Poisons. (See 252.) 20 Am. ed., 1859.
Elwell, J. J., M.D., Esq. Malpractice and Medical Evidence. 8vo. pp. 588.
N. Y., 1860. 2d ed., 1866 (?); 3d ed., 8vo., pp. 600, 1871.
Hall, A. G. Institutes of Med. Jurisp. (“A senseless monthly serial of
a quack, having no reference, eaccept ºn name, to Med. Jurisp.”) 8vo.
pp. 576. Boston, 1860.
Beck, T. R. and J. B. Med. Jurisp. (See 209.) 11th ed., 1860.
Ray, I. Med. Jurisp. of Insanity. (See 234.) 4th ed., 1860.
Wharton and Stillé. Med. Jurisp. (See 264.) 2d ed., 1860.
*Wharton, F. In voluntary Confessions. 8vo. pp. 36. Phila., 1860.
*Wright, T. L. Med. Leg., Inquiry on Influence of Chloroform. 8vo.
pp. 32. Columbus, O., 1860.
f Winslow, F. Brain and Mind. 1st Am. ed., Phila., 1860.
“War between the States,” 1861–1865.
fTaylor, A. S. Manl. Med. Jurisp. (See 247.) 5th ed., 1861.
*Swinburne, John. Case of Rev. H. Budge (Wife-murder). 8vo. pp. 94.
Albany, 1862, and Tr. Med. Soc. State of N. Y., 1862.
*Swinburne, J. Trial of Hendrickson (Wife-murder. Aconite). 8vo. pp.
16. Phila., 1862.
Beck, T. R. and J. B. Med. Jurisp. (See 209.) 12th ed., 1863.
* Parigot, J. Legislation on Insanity. 8vo. pp. 14. N. Y., 1865.
a. Elwell's Malpractice and Med. Ev. (See 290.) 20 ed., 1866 (?).
. Seguin. Idiocy. 8vo. pp. 457. N. Y., 1866.
Hammond, W. A. Insanity in its Medico-legal Relations. 8vo. pp. 72.
N. Y., 1866.
. Storer, H. R. Why Not ? (Abortion.) 12mo. pp. 91. Boston, 1866.
[2d ed., 1871?]
. f. Winslow, F. Obscure Dis. Brain and Mind, 2d Am. from 3d Lond. ed.
8vo. pp. 483. Phila., 1866.
. Wormley, Theo. G. Micro-Chemisty of Poisons. 8vo. pp. 668. N. Y.,
1867.
. Day, A. Methomania. 16mo. Boston, 1867.
. Storer, H. R. Is it I? (Abortion.) 12mo, pp. 154. Boston, 1867.
. *Le Prohon. Voluntary Abortion. 8vo. pp. 24. Portland, Me., 1867.
. *Wetmore, E. Law of New York regarding the Insane. 8vo. pp. 35.
Utica, 1867.
*Forbes, W. S. History of Anatomy Act of Pa. 8vo. Phila., 1867.
# Maudsley. Mind, Physiol. and Pathol. of 8vo. pp. 442. N. Y., 1867.
2d ed., 1871.
. Storer and Heard. Criminal Abortion. 8vo. pp. 215. Boston, 1868.
. *Todd, J. Serpents in the Dove's Nest (Abortion). 8vo. pp. 28. Boston,
1868.
. *Lee, C. A. Report on Insanity. 8vo. pp. 32. Phila., 1868.
. Ordronaux, John. Jurisprudence of Medicine in its Relations to the Laws
of Contracts, Torts, and Evidence. 8vo. pp. 310. Phila., 1869.
. Ordronaux, J. Appointment of a Commissioner to examine Witnesses in
Med.-legal Trials. Tr. Am. Med. Asso., 1869.
. Hodge. Criminal Abortion. (See 236.) 4th ed., 1869.
200
CHAILLE,
320.
321.
322.
323.
3.24.
325.
3.26.
3.27.
328.
3.29.
330.
331.
332.
333.
334.
335.
336.
337.
338.
339.
340.
345.
346.
Richardson, Joseph G. Blood Stains. Am. Journ. Med. Sci., July, 1869.
Echeverria. Epilepsy. 8vo. pp. 386. N. Y., 1870.
*Hammond, W. A. Case of Daniel McFarland (Insanity). 8vo. pp. 35,
N. Y., 1870, and in Quart. Journ. Psychol. Med.
*Lee, Charles A. Case of Carlton Gates (Insanity). 8vo. pp. 30. N. Y.,
1870, and in First Series of Papers of N. Y. Med.-Legal Soc.
*Ray, I. Trial of John Reynolds. N. Y., 1870.
*Nebinger. Criminal Abortion. 8vo. Phila., 1870.
Hammond, W. A. Diseases of the Nervous System. 8vo. pp. 754. N. Y.,
1871. (6th ed., 1876.)
Storer, H. R. Reflex Insanity in Women. 8vo. pp. 236. Boston, 1871.
Calkins, A. Opium and the Opium Appetite. 8vo. pp. 390. Phila., 1871.
Ray, I. Med. Jurisp. of Insanity. (See 234.) 5th ed., 1871.
Elwell, J. J. Malpr. and Med. Evidence. (See 290.) 3d ed., 1871.
*Gray, J. P. Insanity, Dependence on Physical Dis. 8vo. Utica, N. Y.,
1871.
*Conklin, W. J. Relations of Epilepsy to Insanity and Med. Jurisp. 8vo.
pp. 43. Dayton, O., 1871. -
*Dimon, D. Freeman Trial (Murder). Auburn, N. Y., 1871.
#Blandford. Insanity, Medical and Legal, with a Synopsis of the laws
of the several States of the Union respecting the confinement of the
Insane, by I. Ray. 8vo. pp. 472. Phila., 1871.
†Maudsley. Body and Mind. 12mo. pp. 155. N. Y., 1871.
+Maudsley. Mind, Physiology and Pathol. of. (See 313.) 2d ed., 1871.
Delafield, F. Post-mortem Examinations. 8vo. pp. 376. N. Y., 1872.
Fisher, T. W. Plain Talk about Insanity (Med.-legal). 8vo. pp. 97.
Boston, 1872.
Day, A. The Opium Habit. N. Y., 1872.
*Peet, I. L. Physical Status and Criminal Responsibility of the totally
uneducated Deaf and Dumb. 8vo. pp. 31. N. Y., 1872, and in First
Ser. Papers N. Y. Med.-Legal Soc.
. *Van de Warker. Detection of Criminal Abortion. 8vo. pp. 88. Bos-
ton, 1872.
. *New York Med...legal Society. Report on Criminal Abortion. 8vo. pp.
15. N. Y., 1872.
. *C.rothers, T. D. Trial of Mrs. Dr. E. Burleigh (Abortion). 8vo. Albany,
1872.
. *Williams, P. C. Ketchum-Wharton Trial (Antimony). 8vo. pp. 31.
Baltimore, 1872, and Med. and Surg. Report., Phila., vol. xxvi. (See
also Am. Journ. Med. Sci., April, 1872.)
*Wey, W. C. Medical Responsibility and Malpractice. 8vo. pp. 35.
Albany, 1872.
*Stevens, T. M. Med.-legal Science. 8vo. Trans. Ind. State Med. Soc.
Indianapolis, 1872.
346a. Tean, Amos, Esq. Med. Jurisp. (See 254.) 3d ed., 1873.
347.
348.
349.
350.
351.
Ray, I. Contributions to Mental Pathology. 8vo. pp. 558. Boston, 1873.
Hammond, W. A. Insanity in its Relations to Crime. 8vo. pp. 77.
N. Y., 1873.
Wharton and Stillé. Med. Jurisp. (See 264.) 3d ed., 1873.
Hodge. Criminal Abortion. (See 236.) 4th ed., 1873.
*Stevens, T. M. Expert Testimony. 8vo. Indianapolis, 1873, and in
Ind. Med. Journ.
. *McClelland. Civil Malpractice. 8vo. pp. 74. Chicago, 1873.
. *Field, D. D., Esq. Emotional Insanity. 8vo. N. Y., 1873.
. *Clinton, H. L., Esq. Defence of Insanity in Criminal Cases. N. Y.,
1873.
. *Morse, D. A. Dipsomania and Drunkenness. pp. 52, and in Ohio State
Med. Soc. Trans., 1873.
A T) D R E SS O N M E I) IC A. L J U R IS PR U D E N C E . 201
. *Bell, Clark, Esq. Inaug. Address N. Y. Med.-Legal Soc. 8vo. pp. 11.
N. Y., 1873.
. Echeverria. Epilepsy in relation to Med. Jurisp. and Epileptic Insanity.
Am. Journ. Insanity, Utica, April and July, 1873.
. #Taylor, A. S. Principles and Practice of Med. Jurisp. (Reprint of 2d
London ed.) 8vo. 2 vols. Phila., 1873.
. tTaylor, A. S. Manual Med. Jurisp. (See 247.) 7th Am ed., 1873.
. iTuke, D. H. Influence of Mind on Body. 8vo. pp. 415. Phila., 1873.
. f Wynter, A. Borderlands of Insanity. Am. ed. 12mo. pp. 314. N. Y.,
1873.
. Reese, Jno. J. Manual of Toxicology. 8vo. pp. 507. Phila., 1874.
. N. Y. Med.-Legal Soc. “First Series of Papers.” 8vo. pp. 552. N. Y.,
1874. (By Judge Campbell, Wm. and Jacob Shrady, and Tillou, Esq’rs,
Mr. I. L. Peet, and Drs. O'Dea, Rogers, Lee, Hammond, Burr, Clymer,
De Marmon, Parsons, and Peters.)
. *Bell, C., Esq. Inaug. Address N. Y. Med.-Legal Soc. 8vo. pp. 23.
N. Y., 1874.
. *Beard, G. M. Legal Responsibility in Old Age. 8vo. pp. 42. N. Y.,
1874.
. *Morse, D. A. General Paralysis and Blackburn Case. pp. 120. 1874.
. *Morse, D. A. Monomania. pp. 46. This and 366 in Ohio State Med.
Soc. Trans., 1874.
. *Clymer, M. Influence of Epilepsy on Criminal Responsibility. 8vo.
pp. 25. Phila., 1874.
. *Howard, E. L. Legal Relations of Emotional Insanity. 8vo., and
Trans. Am. Med. Assoc. Phila., 1874.
. *Peugnet, E. Gunshot Wounds of Abdomen (Stokes-Fisk Murder).
N. Y., 1874.
. fMaudsley. Responsibility in Mental Disease. 8vo. pp. 313. N. Y.,
1874.
72. f Bucknill and Tuke. Manual of Psycholog. Med. 8vo. Phila., 1874.
. *Richardson, Jos. G. Value of High Powers in Blood-Stains. 8vo. pp.
12, and in Am. Journ. Med. Sci., July, 1874, and London Mic. Journ.,
Sept. 1874.
. *Richardson, J. G. Diagnosis of Blood-Stains. pp. 5. Am. Journ. Med.
Sci., April, 1875.
. Richardson, J. G. Improved Method for Micro-Spectrosc. Test for Blood-
Stains. Phila. Med. Times, Nov. 1875.
. *Woodward, J. J. Blood-Stains in Criminal Cases. pp. 12, and in Am.
Journ. Med. Sci., January, 1875.
77. Smith, J. E. Diagnosis of Blood Stains. Cinn. Med. Times, April, 1875.
. *Ray, I. Duncan Will Case, 1875.
. * Allen, N. State Med. in its relations to Insanity. Boston, 1875.
. *Bell, C., Esq. Inaug. Ad. N. Y. Med.-Legal Soc. 8vo. pp. 16. N.Y., 1875.
. #'Taylor, A. S. Poisons. (See 252.) 3d ed., 1875.
. fSheppard. Madness—Med., Social, and Legal, from London ed. of 1873.
8vo. pp. 186. Phila., 1875.
. f Poppesis, B. Hermaphrodism (Med.-legal), Translated from the French
by Dr. E. W. Sawyer, Chicago, 1875.
. #Sieveking. Med. Adviser in Life linsurance, from London ed. of 1874.
12mo. Phila., 1875.
5. Cowperthwait, A. C. Insanity in its Med.-legal Relations. 8vo. pp. 80.
Phila., 1876.
. Hammond, W. A. Diseases of the Nervous System. (See 326.) 6th. ed.,
1876. -
. *Bell, C., Esq. Waledict. Ad. N. Y. Med.-Legal Soc. 8vo. pp. 26. N.Y., 1876.
. f Brown. J. H. B. Jurisp. of Insanity (from the 2d English ed.). Svo.
pp. 713. Phila., 1876.
202 CHAILLE,
389. i Naquet. Legal Chemistry (English translation from French). [It has
16 pp. Bibliog. of Toxicology, etc.] 12mo. pp. 175. N. Y., 1876.
390. #Woodman and Tidy. Handy-book of For. Med. and Toxicol. Phila.,
1876. (In press, August, 1876.)
INDEx TO SUBJECTS IN THE AMERICAN BIBLIOGRAPHY,
201 to 390.
General Subject.—Beck, T. R. 209. Beck, J. B. 227. Bell, C. 356, 364, 380, 387.
f0.hitty, 231. FCooper, 207. Dean, 254. Dunglison, 214, f Forbes, etc., Cycl. Pract.
Med. 245. Gilman, 271. FCuy, 246. Hall, 291. Hance, 219. N. Y. Med.-Legal
Society Papers, 363. Rush, 202. # Ryan, 223. Stevens, 346. Storer, 258. Taylor,
247, 358. FTraill, 239. Webster, 210. Wharton and Stillé, 264. Williams, 228. iWood-
man and Tidy, 390.
Abortion and Infanticide.—Beck, J. B. 205. Crothers, 343. Hodge, 236. I.e
Prohon, 310. Nebinger, 325. N. Y. Med.-Legal Society, 342. Storer, 305, 309. Storer
and Heard, 314. Suffolk Dist. Med. Society, 279. Todd, 315. Van de Warker, 341.
Allemation, Mental. (Intemperance; Deaf and Dumb.)—Allen, 379. Beard, 365.
†Blandford, 334, f Brierre de Boismont, 270. f Brown, 388. TIBucknill and Tuke, 286.
Clinton, 354. Clymer, 368. #Combe, 226. Conklin, 332. Coventry, 283. Cowperthwait,
385. FCox, 201. Davis, 285. Earle, 276. Echeverria, 321, 357. f Esquirol, 243. Field,
353. Fisher, 338. Gilman, 271. Gray, 331. Hammond, 304, 326, 348. i Highmore,
208. Howard, 369. Jarvis, 275. Lee, 323. fMaudsley, 313, 335, 371. Morse, 366, 367.
N. Y. Med.-Legal Society Papers, 363. Parigot, 302. Perkins, 284, f Prichard, 232.
Ray, 234, 324, 347, 378. Reese, 280. Rush, 203. Seguin, 303. TSheppard, 382. Simons,
216. Storer, 327. Tuke, 360. Watson, Browne, etc. 277. Wetmore, 311. Wharton,
265, 295. FWinslow, 240, 306. Wright, 296. f Wynter, 361. (Intemperance).--Calkins,
328. Day, 308, 339. Morse, 355. N. Y. Med.-Legal Society Papers, 363. Wright, 288.
(Deaf and Dumb).-Peet, 340.
Asphyxia, etc.—Coley, 222. Gross, 225. iTaylor, 233.
Blood Stains.—Fleming, 287. Richardson, 320, 373, 374, 375. Smith, 377. Wood-
ward, 376. * .
Coroner.—Binney, 259. Semmes, 274.
Life Insurance.—N. Y. Med.-Legal Society Papers, 363. TSieveking, 384.
Malpractice and Medical Evidence.—Elwell, 290. Hamilton, 266. Lobstein, 218.
McClelland, 352. Ordronaux, 317, 318. Stevens, 351. Warren, 213. Wey, 345.
Obstetric Medical Jurisprudence.—Dalton, 257. TMontgomery, 238. Poppesio, 383.
Purple, 249.
Pathological Anatomy.—Delafield, 337. Forbes, 312, Gross, 237. Horner, 217.
fMorgagni, 21]. Wetherill, 267.
Poisons, Toacicology, Legal Chemistry.—f Christison, 244. Coley, 222. Costill, 251.
Ducachet, 204. Ducatel, 224. Lee, 268. TNaquet, 389. f.Orfila, 206, 212. TOtto, 280.
Reese, 362. Swinburne, 300. iTaylor, 252. Wormley, 307.
Trials, Legal, Celebrated Cases.—Baker, Dr. Abner, Life and Trial of 248. Blackburn
Case (General Paralysis), 366. Budge, Rev. H. (Wife-murder), 299. Burleigh, Mrs. Dr. E.
(Abortion), 343. Chapman, Lucretia, Trial of, for Poisoning, 221. Duncan Will Case, .
378. Fisk, Jas., Stokes-Fisk Murder (Abdominal Wounds), 370. Freeman Trial (Murder),
250, 333. Gates, Carlton, Case of (Insanity), 323. Hendrickson, Jno., Wife-murder
(Aconite), 268. Huntington, C. B., Case of (Insanity), 278. Ketchum-Wharton Trial
(Antimony), 344. McFarland, Dan'l, Case of (Insanity), 322. Parish Will Case (Apoplexy
and Paralysis), 276, 277. Parkman-Webster Murder, 255. Reynolds, Jno., Trial of 324.
Steinecke-Schoeppe Case (Poisoning), 363.
Wounds.-Peugnet, 370. Purple, 269.
GENERAL ALPHABETICAL INDEX.
N. B.-Under each letter, the authors are recorded in the following national order : Italy, Germany,
France, Great Britain, and the United States. Foreign authors, recorded among the American, are
designated by a f.
ALBERTUs, 31. Ammann, 22.—Allen, 379.
BARZELOTTI, 5. Beccaria, 19.-Baumer, 45. Behrens, 23. Bene, 58. Bernhold, 40.
Bergmann, 77. Bernt, 62. Böcker, 86. Boerner, 39. Bohn, 27. Braendel, 43. Brach,
A D D R E SS ON ME DIC A. L J U R IS PR U D E N C E . 203
78. Buchner, 93.−Bayard, 125. Belloc, 116. Bergeron, 128. Bertrand, 118. Biessy,
120. Blegni, 107. Briand, Briand and Bresson, Briand and Chaudé, 122. Brierre de
Boismont, 133. Bruhier, 109.—Bartley, 151. Brady, 159. Burrows, 149.—Beard, 365.
Beck, J. B. 205, 209, 227. Beck, T. R. 209. Bell, 356, 364, 380, 387. Bemis, 255.
Binney, 259. f6landford, 334. fBrierre de Boismont, 270. #Brown, 388. Hucknill
and Tuke, 286, 372.
CLÉDILLOT, 10.—Casper, 88. Condronchus, 20.-Capuron, 134. Chaussier, 113.−Chitty,
157. Collinson, 145. Conolly, 165. Crichton, 141.-Calkins, 328. iChitty, 231.
†Christison, 244. Clinton, 354. Clymer, 368. Coley, 222. #Combe, 226. Corſklin, 332.
†Cooper, 207. Costill, 251. Coventry, 283. Cowperthwait, 385. f(Jox, 201. Crothers,
343. Crozier, 248.
DoRN, 63.−Devaux, 108. Devergie, 124a. Duval, 104.—Dalton, 257. Davis, 285.
Day, 308, 339. Dean, 254. Delafield, 337. Dimon, 333. Dubois, 221. Ducachet, 204.
Ducatel, 224. Dunglison, 214. ſº
EscIIENBACH, 36. Erhard, 54.— Esquirol, 131.—Earle, 276. Echeverria, 321, 357.
Elwell, 290. FEsquirol, 243.
ForTUNATUs FIDELIs. 1.—Fahner, 52. Faselius, 42. Fischer, 26. Freidreich, 73.
Furstenau, 38.-Foderé, 114.—Farr, 150. Forsyth, 155.-Field, 353. Fisher, 338.
Fleming, 287. TEorbes, etc., Cycl. Pract. Med. 245. Forbes, 312.
GANDOLF1, 17. Gianelli, 12. Grotanelli, 9.-Goelicke, 32. Günther, 8.3.−Gendri, 106.
Georget, 130.—Gavin, 168. Goodwyn, 140. Guy, 161.-Gilman, 209, 271, 278. Gray,
331. Gross, 225, 237. FCuy, 246.
HALLER, 48. Hauska, 87. Hebenstreit, 37. Heinroth, 97. Henke, 60. Hoffbauer,
96. Hofman, 89.-Haslam, 142. Hunter, 139: Husband, 163. Hutchinson, 148.—Hall,
A. G. 291. Hall, B. F. 250. Hamilton, 266. Hammond, 304, 322, 326, 348. Hance,
219. THighmore, 208. Hodge, 236. Horner, 215, 217. Howard, 369.
John, 51.-Johnson, 146. Johnstone, 143.−Jarvis, 275.
KANNEGIEsser, 44. Klose, 64. Kraft-Ebing, 99. Krahmer, 84, 85. Kraus and
Pichler, 94.
LAZZARETTI, 16.-Libavius, 21. Ilion, 91. Ioder, 49. Loew, 33. Ludwig. 41.-
Lecieux, 119. Legrand du Saulle, Ortolan, and ‘Naquez, 126. Legrand du Saulle, 127.
Louis, A. 112.—Lee, 246, 268, 316, 323. De Prohon, 310. Lobstein, 218.
MARTINI, 6. Morgagni, 18.-Masius, 57. Meckel, 67, 80. Mende, 66. Metzger, 50.
Mittermaier, 98. Müller, 53.−Mahon, 115. Marc, 132.--—Male, 152.-flyſaudsley, 313,
335, 352. McClelland, 352. fMontgomery, 238. i Morgagni, 211. Morse, 355, 366, 367.
NEY, 76. Nicolai, 75. Niemann, 61, 69.-finaquet, 389. Nebinger, 325. N. Y. Med.-
Legal Society, 342, 363.
ORFILA, 121.-Ordronaux, 317, 318. f.Orfila, 206, 212. FOtto, 280.
PERRONE, 13. Presutti, 14.—Pichler, 90. Platner, 68. Plenck, 47.-Paré, 100.
Pinel, 129. Pineau, 101. Poilroux, 136. Prévost, 111.-Pagan, 166. Paris and Fon-
blanque, 154. Percival, 138. Perfect, 144.—Parigot, 302. Peet, 340. Perkins, 284.
Peugnet, 370. #Foppesio, 383. iPrichard, 232. Purple, 249, 269.
QUENTNER, 82.
RISCICA, 11.-Rolff, 74. Roose, 95.—Riolan, 100.-Ryan, 156.—Ray, 234, 324, 347,
378. Reese, D. M. 282. Reese, J. J. 362. Richardson, 320, 373–4–5. Rush, 202, 203.
fRyan, 223.
SIDOTI, 4. Speranza, 8.-Schauenstein, 92. Schlegel, 49. Schmidtmuller, 56. Schraud,
55. Schürmayer, 81. Siebenhaar, 72. Siebold, 79. Sikora, 46. Sporer, 71. Sprengel,
65. Storck, 34.—Sebitz, 105. Sédillot, 123.-Smith, J. G. 153.-Seguin, 303. Semmes,
274, f$heppard, 382. #Sieveking, 384. Simons, 216. Smith, 377. Stevens, 346, 351.
Storer, D. H. 258. Storer, H. R. 305, 309, 327. Storer and Heard, 314. Suffolk Dist.
Med. Society, 279. Swinburne, 299, 300. *
7.
TAURINI, Tortosa. 3. Treschi, 15.-Teichmeyer, 30. Tropanneger, 35.--Tagereau,
103. Tardieu, 137. Trebuchet, 135. Trinquier, 124.—Taylor, 160, 162. Traill, 158.—
#Taylor, 233, 247, 252, 358. Todd, 315. Traill, 239. #Tuke, 360. -
VALENTINI, 25, 29.-Verdier, 110. Vigné, 117.-Van de Warker, 341.
204 CHAILLE, ADDRESS ON MEDICAL JURIS PRUDENCE.
WAGNER, 70. Wildberg, 59. Wolf, 24.—Watson, 167. Woodman and Tidy, 164–
Warren, 213. Watson, Browne, etc. 277. Webster, 210. Wetherill, 267. Wetmore,
311. Wey, 345. Wharton, 265, 295. Wharton and Stillé, 264. Williams, P. C. 344.
Williams, S. W. 228. fWinslow, 240, 297, 306. f Woodman and Tidy, 390. Woodward,
376. Wormley, 307. Wright, M. D. 288. Wright, T. L. 296. f Wynter, 361.
ZACCHIAs, 2.—Zittman, 28.
For bibliographical and other aid I owe hearty thanks to my colleagues, Professors
S. M. Bemiss, M.D., T. G. Richardson, M.D., Frank Hawthorn, M.D. (deceased), and to
Drs. W. H. Watkins, and E. Dreifus, of New Orleans; to Dr. John S. Billings, Assistant-
Surgeon, U. S. A. (Surgeon-General's Library); to Dr. Francis H. Brown, of Boston; to
Professors S. D. Gross, and John J. Reese, and Dr. Joseph G. Richardson, of Philadelphia;
to Mr. Clark Bell, ex-President of the N. Y. Medico-Legal Society, and Prof. W. A.
Hammond, of New York City; to Prof. A. B. Palmer, M.D., of the Univ. of Michigan;
to Prof. D. A. Morse, of Ohio; and to Prof. A. S. Taylor, of London, England. Obliga-
tions to others have been acknowledged in the notes to the Address.
ADDRESS ON MENTAL HYGIENE.
BY
JOHN P. GRAY, M.D., LL.D.,
MEDICAL SUPERINTENDENT OF THE NEW YORK STATE LUNATIC ASYLUM, UTICA ;
PROFESSOR OF PSYCHOLOGICAL MEDICINE AND JU RISPRUDEN CE IN BELLEVUE HOSPITAL
MEDICAL COLLEGE, NEW YORK.
THE classical phrase, “Mens Sana in Corpore Sano,” is a general and
true expression of the related condition of the mind and body for the
best functions of human life. Health of body has, in all times, been
regarded as essential to the best balance and culture of mind, and to the
most effective application of its activities to the concerns of the world,
whether educational or practical, whether in the realm of Philosophy
or in the lower plane of Manual Labor. This is true notwithstanding
that there are notable exceptions where great intellectual activity and
application have been conjoined with feeble physical structure, and even
disease."
Indeed we must start with the proposition that what is now denomi-
nated Mental Hygiene, is practically inseparable from Physical Hygiene.
It is comparatively a new application of the word hygiene. Dr. Maudsley,
in his Gulstonian Lectures for 1870, says: “The time has come when the
immediate business which lies before any one who would advance our
knowledge of mind, unquestionably is a clear and searching scrutiny
of the bodily conditions, of its manifestations in health and disease.”
Again, “as physicians, we cannot afford to lose sight of the physical
aspects of mental states, if we would truly comprehend the nature of
mental disease, and learn to treat it with success. The metaphysician
may, for purposes of speculation, separate mind from body, and evoke
the laws of its operation out of the depths of self-consciousness; but the
physician, who has to deal practically with the thoughts, feelings, and
conduct of men, who has to do with the mind, not as an abstract entity
concerning which he may be content to speculate, but as a force in nature,
the operations of which he must patiently observe and anxiously labor
to influence, must recognize how entirely the integrity of the mental
functions depends on the bodily organization, must acknowledge the
essential unity of mind and body.”
And the great change which has taken place in the views regarding
insanity, within the memory of men now living, transferring it from the
domain of mere metaphysics, to the jurisdiction of medical science, as a
recognized physical disease, witnesses to the same thing. But not with-
standing this intimate connection of physical with psychological condi-
tions, in the study of mental hygiene, it will not be expected that I
should go into the former, or into the field immediately related, of Pre-
' Dr. Godman, Dr. Robert Hall, the historian Prescott, and numerous other instances
might be cited.
* Body and Mind, pp. 1, 108.
206 G R A Y,
ventive Medicine, as that whole subject has been assigned to my learned
confrère, Dr. Bowditch, who has already explored and expounded it in
the most exhaustive and satisfactory manner. My range of thought
must, therefore, rather be general, and less limited by professional metes
and bounds than if it were a strictly medical or a purely psychological
one, and may, therefore, not prove as satisfactory to my professional
brethren. I shall also be pardoned, I trust, on this National Centennial,
if I refer to our own nation largely in elucidation of principles, and for
practical illustrations.
This whole subject was formerly confined within the range of phi-
losophy alone. In the days of ancient civilization, before real science
was born, when the oracle “know thyself,” had only a subjective meta-
physical meaning, men like Plato and Cicero placed all mental hygiene
in the delights of literary conversation and philosophizing. The Academic
Groves were the resorts of dreamy contemplation of a State and a World
that never could be realized. The Tusculan Villa was a refuge from the
clamor of Senates and the wrangles of the Forum, where Cicero and
his friends sought their otium cum dignitate, secure from the jealousies
and conspiracies of politics, whether Caesar or Pompey should triumph.
They knew little of the physiological functions of the body, while they
indulged in their acute and poetical, and sometimes touching, specula-
tions upon the immortality of the soul; but modern science, in studying
and dignifying the visible temple of the immortal spirit, has only con-
firmed and followed in the track of Christianity, which first promised to
the human body an equal dowry of immortality with the human soul.
The Resurrection staggered the Stoics and Epicureans; but it is at least
the best warrant in the diploma of modern medical science, now perhaps
somewhat disposed to spiritualize even matter itself, to endow it with
the “promise and potency of every form and quality of life.” On the
other hand, the expression “mental physiology” has been coined to iden-
tify the study of mind with that of body, and some would even attempt
to resolve all psychology into physiology.
Mental hygiene may be variously classified, but, as a whole, it embraces
all that relates to the development, exercise, and maintenance of mental
activity in individuals, communities and nations, and must, therefore, be
considered from an individual, social, and national point of view. It
involves education, social culture, religion and national life. With the
individual, it begins at birth, and takes cognizance of even the constitu-
tional tendencies, under laws of heredity, as well as of all the circum-
stances of subsequent life. To the individual then, in a general way, it
consists in that general and special training which will most perfectly
and harmoniously develop the body and the mental faculties for the
duties of life. At the outset, therefore, on this point, we are met with
the questions, who is the individual 2 What has he to do as an occupa-
tion of life : However we may settle on general principles, the rules for
individuals must be special. Practically, we must consider classes and
conditions. The occupation and pecuniary condition of parents; their
culture, social status, and surroundings; clothing, food, and climate ;
proximity to schools, churches, and places of amusement ; density or
sparseness of population ; laws, government, etc., must all be considered
as among the efficient and constantly modifying conditions of any system
of hygiene proposed.
Thus, it will be seen, it is a many sided and all-embracing subject, evi-
dently too vast for one, in an address of an hour, to do more than simply
A D D R E SS O N M E N T A L H Y G T E N E . 207
glance at its main features. Though it may be looked at from various
stand-points, as men contemplate life, its duties, objects, and ends, from
the work they are doing in the world, the fundamental ideas must be the
same, to lead to any practical results. The views which the minister, the
lawyer, the teacher, the scholar, the physician, the scientist, and the
statesman, may take, will be directed, or colored somewhat, by their field
of observation, and their bias of education ; but on general principles
they must be in accord. Mental hygiene covers all the broad field of
human energy, embracing all the professions and every branch of indus-
trial life. It looks after man’s moral as well as his intellectual nature,
for the two cannot be separated. It enters into his domestic and social
conditions, and follows him in his duties as a citizen.
I. It first looks at human nature—at man as he is born—his utter help-
lessness, his passions, his needs, physical and mental, and his social, moral,
and spiritual wants, and then must devise a scheme for his development.
Is this an easy task * The science that would do this perfectly, must,
from the realm of physiology, single out the laws written on his members,
and harmonize them, in their development and action, with the laws of
the spirit written on the psychological side of his nature, and put these
in harmony with the laws of nature around him, in whose realm he
dwells, and bring all in obedience and loving accord with the eternal
truths of God. Mankind has been working upon this problem ever since
Adam first contemplated the tree of knowledge, in the Garden of Eden,
and was sent forth to his toil and to his own reflections. It will continue
to be a problem, for human nature will not change; the human passions,
in all their wide scope, are not to be obliterated under culture, but regu-
lated and controlled. Indeed, the discipline of the passions is, in a large
measure, the moral side of this great question. Except for speculative
study, there is no separation of the intellectual and moral elements, and
the regulation of the passions and their proper development become a part
of education.
A fundamental principle, therefore, in mental hygiene, is harmonious
intellectual and moral culture, under the recognition of man's essential
nature as a spiritual being. This cultivation is imperative, in order that
man may be able to recognize not only his own needs, but his relations
to others; that he may, while taking care of himself, be able to see that
he forms an integral part of a social organization absolutely essential for
his own welfare. The machinery for the preservative harmony and ele-
vation of social life, must reach to every class and condition; otherwise,
the antagonistic elements would impede, if not prevent, all progress, and
engender discord.
Common customs, common schools, and common laws, are the most
fundamental, and also the most powerful, equalizing agencies in the
great machinery of the politico-social life of a people. Through these
means the rich and poor meet on common ground, and acquire a certain
degree of unity in physical and mental training, and a certain likeness
of character and harmony of thought on the great questions of education,
morals, politics, and religion, highly favorable to stability, both social
and national. Thus great general principles of government become more
readily and universally received, and there are left for difference and
discussion only the methods and forms of development and application.
Still, these means only partially reach into the home life of individuals,
where influences are constantly limiting and modifying development,
both physical and mental. Indeed, however distinctly the laws of
208 G R A Y,
physical and mental hygiene may be stated, like fundamental proposi-
tions in law and morals, their individual application may be difficult.
The circumstances surrounding and controlling, may not only modify,
but entirely forbid, their application; and persons, families, and whole
communities, do thus drift away from any regulated plan of life, or any
reasonable principles of action, as the history of moral epidemics, not
only in the past but the present, would abundantly show. Poverty and
ignorance, the breeders of vices and crimes, and the enemies of culture,
may render all principles nugatory, except as they are enforced by law.
And in this direction political economy is a most important element in
the study of mental hygiene, in its broad application to the interests of
mankind.
Thus we see in hygienic science the ideas which lead to the study of
pauperism and crime, and the care of the dependent classes, whether
made so by disease or misfortune; to the origination of means for pre-
venting social evils of every character; to the enactment of laws for the
regulation of morals by limiting vices, as in licensing prostitution and
the sale of intoxicating drinks; laws for the suppression of gambling,
and providing punishment for the publication of obscene literature; laws
to prevent the spread of contagious and infectious diseases; and also
that higher and grander step, laws for compulsory education, thus com-
pelling the elevation of the masses by undermining ignorance and super-
stition, the prolific sources of human misery and degradation. This is
itself a wide field of inquiry; a field where Christianity and moral
hygiene, social and medical science, and sanitary police, must join
hands with education and law, to lift into social order the victims of
evil and hereditary influences which they are powerless in themselves
either to avoid or to conquer.
That mental activity is highly favorable to physical health and develop-
ment, when systematically directed into useful channels, need hardly be
argued in this day. Intellectual labor seems, as a rule, to contribute to
longevity. It was formerly a sort of proverb, that “one of the rewards
of philosophy is long life.” The ancient philosophers, especially the
Peripatetics, pursued their studies and imparted their instructions largely
out of doors, amid the varied objects of nature. The amount of physical
exercise taken in the open air was a remarkable feature in the life of
antiquity, even among its scholars; and we have among them numerous
examples of great longevity in men of intellect. Homer, Pythagoras,
Plutarch, Thales, Galen, Xenophon, Carneades, Sophocles, Zeno, Hippo-
crates, Xenophanes, Democritus, and others, reached the age of ninety
and upwards, while the majority of such men passed the limit of three-
score and ten.
In the early days of this Republic, with simplicity and plain living,
we find the same rule holding good. Chief Justice Marshall and Thomas
Jefferson reached eighty-four; Benjamin Franklin and John Jay, eighty-
five; James Madison, eighty-seven ; and John Adams ninety-one. All
these men certainly had not only vast intellectual labors to perform, but
great burdens of care, anxiety, and responsibility to carry, and even
serious privations to encounter; and we might greatly lengthen this list.
Bearing on this point I have recently been informed by Governor Sey-
mour, of New York, who has given great attention to the history and
character of the North American Indians, that the more intelligent
tribes were not only the dominant and conquering ones, but that they
afterwards met the struggle with civilization more successfully than
A T) D R ESS O N M E N T A L H Y G. I E N E . 209
those giving themselves up wholly to physical exercises; that they also
maintained a higher physical and mental standard, and lived to a greater
age; that these tribes, this day, number nearly as many as in the early
history of this country; that they maintain their language, and largely
their simplicity of life, in the midst of civilization."
The ancient gymnasia, as well as the modern signification of the word
gymnasium, bear witness to the sense of the importance of combining
mental and physical culture. Mental culture is a powerful influence in
developing the symmetry of the bodily organism, the tone and expres-
Sion of the face, the organs of special sense, and the harmony of co-ordi-
nating movements of the whole body. One can see this illustrated in
Our common schools at any time. The power of attention in the ma-
jority of young children, in any community, is not much aroused in ordi-
nary life, and they often look dull and stupid on this account. These
children enter school, and the direction of the attention to a few simple
exercises, in common, awakens the power of attention; and soon, at the
tap of a rule, the sound of a musical note, or the word of the teacher, the
whole school instantly responds. Now, under such simple but common
and systematic exercises and study, the whole expression of the school
changes. The bodily organism soon conforms to the habit of attention
and to the systematic mental training, and awkwardness and dulness are
Soon transformed into gracefulness, courtesy, and intelligence.
* Extract from Appendix to Address by Gov. Horatio Seymour, of New York, at the
dedication of the Kirkland Monument, Clinton, N. Y., June 25, 1873.−The superiority of
the Indians of New York, over those of adjoining States, is proved, not only by contempo-
raneous history, but by striking facts within our own observation. Their pride, heroism, and
Victories, through a long series of years, affected not only their mental and moral characters,
but even their physical organizations. . . . . Beyond the evidences of their superiority
to be found in history and science, we have living proofs of the vitality and vigor of the
Iroquois. All others of the Indians, who once lived in the States lying east of the Mississippi,
have been swept away, except a few who linger in the wild regions south of Lake Superior.
None of them have withstood the power and influence of the whites, except the Iroquois.
The Mohawks went to Canada, during the Revolutionary War, and most of the Oneidas
removed to Wisconsin about forty years since. The other tribes still live in New York. In
all their homes they are surrounded by the whites, and by high civilization, yet their numbers
do not diminish at this time. For a while after the whites went among them, they fell off
about one-third in population, but they now hold their number, with a slight increase in
Some cases. But the strength of their character is more strikingly shown by another fact.
Although the Indians of New York, for three generations, have lived in the centres of
civilization surrounded by a dense white population, with whom they are in constant con-
tact, as their reservations are small, yet they retain their own language, their own customs,
and about one-half hold their old religious faith; yet they have white teachers and preachers
who live among them. In sermons or addresses, they must be spoken to in their own tongue,
or through interpreters. At the celebration of the Kirkland Monument, a deputation of
Oneidas was present. They belonged to a small remnant of their tribe, numbering less
than one hundred and fifty, who did not go with their people to Wisconsin. They and their
fathers and grandfathers always lived in the heart of New York, in the vicinity of large
cities and villages. The tract of land they own contains but a few hundred acres, yet those
present at Clinton, who were well-dressed men and women, could only speak to the assembly
through an interpreter. In private conversation, with a few exceptions, they speak the
English with hesitancy, as their thoughts are all conceived in the Indian language. The
whole world is sending representatives of every lineage, language, and nationality to our
country: all of these in a few years speak our tongue and adopt our customs, and in a little
time are assimilated in all respects with our people. Even the most stubborn races of Asia
yield to our phases of civilization. There is not in ethnology a more extraordinary fact
than the resistance for more than a hundred years of our influences by this little band of
natives. The continued existence of the Iroquois, while their kindred tribes have been
swept away, and their resistance to our language and mode of thought, while all other
lineages in our land have been assimilated, give proof of the vigor and marked peculiarities
of their race.
14
210 G R A Y,
Another common illustration is the change we mark in servants
under the training of intelligent masters; under simple example and the
stimulation of mind in the direction of systematic attention to duties,
how quickly they are transformed, if they have any reasonable degree of
capacity. The same may also be said of soldiers. Hume, in his Essay
on National Character, says: “The human mind is of a very initative
nature; nor is it possible for any set of men to converse often together
without acquiring a similitude of manners, and communicating to each
other their vices as well as their virtues.”
The great power of mental activity and attention, in modifying expres-
sion, bodily habits and movements, as well as general manners, may not
only be seen in individuals and schools, but in whole communities and
even nations. This is far more than imitation, it is substantial individual
culture, the development of all the faculties in more or less symmetry. If
we were asked the secret of the physical prowess and conquering power of
the Roman people for a thousand years, we should answer it was the mili-
tary education and discipline of the whole population from seventeen
years of age, with its stern system of self-restraint and self-regulation. It
was a civilization based upon the rigorous principles of the Lacedaemo-
nians, rather than the lighter and more artistic life of Athens. The modern
meaning of the word virtue was the cause of its Latin meaning, as con-
fined to the behavior of men in battle, a stern temperance and self-control
behind unflinching courage and endurance. It was once said by an
American orator" that Rome was thrice mistress of the world, by her
arms, her religion, and her law. It is in the last only that she retains
supremacy, for there is hardly a civilized nation in which the maxims
of Roman civil law do not form the basis of equity. And this is all the
result of the primitive training of that great people both physical and
mental. The same principle was illustrated in the Puritan Cromwell’s
troops, the soldiers of William the Conqueror, the German armies of
Frederick William in the Franco-Prussian War, and conspicuously in
the Revolutionary patriots of America and in their descendants, the
soldiers on both sides of the contest in the recent war of Rebellion, in
this country.
The more we examine into this question of mental hygiene, the more
it seems to resolve itself, on the mental side, into a statement of the best
methods of education and training to secure the highest and truest cul-
ture. And this is the line of thought which forces itself upon the mind
as the true exposition of the words mental hygiene—a system of culture
embracing all the interests of man in all his relations of life; education
in its highest expression and broadest application ; education to secure
not simply a knowledge of man, and of nature and her laws, and the
awakening of the faculties to a deep obedience which will make man
reverence her in all her works and ways, or, in the beautiful language of
|Prof. Huxley, “the instruction of the intellect in the laws of nature,
under which name I include not merely things and their forces, but men
and their ways, and the fashioning of the affections and the will into
an earnest and loving desire to move in harmony with these laws,” adding
“for me education means neither more nor less than this”—clear empha-
tic words of which no one can mistake the meaning: but far more than
this, we should demand a broad and deep culture of man which would
do all this, and which would also awaken in the soul a full conscious-
| Hon. Iługh S. Legaré, of South Carolina; N. Y. Review, 1841.
A DI RESS ON MENTAL HY GIENE. 211
ness of its responsibility to One by whom all things exist; an education
which would not only raise man to harmony with the laws of nature,
but which would also raise him to obedience to the laws of God; which
would make his life real, earnest, pure, and useful. To accomplish this,
mental hygiene must include, therefore, not simply the mental and moral
training in a general but also in a particular way; must as well include
Social restraints and duties, as I have heretofore indicated, and embrace a
Supreme regard for the welfare of the country—a true patriotism.
It is not out of place in this centenary year of the nation, to remind
ourselves that this element of moral and religious restraint and discipline,
this spirit of subjection to an overruling power above nature, was not
left out of the practical life and training of its original founders. The
first settlers of this continent began their conflict with wild nature, and
still wilder savages, under a system of self-discipline and sense of religious
responsibility, sterner even than that of the old Romans. It was indeed
their virtue that brought them through successfully in their contest with
the mightiest empire of Europe, and enabled them to lay the foundations
of a governmental fabric which has been the astonishment and the study
of European statesmen.
But to follow up the subject of mental hygiene in relation to indi-
vidual life, it must be evident that I should have to enter into details
not possible in such an address as this ; I should have to take into
consideration, not only the whole scope of what I have denominated,
in a general way, educational means and influences, including domestic
life, but also age, sex, civil condition, heredity, passions, the influence of
climate, social customs, religion, etc., in all their varied relations as
found in action in individuals, as also the questions of food, water, exer-
cise, air, sleep, etc., all essential conditions and vital questions in the
study of individual hygiene.
II. When we come to the question of mental hygiene in communities,
we include all hygiene as to individual life, and at the same time enter
the wide domain of sociology or social science. IIere again we meet the
great problems of education, social customs and laws, intermarriage,
amusements, and indeed all the conditions of social and civil life, together
with religious culture, which, though I have named it last, is really first
and fundamental. In this age of books and thinking, no man can
ignore this latter point if he would. While I have never been able to
See any conflict between Science and Religion, certainly the tendencies
of the times are rather to question closely their relations and their respec-
tive domains. Christianity has been challenged by science, in some
quarters, and the old questions of faith, freewill, responsibility, necessity,
etc., are again discussed in the light of increased physical knowledge
and physiological investigations, and the more advanced views of psy-
chology.
The literature of the age itself illustrates the subject of mental hygiene.
Bulwer, in his “Caxtons,” gives an admirable chapter on the hygiene of
books. He suggests that reading should be governed by the mental
state; that it should be suited to the morbid drift of thought, or the
malady of the individual. As an illustration, he speaks of the folly of
attempting to amuse a man in the midst of a great sorrow; and nothing
could be more in accord with sound psychology. Referring to Goethe
taking up the study of a science, after the death of his son, he says,
“Ah ! Goethe was a physician who knew what he was about. In a
great grief like that you cannot tickle and divert the mind.” He re-
212 G R A Y,
commends for the sorrows of middle life and old age, “bringing the
brain to act upon the heart.” He would thus have philosophy lead and
temper the emotions and the will, and enrich the true life by contem-
plating the lessons of experience. He says: “For that vice of the mind,
which I will call sectarianism, not in the religious sense of the word,
but little narrow prejudices that make you hate your next-door neighbor
because he has his eggs roasted, when you have yours boiled, and gos-
siping and prying into people's affairs, and backbiting, and thinking
heaven and earth are coming together if some broom touch a cobweb
that you have let grow over the window-sill of your brains—what like
a large and generous, mildly aperient dose of history ! How it clears
away all the fumes of the head . . . how your mind enlarges beyond
that little feverish animosity to John Styles''' Here we have a strong
hint, not only against the cultivation of a narrow range of thought, but
also of the great value of that wide mental scope which takes in the
interests of others, and occupies the mind in public and social interests
and affairs of State.
Again he says: “I remember to have cured a disconsolate widower,
who obstimately refused every medicament, by a strict course of geology.
I dipped him deep into gneiss and mica-schist. Amidst the first strata,
I suffered the watery action to expend itself upon cooling crystallized
masses; and by the time I had got him into the tertiary period, amongst
the transition chalks of Maestricht and the conchiferous marls of Gosan,
he was ready for a new wife.” But all men and women cannot grasp
geology. No, but all can find, in morbid states, some serious mental
occupation, if it be only their own sphere of labor, or some useful course
of reading which will occupy them out of themselves ; this is the secret,
out of themselves. This would be substituting action for mere sentiment,
a most in portant principle in mental culture. No lesson is more impor-
tant than this, and it gives emphasis to what all experience teaches, that
in the substantial realities of life are to be found the true sources of
healthful mental discipline and growth ; that while amusements are
useful as recreation after toil and responsibility, they are not to be looked
upon as the daily pabulum of the individual or of society; that, in ex-
cess, amusements become a kind of dissipation which creates a distaste
for systematic and useful labor, and for the quiet of home life and its
practical duties, and for all rational social intercourse. Thus real life
grows tame and insipid ; a constant, restless desire for excitement is
substituted for the deep, solid stimulus of duty, of domestic responsi-
bility, and of that substantial mental culture which alone can give to
society strength and virtue.
Sentimentalism is a tendency of the age, and has a most important
place, but it should not become so dominant in social life and in educa-
tion as to exhaust the mental energy in trivialities, or in mere expression
of the feelings, instead of leading it to action and duty. Mere senti-
mentalism, whether in social life, religion, or politics, demoralizes and
emasculates all life and action; it is but a sensual indulgence at the
expense of all vigor and energy in the practical advancement of the indi-
vidual or of society. What the school of sentiment, as headed by Rous-
seau, did for France—the extravagances, the follies, and the fanaticisms
to which it led—is patent enough from French history since the Revolu-
tion of 1789. By sentimentalism is here meant that exaltation of the
feelings and sympathies of the mind which is always expending itself
upon unworthy objects or causes, or in the mere contemplation of those
A D D RESS ON MENT A L H Y G IEN E. 213
that are worthy; which Butler, in his Analogy, has pointed out with
great psychological penetration, as mere emotional impulse, with no
practical object, and no outlet for reasonable action, and which is,
therefore, always enervating and destructive to mental character.
This tendency is not found simply in the innmense indulgence in novel-
reading in these days; in the graphic and picturesque portrayal of
crimes and social vices; in newspaper serials, which flood the country,
and which are brought before people at every book-stand and in all the
avenues of travel; in the publication, broadcast, of the minute details of
crimes, suicides, and court trials, where sickly sentiment, and social
vices, and the passions of mankind, become the staple and the sum ; but
this tendency is also seen in science and in much quasi-religious teach-
ing, as well as in a multitude of so-called social and humanitarian
schemes which promise to lift man into a realm of thought and feeling
where he will necessarily, as by a law of his being, drift to the good.
This spirit of sentimentalism and restless love of novelty is only a form
of scepticism, and drifts into sensualism in morals, into useless and
vague speculations in science, and into transcendentalism and infidelity
in religion, and in all its tendencies leads to morbid, unhealthful, and
impracticable mental action.
Carlyle has said that “the proper task of literature lies in the do-
main of Belief, within which, poetic fiction, as it is charitably named,
will have to take a quite new figure, if allowed a settlement there,” and
that “the exceeding great multitude of novel writers and such like,
must do one of two things, either retire into nurseries, and work for
children, minors, and semi-fatuous persons, or sweep their whole novel-
fabric into the dust cart, and betake them with such faculty as they
have, to understand and record what is true, of which there is, and ever
will be, a whole infinitude unknown to us;” and he adds, “poetry will
more and more come to be understood as nothing but higher knowledge,
and the only genuine Romance for grown persons, Reality.”
Bulwer, with a sort of prophetic fore-glimpse over the field of these
developing tendencies, speaks in the chapter already mentioned, of
“curing a young scholar, at Cambridge, who was meant for the Church,
when he suddenly caught a cold fit of free-thinking, with great shiver-
ings, from wading out of his depth in Spinosa.” He failed when he
tried him on the divines, but succeeded by dosing him first with chap-
ters of faith, in Abraham Tucker's book; then strong doses of
Fichte; after these the Scotch metaphysicians; ending up with a plunge
bath into certain German trancendentalists. He adds, “having con-
vinced him that faith is not an unphilosophical state of mind, and that
he might believe without compromising his understanding, for he was
mightily conceited on that score, I threw in my divines, which he was
now fit to digest, and his theological constitution since then has become
so robust that he has eaten up two livings and a deanery.” Now “wading
out of his depth in Spinosa” is admirable. These youths are now grown
quite numerous, and count among them some of the ablest scientists, who
seem to be carried away by “winds” or by “doctrine” into what St.
Paul styled, in his day, “science falsely so-called.” They drift so far
out as to get into what they call the “unknowable” and the “unthink-
able,” which phrases, if the veil of time was removed, would disclose
underneath the inscription of the Athenian philosophers on a certain
altar, noticed by St. Paul, as he entered that learned city eighteen
hundred years ago.
214 G R A Y,
If we look through the history of such mental drifting, we cannot but
recognize it as productive of vast evil. Certainly such speculations have,
as yet, made no scholar wiser or better, judging by what they have
imparted to the world on the subjects of Christianity or Revelation. To
be sure, we are aware that doubt has been even dignified as an essential
condition of mind for the highest perception of Truth ! Now the mental
hygiene suggested by Bulwer was as admirable as his diagnosis. He
did not strand his patient, at the start, by discussion and dialectics, but
led him by a line of thought, natural to the patient, through the regions
of apparent contradictions and doubt, according to his powers of mental
digestion, and finally cultured him to the full truth, and at length made
a Dean of him, where he had the widest scope for faith and works, as
well as a field for mental action in the highest range of human duty.
A most notable instance of this “wading out” is the case of a late
President of the British Association. A brilliant man, with rare powers
of analysis of physical facts and phenomena, his mind trained in this
direction, he launches out on the track of the great spiritual ocean, to
which he applies his physical tests, and fails. IIe is followed instantly
by another brilliant mind in physical science, who takes down his system
of astronomy to follow the wake of a new leader. These are conspicu-
ous cases, and in other times the former might have become the founder
of a sect ; but instead of that, his structure falls to pieces as he contem-
plates it. Besides, he confesses that he has moods, which is equivalent
to unsoundness, when moods are confessed in explanation of statements
and opinions. This is encouraging, for it shows that the great and con-
stantly increasing body of truth, extended in all directions, is not only
unmoved by scepticism, but is gradually undermining it by explaining
the phenomena on which it rests for the title of its existence, and is also
revealing principles so much mightier and broader than man's theories
of Nature and of God, that Scepticism dies in the light of Truth.
Newton, after reaching far into the arcana of nature, and finding his
vast knowledge so little of the whole that he compared it to a few peb-
bles on the shore of the ocean, is the modest but grand symbol of true
progress. He illustrates the majesty of science, and her respectful homage
at the feet of the Creator. That science which is “puffed up,” and which
stands ready to unveil the sanctuary, and to enter into the holy of holies
and reveal the Almighty to man by chemistry and telescope, and thus
find out the secret of his creation and existence, and discover the
government of the moral world in a series of correlated forces, is not the
science of religion which can captivate the world of to-day. IIowever
man may move in a cycle of the same truths and deceptions, in kaleido-
scopic variation from age to age, God is unchangeable, and has declared
Himself to be “past finding out.”
So principles are eternal, though our methods change. The ideas of
God, in ancient philosophy, which Pythagoras and Socrates, Plato and
Cicero, saw dimly through the body of science and truth then developed,
cannot, at this day, be accepted as religion, though their faith and loyalty
to an invisible Creative power stand unquestioned, and like a rock in
the desert of centuries. Though Plato is perhaps the grandest figure
standing forth in the history of human mind, his theories are but as the
dawning light to the mid-day sun, in the abstract truths, developed sci-
ence, and revelation of to-day. Much less can we accept Democritus and
his followers. When Horace sang of the “Integer vitae, Seelerisque pu-
rus,” he but struck a glimpse of the same truth which belongs to the
A. I.) I) R. E SS O N M E N T A L H Y G. I. E N E . 215
province of religious culture, and which had long before been uttered by
the Royal Psalmist, “Blessed is the man who hath not walked in the
counsel of the ungodly, nor stood in the way of sinners, nor sat in the
seat of the scornful, but his delight is in the law of the Lord.” The
psalm of Horace and the psalm of David are alike devout confessions of
the blessedness of purity, and are tributes to the importance of moral
culture as an essential to the full development of mind and mental
balance.
Indeed, without this moral culture, we may say, it is well nigh im-
possible to understand even Nature herself. Certainly this is so, as far
as the ideas of purpose and design are concerned. As Baring Gould has
well put it, the world is a visible exhibition of the ideas of God, a mighty
book to be read. But who is to spell out this Created speech and compre-
hend its significance 2 Those who are to catch and understand the ideas
of God, must have a spiritual nature capable of perceiving such truths.
“Therefore, he who is to read Creation, must be neither mere spirit nor
mere body, but must have a spiritual nature combined with a corporeal
nature, so that, through the things revealed to the mind by the bodily
senses, the thoughts of God may be perceived.” Mental hygiene or cul-
ture, from this standpoint, recognizes the essential nature of man as a
spiritual being, and points to the necessity of educating his moral nature
in harmony with his intellectual, to bring forth the full man.
In this view the very wastes and solitudes of nature come to have their
moral and spiritual uses. In a burst of enthusiasm, Baring Gould ex-
claims: “The time of Alpine snow has come; age after age has seen it
powdered on the mountain peaks, slide down the flanks in ice, and flow
away in rivers to the sea, unesteemed save for the water it yielded. But
its time has come, its value is known. There is no medicine to a weary
brain, like the golden light on a distant bank of Alpine snow. . . .
I remember a mountain scramble, leading me suddenly, from rough rocks
and sear grass, upon a dell of rich greensward girt about with pines.
Set in the turf was here and there a fallen star—a yellow anemone ; on
the rocks the carmine Alpine rhododendron was in full blaze of blossom,
and over all the sward was a tender bloom of forget-me-not. Over head
burnt a glacier in the summer sun, and a thread of silver fell in powder
from it, waving in the soft air. I am not ashamed to tell you that that
vision filled my heart to overflowing. God spake through that scene,
through every flower, out of the mountain, out of the ice. The voice of
God, walking in that garden, was as audible as of old in Paradise, when
Adam heard it in the cool of the day.”
No reflecting man can fail to see that the attention given to education,
all over the world, is a most significant fact in the history of this period.
That education, in some degree, shall be universal, seems to be a common
sentiment. That this is essential to the progress of civilization, needs
only to be stated. The great questions that arise are, what shall educa-
tion be, and what shall it include : Shall it include religious instruction
in all fundamental training 2 is the real problem, however the question
may be stated. And reaching higher in the scale, the same great ques-
tion intrudes itself only in a different form. The scientific theory of
culture, set forth by the school of which Professors Huxley and Tyndall
are exponents, as Principal Shairp has so well pointed out, gives little
account of and makes no provision for the moral elements of human
nature, and this would seem to be its deep defect. As he truly says,
“ the knowledge of the highest things, those which most deeply concern
216 G R A Y,
us, is not attained by mere intellect, but by the harmonious action of
understanding, imagination, feeling, conscience, will—that is, of the
whole man—-reason in its highest exercise, intelligence raised to its
highest power.” And this for the single reason that no science can call
our whole nature into play at once. This can only be done by religion,
which alone calls upon the whole of man. When Prof. Huxley presents
life as a game of chess, with an invisible player, he endeavors to save
the idea that a man must respect the rights of others; but there is no
more room for such an idea in his scheme than there is in a shipwreck,
or in Darwin's doctrine of the survival of the fittest. It is not a matural
impulse of man to respect the rights of others, or “to love one's neighbor
as one’s self;” as Principal Shairp has well said, it requires the whole
weight of Christian motive to do either.
III. When we come to examine mental hygiene from a national point of
view, we see that it comprises all that gives intelligence, character, dignity,
progress, and stability to national life. In this greater field the lesser are
included. That hygiene which tends to elevate a people, both mentally
and physically, by a true and rational culture, is in fact mental, moral,
and physical training, resting on definite principles, and these so accepted
as to become the prevailing and growing habit of the people; or, in
other words, culture extending itself into national habits, thoughts, and
pursuits. Whatever theories we may adopt as to the equality of man,
the best practical result of national training must be to give to each class
of minds that bias which will serve to develop useful individual tenden-
cies, and at the same time, in the main, correspond with its social status.
For whatever general education or fundamental culture we may rest upon
as a prescribed system for general application, the professional man, the
merchant and business man, the mechanic, the farmer, the clerk, and
the laboring man, need different training to fit them for practical life.
The question of mental hygiene is therefore not simply how we may best
train men so as to cultivate mental health and physical vigor, but also
how we are to bring about the use and application of all the principles
and agencies which are best adapted to develop, expand, and maintain
in balance the mental and spiritual life of individuals, communities, and
nations, so as to insure progress in civilization, a healthy state of general
and domestic morals, and, at the same time, the advancement of culture,
arts, and industries.
It is only within a comparatively short period, that the study of
general and mental hygiene has been demanded, under the progress of
science. This study has been stimulated by the developing necessities of
civilization, the greater attention to sociology, and the progressive ideas
of personal liberty and responsibility. All the ancient civilizations were
but little concerned in the welfare of the individual, as a unit going to
make up national life. Knowledge and the exercise of governmental
functions were confined to the few. The great masses were only so much
brute force, or mere physical elements, in the hands of rulers and leaders,
to carry out their own ends; and to all this the masses gave almost
absolute assent. The lives of the people were held cheap by the rulers,
as well as by the people themselves. Even the great revolutions, from
time to time, were not movements of the people, but were simply brought
about by kindred though antagonistic governing families, and the people
were used in their respective interests, being aroused under the temporary
stimulation of the passions of the hour. They had no appreciation of
the ultimate tendencies of public movements, and no hope or desire
A D D RESS O N M E N T A L T, Y G I E N E. 217
for personal elevation or advancement. In such a state of national life,
mental culture could have no wide significance, and no place except
among the learned, as a mere subject of contemplation. Therefore
for many ages we have little on the subject of mental hygiene, in any
direction, beyond the philosophic declarations and fables of learned men.
The priestly orders, indeed, in ancient times combined and exercised
largely the professions of minister, teacher, and physician, and were also
the trusted advisers of kings. The Mosaic law laid down the rules of
hygiene, as it did those of morals, intermarriage, and worship, in a single
code. -
The aphorisms of IIippocrates embrace about all that is valuable in
medical literature of the pre-Christian centuries. The Code of Health
of the School of Salernum, for hundreds of years a medical classic, con-
tains the recorded knowledge on the subject of health down to the six-
teenth century. A recent translator, Prof. John Ordronaux, says of it,
“it was for ages the Medical Bible of all Western Europe, and held un-
disputed sway over the teachings of its schools, next to the writings of
Hippocrates and Galen.” It contains a great many precepts and dietetic
rules, but deals little with mental hygiene; and this is the sum :—
“Salerno's School, in conclave high, unites
To counsel England's King, and thus indites:
If thou to health and vigor wouldst attain,
Shun weighty cares—all anger deem profane,
From heavy suppers and much wine abstain.
Nor trivial count it, after pompous fare,
To rise from table and to take the air.
Shun idle, noon-day slumber, nor delay
The urgent calls of Nature to obey.
These rules, if thou wilt follow to the end,
Thy life to greater length thou mayest extend.
Shouldst Doctors need 7 be this in Doctors’ stead—
Rest, cheerfulness, and table thinly-spread.”
The author closes with a valedictory which would indicate that he
felt he had accomplished a great work :-
“The Flower of Physic endeth here its strain;
The Author, happy O'er his garnered grain,
Prays that in Heaven there be prepared for him
A seat near Christ, and His blest Seraphim.
A men '''
We must not forget, however, the great services rendered, during the
dark ages, to Science and Literature by the Monks and Religieux while
buried in their cloisters, as well as their work in preserving the treas-
ures of learning from the all-surrounding devastation. It is admitted
by all historians that, in days of violence and anarchy, the Church was a
defence and refuge of the poor and the oppressed, as well as of the learned,
against the hand of tyranny and rapacity. To the Benedictine orders, at
least in their constant and systematic attention to the cultivation of the
soil, and the implements and improvements of agriculture, we owe a
great lesson of that primitive truth, that in the sweat of man’s face shall
he eat bread. It may even be said that the motto of this order, laborare
est orare, has become the watch word of modern civilization, for in no
period of the world has labor been so dignified as in these times, and the
1uachinery of labor so multiplied for the uses of man.
218 G R A Y,
Mental hygiene, from a national point of view, would also cultivate in
the people a harmonious and universal aim towards elevated and yet
practical ideas. A national sentiment, fostered and dignified by govern-
ment, in favor of education, mechanics, agriculture, arts, becomes a most
powerful mental stimulant to individual effort, and seems to give breadth,
tone, and vigor to national mind and character. No people, perhaps, ever
gave more earnest and practical attention to educational power and the
value of morality, as elements in government, than the Puritan stock of
New England. From the first, the church and the school-house rose
side by side, and whatever economy and frugality they exercised in
affairs, and they were marvels in these virtues, they never stinted the
head and the heart. They had lofty ideals, and they practised stern
virtues, and when national oppression came they had stout hearts,
willing hands, and clear heads, to offer in the struggle for liberty and
the founding of a nation. The sentiments of Union and Liberty, early
and deeply rooted in the mental soil of the early inhabitants of the
American Republic, have propagated their influences and spread their
roots and fibres through the blood-soil of children's children, and we see
the result in millions of active intelligent minds, carrying forward with
united and persistent purpose the vast interests of this great nation, and
subduing this mighty continent, in its multiplied physical resources, to
the utilities of mankind, as though governed by a single national im-
pulse. -
The founders of the Republic, in every part of the land, seemed to
have been thoroughly permeated with the spirit of personal and public
duty. With them, Liberty meant Law and obedience to principles of
Justice—an obedience, as beautifully expressed by Ruskin, “chastise-
ment of the passions, discipline of the intellect, subjection of the will,
fear of inflicting and shame of committing a wrong; respect for all who
are in authority, consideration for all who are in dependence; venera-
tion for the good, mercy to the evil, sympathy with the weak; watch-
fullness over all thoughts, temperance in all pleasures, and perseverance
in all toils.”
Had our ancestors cultivated the softer graces, and given themselves
up to games, sports, and ease of life, and the government contented itself
with hereditary dignities, leaving the mass of the people in ignorance,
and to think and act only in the narrow sphere of providing daily bread
by daily toil, how different would have been the mental status of this
nation to-day ! If, on the other hand, the inhabitants of this country
should ever become so demoralized and degraded as to find their con-
tentment, like the people in the latter ages of Rome, in material com-
forts alone—panem et circenses—mere bread and amusements—then, too,
like the later Romans, they would soon become the prey of family feuds
and contending factions, ending in the despotism of a swift succession of
flagitious rulers, till the whole political system would sink into final
disintegration and ruin.
This Centennial, a part of the movement of which this International
Medical Congress represents, is a great national thought, and a most
powerful influence in stimulating national mind, as well as individual,
in the direction of healthful mental activity. Indeed, it is itself a vast
and far-reaching means of culture, which touches a responsive chord in
nationalties of the most diverse social and political character, but never-
theless in harmony in the one direction of progress. To impress men by
such magnificent displays of wealth, mechanism, and art; to show them
A D D R E S S O N M E N T A L H Y G. I. E N E . 219
that life is more than meat and drink; that a nation is great and power-
ful in proportion as its citizens are cultured to refinement, utility, mo-
‘ality, and personal responsibility; that these constitute the foundation
stones of national greatness and prosperity, is in itself a great national
hygienic measure. As the accumulation of patrimonial treasures, learn-
ing, and office, give dignity to families, and stimulate to higher culture,
so the accumulation of treasures of all kinds, and the recognition and
cultivation of art and learning by nations, tend to dignify national repu-
tation, and to stimulate citizens of all classes to higher efforts and more
patriotic lives.
Thus a nation secures mental and moral growth and breadth of enter-
prise. No one can look at the wonderful Exposition, now held in this
city, without realizing this fact. The world seems, indeed, to be here
assembled. The Egyptian, the oldest civilization, stands before us to-
day as it stood in the days of the Pharaohs. The march of progress and
the attrition of nations may have modified her national life in some out-
ward things, but the central ideas remain the same ; her escutcheon is
unchanged, and she sends to this Centennial, as an essential treasure, the
head of Rameses, thus typifying her original and perpetual dignity,
unbroken through the long tide and flow of centuries. And so down
through the roll-call of nations, to our own, each has its own grand
representative idea. At the end of a hundred years we stand at the
statue of Washington, and relate his virtues, as embodying the central
ideas out of which grew, and on which rests, the deep, broad, and sure
foundation of this Republic. Egypt may come to us; she may take our
ploughs and reapers, our engines and printing presses; but she will only
enthrone Washington when she accepts our ideas.
The true greatness and dignity of any nation will always be measured
by the standard of its mental and moral culture, not simply by the in-
tellectual standard it presents in its military power, its science and arts,
and its dynamic forces, but also by its will and capacity for morally ele-
vating its citizens, without clash of caste; maintaining universal freedom,
with all men equal before the law. The present Emperor of Russia, real-
izing such a sentiment as essential to the dignity, prosperity, and perma-
mence of the government, transformed, in a day, millions of serfs into free-
men, the grandest ukase in the history of time. This is the substance
of Magna Charta, the glory of England. This was the ostensible aim of
Caesar. His memory is quite as much dependent on his philosophic
culture, and his assimilation to the people, as on his conquests. He shed
lustre on Rome, and on mankind, by his amazing combination of sim-
plicity, learning and statesmanship, with the greatest capabilities of a
soldier, all of which he illustrated in the midst of a galaxy of the most
magnificent minds in the annals of the world. His name fitly repre-
sents the power of mental culture in the direction of definite ideas, in a
ruler looking to the elevation of a people as the true source of national
power.
Rome lost in prestige when she accustomed her people to ideas of
conquest and personal ease, above moral culture, in its wide meaning.
Indeed, no nation has ever maintained permanent elevation and power,
which has encouraged or permitted public opinion to act outside of the
pre-ordained boundaries of religious truth. The belief in a God must
be the corner-stone on which a nation rests. Both Greece and Rome
flourished in power, arts, and arms, so long as they clung to a belief
in a supreme Providence, above Nature. But when the speculative
220 G R A Y,
philosophy of Epicurus and Lucretius, with its absorbing sensualism,
usurped the ancient worship, they perished beneath the blight of a
cold scepticism. The glory of Egypt was clouded with Cleopatra, who
represented deified sensuality on the throne of a Nation. The great
Assyrian Empire, in like manner, fell under Sardanapalus, the gilded
monarch of Asiatic licentiousness. France well nigh perished when
she installed the Goddess of Reason in the seat of Worship, and her Chief
Assembly voted Death to be an Eternal Sleep.
Under the cultivation of the ideas, and the practice of the principles,
to which I have referred, by the founders of this Republic, we have the
national fruit, not only in a great and well-established nation, but con-
spicuously in the wonderful development of the resources of high civili-
zation all over this continent. It is a truth, well worthy to bear in mind
always, that education, with them, embraced ideas of religious freedom,
which were cultivated together, no matter what the calling in life. And
it is not too much to say that in the rigid spirit of utility and the high
sense of responsibility of the early fathers, we have the seed from which
has germinated, over this broad land, the personal independence of char-
acter, the inventive genius, the subjection to law, and the matchless
energy, which have made us equal in power to the older nations of the
world, which have also given us an individual national character—
stamped us as Americans—notwithstanding that we represent all the
nationalities of Europe; which have developed a national mental hygiene
which reduces and conforms the cosmopolitan ideas of the vast and
constant drift to our shores, to the national standard, which prevents any-
thing antagonistic to the fundamental principles of the government from
taking root, and which assimilates and harmonizes all the seeming anta-
gonisms to the genius and spirit of the constitution, the moment they
are subjected to its dominating idea, “government of the people, by the
people, for the people.”
I might properly allude to the great influence exerted on the national
mind by such men as Franklin, Rush, William Penn, Robert Morris,
Richard IIenry Lee, John Jay, the Adamses, Hamilton, Jefferson,
Madison, and others, if there were time; but such influence, however
special and potent, was, after all, only the projection and happy presen-
tation of principles which, when thoroughly impressed, acted on the
mind of the people in moulding national thought. The work of these
men was done through the reason and judgment, and not by popular
display and glamour, and it was abiding. Economics and population,
education, statesmanship, finance, constitutional law, Political Economy
in all its wide bearings, received from them the most earnest and pro-
found discussion. However great their attention to religion, they did
not confound it with state morals; but, on the one hand, they main-
tained Christianity and the highest responsibility to God, and, on the
other, they sought to work out, under laws, the mutual rights and
relations of men under their new social and political conditions of
government.
Their lives were illustrations of the principles they advocated; William
Penn exercised a wide and mighty influence in securing not only the
mutual co-operation of Savages, but also of classes of men bred in other
traditions, and in bringing all to the formation of national habits and
character. Yet he represented no victor with temporary plaudits, no
sensational or dramatic phase of social life or regeneration. His power
illustrates what education, aided by elevation of character and equi-
A D ID RESS O N M E N T A L H Y GIE N E . 221
librium of the intellectual life and passions, may do in a man who is
controlled by truth and directed by spiritual light. Wilberforce, in
England, illustrated the same great influence on national mind. He
showed how a strong mind, panoplied in its convictions of universal
justice, might gradually undermine historic precedents, against all the
forces of conservatism arrayed in opposition, as well as against the
apparent interests of the nation. Slavery was then a part of the national
wealth, but it died through the influence of this one peaceful mind,
breathing condemnation upon it, and this in the very presence of those
whose material relations to it were of the closest character. Thus a
whole nation was transformed by a mental revolution, wrought solely in
the name of universal philanthropy, justice, freedom, and religion.
Such are some of the higher triumphs of national culture, when it
embraces the moral and spiritual elements of Christianity. Though
this age may be characterized as one of liberal tendencies of thought, in
all directions, it has been permeated by the principles of Christianity,
and to-day there is more respect for religious truth, and a firmer belief
in the necessity, for both man and nations, of faith in a God, than when
the century commenced. When, in the recent French Revolution, the
Archbishop of Paris, Monsiegneur Darboy, was struck down by the Com-
mune, the nation turned from the act with horror. Yet the Bishop was
only a man, and one among the hundreds of noble men who thus perished.
13ut he represented Religion, and millions of people, alike Protestant
and Catholic, condemned the deed as one of infamy, and as a diabolical
defiance of the very instincts of humanity, as well as of the traditional
sentiment of Christendom.
The lesson of mental hygiene, for nations, which we learn from all
example, is, not that education and wealth, nor the refining influences
of aesthetic art, will suffice for the highest development of national mind,
but that, if underneath and through all these are not interwoven the
great truths of moral responsibility to the author and upholder of all
governments, lifting man above the dominion of the baser passions, the
nation dies as an individual dies ; for “unless the Lord build the house,
they labor in vain who build it.”
In the Convention at Philadelphia, in 1787, for forming a constitution
for the United States, after some weeks had passed in fruitless debate, a pro-
position having been made for daily prayers, Dr. Franklin rose and said :
“In the beginning of the contest with 13ritain, when we were sensible of
danger, we had daily prayers in this room for Divine protection. Our
prayers were heard and graciously answered. All of us who were en-
gaged in the struggle must have observed frequent instances of a super-
intending Providence in our favor. To that kind Providence we owe
this happy opportunity of consulting in peace on the means of establish-
ing our future national felicity. And have we forgotten this powerful
friend ; or do we no longer need His assistance 2 I have lived a long
time, and the longer I live the more convincing proof I see of this truth,
that God governs in the affairs of men. And if a sparrow cannot fall to
the ground without IIis notice, is it probable that an empire can rise
without His aid : We have been assured in the sacred writings that,
except the Lord build the house, they labor in vain that build it. I
firmly believe this, and I also believe that without His concurring aid
we shall succeed no better, in this political building, than did the builders
of Babel.” The motion was carried.
' Debates on the Constitution.
222 G R AY, ADDRESS ON MENTAL HYGIENE.
This illustrates the sentiment and temper of those who founded this
nation, and may we not say, standing where we do, that the influence of
this illustrious example has had some share in determining the tone and
the practice, in that respect, of this renowned University from its founda-
tion, whose successive Provosts have been eminent examples of the
essential harmony between the different qualities of Faith and Science?
These latter thoughts have come into my mind since entering this hall,
while looking round upon the long line of Reverend Provosts speaking
out from the canvas, and then reading over the door of entrance the
grand inscription, “IN HONOREM DEI.” An institution, like a State,
which writes over its portals, “in honor of God,” cannot fail of success
and power, before the people, as more than a century has here demon-
strated. And this is my Alma Mater.
For individuals and communities, the quaint lines of George Herbert,
with which I close this Address, are a suggestive and pregnant sum-
mary:—
Slight those who say amidst their sickly healths,
Thou livest by rule. What doth not so but man 7
Houses are built by rule, and Commonwealths.
Entice the trusty sun, if that you can,
From his ecliptic line ; beckon the sky.
Who lives by rule then, keeps good company.
Who keeps no guard upon himself, is slack,
And rots to nothing at the next great thaw.
Man is a shop of rules, a well-trussed pack,
Whose every parcel underwrites a law.
Lose not thyself, nor give thy humors way;
God gave them to thee under lock and key.
223
ADDRESS ON AMERICAN MEDICAL LITERATURE.
BY
LUNSFORD PITTS YANDELL, M.D.,
OF LOUIS WILLE, KENTUCKY.
I HAVE attempted in this Address to give some account of the books
which have been written by the physicians of the new world, since the
settlement of America by white men. The history embraces a period of
nearly two hundred years, and includes the names of as many authors,
and the titles of more than as many publications. Restricted as I am,
both in space and time, my notices are necessarily brief. As to most of
them, they are nothing more, indeed, than a catalogue of names and
titles. But it occurred to me that I could not in any other way so well
meet the wants of the profession in an address like this, as by presenting
a full list of our medical works in the order in which they have appeared,
so that we may see, and that those who shall come after us may learn,
what the medical men of America have done in the first century of our
national existence. My references are confined almost exclusively to
books, but occasionally I have noticed pamphlets and articles in Transac-
tions of Societies, which appeared to me to possess unusual value. To do
justice to the medical literature of America, would require something
more than a single discourse. All that is proposed in this, is to give an
outline of the subject; and, with all the pains I have taken to make my
list complete, I can hardly hope that it will not be found chargeable with
many Omissions.
The Literature of Medicine had acquired but little extension, and was
still expanding slowly in Great Britain, when the first emigrants for
America left her shores. Harvey was just then announcing his grand
discovery of the circulation of the blood. Sydenham had not been born,
and it was half a century afterward that his works, conceived in the true
spirit of the Baconian philosophy, and the standing glory of English
medical literature, made their appearance to put a new countenance upon
the Science of Medicine. Mead and Cheselden were born more than half
a century afterward. The writings of the Hunters, and of Cullen,
appeared only as the Colonies were ready to set up in the world for them-
selves; and the discoveries in chemistry which imparted to it the
character of a science, were made by Black and Priestley on the eve of
our great political revolution.
It is not surprising, then, that hardly anything was accomplished in
the way of authorship by the physicians of the Colonies during the first
century of their settlement. For fifty years nothing at all was published
by them, of which we have any record. The first essay came out in 1677,
bearing the title “A Brief Guide in the Smallpox and Measles.” It was
published in the province of Massachusetts, thirty years before the first
newspaper was issued in America, and more than forty years before one
was established in Philadelphia. Its author, Dr. Thomas Thacher, as
224 Y AND E L T, ,
was not uncommon in the new settlements at that day, united in lis
person the two professions of divine and practitioner of medicine. He
was the first minister of the Old South Church, in Boston, and was
accounted “a great divine” as well as “a learned physician,” who,
preaching and practising “to general approbation” as long as he lived,
had his name worthily perpetuated in the Magmalia of the famous Cotton
Mather. His unpretending essay, composed especially for the instruction
of the people, seems to have remained more than half a century without
a successor. It was not until 1720 that the next tract relating to medi-
cine appeared. Dr. Cadwallader Colden, in that year, published an account
of the climate and diseases of New York, founded on his own observa-
tions and experience; and from that time medical publications followed
in quicker succession.
Three essays respecting inoculation for smallpox were published within
a few years of each other, by three Poston physicians. Dr. Nathaniel
Williams, one of the three, was, like Thacher, both physician and
preacher; another was Dr. Benjamin Colman; and the third was the
celebrated Zabdiel Boylston, who was the first physician to make trial
of the hazardous practice in the new world, and who narrowly escaped
falling a martyr to it. Pharmacy and the Medical Botany of the new
territory, attracted the attention of its physicians at an early day; and
treatises on the preparation of drugs, the polygala Senega, and the great
water dock, were written by Dr. Howard, Dr. Tennent, and Dr. Colden.
Dr. John Clayton, of Virginia, produced, in 1743, a Flora Virginica, so
highly esteened that an edition of his work was issued some years after-
ward in Leyden. An essay on fevers was written by Dr. Walton in 1732;
one on scarlatina, by Dr. Douglas in 1736: one on the iliac passion, by
Dr. Cadwalader in 1740; and one on yellow fever, and a second on the
causes of the variety of colors in people of different climates, by Dr. John
Mitchell in 1743. Dr. Dining also wrote an account of yellow fever, in
which he started the idea, never before advanced, that persons who have
suffered with the fever are not subject to a second attack.
Douglas, in his paper, was the first to recommend calomel in scarlet
fever. Cadwalader had the good sense to condemn the use of quicksilver
and drastic purgatives in lead colic, which he described as the “iliac
passion,” and advised Opiates as preparatory remedies in that affection.
The letters of Mitchell on yellow fever are of peculiar interest, as having
led to the heroic practice in the disease for which Dr. Rush was noted
at a subsequent day. T)r. Chalmers, of South Carolina, published a paper
on tetanus in 1754. Dr. Bond, of Philadelphia, published, in 1759, an
essay on the use of bark in scrofula; and in 1760 Dr. John Bard, of New
York, made public the facts in a case of extra-uterine foetation which
had come under his notice. T)r. Dard, the same year, also published a
valuable essay on the nature and causes of “Malignant Pleurisy,” as it
prevailed on Long Island in the winter of 1749, a disease since recognized
in the epidemics of typhoid pneumonia which have more than once swept
over our continent. In 1769 some letters on malignant sore throat were
published by Dr. Ogden, of New York; and Dr. Kearsly, of the same
place, sent the same year a paper to the Gentleman’s Magazine, at Lon-
don, on angina maligna. The thesis of Dr. John Moultrie, of Charleston,
the first graduate in medicine from South Carolina at Edinburgh, was
printed in 1749. It described yellow fever as he had seen it in his native
city. The theses of Morgan, Shippen, Kuhn, Rush, Bard, Kissam, and
other American students, were printed at Edinburgh from 1749 to 1776.
A DD RESS ON ME DICAL LITER ATU R E. 225
Some of these essays, treating of the diseases incident to the new
World, deserve to be rescued from the oblivion that has overtaken them,
and if collected would form a volume acceptable to the profession. But
it is to be remarked that they were all issued in a fugitive form ; many
of them treated of subjects the interest of which has long since passed
away; most of them were brief papers, such as would now make arti-
cles in our medical journals, and nearly all are now wholly inaccessible.
At most, they can be regarded as nothing more than an introduction to
the medical literature which in the course of the century succeeding
them has become so voluminous.
The medical literature of America may with truth be said to have
commenced with the century whose years we have just numbered. Just
as it was about to open, Dr. John Jones, of New York, foreseeing the
need of surgical knowledge likely soon to arise, prepared, in the autumn
of 1775, and in anticipation of the impending struggle, a little volume
On wounds and fractures. It is the first, in time, of American works on
surgery. Its claims to merit were small, if regarded as an original work,
since it was little more than a compilation; but the compiler was a sur-
geon familiar with the art about which he was writing, and his volume
proved highly serviceable to our inexperienced and young surgeons during
the war. In 1776, an able work was published in two volumes, on the
Climate and Diseases of South Carolina, by Dr. Lionel Chalmers, of
Charleston. t
But ten years before this time, an event occurred which marks an epoch
in the medical history of the country. I refer to the creation of a pub-
lic school of medicine. This, more than any other movement recorded
in our history, has shaped our medical literature and contributed to its
growth and development. The school was inaugurated under circum-
stances that invest it with uncommon interest. The address delivered
on the occasion was published, and is extant in our libraries. Among
the Trustees of the College, who weighed the arguments urged for the
erection in it of a Medical Department, was Benjamin Franklin, President
of the Board. Dr. John Morgan and Dr. William Shippen, its founders.
and earliest professors, were medical scholars such as might rightfully
aspire to lay the foundations of medical education in a new empire. They
had prepared themselves for teaching by long and laborious study. An
imposing assemblage of the citizens of Philadelphia was present to
witness the commencement in their college, and to hear Dr. Morgan’s
address on the institution of medical schools in America.
“It is now,” he said, “more than fifteen years since I began the study
of medicine, and I have arrived at the middle age of life endeavoring
to lay up treasures of knowledge.” And he continued, in words that
proved prophetic, “Perhaps this medical institution, the first of its kind
in America, though small in its beginning, may receive constant increase
of strength, and annually exert new vigor. It may collect a number of
young persons of more than ordinary abilities, and so improve their
knowledge as to spread its reputation to distant parts. By sending
those abroad duly qualified, it may give birth to other institutions of a
similar nature calculated to spread the light of knowledge through the
whole American continent wherever inhabited.”
In the great concourse of “respectable citizens” gathered to hear this
discourse, was a young student of medicine who was destined to become
not only the great luminary of the school, but the foremost of American
medical teachers and writers. Benjamin Rush had been for three years
15
226 sº Y AND ELL,
a student under Dr. John Redman, in Philadelphia, translating Hippo-
crates, and making memoranda on yellow fever and other current epi-
demics of the time. Three years later he was admitted to the degree of
Doctor of Medicine in the University of Edinburgh, having defended a
thesis De Concoctione Ciborum in Ventriculo. Returning home he was
elected, in August, 1769, when under twenty-four years of age, Professor
of Chemistry in the Philadelphia Medical College, now the University
of Pennsylvania.
With Rush, to teach was to write. The motto on which he was in the
habit of insisting most strongly to his pupils was, legere sine calamo est
sommere ; and he studied his profession with pen in hand, recording ob-
servations which are still of value to writers on yellow fever. The year
after his election he appeared before the public as author of what he
styled “Sermons” to young men on temperance and health. Three years
later he was invited to deliver the annual oration before the American
Philosophical Society, of which Franklin and Jefferson were members.
He chose as his subject “The Natural History of Medicine among the
Indians of North America, and a comparative view of their diseases and
remedies with those of Civilized Nations.” This oration makes the first
paper in his “Inquiries,” the first volune of which was issued in 1788.
No one can read it without a feeling of profound respect for the talents
and scholarship of its author. It is philosophical in tone, rich in original
observations, and written in a simple, graceful style. The volume to
which it forms the introduction raised its author at once to a position
among the leading medical writers of the time. Of the other papers in
the volume, one is devoted to pulmonary consumption, and it is interest-
ing to remark that in his treatment of that disease Dr. Rush anticipates
the therapeutics of the present day. He gives a graphic description of
“breakbone fever,” in which he was the first to note the unwonted de-
pression of spirits which attends the disorder. For scarlet fever, on
which he has a chapter, he thought that he had found a specific in calo-
mel, which he believed to be as sure a remedy for croup, also, as bark is
for intermittent fever.
A second volume of “Inquiries” followed on the 4th of July, 1793.
Another oration before the American Philosophical Society forms the
first paper in this volume. Its subject is “The Influence of Physical
Causes on the Moral Faculties.” The titles of his orations indicate the
decided turn of his mind to philosophical disquisitions; the matter com-
posing them proves how closely and widely he had observed, and how
profoundly he had reflected on, the subjects of discussion. A second
paper of great interest in this volume is an inquiry into the causes of
the increase of bilious and intermittent fevers in Pennsylvania. A
third relates to pulmonary consumption, to which he returns in his
second volume to insist, with greater emphasis, on the utility of iron,
cold baths, and horseback exercise, in the early stage of the disease.
Another chapter is given to an inquiry into the state of the body and
mind in old age, with observations on its diseases and their remedies.
It is, perhaps, the best in the volume. It is a charming article, and will
compare most favorably with any essay on the subject to be found in
any literature. -
Dr. Rush’s third volume was issued in 1794, and is taken up with a
history of the yellow fever, which ravaged Philadelphia the year before.
It will be read, it is safe to say, while yellow fever continues to scourge
the human race. No more graphic account of a pestilence was ever
A D DIRESS O N M E DIC A. L T, ITER AT U R E. 227
written by a medical man. It possesses all the charm of a personal nar-
rative. The author reveals the state of his feelings under the varying
aspects of the epidemic. “IIeaven alone,” he says, “bore witness to the
anguish of my soul in this awful situation,” baffled in every attempt to
stop the ravages of the disease. And when, after reading the manuscript
account of the fever by Dr. Mitchell, he became successful, he says:
“Never before did I experience such sublime joy as I now felt in con-
templating the success of my remedies. It repaid me for the toils and
studies of my life. The conquest of this formidable disease was not the
effect of accident, nor of the application of a single remedy ; but it was
the triumph of a principle in medicine. The reader will not wonder at
this joyful state of my mind when I add a short extract from my note-
book, dated the 10th of September: “Thank God, out of a hundred
patients whom I have visited or prescribed for this day, I have lost
none.’”
The principle by which Dr. Rush was conducted to these happy re-
sults, was that the debility attending this malignant fever is apparent
merely——an indirect debility—in which the abstraction of blood and
evacuation by purgatives tend to raise the pulse and increase the
strength of the patient. His practice consequently was to bleed again
and again, and give calomel and jalap in active doses, reducing heat by
cold water. Finding the dose of ten grains of each drug too slow in its
operation, he increased the quantity of jalap to fifteen grains. But the
pleasure derived from his great triumph was attended by a serious draw-
back; his practice was denounced in unmeasured and bitter terms by
many of his professional brethren. The effect of this was to excite such
a prejudice in the public mind against his mode of treatment that he
found it difficult to carry it out. Two of his colleagues, Kuhn and Wis-
tar, united in its condemnation. Currie, a practitioner and writer of
note and influence, declared in the public prints of Philadelphia that it
“could not fail of being certain death.” The report was started by
some enemy that Dr. Rush was insane, and he relates that one of his
former patients, a lady, “who had believed the report, expressed her
surprise at perceiving no deviation from his ordinary manner in a sick
room.” It was even proposed by some of his excited fellow citizens to
“drum him out of the city.”
The terms in which Dr. Rush referred to the conduct of his enemies,
under these trying circumstances, are worthy to be reproduced in this
narrative, as illustrating the magnanimity of his nature. He says: “I
allude to these slanders now only for the sake of declaring, in this public
manner, that I most heartily forgive them ; and that if I discovered at
any time an undue sense of their unkindness and cruelty, it was not
because I felt myself injured by them, but because I was sure they would
irreparably injure my fellow citizens, by lessening their confidence in
the only remedies that I believed to be effectual in the reigning epi-
demic. I commit the caiumnies which have followed my opinions and
practices in this fever to the dust.”
The fourth and last volume of the “Inquiries” was issued in 1796;
and in this the author took occasion to announce that he was engaged
in preparing a work on Diseases of the Mind. This volume opens with
an account of another epidemic of yellow fever, by which Philadelphia
was visited in 1794. Dr. Rush contends earnestly for the doctrine, so
unpalatable to the citizens, that the fever was of local origin, and de-
pended upon accumulations of filth which it was in their power to
228 Y AND ELL,
remove, even going so far as to say that he believed the time would
come when municipal authorities would be held responsible for the
spread of all such fevers. “Seasons and climates,” he continues, “are
not necessarily sickly. The sun would seldom strike by day, nor the
moon by night, were pains taken to prevent the accumulation and putre-
faction of those matters which occasion malignant fevers.” He believed,
when first asserting this opinion, that it was new, but, discovering his
error, he was careful to state that it had been advanced by Dr. Thomas
Bond, as early as 1766, in a clinical lecture at the Pennsylvania Hospital.
At one time Dr. Rush regarded the fever as contagious, but he candidly
admits that he was convinced by the arguments of his pupil, Dr. Charles
Caldwell, that “the pestilence is devoid of any such power.”
One of the papers in this volume is an inquiry into “the proximate
cause of fever,” which he found in spasm of the extreme blood vessels;
but the leading paper is a defence of bloodletting, which brings out all
his power and eloquence as an advocate. It is written with the earnest-
ness and spirit of one who felt himself engaged in establishing a great
truth ; who believed that he was contending for a principle that involved
the interests of his race. While candid in its statements, his defence is
heroic in spirit, and its influence in popularizing the use of the lancet
was felt in every part of our country. The practice is now spoken of as
“atrocious.” There can be no doubt that bloodletting was carried to
excess by Rush and his followers, but it admits of a doubt whether the
practitioners of the present day have not run to the other extreme.
In this volume, and in connection with bloodletting, Dr. Rush repeats
a belief which he had before expressed, that the pains of labor would be
annulled by the discovery of an anaesthetic. This was no mere guess, but
an opinion reached by a process of induction. “I was encouraged to
cherish this hope,” he says, “by having known delivery to take place in
one instance during a paroxysm of epilepsy; and having heard of another
during a fit of drunkenness in a woman attended by Dr. Church, in both
of which there was neither consciousness nor recollection of pain.”
In 1798, Dr. Rush published a volume of “Essays; Literary, Moral,
and Philosophical,” which had previously appeared in the magazines of
the day. It is in one of these that he contends against the ancient lan-
guages as a necessary part of the education of students of medicine. In
1801 he added to his other works a volume of Introductory Lectures, in
one of which he unfolds his views on the unity of disease. Nosology
appeared to him mischievous, as directing the attention of practitioners
to the name rather than the character of the disease; and in his lectures
he inveighed warmly against it. Rising from his chair, to give greater
emphasis to his words, he would exclaim, Nosologia delenda est / But this
question, in which he was able to create a lively interest while he was
the popular teacher of the period, has long since been put to rest. His
great work on Diseases of the Mind appeared in 1812, only a short time
before the death of the author, which took place in 1813.
This work, the result of a lifetime of careful observation and honest
inquiry, is, of all his writings, the one now most read and most fre-
quently quoted by medical authors. Nearly all who have followed him
on psychological medicine, refer to it as one of the most instructive of the
treatises on that subject, and as especially rich in facts. Adopting the
enlightened views which Pinel had just promulgated in France, Dr.
| Inquiries, vol. iv. p. 376, 3d ed.
A. I.) I) R. E S S O N M E DIC A. L L IT E R A T U R E. 229
Rush gave an impetus to the revolution which this country has wit-
nessed in the management of the insane; and it is his noble eulogy that
he aided “in opening the prison doors of the maniac, unbarred his
noisome dungeon, and knocked the shackles from his limbs, substituting
moral treatment for brute force, and love for fear.” He saw, as the
great French alienist had pointed out, that the law of kindness is the
true one in the management of lunatics; his work gave currency to the
novel idea, and, as a result of the light diffused abroad by him, the con-
dition of the insane in all our asylums has been one of steady improve-
ment from his day to our own.
In the century that has passed away since Rush appeared as an au-
thor, no one of all the medical writers of America has attained to the
popularity which he enjoyed, nor exerted so wide and lasting an influ-
ence on the professional mind of his country. During the generation in
which he lived he was more generally read and followed, not only than
any other medical author of this country, but than all our other writers
on medicine put together. Nor is it likely that his name or his works
will be forgotten. His writings form, as a whole, a body of philosophi-
cal medicine—defective, indeed, in many points—but exhibiting a
breadth of view, an originality of thought and conception, an accuracy
and extent of observation, and a terseness, vivacity, and clearness of
style, that compare well with the best medical works of their period.”
A host of minor writers on yellow fever was brought out by the epi-
demics, as they appeared toward the close of the last century in our
Atlantic cities. Among these was Dr. William Currie, of Philadelphia,
whose writings on that subject were only less voluminous than those of
Rush. He was an independent thinker, a careful investigator of the
diseases of the country, and a faithful observer and recorder of facts;
but he is likely to be longest remembered for the violence with which he
assailed Rush's doctrines and practice. It is, however, due to his memory
to record that he retracted publicly, soon after making the harsh stric-
tures on his great contemporary.”
| Dr. Edward Jarvis.
* Before the first volume of Rush's Inquiries was written, Samuel Stanhope Smith, D.D.,
President of Princeton College, had published a small volume on “The Causes of the
Variety of Complexion and Figure in the Human Species,” which was republished, with
notes, in Edinburgh, by a professor of that university. Dr. Caldwell reviewed it with
great acrimony, urging the insufficiency of the causes assigned to produce the existing
varieties. The question has been much discussed since that day, but remains still in an
unsatisfactory position. In 1781, Dr. James Tilton published a short treatise on the Dis-
eases and Management of Military Hospitals. Dr. Samuel Tenney published, in 1783, an
Account of the Saratoga Springs. In 1786, Dr. Matthew Wilson produced an essay on
the diseases arising from the air, contending that most of them are generated by miasmata.
The same year he wrote for Atkins's American Magazine an account of a malignant fever
which prevailed in Sussex County, Delaware, in 1774; and also an account of the severe
winter of 1779, which appeared in the Transactions of the American Philosophical Society.
In 1788, the Medical Society of the County of New Haven, Conn., published a volume of
Transactions, which was much quoted by British writers. In 1793, part of a volume of
Transactions was published by the Philadelphia College of Physicians, which, after many
years, began to issue a quarterly summary, and now publishes annual volumes. , Dr.
Charles McLean wrote a work, in 1797, to prove that pestilential diseases were dependent,
in all cases, upon certain altered conditions of the atmosphere, and were never communi-
cated by contagion. An oration delivered at the University of Virginia, by M. Coste,
Medical Director of the French forces, in 1782, forming a volume of 103 pages, 8vo., was
printed at Leyden in 1783. Dr. John Leigh, of Virginia, obtained in 1785 the Harveian
prize for an essay on the properties of opium, which was printed at Edinburgh in 1786.
* Dr. Currie published, in 1792, a historical account of the climate of the United States.
In 1798 he wrote on the causes and cure of remitting or bilious fevers. In 1800 he wrote
230 Y AND ELL,
Few of our authors on yellow fever are entitled to more honorable
mention than Dr. Richard Bayley, of New York, who before writing on
this subject had acquired a reputation abroad by his researches in mem-
branous croup. His history of yellow fever in New York is one of the
most graphic and instructive produced in our country, and affords evi-
dence of powers which might have placed him in the front rank of our
writers, had he lived to develop them; but his fearlessness in visiting the
localities in which the epidemic raged, brought on an attack of the fever,
which terminated his life just as his labors promised the greatest useful-
ness to his profession. Another writer, who afterwards rose to great dis-
tinction, was Dr. Charles Caldwell. He began to write on yellow fever
while yet a student of medicine, having seen much of the epidemic in
Philadelphia, in 1793. Of those who contended against its contagious-
ness, and for its domestic origin, he was among the first and the most
earnest. He also wrote against the expediency of quarantine. Dr. John
Beale Davidge, at that time a young physician in Baltimore, was also an
early writer on yellow fever. He published a paper on that subject in
1798, in which he contended for the doctrine that the fever originated
in the places where it prevailed, believing, when he asserted it, that it
had not before been taught in this country."
Our medical journalism commenced in New York towards the close of
the last century. The first journal was a reprint, in 1790, of the
Journal de Médecine Militaire, annotated from the French by Joseph
Brown. The Medical Repository made its appearance on the 26th of
July, 1797, under the editorial care of Dr. Elihu H. Smith, Dr. Ed-
ward Miller, and Dr. Samuel L. Mitchill. Its origin marks an im-
portant era in Our medical history. Its editors were men of marked
ability. Dr. Mitchill was especially noted as a theorist, but he was
admirable for the extent and diversity of his attainments, and in ver-
satility of powers had no superior among the medical men of his day.
Dr. Miller was an original thinker, an acute observer, of solid judgment
and learning, and a pleasing writer. Dr. Smith, the projector of the
work, and the most gifted of the remarkable triumvirate, fell a victim
to yellow fever in the twenty-seventh year of his age, but not until
after he had achieved a national reputation. Among the productions
a sketch of the rise and progress of the yellow fever of 1798 in Philadelphia. In 1811 he
wrote a treatise on the diseases most prevalent in the United States at different seasons of
the year; and in 1815 he published a synopsis of the theories and doctrines of disease.
Other writers were the following: Deveze, who has the distinction of having been the first
American writer to declare against the contagiousness of yellow fever; Cathrall, who wrote,
in 1796, on the synocha maligna of Philadelphia; Dr. J. O'Reilly, who, in 1798, wrote on
the “Contagious Epidemic Yellow Fever” of that city; Seaman, who wrote, in 1796, on
the yellow fever of New York; and Dr. Samuel Brown, who, in 1797 and 1800, wrote on the
yellow fever of Boston. Noah Webster also published, in 1796, two volumes on Pestilential
Diseases, forming a valuable work of reference. Among other writers at that period were
Hardie, Tytler, Pfaff, Hosack, and Davis. J. Henry C. Helmuth, of Philadelphia, wrote
a tract in German “for the reflecting Christian,” in which he presented the subject in its
religious bearings. Ffirth, a few years later, published a number of experiments made to
determine the question whether the disease could be communicated from person to person.
One of these experiments was to swallow the black vomit.
| To the list of our early writers on yellow fever, the following names are to be added:
Matthew Carey, Pascalis, Condie and Folwell, Chadwell, Manly, Rushton, Addoms, Mar-
tin, Monson, and Monson, Jr. The various publications relating to the early epidemics
of yellow fever on our continent would form a curious body of medical literature, which it
would be interesting to study. While the discussions were going on about the nature and
treatment of yellow fever, Drs. Yates and McLean found time to write a volume of a hun-
dred and fifty pages on the Brunonian theory of Life.
A D D RESS O N M E DIC A. L. LITE R A TU R E. 231
left behind him to testify to his genius, is a poetical introduction to
Darwin’s “Botanic Garden.” The Repository, under these gentlemen's
guidance, acquired great popularity and influence, reaching every part of
the country, and receiving contributions from its best writers. Among
other articles were Physick’s report of his autopsies in yellow fever, and
the papers of Stearns and Prescott announcing the oxytocic properties
of ergot. In the hands of numerous editors the Repository continued
until it reached its twenty-third volume."
In 1805, Dr. Caldwell, who had become widely and favorably known
by a translation of Blumenbach’s physiology, and by his writings on
yellow fever and quarantine, issued a volume of Select Theses, written
by graduates of the University of Pennsylvania, with a preliminary
discourse and appendix from his own pen. A second volume followed
in the succeeding year, the appendix containing a paper by the editor
on the “vitality of the blood,” one of his favorite doctrines. It was
his purpose to continue the work annually, but the trustees, by the
advice of the Medical Faculty of the University, saw fit to relieve can-
didates of the burden of printing their theses, and in consequence Cald-
well’s publication fell through. Strangely enough, he looked upon the
action of the faculty in this matter as “a measure of vengeance and
mischief” to himself.
Dr. Caldwell was one of the most prolific of American medical authors.
His writings were fragmentary, consisting of essays, reviews, and dis-
courses, scattered through the literary magazines and medical journals of
the day, but if collected would make not less than ten octavo volumes of
a thousand pages each. Almost always in a controversy on some point in
medicine or medico-theology, he was seldom lost to the public eye from
the time he entered his profession till near the close of his life. He was a
man of varied attainments, but his learning was remarkable for extension
of surface, rather than accuracy or depth; and, while he wrote on a great
variety of subjects, it cannot be said that he added much to the stock of
medical science. It was a peculiarity of his mental constitution that
he continually set himself to advocate opinions and systems generally
rejected, and to assail the most cherished beliefs of men. “Better
occasionally broach startling error, than deal continually in time-beaten
truisms,” was one of his maxims; and it may be said that he wasted his
fine powers, as another great scholar declared he had wasted a life, “in
levities and strenuous imanities.” Many of his best years were devoted
to the exposition and defence of phrenology, which, towards the close of
his career, was superseded by mesmerism and spiritualism. Such was
| The New York Medical Repository was followed, in 1803, by a periodical at Philadel-
phia, the Philadelphia Medical and Physical Journal, edited by Dr. Benjamin Smith Bar-
ton ; but this contained too much botany and Zoology to suit the profession, and it expired
at the end of the third volume. It was succeeded, in 1806, by the Medical Museum, under
the editorial care of Dr. John R. Coxe, which was continued seven years. In 1808 a jour-
nal was started at Baltimore, by Dr. Tobias Watkins, the Baltimore Medical and Physical
Recorder, which had a brief career, and gave place to another in that city, of still shorter
duration, edited by Dr. Nathaniel Potter, under the name of the Medical and Philosophical
Lyceum. In 1810 the American Philosophical Register was set on foot by Dr. Hosack and
Dr. J. W. Francis, at New York, its fourth volume containing the famous letters of Dr.
Mitchell to Dr. Franklin on yellow fever, communicated by Dr. Rush to Dr. Hosack. The
Eclectic Repository and Analytical Review was started at Philadelphia in 1811, by Drs.
Otto, Hewson, James, and other physicians of that city, and reached its tenth volume,
when it was discontinued. Among its notable papers is a brief account of McDowell's
renowned operations for diseased ovaria. In 1812 the New England Journal of Medicine
and Surgery was established by a number of the physicians of Boston.
232 Y AND ELL,
his assurance of the truth of organology, that he advised the use of the
trephine to the head in mania, over the part of the brain indicated by
phrenology as affected. He wrote an analysis of fever which would have
possessed value if it had been the fruit of clinical observation ; but it was
purely a work of the closet. As a writer of critical reviews, he was one
of the readiest, most affluent, and most formidable of his day; in tone
somewhat too domineering and dogmatic, and in language often unne-
cessarily bitter, but always vigorous and independent. His most elabo-
rate work was an autobiography published since his death, which has
added nothing to his fame. Exhibiting, throughout, the temper which
caused him to suspect his old friends and teachers in the University of
Pennsylvania of framing “a measure of vengeance” against him, he is
every where unjust to the memory of his contemporaries.
About the beginning of the present century, the first works on syste-
matic medicine began to appear, nearly all up to this time having been
monographs. In 1801, Dr. B. S. Barton published some contributions for
an essay towards a Materia Medica of the United States, having com-
menced in 1798 to make collections for such a work. In 1803, he issued
a work on the Elements of Botany, with some references of a desultory
character to vegetable physiology. Dr. J. R. Coxe, in 1806, compiled a
Dispensatory, which in the scarcity of medical books at the time proved
of much service to practitioners.
In 1807, Dr. Samuel Bard, of New York, gave to the profession a
small but admirably written volume on the Science and Art of Mid-
wifery. His “ compendium” was the vade-mecum of our accoucheurs for
more than a quarter of a century, and is still quoted with respect by
writers on obstetrics. Its sound judgment and good sense made it a safe
guide, and the clearness and simplicity of its language adapted it to the
capacity of midwives, in whose hands, when it appeared, was most of
the obstetrical practice of the country." In 1810, Dr. James Thacher pre-
pared a valuable Dispensatory, on a plan which had been proposed by the
Medical Society of Massachusetts for securing uniformity in the Phar-
macopoeias of the United States; this work remained long in use by the
profession. -
In 1811 appeared the System of Anatomy, by Dr. Caspar Wistar, of
the University of Tennsylvania, which was the popular text-book in
American medical schools for more than thirty years. It passed through
nine editions, enriched and enlarged by successive editors, its author
having died shortly after the publication of the second volume. Wistar
was the first writer on anatomy to describe accurately the extremities of
the ethmoid bone, which previously had been supposed to belong to the
sphenoid, and hence they have ever since been known as “the pyramids
* Dr. George C. Shattuck, in 1808, published three dissertations on Boylston prize-ques-
tions for 1806 and 1807. They treated of Diseases of the Skin, Mortification, and Biliary
Concretions. Dr. Edward Cutbush, of the U. S. Navy, wrote in 1808, a work on Preserv-
ing the Health of Sailors and Soldiers. In 1808 and 1811, the monograph of Dr. Bayley
on Membranous Croup appeared in the Medical Repository. The true nature of the com-
plaint had been pointed out by him as early as 1781 in a letter to Dr. Hunter. In 1809
Dr. J. C. Warren published a valuable paper on Organic Diseases of the Heart. Dr. Na-
than Strong, in 1810, wrote a treatise on Spotted Fever, which was followed the next year
by papers on the same subject by Dr. North, Dr. Woodward, Dr. Bester, and Dr. Fish. Dr.
Hugh Williamson, in 1811, published Observations on the Climate of different parts of
America, to which he added a history of North Carolina, including an account of its dis-
eases in 1812.
A D D RESS ON ME DIC A. L. LITE R A TU R E. 233
of Wistar.” His volumes contained little that was original, but the
matter was presented in a shape highly convenient to students, and it is
not too much to say that their publication marked an era in the history
of American authorship.
Of scarcely inferior popularity at the time, and of the greatest value
to the profession of our country, was another work which proceeded
from the same institution a few years later. The “Elements of Surgery,”
by Dr. John Syng Dorsey, in two volumes, appeared in 1813. The au-
thor was a young man, and could not claim to have had much personal
experience in surgery, but that of his distinguished uncle, Physick, then,
as long afterward, the leading surgeon of the United States, was at his
command with which to enrich his work. It was written in a simple,
graceful, flowing style, with special reference to the needs of students,
and so well did the author succeed in his design that his book was at
one time adopted in the University of Edinburgh as a text-book. That
place it assumed at once in our schools, and maintained until later sys-
tems supplanted it. Nor was it less prized by the profession as a work
of reference. It passed through four editions, two after the author's
death, which occurred while he was still young. Had he lived to dis-
cipline and mature the high gifts with which he was endowed by Nature,
he would have attained undoubtedly to great eminence as an author.
He indulged occasionally in poetical effusions, some of which, says Pro-
fessor Gross, his biographer, “embody uncommon vigor of thought and
power of description.” Something of the glow of poetry may be de-
tected in his professional writings.
At all times, while acknowledging his indebtedness to foreign sur-
geons, Dorsey does not hesitate to criticize their prejudices and prac-
tice. Thus, in the preface to his Elements he says: “Great Britain and
France have been foremost in the cultivation of modern surgery, but
their deficiency in philosophical courtesy and candor has in some in-
stances greatly retarded its progress. To illustrate this remark it will
be sufficient to state that the doctrine of adhesion, so ably developed in
England, has been shamefully neglected in France; and that French
surgery in fractures finds no advocates in Britain. Some of the best
writings of Desault have never been translated into the Euglish language,
and those of Hunter are unknown or disregarded throughout the conti-
ment of Europe. This spirit of hostile rivalship, extending from the field
of battle to that of.science, cannot fail to exert a pernicious influence on
practical surgery; a truth too palpable to escape the observation of any
foreigner who visits a European hospital. An American, in walking
their wards, sees with surprise in London a fractured thigh rudely bound
in bundles of straw, and the patient discharged limping with a crooked
limb. In the French capital he witnesses an amputation, and is dis-
gusted with the officious zeal with which the surgeon crams a handful of
lint between the stump and the flap which covers it, with an express
design to prevent their adhesion.”
While the University of Pennsylvania was contributing thus liberally
to our literature, the University of Maryland was not idle. Dr. Davidge,
its honored founder, in 1812, essayed another System of Nosology, more
simple and therefore more eligible than that of Cullen then prevailing.
In 1814 he republished his memoir on yellow fever, and with it his in-
augural thesis on the Catamenia, in a volume entitled “Physical Sketches,
| Gross, Introductory Lecture on American Medicine.
234 Y AND ELL,
or outlines of correctives applied to certain errours in Physick,” which,
besides these, contains an elaborate history of the various methods of
amputation, including one of his own. The introduction to his Nosology
contains a powerful argument against Rush's theory of “the unity of
disease,” which at that time excited a good deal of interest. His thesis,
written in Latin, and first printed at Glasgow in 1793, maintains the
doctrine that the menstrual flux is a true secretion. Not the least
pungent article in his sketches is the review of a case related by Cald-
well in his paper on the vitality of the blood. The case was as fol-
lows: The writer, after the extraction of a tooth, had some trouble with
hemorrhage, but, keeping the blood in the alveolus by pressure, at last
arrested its flow. The weather being warm, he examined the coagulum
several times a day, but instead of its becoming “putrid and offensive, he
was surprised to observe it on the fourth or fifth day after coagulation be-
ginning to assume the appearance of flesh.” And this incarnation com-
menced, he relates, not at the circumference, “but in the centre of the
coagulum, at the greatest possible distance from any vessels that might,
by elongation, have been protruded from the adjacent gums;” so that
“what had been at first nothing but congealed blood, became a piece of
perfect flesh, similar in texture and appearance to that of the gums.”
Upon this remarkable case Davidge makes the following comments:
First, that it is “solitary of its kind;” then, that the clot is singular
“from its transparency,” all other clots of blood being opaque; and,
finally, he is bold to say, that “the asserted fact is bottomed upon the
broad basis of human credulity.”
As a controversialist, Davidge displayed undue acerbity, as the reader
will conclude from the foregoing quotation. His style, at the same time,
was stiff, involved and affected, entirely unlike that in which he lectured.
His lectures, indeed, afforded a model of simple elegance, while the mo-
ment he took pen in hand he seemed to forget the English idiom. Ten
years after the appearance of his “sketches,” he issued the first number
of a journal, The Baltimore Philosophical Journal and Review, which
he proposed to continue, but was obliged to give up for want of
encouragement. The number published was written almost entirely by
himself, in his peculiar, crabbed style, and in a temper so acrimonious
that it was hardly read at all when it came out, and might soon after
have been bought almost as waste paper."
In 1816, a syllabus of the lectures of Dr. James Jackson in the Massa-
chusetts Medical College, was published, and only increased the general
feeling of regret that the learned and able author did not prepare a
systematic treatise on the principles and practice of medicine.
In 1817 was published a volume of lectures on the “Elements of
Therapeutics and Materia Medica,” delivered by Dr. Nathaniel Chap-
| Dr. J. W. Francis in 1811 published an able paper on Mercury. It was in 1813 that
Dr. Prescott wrote his article on Ergot, which was inserted in the thirteenth volume of the
Dictionnaire des Sciences Médicales. The same year Dr. John Warren wrote ably on Calo-
mel, arguing against its utility in hydrocephalus. Dr. Charles Wells, a native of South
Carolina, also published that year, in London, his philosophical theory of dew, which was
crowned by the Royal Society in 1814 with the Rumford medal. Dr. E. Hale, Jr., in 1814,
published an instructive volume on spotted fever; and in that year Dr. J. Dyckman pro-
duced an elaborate dissertation on the pathology of the human fluids. Dr. Joseph Gallup,
in 1815, contributed a practical work on the epidemic diseases of Vermont from its first
settlement. In the same year Dr. Job Wilson wrote an inquiry into the nature of spotted
fever, and Dr. Ennalls Martin produced a history of the epidemics of the winter of 1813
and 1814 in Talbot and Queen Anne's counties, Maryland.
A L) D R E S S O N M E DIC A. L. LITE R A T U R E. 235
man in the University of Pennsylvania, to which a second volume suc-
ceeded in 1819. Nothing so fresh in style, or so original in theory, had
been contributed to our literature since the days of Rush. These lec-
tures were received by the profession with abundant favor. As “dis-
courses” they were characterized by some redundancy of expression, and
a severe critic would have termed their style florid; but they were, per-
haps, more pleasing to youthful readers on that account. The writer
remembers well the feeling of relief, not to say delight, with which he
turned to them from the dry treatises on Materia Medica, and the drier
dispensatories which they came to supplant. Chapman’s theory of the
operation of medicines was of modern date, as he expressed it, and of
captivating simplicity. It was this: “That all such agents act by ex-
citing a local impression, which is extended through the medium of
sympathy.” No article, he held, “ever enters the circulation as a medi-
cine.” “It cannot, indeed, be credited,” he says, “that any substance,
after a subjection to the digestive and assimilative process, retains in
the slightest degree its original properties.” Besides this, everything
that acts upon the system “is a stimulant.” Such was his philosophy
in a few words, which one of his critics hardly ventured to controvert
when it was announced, feeling himself tibi miles impar." How success-
fully it has since been opposed need not be related here.
With this popular work came out some numbers in quarto of a treatise
on the “Vegetable Materia Medica of the United States,” by Dr. W. P.
C. Barton, of the same University; and a treatise on Medical Botany, of
much research and substantial value, in three volumes octavo, by Dr.
Jacob Bigelow, of Harvard University. The work of Barton was sub-
sequently issued in a form magnificently illustrated, under the name of
“Flora of North America.”
In 1817 was originated a Journal of Science, which, though not medi-
cal in character, exerted a decided influence on medicine in the United
States. This was the “Journal of Science and Art,” projected at New
Haven by Prof. Benjamin Silliman, of Yale College. The work re-
mained under his editorial care until it reached its fiftieth volume. No
American serial, it may be safely said, has contributed more to the fame
of our country, and none has done so much to develop its science in the
direction of natural history. Its volumes form a magazine of facts and
observations indispensable to writers on any branch of natural science,
and contain many articles relating directly to medicine. Among the
authors of our country it would be difficult to name a writer more
polished and graceful, or more variously gifted and informed, than the
elder Silliman, who devoted a long life assiduously to the advancement
of useful knowledge among his countrymen, and who, on retiring from
his work as editor, had the good fortune to find in his own family suc-
cessors qualified to sustain the high reputation of his journal. Under
the direction of Prof. B. Silliman, Jr., and Prof. James D. Dana, the
American Journal of Science has maintained its rank as one of the lead-
ing periodicals of the world.
Dr. James Thacher, in 1817, published a work styled the “Modern
Practice of Physic,” the reception of which by the profession was so
favorable that a second edition was called for in a few years. Dr.
Thacher was at the same time a scholar and a practical physician,
equally at home in the sick-room, in writing on the nature and treat-
! See Med. Recorder, vol. i. p. 189,
236 Y AND ELL,
ment of disease, or in drawing up his well-known biographical sketches
of noted American physicians. His is one of the names which will be
long held by the profession in grateful remembrance."
In 1818, Dr. Nathaniel Potter, the learned Professor of Theory and
Practice of Medicine in the University of Maryland, published an elabo-
rate memoir on Contagion, more especially as respects the yellow fever.
In the same year the Medical Recorder, which for a time was the most
influential journal of medicine in the country, was set on foot by several
respectable physicians of Philadelphia. Drs. Eberle, McClellan, and Cal-
houn were subsequently announced as its editors. In 1829 it was merged
in the American Journal of the Medical Sciences. Among other inter-
esting papers it contains a report of the famous operation of Deaderick,
of Tennessee, for removal of the lower jaw, the first on record. Many
other papers by the ablest medical writers of our country found their
way into the Recorder.
In 1819, the first American works on Chemistry appeared. Dr. John
Gorham published his Elements of Chemical Science in two volumes;
and Dr. Franklin Bache, of Philadelphia, prepared an elementary treatise
on chemistry about the same time. During this year, also, was an-
nounced a new theory of Galvanism, with an account of the calorimotor,
a new galvanic instrument, by Dr. Robert Hare, the gifted Professor of
Chemistry in the University of Pennsylvania.”
The United States Pharmacopoeia, proposed in 1808 by the Massachu-
setts Medical Society, was issued in 1820, and having been repeatedly
revised at intervals of ten years, retains its place among our standard
works as a book of reference. In 1820 also was established the medical
journal which has done more than any other of our serials to advance and
shape the medical literature of the United States. Dr. Nathaniel Chap-
man, Professor of Theory and Practice in the University of Pennsylva-
nia, started that year the Philadelphia Journal of the Medical and Physi-
cal Sciences. In the inception of the enterprise he was alone, but in a
short time he secured the valuable assistance of Drs. Dewees and Godman
as associate editors. From the beginning, the Journal evinced the vigor
to have been expected from the editorial talent engaged upon it. Its
editor in chief was then in the prime of his great intellectual powers, and
Godman had already given proof of a genius rarely equalled in our pro-
fession.” In 1827, the name of the Philadelphia Journal was changed,
' Dr. James Mann, of New York, contributed an interesting History of the Campaigns of
1812, 1813, and 1814, to which are added surgical cases, and observations on military hos-
pitals and flying hospitals attached to a moving army. Dr. Jabez Heustis published, in
1817, Some Physical Observations and Medical Facts and Researches on the Topography
and Diseases of Louisiana. In the same year, Dr. W. C. P. Barton issued a work on the
Internal Organization and Government of Marine Hospitals, based on his own experience
and observation. The year following, Dr. John King published, at Norwich, a treatise on
Extra-uterine Foetation and Retroversion of the Uterus. Dr. J. C. Shecut, of Charleston,
the same year, produced an Essay on Contagions and Infections. Dr. A. H. Stevens pub-
lished some cases of Fungus Haematodes of the Eye, in 1818.
* This year appeared also a work by Dr. L. Spalding, of New York, entitled Reflec-
tions on Yellow Fever Periods; one by Dr. Felix Pascalis, on the Malignant Yellow
Fever of New York in 1819; and one by Dr. Shecut, of Charleston, containing a history
of Yellow Fever.
* The first account of that strange disease, “Milk sickness,” so far as is known, was given
by Messrs. Lea and McCall, students of medicine from Tennessee, in one of the earlier num-
bers of this journal, and it is proper to record that the editor was disposed to reject their
history of this disease as apocryphal, for the reason that the facts stated seemed wholly
irreconcilable with his hypothesis that poisons in a formal state never entered the circula-
tion.
A DI) RESS O N M ET) IC A. L T, ITER AT U R E. 237
and it passed into the hands of Dr. Isaac Hays, who, with a judgment,
perseverance, and industry, seldom witnessed in journalism, has continued
it down to the present day, as the American Journal of the Medical
Sciences.
This is the medical journal of our country to which the American
physician abroad will point with greatest satisfaction, as reflecting the
state of professional culture in his country. For a great many years it
has been the medium through which our ablest writers have made known
their discoveries and observations. -
In 1821, Dr. Hosack's Nosology, which had been issued some years
before, reached a second edition, and the Journal of Foreign Medical
Literature was set on foot, by Drs. Emlen and Price, and afterwards con-
tinued for a time by Drs. Godman and Littell. Dr. Donaldson, in 1821,
published a treatise on the present system of medicine and surgery in
Europe and America; and Dr. E. Hale, Jr., the same year issued an essay,
which had been crowned by the Boylston prize, on the connection be-
tween the Stomach and the Urinary Organs.
The following year was an eventful one in the history of our medical
literature. A work of much research was produced by Dr. John C.
Warren, styled “A Comparative View of the Sensorial and Nervous Sys-
tems in Man and Animals;” a treatise, by Dr. John Eberle, on Materia
Medica, was published; and two journals appeared, the New York Medi-
cal and Physical Journal, conducted by Drs. Dyckman, Francis, and
John B. Beck ; and the Western Quarterly Reporter, edited by Dr. John
D. Godman, at Cincinnati, marking the rise of medical journalism in the
Valley of the Mississippi. The Materia Medica of Eberle was a work of
sterling merit, at once learned, practical, and judicious, and written in a
clear, simple style. Those most partial to Chapman could hardly help
admitting that, in all the qualities sought for by students and practi-
tioners in a text-book or a manual, it was superior to his treatise on the
subject. Its author, with far less genius, was a scholar of very much
greater research, who had taken time to look extensively through the
German and French literature on the subject as well as that in his own
language, and to make his work as thorough as industry could render it.
t was long one of the most popular text-books in our schools, as well as
an authority in the profession. Dr. J. Bigelow, the same year, published
a valuable treatise on Materia Medica, intended as a sequel to the Phar-
macopoeia of the United States. An era was opened in the professional
literature of the West by the appearance of Godman's journal at Cincin-
nati, which, though of short duration, was the beginning of a most pro-
lific series. Only six monthly numbers of his work were issued, but as
proof of the activity and zeal with which the editor devoted himself to
it, it is worthy of mention that, of the matter composing them, he wrote
more than three hundred pages."
The year 1823 is also memorable as having produced the classical work
on Medical Jurisprudence by Dr. T. Romeyn Beck and Dr. John B.
' Dr. Godman, in 1824, published a thin octavo volume made up of anatomical researches,
which was followed, the succeeding year, by a smaller volume, entitled Contributions to
Physiological and Pathological Anatomy, founded on his own dissections. His American
Natural History, in three volumes, appeared in 1826, and gave him standing with the natu-
ralists of his time. A small volume, composed of Addresses delivered on various occasions,
followed in 1829. The “Rambles of a Naturalist,” written for a weekly magazine in Phila-
delphia, and published in a small volume after the author's death, was the last of his labors,
all of which bore evidence of a passionate devotion to, and of a genius capable of the
highest achievements in, science.
238 Y AND ELL,
Beck. This admirable treatise has rather gained in reputation than
declined during the many years that have elapsed since its publication;
nor is there any reason why it should not maintain its enviable position
among the works of its class, since the changes which, under a rapid suc-
cession of systems, are inevitable in other departments of medicine, are
not met with in medical jurisprudence. Besides this learned work, which
has conferred so much fame upon our authorship, others of note were
written in 1823. One of these was on Diseases of the Eye, by Dr. George
Frick, of Baltimore; and a larger one on Fevers, from the pen of Dr.
Thomas Miner and Dr. Wm. Tully, two eminent physicians of New Eng-
land, had the recommendation of being founded on the observation and
experience of its authors at the bedside."
Dr. William P. Dewees, who had become eminent in Philadelphia as
an accoucheur, and was known in all parts of his country as a writer on
obstetrics, appeared in 1824” as author of a System of Midwifery, which
not only gave new dignity to the art in the New World, but may be said
to have created an American School of Obstetrics. The popularity of
this work was very great, and in thirteen years it had passed through a
dozen editions. The author wrote from his own experience, and ex-
pressed himself as one having a right to speak. If he was dogmatic, it
must be remembered that he was almost without a rival near him to
question his authority, and if his pages betray haste and carelessness, the
defect must be set down to the incessant press of business which left him
little leisure for correcting what he wrote. There is something painful
in the thought that a work once so much read, and held in such high
esteem, should now be entirely neglected. But the march of science
renders such a fate inevitable. Other systems more advanced have long
since taken its place.
A treatise on the Diseases of Females, and one on the Physical and
Medical Management of Children, followed Dr. Dewees's Midwifery in
1826, and extended his fame as an author. It was many years before
either work was superseded, and while they stood their ground they
were to be found in nearly every medical library of the country. In
1830 he entered a new field, sending forth a “Practice of Physic,” com-
prising most of the diseases not treated of in his “Diseases of Females”
and his work on Children ; but this proved a failure. The writer had
undertaken too much. Of all subjects pertaining to obstetrics, he was
master, but his medical philosophy was tainted by the declining system
of Broussais, and his therapeutics proved unpopular. As a specimen of
his practice, it may be mentioned that he reports having bled one of his
patients six times for a fever, brought back, after she was convalescent,
by a single plate of soup.
Few more remarkable men have appeared in the American profession
than Dr. Nathan Smith, author of a treatise on typhus fever written in
* The following works were also issued in 1823: An Essay on Suspended Animation, by
Dr. Samuel Calhoun; a Guide for Practising Physicians in Visiting the Sick, by Dr. J.
Lobstein; a Treatise on Cynanche trachealis, by Dr. W. Sweetzer, of Boston, who also wrote
on Consumption and on Indigestion in 1836 and 1837; an Account of Yellow Fever in New
York, in 1822, by Dr. T. S. Townsend; and a History of Yellow Fever as it appeared in
Natchez, in 1822, by Dr. Henry Tooley.
* A work on the Philosophy of Epidemics was contributed in 1824 by Dr. Joseph M.
Smith, and also three volumes of Essays on various medical subjects by Dr. David Hosack.
The Medical Intelligencer, a monthly in quarto form, was started in the winter of 1823–4
by Dr. J. V. C. Smith, at Boston; and the Medical Review and Analytical Journal by Dr.
Eberle and Dr. George McClellan, in Philadelphia, in 1824.
A DI) RESS O N M ET) I C A L LITE R A T U R E. 239
1824. He was a great surgeon, an able teacher, and a judicious author.
In independence of thought, and in sturdy, common sense, he had few
equals in his day, and has never had many superiors in the profession.
When his little volume appeared, the distinction between typhus and
typhoid fever had not been recognized, and it was evidently the latter
that he had under consideration. “I have never been satisfied,” he de-
clares, “that I have cut short a single case of typhus fever that I know
to be such. Typhus has a natural termination like other diseases which
arise from specific causes.” His readers, fresh from the work of Arm-
strong, on typhus fever, recommending a vigorous treatment by the
laneet and purgatives, were not a little disappointed when they came to
his concluding words as to its cure : “All that is required is simple de-
mulcent drinks, a very small quantity of farinaceous food, and avoidance
of all causes of irritation.” Another work on surgery was produced in
1824, by a professor in the University of Pennsylvania, Dr. William Gib-
son. It was a heavy work, compared with that of Dorsey, and in com-
parison with later systems it was greatly wanting in information ; but
the author made amends for these early defects in succeeding editions,
and his surgery acquired at last a just claim to the position given it by
his official connections. It was not long in supplanting the treatise of
Dorsey as a text-book in the American schools."
In 1826, the North American Journal of Medicine and Surgery was
established at Philadelphia, under the auspices of the “Kappa Lambda
Society of Hippocrates.” Its corps of editors embraced some of the best
medical talent of the country. It included the names of H. L. Hodge,
C. D. Meigs, B. H. Coates, F. Bache, and R. LaRoche, to which, after
two years, those of John Bell, George B. Wood, and D. F. Condie, were
added. The aim of the Society was to promote harmony in the ranks of
the profession, and with its patronage the journal was expected to have
wide circulation. It assumed at once a high rank among the periodicals
of the day, but, notwithstanding its acknowledged ability, and the
favorable circumstances attending its origin, it was discontinued at the
end of the twelfth volume for want of adequate pecuniary support. A
systematic treatise on anatomy was added to the list of American books
in 1826, by Professor William E. Horner, of the University of Pennsyl-
vania, one of the most pains-taking and assiduous of modern authors;
but though fuller and more accurate than the volumes of Wistar, it failed
to secure the footing in the schools so long maintained by our earliest
work on anatomy.
Dr. James Rush produced, in 1827, a work on the Philosophy of the
Human Voice, which for originality and depth of research has been pro-
nounced by competent judges one of the most creditable of the produc-
tions of our country relating to medicine. The same year, the Monthly
Journal of Medicine originated in Philadelphia, and Dr. Drake took
charge of the Western Journal of the Medical and Physical Sciences, at
Cincinnati. When he projected his periodical, he assumed as its motto,
E sylvis nuncius; to which, no readers being secured east of the moun-
tains, he added subsequently the words, aeque atque ad Sylvas nuncius.
' Dr. Thomas Miner gave an interesting account of typhus syncopalis in 1825, and an
epitome of chemical philosophy was published the same year by Dr. James D. Dana. In
1825 also appeared a Manual of Chemistry by Dr. John W. Webster, Professor of
Chemistry in Harvard University, who was executed at Boston in 1850 for the murder of
Dr. George Parkman.
240 Y AND ELL,
He conducted it with great energy for twelve years, when it was merged
in a journal at Louisville."
In 1828, Dr. John E. Cooke produced a work in two volumes of decided
originality. It was entitled a Treatise of Pathology and Therapeutics,
and proposed a new theory of disease. The theory was one of the most
compendious ever framed. It referred all fevers, with cholera, dysentery,
and a host of other varying affections, to congestion of the vena cava.
And his therapeutics were no less simple. All his remedial measures
had reference to unlocking the liver by purgatives, at the head of which,
in point of efficacy, he reckoned calomel. The aim being to secure bilious
purging, cathartics were to be repeated, in increasing doses, until the
effect was produced. In the end, this led to an abuse of calomel which
brought it into great disrepute; and with its popularity the writings and
the system of one of the most learned and conscientious of American
authors have passed away. With this work, Dr. Cooke, in conjunction
with his colleague, Dr. C. W. Short, started the Transylvania Journal
of Medicine, which was edited by them for four years. At the close of the
fourth volume it passed into the hands of Dr. L. P. Yandell. Dr. Robert
Peter became its editor in 1837. Among its more valuable papers are
the reports by Dr. B. W. Dudley of his operations for stone in the
bladder, and his cure of chronic epilepsy by removing portions of the
skull bone depressed by mechanical injuries.
The Boston Medical and Surgical Journal was also set on foot in 1828,
by Dr. J. V. C. Smith, author of a work on the Fishes of Massachusetts.
In that year, too, the Medical Biography of Dr. Thacher, a work not
likely to be superseded, was contributed to our literature. A year later
Dr. Horner produced his System of Pathological Anatomy, founded on
original observations.”
In 1830, an elaborate work on Chemistry, by Prof. Silliman, was an-
nounced. Its arrangement was regarded as defective, and, added to
this, its size unfitted it for the use of students, so that it never attained
general currency ; but as a repository of chemical knowledge interesting
to all readers, nothing superior to it has been produced in the English
language. Dr. Samuel D. Gross, who has since contributed so largely
to the literature of the profession, appeared this year as author of a
modest volume on the Anatomy, Physiology, and Diseases of the Bones
and Joints, which, it is interesting to remark, contains the first account
of adhesive plaster as a surgical appliance in fractures.”
In 1831, the classical work of Dr. John Bell on Baths and Mineral
Waters appeared. The same author, in 1842, produced another work,
1 Dr. Guy W. Wright and Dr. James M. Mason had started a semi-monthly, the year
before, under the name of the Ohio Medical Repository. In 1832 the Western Medical
Gazette was set on foot by the Faculty of the Medical College of Ohio, but at the end of
nine months was suspended. It was revived five months afterwards by Dr. Silas Reed and
Dr. Samuel D. Gross, who continued it until two volumes were completed. In 1842 the
Western Lancet was projected at Cincinnati by Dr. Leonidas M. Lawson ; and in 1847 the
Dental Register of the West was started at the same place by Dr. James Taylor, of the
Ohio College of Dental Surgery.
2 In 1829 the Journal of Health was projected by Drs. John Bell and D. Francis Condie,
at Philadelphia. A Formulary, which was greatly useful to the profession, was published
by Dr. Benjamin Ellis; a System of Dental Surgery was contributed by Dr. Samuel Fitch;
a Journal of Pharmacy was started by Dr. B. Ellis; and a treatise on the Distinct and
Confluent Smallpox was produced by Dr. John D. Fisher.
* Dr. S. W. Avery, in 1830, issued a work, meant especially for the people, entitled
“The Dyspeptic's Monitor.”
A L) I) RESS O N M E DIC A. L. LITE R A T U R E. 24.1
written in the same elevated style, on Regimen and Longevity. The
kindred topics of Alcohol in its Relations to Medicine, and the Import-
ance and Economy of Sanitary Measures to Cities, were treated of in
works issued in 1859 and 1869, and discussed with marked ability. Dr.
John Eberle, in 1831, enriched our literature by two works of the highest
merit—his treatise on the Diseases and Physical Education of Children,
and his treatise on the Practice of Medicine. Nothing equal to them, in
every respect, had been produced by an American writer. Not only
were they admirable in style, but they were full, accurate, and practical
in matter. Both were adopted as text-books in our schools, and passed
through many editions before they were superseded."
Dr. Nathan R. Smith issued a volume of great interest, in 1831, con-
sisting of memoirs, medical and surgical, by his honored father, with
additions from his own pen. In 1832 the same author contributed a
work on the Anatomy of the Arteries, which was of value to the pro-
fession.
Dr. Amariah Brigham also, in 1832, commenced a series of publica-
tions which excited much interest among students of psychological
medicine. The first treated of the influence of mental culture on health.
It was republished in Glasgow, with notes by Dr. Robert McNish, and
was followed, in 1836, by a treatise on the Influence of Religion on
Health and the Physical Welfare of Mankind, which involved the author
in an embittered controversy. With these a small volume was brought
out by Dr. Brigham, in 1833, on Epidemic Cholera ; and, in 1840, one of
much more note and significance on the Diseases and Functions of the
Brain, the Spinal Cord, and the Nervous System. -
The leading production, however, of 1832, was the treatise of Dr.
Samuel Jackson, on the Principles of Medicine. This volume came out
with a heraldry before unknown in the literary history of our country.
“Knowing the anxiety of the profession in regard to the forthcoming
work of Dr. Jackson,” said the leading journal of the Union, “we applied
to its publishers for an early copy,” which was duly noticed in terms
of the strongest commendation. “Its publication,” declared the re-
viewer, “will constitute an epoch in the history of American medical
literature.” For years before it was published it had been understood
that the author was at work on a treatise in which justice should be
done to the merits of physiological medicine; but, unfortunately for it,
l'hysiological medicine was about to vanish away when it appeared, and
its interest declined with the system. One edition of it was sold, and
the publishers proposed to issue a second ; but the author would not con-
sent to the labor of remodelling it in a way to make it conform to the
medical science of the period, and no other was ever issued. It has been
often repeated, without truth, that the work fell still-born from the press,
and much has been credited to unfriendly criticism as the explanation of
this defeat, but with only a show of reason. Certainly, if it was re-
viewed harshly in some quarters, in others it received, as has been shown,
a full meed of praise. And the most formidable of its critics, a writer
in the Transylvania Journal of Medicine, at Lexington, assailed it with
' The following works also appeared in 1831: Drawings of the Anatomy of the Groin,
by Dr. William Darrach; a Treatise on Malaria, by Dr. U. Parsons; a small volume, by
Dr. John Ware, on Delirium Tremens; a work on Chemistry, by Dr. Lewis C. Beck; a
modest little volume of Essays on Materia Medica, by Mr. Geo. W. Carpenter; and a sin-
gular treatise on Dyspepsia, by Mr. O. Halsted, proposing to cure the complaint by shaking
and kneading the digestive organs after eating.
242 Y AND ELL,
arguments which rather recommended than injured it with most readers.
The chief objections urged against it by this reviewer were that it leaned
to humoralism in pathology, and ignored the claims of phrenology.
The book failed, so far as it was a failure, because its philosophy was de-
fective. It perished with the narrow and fanciful system which the
author himself lived to renounce as unfounded. -
The treatise of Dr. Robley Dunglison on Physiology also appeared in
1832, and formed a contribution to our literature which all readers
hailed as of true value. It was such a compend of physiological science
as was before nowhere extant in the English language; incomparably
superior to the works of Bostock, Richerand, and Blumenbach, which
had previously been the dependence of our students of medicine. Avail-
ing himself freely of the labors of others, the author's aim was to present
a view of the existing state of physiology, without any straining after
originality; so that his volumes are marked by learning rather than
novelty of doctrine, but are none the less valuable to students on that
account. The style in which they are written is unambitious, simple,
clear, and pleasing. That many of his views were not accepted at the
time, and that not a few have since been set aside, is what was to have
been expected in a science advancing like physiology; but his work, the
most advanced of its day, forms a rich treasury of facts and learning
which the student may still consult with advantage."
A work in some respects the most fortunate that has been produced
in America, appeared the next year in Philadelphia. In 1833, the United
States Dispensatory, the joint production of Dr. George B. Wood and Dr.
Franklin Bache, two of the ablest medical scholars of our country, was
published, and at once took the foremost place among American works of
its class. Nearly half a century has been completed since it was brought
before the profession, but it may be doubted whether its standing was
ever higher than it is at the present day. Its authors commenced life in
Philadelphia about the same time, and were early friends. When they
rose to distinction they were called to teach in rival institutions, but the
jealousies of the schools, if any ever arose, never entered their studies,
nor for an hour disturbed their fraternal relations. Laboring on together
as edition after edition of their great work was called for, one on the
chemical, the other on its botanical department, their cordial intercourse
ceased only when one of the laborers was called away by death. T)r.
Wood, who survives to enjoy the fruits of his honorable industry, may
well recount this enduring friendship as among the greatest blessings of
a fortunate life.
In 1833 the profession was enriched by a work which may be said to
have enlarged our knowledge on some points in physiology more than
all that had preceded it—a work that resulted from an accident. Dr.
William Beaumont, a surgeon in the United States Army, had the rare
opportunity of observing how digestion is accomplished in the human
stomach. A Canadian soldier received a wound from the discharge of a
gun, that exposed the interior of his stomach to view. An orifice re-
mained after his recovery, through which food could be introduced, and
! In 1832, Dr. Thomas D. Mitchell brought out a treatise on Chemistry, on the basis of
that of Reid, his chief additions to which consisted in an argument to show that alcohol
might be dispensed with not only in medicine, but in pharmacy. Dr. I. Hays originated, in
this year, the Cyclopædia of Practical Medicine, to which some of the best writers in our
country contributed articles. Dr. James Jackson, Jr., published also, in 1832, a small
volume on Cholera, made up of cases which he had witnessed in the Paris hospitals.
A D D R E S S O N M E DIC A. L L IT E R A T U R E. 243
the action of the gastric juice upon it noted. The results of his nume-
rous experiments and observations, in many of which he had the aid of
Dr. Dunglison, are given by Beaumont in a volume which must remain
in all coming time an authority on the subject of digestion. Some of
the facts first established in the case of his patient will find a place in
every treatise on physiology.
With this valuable monograph, another work appeared in 1833, most
creditable to the literature of medicine in our country. This was the
medical dictionary of Dr. Dunglison, which has gone on increasing in
popularity with the profession from year to year. It was at first issued in
two volumes, and contained biographical notices of many of the most emi-
nent medical men of the world. but this feature disappeared in the second
edition, the author finding that the biography would swell his work to
an inconvenient size. Each successive edition has increased the value
as much as the bulk of the dictionary, which it is safe to say stands now
unrivalled in the English language. Dr. Dunglison's son, fortunately for
the profession, has inherited the gifts which rendered his father the first
of medical lexicographers, and promises to maintain the work in its
present high position during at least another generation.
T)r. E. Geddings, of the University of Maryland, set on foot another
periodical, the same year, the Baltimore Medical and Surgical Journal
and Review, but though among its correspondents it numbered such
writers as T. R. Beck, N. Potter, and N. R. Smith, it fell through after
a few months. Dr. Samuel Metcalf, this year also, added something to
our literature in the shape of a small volume presenting a new theory of
terrestrial magnetism. Magnetism, he held, was but another form of
caloric, which, passing from south to north, gave the directive force to
the needle. Ten years later, and after much investigation of the subject
abroad, he published, in London, a second and much larger edition of his
book. It cost the author, indeed, a vast amount of labor, which was but
poorly requited either in fame or money, while the advancing years of
his life were embittered by disputes with contemporary scientists about
his claims to priority of discovery.
In 1834 numerous works were contributed. Dr. J. R. Coxe started an
“Inquiry into the Claims of Harvey to the discovery of the Circulation
of the Blood,” in which he succeeded in showing that in this memorable
instance, as in all cases before and since, the truth was not reached at
once by the intuition of a single mind, but by the efforts of a succession
of inquirers. Dr. Frost, of the University of South Carolina, published
a volume of lectures on Materia Medica. Dr. Wm. W. Gerhard made a
valuable publication on the cerebral affections of children, which he fol-
lowed, in 1836, by a volume of lectures on the diseases of the chest, and,
in 1837, by a clinical guide for students." A work of much merit on
Pulmonary Consumption was produced, in 1834, by Dr. Samuel George
Morton, whose labors in other fields subsequently made his name illus-
trious in science. In 1849, he brought out a work on human anatomy,
but, in 1839, he had published his great work, entitled “Crania Ameri-
* Dr. Gerhard's treatises were founded on clinical observations, from which they derived
unusual interest. He did much for the education of his young countrymen in physical diag-
nosis of diseases of the chest; and was the first, or among the first, to point out the distinc-
tion between typhus and typhoid fever. He made the diagnosis unequivocal. He also
called attention to the relation of hydrocephalus, in infants, to tubercular meningitis. Few
more successful investigators than Dr. Gerhard have labored in our country to advance
medicine.
244 Y AND ELL,
cana.” His “Crania AEgyptica” followed in 1844. His collection of
crania enabled him to compare the cerebral capacity of most of the
nations of the earth, thus furnishing data from which physiologists are
able to draw interesting conclusions."
Dr. James Jackson, in 1835, published a memoir of his lamented son,
Dr. James Jackson, Jr., who gave promise of great distinction in his pro-
fession; and, in 1838, he reported a number of cases of typhoid fever,
which occurred in the Massachusetts hospital; a paper which Dr. Bart-
lett found of the greatest service in the preparation of his work on fevers.
In 1835, Dr. Dunglison published his scholarly work on Hygiene; Dr.
John P. Harrison collected and published a volume of Lectures and
Essays on Medical Subjects, which had previously appeared in another
form ; and Dr. John B. Beck issued a volume of Researches in Medicine
and Medical Jurisprudence. A volume consisting of papers read before
various learned bodies was also issued, by Dr. Richard Harlan, entitled
Medical and Physical Researches, or Original Memoirs; it embraced
valuable contributions to Zoology and Comparative Anatomy. But the
most original work of this year, and, in its effects, far the most import-
ant, was the paper read before the Massachusetts Medical Society, by Dr.
Jacob Bigelow, on Self-limited Diseases. The conception of such a class
of affections did not originate with the author, but its existence was never
so fully recognized before he wrote. The recognition has effected a revo-
lution in the treatment of many complaints, while the class in which the
principle obtains has been steadily extending since he called professional
attention to it. Another work of this year, which, though a compilation,
claims a favorable notice, is the First Lines of Physiology, by Professor
Daniel Oliver, of Dartmouth College. It is an admirable digest of the
facts of the Science. The Author was in advance of the Physiologists of
his day in ignoring the pretensions of Phrenology, and in admitting the
truth of certain phenomena in animal magnetism which rest, as Sir W.
Hamilton expresses it, “upon a tenfold superfluous evidence.”
From Dr. Dunglison’s prolific pen another work appeared the following
year; his General Therapeutics, or Principles of Medical Practice, with
tables of the chief remedial agents and their preparations, and of the dif-
ferent Poisons and their Antidotes. But as it was a production of the
closet, and not the result of clinical observation, though it was written
by a profound and judicious scholar, it never took rank with his Physio-
logy, or his Dictionary. Dr. John C. Warren this year published an
•laborate treatise on tumors. During the year, an interesting prize essay,
on the Physical Signs in Diseases of the Abdomen and Thorax, was pub-
lished by Dr. R. W. Haxall, of Richmond.”
* Dr. Togno, in 1834, published a work on the Anatomy and Physiology of the Ear. Dr.
Casanova published some observations on cholera morbus. Drs. Ogier and Logan issued a
compend of operative surgery, and Dr. Edward Barton, who had appeared as an author in
1828, wrote a treatise on yellow fever.
* Dr. Caleb Ticknor, of New York, published, this year, a popular volume in Harper's
Family Library, on the Philosophy of Living, taking for his motto the wise saying of
Bacon, that “A man's own observation, what he finds good of, and what he finds hurt of, is
the best physic to preserve health.” And a volume was issued by Dr. Parrish, of Philadel-
phia, entitled Practical Observations on Strangulated Hernia, based on a large experience.
Two new journals also appeared this year—the Electic Journal of Medicine, aſterwards the
Bulletin of Medical Science, projected by that indefatigable writer, Dr. John Bell, and the
Southern Medical and Surgical Journal, at Augusta, Ga., edited by Dr. M. Anthony and
I)r. Joseph A. Eve. Dr. Luther W. Bell, of New Hampshire, published this year some
Observations on certain obscure and undecided Doctrines in relation to Smallpox, Varia-
loid, and Vaccination. Dr. George Bushe, of New York, in 1837, wrote a treatise on the
A DT) RESS ON ME DIC A. L. LITE R A TU R E. 2.5
In 1838, also, a large number of works was issued, first among which,
in ability and in the impression it produced, was the Philadelphia Prae-
tice of Midwifery, by Dr. Charles D. Meigs. Another was the Medical
Jurisprudence of Insanity, by Dr. Isaac Ray, which treats ably of a sub-
ject too little understood by physicians. The lectures of Dr. Hosack on
the Theory and Practice of Physic, edited by Dr. Henry W. Ducachet,
were published this year, as were also Lectures on Lithotomy, by Dr. A.
H. Stevens. Dr. Charles Hooker, too, produced a well written Essay on
the Relations between the Respiratory and Circulatory Functions, while
Dr. Tripler wrote on Recruiting, and Dr. J. W. Monette on Yellow
Fever in New Orleans and Natchez; and the Philadelphia Medical
Examiner, edited by Drs. Biddle and Clymer, was originated.
T}r. Henry I. Bowditch, the succeeding year, made an important com-
munication in reference to thoracentesis in chronic pleurisy; an opera-
tion much opposed at first, but now generally conceded to be legitimate.
It has been performed by Dr. Bowditch 325 times, and on 204 patients.
To this valuable contribution to our literature, that author has added
some interesting statistics relating to the influence of a wet soil on pul-
monary consumption. Dr. Dunglison came out this year with still
another book, entitled New Remedies, which, like all the productions of
his pen, was marked by industry, sound judgment, and a clear English
style. Dr. Samuel D. Gross, then a professor in the Cincinnati Medical
College, produced a work of much labor on Pathological Anatomy, the
first in our language to present a systematic view of the science, and
useful in directing the attention of students more generally to that im-
portant study.
In 1840 the following works appeared: Dr. B. B. Shober, of Charles-
ton, issued an Essay on Yellow Fever, designed to prove the transmissi-
bility of the disease; and Dr. Upham wrote on Disorders of the Mind ;
but the great work of the year was from a professor in the University of
New York, Dr. Martyn Paine, entitled Medical and Physiological Com-
mentaries. IIardly a work issued from the medical press of America
will compare with these ponderous volumes in the learning or in the
tedious prolixity with which they are composed. Holding resolutely to
an exploded medical philosophy, the author was born too late to com-
mand the reverence which his great erudition would have excited in an
earlier age. IIis elaborate and exhaustive commentaries were followed,
some years later, by a volume on Materia Medica, characterized by all
their merits and all their defects. His volumes are works for teachers
and writers, rather than for practitioners or students of medicine. Dr.
Edward Warren published, this year, two Boylston Prize Essays, on
Scrofula, Rheumatism, and Erysipelatous Inflammation. The Western
Journal of Medicine and Surgery was started at Louisville. It suc-
ceeded to the Louisville Journal of Medicine, edited by Drs. Miller,
Yandell, and Bell, two numbers of which were issued in 1838, and to
the Western Journal of the Medical and Physical Sciences, thirteen vol-
umes of which had been completed by Dr. Drake at Cincinnati. It was
edited by Dr. Daniel Drake and Dr. L. P. Yandell, with whom, after the
second year, Dr. T. W. Colescott was associated, and on the retirement
Malformations, Injuries, and Diseases of the Rectum. The American Intelligencer and
Medical Library was set on foot the same year, by Dr. Dunglison. In it were republished
many valuable English works on medicine. I)r. I)oane also issued this year an illustrated
Surgery, and Dr. Dunglison added his Medical Student or aids to the Study of Medicine.
246 Y AND E L L ,
of Drs. Drake and Colescott, some years later, Dr. T. S. Bell became one
of its editors. -
The only publications in 1841, of which I have been able to find any
account, were a volume of Essays on Fevers, by Drs. Davidson and
Hudson, and a Practical Dictionary of Materia Medica, by Dr. John
Bell.
The following year, Dr. Elisha Bartlett, who had made himself
known as one of the most elegant of our writers by his papers in the
medical journals of the day, published his well-known work on Fevers.
It was succeeded in 1844 by his Philosophy of Medical Science, and in
1848 he added his Inquiry into the degree of certainty in Medicine;
three volumes which, for grace of manner and philosophical breadth of
view, will not suffer by comparison with any medical works in our lan-
guage. Dr. Samuel Forry also contributed to our literature, in 1842, a
volume which attracted the attention and elicited the praise of the great
Humboldt—his work on the Climate of the United States and its endemic
influences. It will remain a lasting monument to the genius and industry
of the lamented author. While preparing this treatise for the press, he
also set on foot the New York Journal of Medicine and the Collateral
Sciences, to which he continued to contribute largely, though with fail-
ing powers, until removed by death. The name of this young physician
ought not to be passed over without at least a word of respectful com-
memoration. He was “learned, without any fondness for display; a
lover of exact detail, but always searching for principles in the facts he
accumulated so largely ; a statistician, and yet a fluent writer. How
entirely his devotion to his pursuits prevailed over the common weak-
nesses and interests by which most men are influenced, was shown by the
fearless readiness with which he threw himself into the focus of a pesti-
lential disease for the sake of studying its nature and causes, as a mere
episode in a pleasure trip which he had undertaken to recruit his ex-
hausted forces.”
In 1843, a work was produced at Louisville by Dr. W. A. M’Dowell,
styled a “Demonstration of the Curability of Consumption in all its
stages;” and the same year the St. Louis Medical and Surgical Journal
was established by Dr. M. L. Linton. A work of great merit was also
published by Dr. Gross, of the University of Louisville, entitled “An
Experimental and Critical Inquiry into the Nature and Treatment of
Wounds of the Intestines,” the result of a series of experiments which
he had performed on dogs. -
In 1844, numerous works of real value appeared. The following is a
list: A Treatise on the Diseases of Children, by Dr. D. Francis Condie;
a quarto volume on Operative Surgery, by Dr. Joseph Pancoast; an
Atlas illustrative of the structure of the human body, prepared with
great care by Dr. Henry H. Smith; a treatise on the Teeth, by Dr. Paul
B. Goddard and Joseph E. Parker, a practical Dentist of Philadelphia;
an ingenious essay by Dr. John Harrison, of the University of Louisiana,
towards a correct Theory of the Nervous System ; two volumes of
lectures, by the veteran teacher Dr. Nathaniel Chapman ; and the
American Journal of Insanity. Few physicians in our country have
used their pens more industriously or more profitably than Condie, whose
work on Diseases of Children was accounted, when written, the most
learned and judicious that had appeared on the subject in the English
1 O. W. Holmes, Report Med. Literature, Trans. Am. Med. Assoc., 1848.
A D D R E SS O N M E I) I C.A. L L IT E R A T U R E. 247
language. The great fame of Chapman as a writer and teacher gave
currency to his volumes. Dentistry, which was already making rapid
progress, both as a science and an art, in our country. Feceived a favor-
able impetus from the work of Goddard and Parker. The splendid
work of Pancoast secured him a reputation wherever surgery was culti-
vated. As a guide to the practical surgeon, it was of the highest value,
each operation being illustrated by drawings representing the anatomy
involved.
The first work by an American, on Diseases of the Skin, appeared in
1845, and was written by Dr. N. Worcester, of the Cleveland Medical
College. Other valuable works were issued at the same time, one of
which was a volume of essays on Pathology and Therapeutics, by Dr.
Samuel H. Dickson of the Medical College of South Carolina, one of the
most accomplished of American authors." Another addition was also
made this year by a western teacher of medicine to our works on Materia
Medica; Dr. John P. Harrison, of the Medical College of Ohio, wrote a
treatise on that subject in two volumes, earnestly inculcating “Solidism.”
“In the discussion of the action of medicines, we have endeavored,” he
says, “to place the whole question on a footing conclusively vital.” He
discusses blood-letting at great length. His classification is recommended
by its simplicity, all his remedies being embraced in six classes. The
work is written in a diffuse style, and was recommended more by its
judicious therapeutics than by its scientific teachings.
A volume of Lectures, by Dr. Chapman ; a work on Fevers, by Dr.
Meredith Clymer; a treatise on Scrofula, by Dr. Phillips; the Young
Stethoscopist, by Dr. H. I. Bowditch ; an Epitome of the writings of Hip-
pocrates and Galen, prepared by Dr. John Redman Coxe; a valuable
memoir by Prof. Robert Peter, containing an analysis of the calculi in
the museum of Transylvania University, with remarks on the relative
frequency of calculous affections at Lexington, and the probable causes;
and First Principles of Chemistry, by Prof. Benjamin Silliman, Jr., who
was fast succeeding to the fame of his father, were some of the contri-
butions to our literature in 1846.” Dr. Lewis C. Beck, in 1846, wrote on
the Adulteration of various substances used in Medicine and the Arts,
with the means of detection ; and a practical Treatise on Ventilation
was also published by Dr. Morrill Wyman.
The discovery of anaesthesia renders this year memorable in the history
of our profession. Towards its close, Dr. Henry J. Bigelow read before
the Boston Medical Improvement Society, a paper in which he detailed
the facts concerning the great event that had fallen under his observation,
and vouching for the efficacy of sulphuric ether in annulling pain in
surgical operations. This first communication on the subject appeared
in the Boston Medical and Surgical Journal, Nov. 18, 1846, and is note-
worthy as announcing to the world one of the noblest discoveries in
Medicine.
| Dr. G. R. B. Horner added an interesting volume on the Medical Topography of Brazil
and Uruguay, and Dr. Stephen W. Williams contributed one on the Medical Biography of
the United States. The Buffalo Medical and Surgical Journal, under the able editorial
direction of Dr. Austin Flint, was established. Dr. Horner had in 1839 published a work
on the Mediterranean, and in 1854 he contributed one on the diseases and injuries of sea-
men. Dr. J. H. Griscom published in 1845 an instructive little work on the Sanitary con-
dition of the laboring Population of New York.
* Dr. Peter also contributed to Medical Science by his Analysis of the Mineral Springs
of Kentucky, contained in the geological reports of that State.
248 Y AND ELL,
The meeting of physicians at New York, which resulted in the organi-
zation of the American Medical Association, is another event of this
year, which marks an era in the history of Medicine in the western
hemisphere. The effect of the Association upon the profession has been
in every way beneficent, elevating its tone, promoting harmony among
its members, and stimulating and improving its literature. Few move-
ments of the century to which these papers refer have contributed so
much to the advancement of American Medicine.
Dr. Horace Green, in 1846, startled the profession by a work on the
I)iseases of the Throat and Air-passages, proposing to introduce reme-
dies into the larynx; but his bold practice has been justified by subse-
quent experience, and he is now admitted to have been a pioneer in this
department of medicine, and to have led the way to what others with
better instruments have accomplished.
Numerous works apeared in 1847, conspicuous among which was the
learned treatise of Dr. George B. Wood on the Practice of Medicine. It
had the advantage over all its predecessors in that department, of being
founded on clinical observation, and as a consequence was soon adopted
as the text-book in our schools, and became the popular work of reference
with practitioners. Dr. Charles D. Meigs issued another of his works,
written in his peculiar, somewhat fantastic style—his “Woman; her
Diseases and Remedies,” with the effect of increasing the growing in-
terest of the profession in Gynaecology. Dr. Joseph Carson commenced
the issue of a series of colored “Illustrations of Medical Botany,” and
Dr. R. Eglesfeld Griffith produced a practical volume on the same sub-
ject. A most valuable contribution was made to pathological anatomy
by Dr. J. B. S. Jackson, in his Descriptive Catalogue of the Anatomical
Museum of the Boston Society for Medical Improvement. In 1847 Dr.
David H. Tucker produced a small volume entitled Elements of the
Principles and Practice of Midwifery."
In 1848, a volume of Transactions was issued at Baltimore by the
American Medical Association, which had been organized at Philadel-
phia the year before. A volume has been sent out by the Association
annually since, and while it would be easy to point out defects in them
all, it will not be denied by any unprejudiced reader that they form a
valuable body of medical literature. All that comes before each meet-
ing, or nearly all, appears in the Transactions, and it follows that much
is published which if submitted to a rigid criticism would never see the
light. But the series embraces many strong, original, and truly valuable
papers from the best minds in the profession, and, apart from the diffu-
sion of knowledge thence directly resulting, the effect of inviting physi-
cians everywhere to write for the Association has been to develop and
improve professional talent in a way that nothing but such a society
could have done.
The following works also came out in 1848: A volume by Dr. Alfred
Stillé, on General Pathology, which possessed great merit, both as to its
| Dr. H. H. Smith also published this year a Minor Surgery; and Dr. Edward Jarvis
contributed a treatise on Physiology for the Use of Schools and Families. Dr. J. W.
Francis delivered an admirable anniversary address before the New York Academy of
Medicine, which was published; Dr. John Ware published an able address on Medical
Education. “Water versus Hydropathy” appeared, a practical essay on Water in its rela-
tions to Medicine, by Dr. Henry Hartshorne. Dr. John Neill published Outlines of the
Veins and Lymphatics; and Dr. J. J. Reese a small work on Physiology. The Dental
Register of the West also came out this year.
A D D R E SS O N M E DIC A. L. LITE R A T U R E. 249
matter and the style of its execution; a practical and excellent Treatise
on the Diseases of Children, by Dr. J. Forsyth Meigs; the learned lec-
tures on the Theory and Practice of Physic, of Drs. Bell and Stokes; a
treatise on Etherization, by Dr. Walter Channing, embodying his expe-
rience of anaesthesia in midwifery; a work of much originality on Croup,
by Dr. Horace Green ; the ingenious essay on the Cryptogamous Origin
of Diseases, by Dr. J. K. Mitchell, a man of genius as well as of learning
and large experience; a posthumous volume on Surgery, by the gifted
Dr. George McClellan, of the Jefferson Medical College, edited by his son,
Dr. J. H. B. McClellan; Observations on Diseases of the Chest, and on
Auscultation, by Dr. Blakiston; Dr. Pliny Earle's interesting history of
the Bloomingdale Asylum for the insane; and two new journals of
Medicine, the Charleston Medical Journal and the Northwestern Medi-
cal and Surgical Journal."
The additions to our literature in 1849 were hardly less numerous than
those of the preceding year. Dr. Meigs produced a treatise on Obstet-
rics; and one on the same subject appeared from the pen of Dr. Henry
Miller, of the University of Louisville. Both works possessed great
merit, as the productions of independent, vigorous minds long turned
upon that branch of medicine. Dr. E. D. Fenner issued a volume of
Southern Medical Reports, full of original observations on the diseases
of the Southern States, which was followed by a second volume in 1851.
Dr. Worthington Hooker produced his “Physician and Patient,” pre-
senting a sensible view of the mutual duties, relations, and interests of
the medical profession and the community; and Dr. J. W. Powell con-
tributed a work on the eye and its diseases. Equal in merit to any of
these, and superior to most, was a volume of Essays, by Dr. John B. Beck,
on Infantile Therapeutics, to which are added observations on ergot, and
an interesting account of the origin of the use of mercury in inflammatory
complaints.”
The contributions of 1850 embrace some of the ablest made to our
literature by the American medical profession. They are the following:
a Treatise on the Diseases of the Great Interior Valley of North America,
by Dr. Daniel Drake; Observations on certain of the Diseases of Young
Children, by Dr. C. D. Meigs; a work on Materia Medica and Therapeu-
tics, by Dr. Thomas D. Mitchell; the Principles of Medical Jurisprudence,
by Amos Dean, Esq., of the Albany Medical College; a work on the
Diagnosis and Pathology of Renal diseases, by Dr. Charles Frick; a
History of Medical Education and Institutions in the United States, by
* A small volume on Etherization, with surgical remarks, by Dr. John C. Warren, was
contributed to the literature of that subject: and an absurd work, by Dr. J. W. Hood, of
Kentucky, was issued setting forth a theory that all abdominal diseases are caused by dis-
placement of the abdominal organs, and curable by pads, trusses, and supporters. In addi-
tion to these, the following also appeared that year: a small volume on Bandaging and
other operations in Minor Surgery, by Dr. F. W. Sargent; a Compendium of the various
branches of medical science, by Drs. J. Neill and F. G. Smith ; a Handbook of Surgery, by
Dr. J. Neill; Lectures on Yellow Fever, by Dr. John Hastings. U. S. A.; a Medical Chem-
istry for the use of Students, by Dr. D. P. Gardner; an essay on epidemic meningitis, by Dr.
S. Ames; and a dictionary of dental surgery and medical terminology, by Dr. Chapin
Harris.
* The following also appeared in 1849: a small volume on Epidemic Cholera. by Dr. C.
B. Coventry; a Treatise on the Diseases of the South, by Dr. G. McGowan; Surgical
Essays and Cases, by I)r. D. L. Rogers; and an Essay on Respiration and its effects, by
Dr. E. Willard. The Transylvania Journal of Medicine, which had been discontinued, wa
revived by Dr. Ethelbert L. Dudley for a short time. A paper on Aneurism, by his illus-
trious uncle, Dr. B. W. Dudley, enriched one of the early numbers of the journal.
250 Y AND ELL,
Dr. N. S. Davis; a work on the Practice of Surgery, by Dr. J. Hastings;
a work on Mental Hygiene, by Dr. Wm. Sweetzer; a Practical Treatise
on the Diseases and Injuries of the Urinary Bladder, by Dr. Samuel D.
Gross; and a work on Sleep, psychologically considered, with reference
to Sensation and Memory, by Dr. B. Fosgate. To this long list must be
added a history of Typhoid Fever, as it appeared in Georgetown, Ken-
tucky, by Dr. W. L. Sutton; the American Medical Formulary, by Dr. J.
J. Reese; an Encyclopædia of Chemistry, by Dr. Jas. C. Booth ; and a
treatise by Dr. Thomas E. Bond, on Dental Medicine, which is a com-
pendium of Medical Science as connected with the study of Dental Sur-
gery. In the same year four medical journals were started : the New
Hampshire Journal of Medicine, at Concord, edited by Dr. H. Parker;
the Western Medico-Chirurgical Journal, at Keokuk, edited by Drs. J.
F. Sandford and S. G. Armor; the Stethoscope and Virginia Medical
Gazette, at Richmond, edited by Dr. F. C. Gooch ; and the Nashville
Journal of Medicine and Surgery, edited by Dr. W. K. Bowling.
This list embraces several works of great labor and uncommon merit.
The Observations of Meigs, like all his other contributions to Medical
Science, abound in original views, at the same time practical and judi-
cious. The work of Sweetzer is suggestive and ingenious; that of Gross,
elaborate and exhaustive; but foremost among them all, in research, in
breadth of scientific view, and in the wide scope of observations recorded,
is the treatise of Drake. The author had planned his work when a
young physician, even before taking his degree in Medicine, and had
been collecting materials for its composition during the term of an ordi-
nary lifetime. It is not made up, as so many books in all ages have been,
of matter borrowed from other books, but of facts collected by himself,
in a long experience, during protracted journeys, and from original Ob-
servers. In the accomplishment of his design he traversed the whole
Mississippi Valley, tracing the causes of its diseases from the Northern
Lakes to Cape Sable. He sought to indicate in his treatise whatever
there was that was distinctive in the complaints of the region of which
he was writing, as induced by climate, race, mode of living, and the other
agencies that modify disease. The result of his extended researches was
given in two ample volumes, the second of which was published in 1854,
two years after his death. That in every sense the production is a great
one, has been conceded by all writers who have noticed the work ; and
yet it never acquired general popularity, and is now comparatively dis-
regarded. A quarter of a century has passed away since it appeared, and
no second edition has been called for by the profession. It is not of a
form to be used as a text-book by students, and it must be owned that it
is not quite suited to the practitioner as a book of reference. But it is a
vast repository of facts, upon which all future writers must hereafter
draw who would give an account of the climate, topography, and dis-
eases of the great valley to which it relates. It can hardly be doubted
that it belongs to a class of works, once described by Dr. Drake himself,
that “lie embalmed in the truths with which they are penetrated, and
cannot decay: but like the bodies of kings and philosophers steeped in
spices, and deposited in the catacombs, are found only in unfrequented
closets and alcoves of libraries.”
The most important works published in 1851 were a volume of lec-
tures on Materia Medica, by Dr. John B. Beck, prepared for the press
after his death, by his friend, Dr. R. C. Gilman; and a system of Opera-
tive Surgery, by Dr. H. H. Smith, based on the practice of the surgeons of
A D DRESS ON MEDICAL LITE RATURE. 251
the United States, and comprising a bibliographical index and historical
record of many of their operations during a period of two hundred years.
Besides these, a history of the Massachusetts General IIospital was con-
tributed by Dr. N. O. Bowditch. Dr. M. L. Linton, of the University
of St. Louis, also made this year a contribution which is worthy of
notice, his Outlines of General Pathology; an unpretending little volume,
but abounding in sound medical philosophy, and written in a lucid,
vigorous style.
Dr. Austin Flint, in 1852, commenced a series of publications, the
result of his observations of disease in hospitals and private practice,
which have placed him at the head of American writers on practical
medicine. That year he issued a volume of Clinical Reports on Con-
tinued fever, based on an analysis of 164 cases. The same year, Dr. R.
U. Piper published an elaborate work on Operative Surgery, containing
more than 1900 engravings, with explanatory text; to which is appended
an interesting chapter on the use of Ether in Surgery, written by Dr.
Henry J. Bigelow. This year, too, was produced a volume of essays
written in a charming style, by Dr. S. H. Dickson, on Life, Sleep, and
Pain.”
Dr. William H. Boling, of Alabama, whose various articles on mala-
rious fevers in the periodicals of the day had given him a wide reputa-
tion, published, in 1853, an instructive essay on the mechanism and
management in Parturition of shoulder presentment. In the same year
T}r. Joseph Warrington contributed an Obstetric Catechisin, containing
2347 questions and answers on obstetrics proper. Dr. C. E. Brown-
Séquard commenced in 1853 a series of publications of great interest to
physiologists and practitioners. The first was a small volume of experi-
mental researches applied to physiology and pathology. A smaller
volume followed in 1855, on the physiology and pathology of the spinal
cord ; and in 1857 another thin volume appeared, entitled Researches on
Epilepsy. In 1860 he published a volume of Lectures on the Physiology
and Pathology of the Central Nervous System, delivered at the Royal
College of Surgeons of England; and in 1868 this was followed by
another volume of Lectures on the Diagnosis and Treatment of func-
tional nervous affections.
In 1854, a volume of substantial merit was produced by Dr. René La
Roche, the title of which describes its character: Pneumonia, its sup-
posed connection, pathological and etiological, with autumnal fevers,
including an inquiry into the existence and morbid agency of malaria.
It is a monograph of enduring interest. Other works that enriched our
literature also appeared in that year, among which the following are
| Dr. Charles Delevy wrote De la Fièvre pernicieuse de la Nouvelle Orléans, following
this history, in 1859, with a Précis historique de la Fièvre. Dr. F. B. Flagg published a
work on Ether and Chloroform.
* The following works were also published: A Treatise on Diseases of the Chest, by Dr.
John A. Swett ; Records of Maculated Typhus, or Ship Fever, by Dr. J. B. Upham; a
Treatise on Uterine Displacements, by Dr. W. E. Cole; Analysis of Physiology, by Dr. J.
J. Reese; Outlines of the Arteries, by Dr. John Neill; and a description of a skeleton of
the mastodon giganteus, by the veteran anatomist and surgeon, Dr. John C. Warren. Dr.
A. Clapp, of New Albany, a man of great attainments in general science as well as in medi-
cine, contributed a valuable synopsis or systematic catalogue of the medicinal plants of the
United States, to the American Medical Association, which appeared in its Transactions
for that year, and was afterwards issued in a separate volume of more than 200 pages.
In 1852 two periodicals were published in New Orleans—the New Orleans Medical
Journal. and the Monthly Medical Register. Since the war, the former has been revived,
and is ably conducted by Dr. Samuel M. Bemiss.
252 Y AND ELL,
conspicuous: a treatise, by Dr. Gross, full and exhaustive, on Foreign
Bodies in the Air Passages; Dr. T. G. Richardson’s Elements of Human
Anatomy, in which the author, as far as he could, has substituted English
for the Latin terminology—a manual admirably adapted to the dissecting
room; Dr. Bennett Dowler’s “Tableau of Yellow Fever” as it prevailed
in New Orleans in 1853, with topographical, chronological, and historical
sketches of the epidemics of that city since their origin in 1796; and a
history of the yellow fever of 1853, in New Orleans, by Dr. E. D. Fenner."
Dr. Meigs also added to his other valuable works, this year, a volume
written with great force, on the nature, signs, and treatment of childbed
fevers, contending against their transmission by contact. And Dr. Jacob
Bigelow laid the profession under additional obligation by a volume
entitled “Nature in Disease, illustrated in various discourses and
Essays,” recommending by conclusive arguments the conservative medi-
cine, toward which the professional mind of the age is so strongly tend-
ing. A volume was published in 1854, by Dr. A. S. Piggott, entitled
Dental Chemistry and Metallurgy, which was of much use to practition-
ers of Dentistry.
The publications of 1855 were, many of them, of very great excellence
and interest. The Letters of Dr. James Jackson to a Young Physician,
in a small volume, to which he added a second series in 1860, are adapted
to the wants of the inexperienced of every age, and may be read with profit
by all young practitioners. A small work, by T)r. Hugh L. Hodge, on
criminal abortion, discusses a subject, the interest of which is likely to
increase with time. The treatise on Medical Jurisprudence, by Francis
Wharton, Esq., and Dr. Moreton Stillé, stands on a level with the great
work of Beck. The joint production of a learned jurist and an able
physician, it possesses merits not likely to be found in a work by a single
hand. It is a noble monument to the memory of its medical contributor,
who died almost at the moment when the last sheets of his work were
issuing from the press. Gifted, cultivated, and laborious, Stillé, in his
short life, accomplished a work of which his profession is justly proud,
and which only increases the regret at his early death. The monograph
on the Diseases affecting the Respiratory Organs, by Dr. Flint, was in the
line of his work on Continued Fever, and worthy of it. The tract of
Dr. O. W. Holmes, entitled Puerperal Fever as a Private Pestilence, pre-
sents strong reasons for believing in the contagiousness of the disease.
It was pronounced by Ramsbotham, when it came out, “a masterly per-
formance.” Dr. Zina Pitcher, in a paper on the Induction of Puerperal
Fever by Inoculation, so called, takes the opposite side of the question,
which he supports by a great array of facts. An Army Meteorological
Register, for twelve years, originating from an office suggested by Hon.
J. C. Calhoun, while Secretary of War, and prepared under the direction
of Surgeon-General Thomas Lawson, is of value. Dr. E. R. Peaslee wrote
this year a valuable work on Croup, and a work for students on Chemis-
try was issued by Dr. B. Howard Rand.
But the great work of this year was that on Yellow Fever, by Dr. La
Roche. The American press has given birth to no original work supe-
rior to it in research or learning. As a monograph on one of the most
| To this list must be added a text-book of Anatomy, for the use especially of students of
Dental Surgery, by Dr. R. Handy, of the Dental College of Baltimore; a volume of Lec-
tures on pulmonary consumption, by Dr. T. Thompson; Letters on Yellow Fever, Cholera,
and Quarantine, by A. F. Vaché; and a work on Human Physiology, by Dr. Worthington
Hooker, designed for Colleges and general reading.
A D D RESS O N M E DIC A. L. LITE R A T U R E. 253
formidable of the epidemics that afflict our race, it may be doubted
whether anything more exhaustive is contained in any language. It
was the production of a laborious student, a thorough medical scholar, and
an amiable and accomplished gentleman. .
In 1855, the Atlanta Medical and Surgical Journal, under the care of
Drs. Westmoreland and Batty, was set on foot, and in the same year a
History of the American Medical Association was written by Dr. N. S.
Davis."
The following year was also productive of valuable additions to the
stock of our literature. Professor Edward Parrish, of the Philadelphia
College of Pharmacy, wrote an introduction to practical pharmacy, which
was useful in that department of medicine; an original and most able
work on Human Physiology, statistical and dynamical, was contributed
by Dr. John W. Draper, who before had written a remarkable treatise on
the forces which produce the organization of plants, in which he proposed
a simple and ingenious theory of the capillary circulation. Dr. George
B. Wood communicated the results of his matured researches concerning
medicines, in his able treatise on Therapeutics and Pharmacology, or
Materia Medica, which has long been an authority in the profession. A
prize essay of great interest was published by Dr. George H. Lyman,
giving the history and statistics of Ovariotomy, and the circumstances
under which the operation may be regarded as safe and expedient. A
Treatise on Surgery, the result of much labor, by Dr. H. H. Smith, was
added to our literature on that subject. A history of the medical pro-
fession in ancient times was contributed by Dr. John Watson. Dr.
James Stewart produced a practical treatise on the Diseases of Children.
Dr. Isaac Taylor, in a short paper, called the attention of the profession to
the sun-burnt appearance of the skin as an early diagnostic symptom of
supra-renal capsule disease. Dr. J. M. Allen added another to the list of
our anatomical works, in his Practical Anatomist. The North Ameri-
can Medico-Chirurgical Review, which originated in Louisville, but was
shortly afterward transferred to Philadelphia, was added by Drs. Gross
and Richardson to our long list of medical journals.”
The question of the original unity of the human race has been a good
deal discussed in our country since the appearance of Dr. S. S. Smith's
work on the subject, and in 1857 a treatise of much bulk and labor was
contributed by Drs. Nott and Gliddon, On the Indigenous Races of the
Earth, of the merits of which various opinions have been expressed, ac-
cording to the preconceived notions of the writers. Dr. E. R. Peaslee in
this year published a work on Human Histology, to which, in 1872, he
added one of great interest, on Ovarian Tumors. Dr. Paul F. Eve did
the profession a service by collecting into a volume many Remarkable
Cases in Surgery, showing into what errors surgeons of experience and
* An Essay on Malignant Cholera, by Dr. B. M. Byrne; the Practitioner's Pharmaco-
poeia, by Dr. J. Foote; a Discourse, by Dr. J. H. Griscom, on the relation between the
people and the Science of Medicine; and a volume, by Drs. Comstock and Comings, on
Physiology, chiefly taken without acknowiedgment from the writings of Carpenter, were
also among the publications of 1855.
* Dr. Joseph Jones published in this year some investigations relative to American Ver-
tebrata; and Dr. M. L. Knapp wrote an interesting inquiry into the cause of Nurse's Sore
Mouth, and in the following year produced a rambling treatise, styled Researches as to the
Pathology and Origin of Epidemics, tracing all to the existence of a scorbutic taint. Dr.
Benjamin Haskell also published this year some ingenious Essays on the physiology of the
nervous system, with an appendix on hydrophobia, and the Medical and Surgical Reporter,
under the editorial care of Dr. S. W. Butler, took its place among our periodicals.
254 Y AND ELL,
skill may fall, and under what extremities patients may sometimes
recover. This year, also, was published an interesting Catalogue of
Crania, by Dr. J. Aitken Meigs. But a more important contribution to
our literature was made by Dr. H. F. Campbell, in an essay to which a
prize was awarded by the American Medical Association, On the Excito-
Secretory System of Nerves. In the views advanced on this subject, Dr.
Marshall Hall admitted that Dr. C. had anticipated him, as well as
M. Claude Bernard.
The succeeding year two large octavo volumes on Materia Medica, full
of useful matter, were issued by Dr. William Tully; a text-book on
vegetable and animal physiology was produced by Dr. H. Goadby, and
an interesting monograph on Scarlatina, by Dr. Caspar Morris, appeared
in a new dress, having been first issued some years before ; a work, too,
on the diseases of the urinary organs, which was followed by one, in
1861, on the effects of the retention of the elements of urine in the
blood, was published by Dr. W. W. Morland." A volume of lectures on
Surgery, delivered by Prof. E. Geddings, of the Medical College of
Charleston, was published in 1858. It is to be regretted that the learned
and able author has not followed up his work.
In 1859, the treatise of Dr. John C. Dalton, on Physiology, which still
maintains its place as a text-book in our schools, was published, and is
not likely to be soon superseded. It is a work which has advanced
physiological science, and in which the student finds a condensed but
lucid summary of its truths, communicated in a pleasing style. With it
appeared another work which has conferred lustre upon the medical lit-
erature of our country, the learned and able System of Surgery, by
T}r. Samuel D. Gross. With an industry truly indefatigable, the author
has continued to add to its successive editions, until he has made it one of
the most thorough systems of surgery to be found in any language. Dr.
Austin Flint, the same year, produced a practical treatise on the Diseases
of the Heart, which ranks among the high authorities on that subject.
A volume of essays, written by his gifted father, was published this
year by Dr. S. Weir Mitchell. In these essays, the author appears as a
chemist and philosopher, and shows that, if he had continued his labors,
so successfully begun in that direction, he might have attained a high
rank among the scientific men of his time. His researches concerning
the diffusion of gases gave him a glimpse of some of the most interest-
ing discoveries of which modern chemistry can boast.”
In 1860 a number of excellent books were produced, foremost of which
in research and learning, as well as in size, is the treatise of Dr. Alfred
Stillé, on Therapeutics and Materia Medica. Of the progress of our medi-
Valuable contributions to operative surgery and surgical pathology were made this
year by Dr. J. M. Carnochan, and Dr. Horace Green published selections from favorite pre-
scriptions of living American practitioners. The following journals were set on foot in
1858: The Chicago Medical Journal, by Dr. J. Adams Allen ; the Cincinnati Lancet and
Observer, by Dr E. B. Stevens; and the Cincinnati Medical News, by Dr. J. A. Thacker.
A little work was also published by Dr. Jacob Bigelow, entitled Brief Expositions of Prac-
tical Midwifery, to which is prefixed the Paradise of Doctors.
* Dr. E. J. Coxe wrote, this year, on the Yellow Fever of New Orleans; Dr. V. M. Fran-
cis published a Thesis on Hospital Hygiene, and a work styled Contributions to Midwifery;
the Diseases of Children was issued by Drs. Noeggerath and Jacobi; Dr. J. J. Moorman
wrote an account of the Virginia Springs and the Springs of the South-West, which was of
great value to invalids in search of watering-places. A small treatise was published by Dr.
John M. Watson, of the University of Nashville, on trismus nascentium, which he traces to
irritation of the umbilicus in the young child. Dr. James E. Reeves, the same year, pub-
lished a Practical Treatise on Enteric Fever.
A D D RESS ON ME DIC A. L T, ITER AT U R E. - 255
cal literature during the century, we could hardly point to any evidence
more conclusive than that afforded by a comparison of this scientific work
with the elementary treatises on the same subject written forty years be-
fore... We are quite willing that by it the world shall judge of American
Medical authorship. The “Practical Treatise on Fractures and Disloca-
tions,” by Dr. Frank Hastings Hamilton, has become a standard authority
on the subject.' . An Elementary Treatise on Anatomy was prepared by
the learned Professor of Anatomy in the University of Pennsylvania, Dr.
Joseph Leidy. Dr. Henry Hartshorne published “Memoranda Medica,”
or note-book of medical principles. A very instructive work was issued
by Dr. Hugh L. Hodge, on the diseases peculiar to females, including
displacements of the uterus. And among the “Contributions” of the
Smithsonian Institution appeared an original paper of much interest, by
Dr. S. Weir Mitchell, on the venom of the rattlesnake.”
Of the publications of 1861, the most important was a work on the
principles and practice of Obstetrics, by Dr. Gunning S. Bedford, of the
University of New York. But the American Medical Biography, edited
by Dr. Samuel D. Gross, has also high claims upon the profession, and
ought to be extended. It is a work which must be of interest to every
American physician, as a record of the lives of men who have done
honor to the profession. Dr. Gross, the same year, produced an excellent
manual of military surgery. A “Manual of Military Surgery,” was also
produced by Dr. J. Julian Chisholm, at Columbia, South Carolina, and
was the text-book of the surgeons of the Confederate army during the
civil war. And one on the same subject was contributed by Drs. Black-
man and Tripler.”
The effect of the civil war in repressing our literature, was manifest
in 1862, in the course of which very few original books were published.
One of these was the Medical History of the Philadelphia Almshouse, by
Dr. D. Hayes Agnew ; a second was a treatise, by Dr. A. Jacobi, on den-
tition and its derangements; and a third was a practical guide to diseases
of the eye, by Dr. H. W. Williams, Dr. Stephen Smith added an oppor-
tune hand-book on surgical operations.
In 1863, the number was also small. They were a Manual of the
institutes of military surgery, by Dr. J. Ordronaux; a manual of minor
surgery, by Dr. J. H. Packard, and the practice of surgery for field and
hospital, by Dr. E. Warren. Dr. J. J. Woodward made a practical and
substantial contribution to military medicine, in a volume on the chief
* A useful medico-legal treatise on Malpractice was written by Dr. John J. Elwell. Dr.
Samuel W. Francis presented to the profession a report of the Clinical Lectures of Dr.
Valentine Mott in the University of New York.
* A Catalogue of the Pathological Cabinet of New York Hospital, classified and
arranged, was published this year by Dr. Robert Ray, Jr., and also an epitome of medicine
and surgery, by Dr. W. S. Wells. Dr. Edward Warren, in 1860, published an interesting
biography of Dr. John C. Warren. Two new medical journals were also projected: the
Facific Medical and Surgical Journal, edited by Dr. Henry Gibbons, and the Chicago
Medical Examiner, edited by Drs. N. S. and F. H. Davis.
* Besides these, the following works also appeared in 1861: A Practical Treatise on
Phthisis Pulmonalis. by Dr. L. M. Lawson, of Cincinnati; a work by Dr. R. M. Hodges,
on Excision of the Joints; one by C. H. Jackson, on Etherization; a sprightly paper on
Currents and Counter-currents in Medical Science, by Dr. O. W. Holmes; a work on
Placenta Praevia, by Dr. William Reid; and two valuable Essays, by Dr. Fordyce Barker,
one on an Effort to shorten the first stage of Labor; the other on the use of anaesthetics
in Midwifery. Dr. Edwin R. Maxson also published this year a volume on the Practice
of Medicine, and, in 1868, he published an account of Hospitals, British, French, and
American.
256 - Y AND ELL,
camp diseases of the U. S. armies as observed during the war of the
rebellion.
In 1864, an important work on Gunshot Wounds and Injuries of Nerves
was contributed by Dr. S. Weir Mitchell and Drs. Morehouse and Keen ;
and in this year the following works also appeared : Lectures on Vene-
real Diseases, by Dr. William A. Hammond ; a Medical Dictionary, by
Dr. J. Thomas; a paper on the puerperal disease, by Dr. B. F. Barker; a
work by Dr. Bartholow on disinfection, which was followed in 1867 by a
manual on enlisting and discharging Soldiers, and in 1868 by a work on
spermatorrhoea ; a prize-essay by Dr. H. F. Damon, on leucocythaemia; a
volume of Medical and Surgical Essays, by Dr. W. A. Hammond; a
“Mémoire sur la fièvre paludienne,” by Dr. J. C. Faget; and an ac-
count, by Dr. J. O’Reilly, of the Nervous and venous connection
between the Mother and the Foetus.
The following is a list of the publications in 1865: a Monograph
on glycerin, by Dr. H. Hartshorne; the Book of Prescriptions, by Dr.
Henry Beasley ; a Treatise on Military Surgery and Hygiene, by Dr. F.
H. Hamilton; a Vest-pocket Medical Lexicon, by Dr. D. B. St. John
Roosa ; a Treatise on the Diseases and Accidents incident to Women, by
Dr. W. H. Byford ; and Elements of Materia Medica for the use of stu-
dents, by Dr. John B. Biddle. The last two are substantial additions to
our practical medical literature. No more eligible text-book than Dr.
Biddle's has yet been written ; and the volume by Dr. Byford illustrates
a class of affections which he has studied with success. To this list we
have to add the able work of Dr. W. H. Van Buren on the Surgical Dis-
eases of the Genito-Urinary Organs, and his contributions to Practical
Surgery; and the Lectures of Dr. J. H. Packard on inflammation."
Cholera prevailed in the United States in 1866, and a number of works
were written concerning the epidemic ; but besides these, that year was
productive of some of the best contributions made by American writers to
medical science. The work of Dr. Austin Flint, on the Principles and
Practice of Medicine, is entitled to the first place among our treatises on
that subject. It is the production of a practical, able, and patient ob-
server, who speaks from long clinical experience, and is written in a clear,
direct, concise style, and with a fulness that leaves nothing to be desired.
And by the side of this admirable work deserves to stand the treatise of
Dr. Austin Flint, Jr., on Physiology, the first volume of which appeared
about the same time, and which has since been completed in five volumes.
Few works of equal merit to these, the productions of father and son, have
proceeded from American authors. Another publication of that year
possessing great value was the treatise of Dr. J. M. Da Costa, on Medi-
cal Diagnosis, a work with which our students of medicine can hardly
dispense; and one of equal value to the practitioner was that of Dr. J.
Marion Sims, entitled Clinical Notes on Uterine Surgery, with special
reference to the sterile condition ; the first treatise written in our lan-
guage on the surgery of the uterus.”
! In this year the following works too appeared: A Sanitary Code for Cities, by Dr. H.
G. Clarke; a volume on Hypodermic Injections, by Dr. Antoine Ruppaner; and the New
York Medical Journal, edited at first by Dr. W. A. Hammond, and subsequently by Drs. J.
B. Hunter and W. T. Lusk.
* A treatise appeared, this year, by Dr. J. W. Wright, on Psychology, and one by Dr. S.
G. Webber, on cerebro-spinal meningitis. Tºr. A. C. Garratt also contributed one on electro-
therapeutics, and three new journals of medicine were projected—the Detroit Review of
Medicine, by Drs. Conner and Lyons; the New York Medical Record, by Dr. Geo. F. Shrady,
A D D RESS ON ME DIC A. L. LITE R A TU R. E. 257
Dr. Henry Hartshorne in 1867 produced a volume which has met with
much professional approbation, entitled Essentials of the Principles and
Practice of Medicine. A very able work of an original character, on the
micro-chemistry of poisons, was produced by Dr. Theo. G. Wormley. Dr.
J. Solis Cohen contributed a valuable volume on Inhalation, its thera-
peutics and practice. One was produced on injuries of the Spine, by
Dr. John Ashhurst, Jr., containing an analysis of nearly four hundred
cases. Drs. Francis Minot and Charles Homans, Secretaries of the
Society, published a volume of Extracts from the Transactions of the
Boston Society for Medical Improvement, with Papers read before the
Society. The lamented Dr. J. Mason Warren contributed a valuable
volume of Surgical Observations, with Cases and Operations. Dr. N.
R. Smith wrote on the treatment of fractures of the lower extremi-
ties, by the use of the anterior suspensory apparatus; and Dr. John
H. Packard published Notes on Fractures of the Upper Extremity. A
volume of Researches upon Spurious Vaccination was contributed by Dr.
Joseph E. Jones. Dr. Henry J. Bigelow published a practical paper on
Ununited Fractures successfully treated ; and Dr. B. Howard Rand con-
tributed an elementary work on Chemistry. A work of much labor was
issued under the editorial supervision of Dr. A. Flint, entitled Contribu-
tions relating to the Causation and Prevention of Disease, and to Camp
Diseases, together with a report of the diseases, etc., among the prisoners
at Andersonville. A large volume, entitled Mechanical Therapeutics, a
treatise on surgical appliances, was produced by Dr. Philip S. Wales, at
Philadelphia. A Monograph on Cerebro-Spinal Meningitis, treating ably
of the subject, was issued by Dr. Alfred Stillé. Dr. S. H. Dickson made
a valuable contribution to Studies in Pathology and Therapeutics; and
an interesting work on the Medical Use of Electricity was produced by
Drs. George M. Beard and A. D. Rockwell. To which long catalogue
of publications for that year we have to add the Leavenworth Medi-
cal Herald, by Dr. Tiffen Sinks, and the Medical Archives, by Dr. J. C.
Whitehill, published at St. Louis."
In 1868 three important works were produced on the diseases and acci-
dents incident to females; an Obstetric Clinic, by Dr. George T. Elliot;
a Practical Treatise on the Diseases of Women, by Dr. T. Gaillard
Thomas; and a work on Vesico-vaginal Fistula, by Dr. Thomas Addis
Emmet. Dr. Dalton wrote a Treatise on Physiology and Hygiene, for
schools, families, and colleges; a volume of Reports of the Pennsylvania
Hospital, was edited and issued by Dr. Da Costa and Dr. W. Hunt; and
a work on Physical Diagnosis was published by Dr. Alfred Loomis.”
and the Richmond (now Richmond and Louisville) Medical Journal, by Dr. E. S. Gaillard,
editor and proprietor. This year the following works also were published: Contributions to
bone and nerve Surgery, by Dr. J. C. Nott; a small treatise on food and digestion, by Dr.
Howard Townsend; Lectures on Orthopedic Surgery, by Dr. L. Bauer; a small treatise on
Orthopedics, by Dr. D. Prince, followed, in 1871, by one on Plastics; and works of greater
or less length on Cholera, by Drs. J. C. Peters, R. Nelson, E. Whitney, F. A. Burrall,
Palmer, Fletcher, and Henry Hartshorne.
| Two works on conservative surgery, one by Dr. H. G. Davis, and another by Dr. A.
G. Walter, appeared in 1867, and with them a Manual of Examinations, by Dr. J. L. Lud-
low ; a paper on Epidemic Cholera, by Dr. G. Hurt; a Treatise on Polypus of the Ear, by
Dr. Edward H. Clark; a work by Dr. D. Wooster, on Diseases of the Heart, and a Thesis
on Aneurism of the Aorta, by I)r. E. Souchong.
* Beside these the following also appeared: The Law of Human Increase, or Population
based on Physiology and Psychology, by Dr. Nathan Allen; a Practical Anatomy, by Dr.
D. H. Agnew, who followed it in 1873 by a work on laceration of the perineum; a Trea-
tise, by Dr. W. Bodenhamer, on Diseases of the Rectum; a Dissertation, by Drs. Edes,
258 Y AND ELL,
The following list comprises the most noted publications of 1869: A
Treatise on the Diseases of Infancy and Childhood, by Dr. J. Lewis
Smith; a Conspectus of the Medical Sciences, by Dr. H. Hartshorne;
Outlines of Comparative Anatomy and Medical Zoology, by Dr. Harrison
Allen; a History of the Medical Department of the University of Penn-
sylvania, by Dr. Joseph Carson; the Intermarriage of Relations, by Dr.
Nathan Allen ; a treatise, by Dr. J. S. Lambert, on Longevity; Con-
tribution to the Medical History of the United States, by Dr. J. M.
Toner; the Mechanism of Dislocation and Fracture of the Hip, by Dr.
H. J. Bigelow; an essay on External Perimeal Urethrotomy, by Dr. J.
W. S. Gouley; a volume on the Jurisprudence of Medicine, in its rela-
tions to the law of contracts, by Dr. Ordronaux; a work, in quarto, on
Amputation of the Cervix Uteri in certain cases, by Dr. Isaac E. Taylor;
a compend of Materia Medica, by Dr. John C. Riley, and a volume on
the physiology and pathology of the sympathetic nervous system, by Dr.
Robert T. Edes. In addition to these, a small treatise was written on
Veratrum Viride, by Dr. R. Amory; one on physical culture in Amherst
College, was contributed by Dr. N. Allen; and one, of much greater size,
on the Principles of Naval Staff Rank and its History for over half a
century, by a Surgeon in the U. S. Navy. The Archives of Ophthalmo-
logy, edited by Profs. Knapp and Moos, and the Oregon Medical and
Surgical Journal were projected this year.
The most important contributions in 1870, were the Surgical Memoirs
of the War of the Rebellion, which when completed will form the most
magnificent work pertaining to medicine that our country has produced;
and the Treatise on the Theory and Practice of Obstetrics, by Dr. W. H.
Byford, which stands on a level with the best of a class of works in
which the profession of America is conceded to have excelled. The Lee-
tures on the Diseases of the Rectum, by Dr. W. H. Van Buren, and the
Hand-book of Operative Surgery, by Dr. J. H. Packard are valuable
contributions to practical surgery; as are also the Bellevue and Charity
Hospital Reports; the Medical and Surgical Reports of the Boston City
Hospital, and the work of Dr. J. A. Lidell on wounds of the bloodves-
sels."
The publications of the Surgeon General’s Office were continued in
1871, and some very able works appeared with them, at the head of
which professional opinion ranks the Principles and Practice of Surgery,
Hibbard, and Spare, on Nature and Time in Disease; a posthumous work on Electro-
Physiology, by Dr. Morgan, edited by Dr. Hammond; and the Principles and Practice of
Laryngoscopy, by Dr. A. Ruppaner. The American Journal of Obstetrics, edited by Dr.
B. F. Dawson, was also added to the list of our serials.
! An excellent little Manual of the Urine was published by Dr. A. Flint, Jr.; and an
interesting tract styled “New Facts and Remarks concerning Idiocy” was issued by Dr.
Edward Seguin. The Microscopical Anatomy of the Liver was illustrated by Dr. H. D.
Schmidt, in an article in the New Orleans Medical Journal, which was afterwards issued in
a separate form ; and a useful treatise was produced, on naval hygiene, by Dr. Joseph G.
Wilson and Dr. Albert C. Gorgas; in addition to which Dr. M. Clymer published valuable
notes on the physiology and pathology of the nervous system ; Dr. J. C. Hutchison con-
tributed a small treatise on physiology and hygiene; and Dr. L. H. Morgan published a
system of consanguinity of the human family. The new journals set on foot in 1870 were
the Clinic, at Cincinnati, by Dr. J. T. Whittaker; the Philadelphia Medical Times, edited
by Dr. H. C. Wood; the Michigan University Medical Review, by Drs. Cheever, Rose,
Prescott, and Frothingham; the American Journal of Syphilography, by Dr. M. H. Henry ;
and the American Practitioner, by Dr. David W. Yandell and Dr. Theophilus Parvin—a
continuation of the Western Journal of Medicine, which was for some years conducted by
Prof. Parvin at Indianapolis. The Photographic Review of Medicine and Surgery was
also set on foot.
A D [) RESS ON ME DIC A. L. LITE R A TU R E. 259
by Dr. John Ashhurst, Jr. The treatise of Dr. W. A. Hammond, on
Nervous Diseases, is also a graceful addition to our professional litera-
ture, albeit his readers may not always obtain the gratifying results
from remedies reported as occurring in his practice. The Report to the
Surgeon General’s Office of the surgical cases in the army of the United
States from 1865 to 1871, is an invaluable storehouse of facts; and emi-
nently useful also, for its statistics, is the first annual Report of the Board
of Health Department of New York."
In 1872, a volume was produced by Dr. S. Weir Mitchell on Injuries
to the Nerves, and their consequences, which is esteemed one of the most
valuable contributions to surgical science made by an American writer.
An elaborate work on ovarian tumors was issued by Dr. E. R. Peaslee.
Dr. Gurdon Buck illustrated lithotomy and lithotrity by a number of
cases in a brief memoir on the subject. Dr. Thomas M. Markoe wrote
an able treatise on diseases of the bones, and Dr. J. W. S. Gouley con-
tributed one on the diseases of the genito-urinary organs, which has been
much commended. The little volume of Dr. H. C. Wood, Jr., on Thermic
Fever or Sunstroke, is scientific and practical, the production of a mind
trained and adapted to philosophical investigation. With it appeared
his Year Book of Therapeutics, Pharmacy, and the allied sciences. A
volume of clinical lectures on various important diseases, possessing
uncommon excellence, was contributed by Dr. N. S. Davis.” In this year
also appeared the last work of the learned and indefatigable Dunglison,
who had been called away from his earthly labors, leaving his History of
Medicine to be completed by his son Dr. Richard J. Dunglison. This
posthumous work of the great medical scholar is a fit companion of his
dictionary, by which his name is destined to be transmitted to the latest
| A Handbook of Medical Microscopy was a seasonable contribution by Dr. Joseph G.
Richardson. Three new journals appeared during the year, viz.: New Remedies, by Dr.
H. C. Wood, Jr., at New York; the Kansas City Medical Journal, by E. W. Shauffler;
and the Southern Medical Record, at Atlanta, by Drs. Powell and Goldsmith. Dr. B. Joy
Jeffrics wrote a treatise on the eye in health and disease: Dr. M. L. Holbrook produced one on
parturition without pain; 1)r. A. L. Gihon wrote on surgery and naval hygiene; and Dr.
Joseph Jones appeared in one of his laborious memoirs, giving an account of the clinics at
the Charity Hospital in New Orleans. Emergencies, and how to treat them, is the title
of a manual by Dr. Joseph W. Howe, of the University of New York, which affords know-
ledge useful to all; and the work on Bromides, by Dr. Bartholow, was read with interest
at a time when the action of these medicines was so much discussed. Internal urethrotomy
was discussed in a short paper by Dr. C. H. Mastin ; Dr. Allen produced another treatise
bearing on vital statistics, entitled Lessons on Population, suggested by Grecian and Roman
History. Dr. B. W. Neftel added one on Galvano-Therapeutics, and Drs. Beard and Rock-
well brought out their work on the Medical and Surgical uses of Electricity in an enlarged
form, rendering it complete as to the present state of that branch of therapeutics. The
tenth edition of the Medical Students' Wade mecum, by Dr. George Mendenhall, was issued
that year.
* The little works of Drs. Clarke and Amory on the Bromides of potassium and sodium,
and Dr. Morrill Wyman on Catarrh or hay fever, are both admirable in their way. A
hand-book of post-mortem examinations and of morbid anatomy, by Dr. Francis Delafield,
also appeared. The attention of the profession was directed to Earth as a topical applica-
tion in Surgery, by Dr. Addinell Hewson, in a work on that subject. A Clinical Manual of
the Diseases of the Ear was prepared by Dr. Lawrence Turnbull. A brief account of the
treatment of the Venereal Disease in the Vienna Hospitals was published by Dr. M. H.
Henry. Two excellent little monographs on Diseases of the Skin, and Animal and Vege-
table Parasites of the Human Skin, were issued by Dr. B. J. Jeffries; the Ten Laws of Health
were illustrated by Dr. J. R. Black; and Dr. J. S. Cohen contributed a practical work on
Diseases of the Throat. Dr. J. W. Richardson read a judicious paper on puerperal convul-
sions to the Medical Society of Tennessee; and Dr. Stephen Smith produced a volume styled
Doctor in Medicine, with other papers. The Charleston Medical Journal, which for some
time had been suspended, was revived this year by Drs. Porcher and Kinloch.
260 Y AND ELL,
ages. The medical journals originated in 1872 were the Western Lancet,
at San Francisco, by Drs. Trenor and Babcock; and the Sanitarian, edited
by Dr. A. N. Bell, at New York."
In 1873 a number of valuable works were published, prominent among
which was Contributions to Surgery, by that faithful worker and accom-
plished medical scholar, Dr. George W. Norris. A handsome volume of
superior merit on ovarian tumors was brought out by Dr. Washington
L. Atlee, and Dr. John A. Lidell produced one on apolexy. A volume
of clinical lectures on diseases of the nervous system swelled the con-
tributions of Dr. W. A. Hammond to medical science. A volume of
huge proportions was written by Dr. James E. Garretson on the somewhat
limited subject of oral surgery, and Dr. Isaac Ray published one entitled
Contributions to Mental Pathology.
In 1874, a work possessing some novel and attractive features was
issued by Dr. Horatio C. Wood, Jr., on Therapeutics, Materia Medica,
and Toxicology. The author devotes much more space than any previous
writer has done to the physiological action of medicines, facts bearing
upon which he has collected with great industry from every accessible
source. This departure of Dr. Wood from the old beaten track of writers
on materia medica imparts unusual interest to his pages. The other
works of this year were a treatise by Dr. R. A. Gunn, on the Venereal
Disease, and a small volume on Croup, by Dr. J. Solis Cohen.”
In 1875, an exhaustive volume was issued on the Epidemic Cholera of
1873. It was the joint production of Drs. Ely M’Clellan, J. C. Peters,
J. M. Woodworth, and J. S. Billings, prepared by order of the General
Government. No more thorough discussion of the etiology of cholera is
to be found in any American work, and, as a whole, it will take its place
with the foremost of the many volumes called forth in our country by
that pestilence. The work of Dr. Loomis on the Diseases of the Respi-
ratory Organs, notwithstanding the fulness with which the subject had
been treated in earlier works, was an acceptable contribution. A volume
was published by Dr. R. W. Taylor on Syphilitic Lesions of the Osseous
System. Dr. C. S. Fenner contributed a work on Vision, its optical de-
fects, and the adaptation of Spectacles. A work on pulmonary tubercu-
losis was brought out by Dr. Addison P. Dutcher. Dr. W. B. Atkinson
issued a small but practical volume, entitled Hints in the Obstetric Pro-
Cedure. Dr. James E. Reeves established, at Wheeling, a journal styled
the West Virginia Medical Student. Two volumes of immense labor,
made up of Statistics, medical and anthropological, of the Provost-Mar-
shal-General’s Bureau, were prepared by Dr. J. K. Baxter; and Dr. B. J.
Cotting produced a volume of medical addresses.
The works issued in the first months of 1876 belong to the century we
are commemorating. Of these, one was a characteristic volume of medi-
cal and surgical memoirs, by Dr. Joseph Jones, the first of an elaborate
series which the author contemplates. This treats of many subjects, and
* Dr. H. W. W. Sweringen also added a pharmaceutical lexicon; Dr. M. A. Milland
wrote a work on civil mal-practice; Dr. D. B. St. J. Roosa produced a treatise on diseases
of the ear; Dr. Prince published a report on galvano-therapeutics, and Dr. Henry G.
Piffard wrote a little work on urinary analysis.
* Besides these the following were contributed : A treatise by Dr. A. D. Williamson on
diseases of the ear; one on the “breath and fetid odors,” by Dr. J. W. Howe; one by Dr.
E. Holden on the Sphygmograph; a manual of toxicology, by Dr. J. J. Reese, and a small
volume by Dr. Thomas C. Minor on erysipelas and childbed fever. A new journal, the
Virginia Monthly, was also started by Dr. L. B. Edwards, at Richmond, and one, the Medical
Times, at Louisville, by Dr. E. S. Gaillard.
A D D R E SS O N M E I) IC A. L. LITE R A T U R E. 261
with a patient industry seldom shown by native writers. Dr. Austin
Flint, Jr., issued a splendid volume, comprising the substance of his five
volumes on physiology, intended as a text-book for students. A work
on extra-uterine pregnancy was produced by Dr. John S. Parry, whose
early death the profession was called on to deplore soon after the appear-
ance of his work, giving so much proof of his ability to enrich his pro-
fession. Two works were contributed by Dr. Austin Flint, a monograph
on Phthisis, and a small volume of essays on Conservative Medicine,
works worthy of the fame of their admired author. Dr. Lewis A. Sayre
added to the productions of the century a volume, abundantly illustrated,
on Orthopaedic surgery and diseases of the joints, which has already
been translated into more than one foreign language. A new journal, too,
was added to our long list of periodicals, the Louisville Medical News, a
weekly publication, edited by Dr. Richard O. Cowling and Dr. William
H. Galt, writers of wit as well as learning, whose keen satire of abuses
in medical schools will cause their work to be remembered as one of the
most useful of its period.
This retrospect of our literature ought not to be concluded without a
reference to the publications of the various medical societies of our coun-
try. The Transactions of the great National Association have been
mentioned ; but there are societies in nearly all the States of the Union
which annually send forth volumes of greater or less bulk, containing
papers of lasting interest. They began as far back as 1788, when the
Medical Society of New Haven County, Conn., issued a volume of “Cases
and Observations.” This was followed, in 1793, by a volume from the
Philadelphia College of Physicians. Massachusetts has been for seventy
years sending out valuable communications through her societies. The
Medical Society of the State of New York, too, has for more than half a
century been making contributions to medical science. The effect of
these societies, not only upon the literature, but upon the tone of the
profession, is every where felt to have been most salutary.
The reports of the lunatic asylums, now founded in all but a few of the
States, are also to be mentioned as works which have enriched our pro-
fessional literature. It was a sagacious remark of the Governor of Ken-
tucky, General Adair, in his message urging upon the legislature the
establishment of an asylum at Lexington, that “the hospital would help
the medical school, which would return the obligation by improving the
hospital system, making discoveries in treatment.” Since the day that
medical men were first placed over these institutions, it is a fact conceded
by all that a steady improvement has been going on, as well in the thera-
peutic treatment of their inmates as in their whole administration. The
annual communications of Earle, Kirkbride, and others who have labored
so successfully in psychological medicine, have received their full mea-
sure of applause.
As forming a voluminous branch of our literature, the introductory lec-
tures published at the opening of the numerous schools of the country
each autumn, deserve a passing notice. Many of these efforts are worthy
of preservation, as the offspring of the best minds in the American pro-
fession; but others are “open to severe comment,” as was remarked by
Dr. Holmes thirty years ago, who then added that “turgid and extrava-
gant attempts at eloquence, a fondness for effete Latin quotations, a
parade of scholastic terms where simple ones only are called for, are the
common faults of these productions.”
262 Y AND ELL,
In reviewing the literature of medicine in the United States, the first
fact that will strike the mind of the reader, perhaps, is the very large
proportion of the works that have emanated from the medical schools.
Another that must occur to every reader is the disproportion between
monographs and the manuals written for the use of students. Teachers
have both greater leisure and greater facilities than others of the pro-
fession for making books, as they are also more likely to find sale for
them ; and they write text-books rather than monographs, because stu-
dents demand them. Dut, in the nature of things, such productions
are short lived. The manual that gives a fair view of its subject to-day,
must fall short of representing it to-morrow, and yields of necessity to a
later system. Mundinus, when medical science stood still, held his place
as a text-book on anatomy in the medical schools of Italy two hundred
years. Wistar, who stood his ground longer than any of our text-
books, hardly kept his place thirty years; and as to those that have
succeeded him, “clouds that rake the mountain summit” scarcely follow
each other faster than they have followed one another as popular
favorites.
The growth of our periodical literature has been unprecedented. In
1848, the committee on medical literature reported to the Medical Asso-
ciation, that the number of journals in the United States was about
twenty. They had been fifty years reaching that number; but in a little
more than half that time their number has been doubled. Since the ori-
gin of the first, in 1797, one hundred and ninety-five, including reprints
of foreign journals, have been set on foot, of which more than fifty,
counting those that relate to pharmacy and dentistry, are still in pro-
gress. In all, they have made one thousand six hundred and thirty-
seven volumes, a bulk which exceeds that of our monographs and
manuals. Hardly any other country in the world has projected so many
in the same period, or is now sustaining so large a number. Germany
and Austria together have only fifty-seven ; France has but fifty-two;
Great Britain has but twenty-nine; Italy thirty-one; Holland six ; and
Spain the same number. Most of our journals have subscribers enough
to justify their publication, and to support them in a state of eomparative
ease, though one is dropped, from time to time, for want of patronage.
They have, collectively, a large circle of readers, and tend to a wide diffu-
sion of medical knowledge. The discoveries in any branch of medicine
are at once announced by them, and carried in a little while to the door
of every reading physician, by which the profession in country and city
is placed on comparative equality. And besides these benefits, they
increase a taste for reading, and stimulate practitioners to become writers;
so that the admitted superfluity of our journalism has been beneficial to
the profession, promoting activity among its members, bringing to light
much useful matter, exciting greater and more general exertion.
But it cannot be denied that these benefits are secured at the expense
of many countervailing evils. To the excess of this literature we are to
attribute its deficiencies, which all admit to be greater than those that
attach to our books. The aliment that would keep a dozen journals
vigorous, divided between four times that number, is barely sufficient to
keep many of them alive. The support of too many of them, mental,
pecuniary, and literary, is flagrantly inadequate. Not only is their list
of subscribers insufficient for anything beyond a feeble existence, but the
corps of contributors is too limited to give the necessary variety to their
pages. The editor in the hour of pressing need is often obliged to admit
A DI) RESS ON ME DIC A. L. LITE R A TU R E. 263
articles which he would not hesitate to reject if he had anything better
on hand. But no choice is left him. The inevitable day is coming
round when the number must appear; the printer is waiting, and copy
must be forthcoming.
Nor is this the only fault of our journalism attributable to its excess.
The editors in too many cases devote only such odds and ends of their
time to their publications as they can spare from more profitable engage-
ments. Deriving hardly any pecuniary emolument from their journals,
they are compelled to look to other employment for subsistence. Nearly
all their time and thoughts are engrossed by other duties, and their edi-
torial functions are necessarily performed in a hurried and slovenly man-
ner. They cannot take the time to “edit” their publications in any true
sense of that term. They have no leisure for correcting the papers sent
them, and for putting them into a shape suitable for the public eye.
These contributions, it is safe to say, are for the most part hurriedly
written, very often by young, unpractised writers, and while presenting
many grains of valuable truth, contain mixed up with them no small
amount of chaff which calls for the winnowing hand of the editor.
Wanting this friendly office, they appear before a critical public “with
all their imperfections on their heads.”
Editors are not responsible for either the facts or the opinions of their
contributors, but the public has undoubtedly the right to expect that the
matter composing their pages shall be free from glaring literary blunders.
It has a right to insist, at least, that their own papers shall be written
carefully, and with a moderate show of accuracy.
But the department in which our periodical literature stands most in
need of improvement is that of critical reviews. In only a few of Our
journals has this office—one of the most important pertaining to journal-
ism—been properly performed. It is not too much to say that it has
been generally neglected. The articles that appear in the critical depart-
ment rarely aspire to the dignity of reviews, but are, as a rule, mere
bibliographical notices, written after the most cursory examination of
the books in hand, and often with slight knowledge of their contents.
The notices, therefore, are too generally made up of commonplace stric-
tures or indiscriminate praise—mere vague generalities which leave the
reader as much as ever in the dark as to the true character and value of
the book reviewed.
Still, with all these deficiencies, and others that might be pointed out,
our journalism is of a character to commend it to the respect of the pro-
fession. No one who has carefully observed its progress in the last fifty
years can have a doubt that it is fast outgrowing its defects. Not only
are the journals appearing in a mechanical dress more meat and pleasing
to the eye, and with fewer typographical errors, but in point of style they
are more scholarly than those of half a century ago. The articles are more
generally practical, and the selections are almost always made from original
sources. If many of them were started in the interest of medical schools
(which will hardly be denied), it must be owned that their conductors
have generally been observant enough of public opinion to keep that
object in the background. Few of them have betrayed a narrow, partisan
temper. Hardly an editor has availed himself of his station to defame
his professional brethren. While many articles find their way into the
journals that are not instructive—many that are carelessly written and
marred by many literary blemishes—it is seldom that we meet with one
that offends against decency or the proprieties of social life. Personali-
264 Y AND ELL, ADDRESS ON MEDICAL LITE RATURE.
ties, as they are discountenanced by the profession, are almost univer-
Sally eschewed. - -
It is easy to see that the rivulet which represented our literature at
the beginning of the century just closed, “has swollen into a torrent,
augmented into a river, expanded into a sea.” When we assumed our
position among the sovereignties of the earth, we could hardly point to
a single original volume on medicine. We were dependent as a profes-
sion almost wholly upon our brethren of the old world for instruction.
All our books were the production of foreigners; but we may now claim
to be independent of the world. If by any chance we could be cut off
from all intercourse with other nations, the authors of America would
supply the text-books required by its students, and guides to its practi-
tioners, in every department of the profession. Nor am I assuming too
much when I assert that, as lucid exponents of the existing art and sci-
ence of medicine, as trustworthy companions in the sick-room, as lights
in everything relating to the practice of physic, using that term in its
widest scope, the works of American physicians are up with the times,
and equal to the books which come to us from abroad. And this is said
in full view of the fact that in some branches of medical science we have
not done our part towards its advancement, while in others we have
hardly done anything at all. But whether we compare the later issues
of our medical press with its earlier productions, or with analogous works
by physicians of the old countries, we find cause for congratulation as
to the past, and for high expectations in regard to the future.
265
ADDRESS ON THE PROGRESS OF MEDICAL EDUCATION IN
THE UNITED STATES OF AMERICA,
DURING THE CENTURY COMMEN CING IN 1776.
BY
N. S. DAVIS, A.M., M.D.,
OF CHICAGO, ILLINOIS.
FROM the date of the first English settlement in America, which was
in 1607, to the Declaration of Independence in 1776, thirteen separate
colonies had been established, embracing the Atlantic Coast from Massa-
chusetts to Georgia inclusive, and all acknowledging allegiance to the
government of Great Britain. Distributed over this wide extent of ter-
ritory, there had accumulated about three millions of people, among
whom there were between three and four thousand engaged in the prac-
tice of medicine. Of these, it has been estimated that not more than
four hundred had received the degree of Doctor in Medicine from any
medical college ; and these, with but few exceptions, had received their
collegiate education and honors in the medical schools of Europe. Only
two medical schools had been organized in the colonies, namely, the
Medical Department of the College of Philadelphia (now the Medical De-
partment of the University of Pennsylvania), in 1765, and the Medical
Department of King's (now Columbia) College, in New York, in 1768.
Only fifty-one medical degrees had been conferred by both of these insti-
tutions prior to 1776, when active operations in them were suspended by
the progress of war. In all the colonies there were not more than twelve
or fifteen cities and towns having over five thousand inhabitants, and
these were so widely separated from each other, and possessed of such
limited means of communication, that attendance on a medical college,
or on the meetings of medical societies, was hindered by delays and diffi-
culties but little thought of at the present day.
The same condition of the country compelled many of those practising
in the smaller and more remote settlements to unite other occupations
with their practice. In the New England Colonies, the offices of physi-
cian and clergyman were often united in the same person, and in all the
colonies it was common for the physician to occupy a part of his time
and increase his income by agricultural labor. g
Notwithstanding all the obstacles presented by the sparseness of the
population, and the want of roads and means of communication, a large
proportion of those engaged in practice had attended one course of medi-
cal college instruction, and had served a regular apprenticeship with
some practitioner of note, before entering upon the active duties of the
profession. Only three medical societies are known to have been organ-
ized during the colonial period of our history. The most important of
these was the Medical Society of the State of New Jersey, which was
organized in July, 1766. It appears that a few months previous to this,
a society called the Philadelphia Medical Society was formed in that
266 DAVIS,
city, chiefly through the influence of Dr. John Morgan, who had returned
from Europe the year previous. It did not probably survive the war
for Independence, and is not known to have left any permanent record
of its doings. The Delaware State Medical Society was organized in
1776, and hence has a history parallel with that of the independence of
the States.
In nearly all of the colonies, laws had been enacted concerning some
topics of interest to the profession. Most of these laws were designed
either to protect the people of the colonies from the introduction and
spread of contagious diseases, from injury by ignorant and reckless mid-
wives, or from exorbitant charges by physicians; or for the establish-
ment of hospitals for the sick and insane. In only two of the colonies
had laws been enacted to define the qualifications of physicians and
surgeons, with provisions for enforcing an observance of the same. The
General Assembly of New York, in 1760, ordained that “no person what-
soever shall practise as Physician or Surgeon in the City of New York
before he shall have been examined in Physic and Surgery, and approved
of and admitted by one of His Majesty’s Council, the Judges of the Su-
perior Court, the King's Attorney-General, and the Mayor of the City of
New York for the time being, or by any three or more of them, taking to
their assistance for such examination such proper person or persons as
they in their discretion shall see fit.” Such candidates as were approved
received certificates conferring the right to practise physic or surgery, or
both, throughout the whole province; and a penalty of five pounds was
prescribed for all violations of this law." A similar act was passed by
the General Assembly of New Jersey in 1772. -
Although most of the colonies had provided temporary hospitals for
seamen, emigrants, and the victims of smallpox and other epidemic dis-
eases, the only permanent general hospital for the sick was established
in Philadelphia, in 1752, and was aided by a grant of two thousand
pounds from the Colonial Assembly. Dr. Thomas Bond was appointed
superintendent, with Drs. Lloyd Zachary, Thomas Cadwalader, Samuel
P. Moore, John Redman and Phineas Bond, as associates.
Dr. Thomas Bond, from the opening of the institution, introduced his
class of students for bedside instruction, and thereby became the first
regular clinical lecturer in America. In 1767, the colonial government
of New York was induced to grant a charter for a general hospital, and
an organization was effected, and the work commenced. But the build-
ing when nearly completed was destroyed by fire, in 1772, and owing to
the supervention of the Revolutionary war was not rebuilt until 1791.
From this very brief glance at the condition of medical matters in the
colonies, more especially in relation to educational facilities, it will be
seen that at the commencement of our history as an independent nation,
in 1776, there were between three and four thousand practitioners of
medicine, supplying about three millions of people, their field of duty
occupying thirteen States, embracing the whole Atlantic coast from
Maine to Florida, and containing two medical colleges, two organized
medical societies, and One permanent general hospital. Small as were
these beginnings, they nevertheless constituted the germs from which
have since developed all the educational institutions belonging to the
profession in Our country.
* See History of Medical Education and Institutions in the United States, by N. S.
Davis, M.D., p. 22.
A DI) RESS O N M E DIC A. L E D U C A TI O N . 267
The Medical Department of the College of Philadelphia, which had
been organized in 1765, with Dr. William Shippen, Jr., as Professor of
Anatomy and Surgery, and Dr. John Morgan, as Professor of Medi-
cine, had continued regular annual courses of medical instruction until
1776, when the session was broken up by the vicissitudes of war, and
the most valuable movable materials of the college were privately re-
moved to places of safety by the provost and members of the faculty.
Previous to this time, Drs. Adam Kuhn and Benjamin Rush had been
added to the medical faculty of the college—the first, as Professor of
Materia Medica and Botany, and the second, as Professor of Chemistry.
During the same time, Dr. Thomas Bond had been lecturing on clinical
medicine in the Pennsylvania Hospital. On an attempt being made to
resume the courses of medical instruction in the College, in 1779, politi-
cal differences and suspicions caused the State Legislature to pass an act
abrogating the charter of the college, removing its officers, and transfer-
ring its property to a new institution, called the “University of the State
of Pennsylvania.”
The new University was granted a very liberal charter and consider-
able endowments. The Rev. John Ewing, D.D., was appointed Provost,
and an effort immediately made to organize a medical department, by
offering those who had held professorships in the College, the same posi-
tions in connection with the University. Regarding the act of the Legis-
lature abrogating the charter of the College and confiscating its property
as unjust, all but Dr. William Shippen, Jr., refused the offer and con-
tinued their annual courses of instruction independently, but without
legal authority to confer degrees. The Trustees of the University, find-
ing themselves unable to fill the several medical chairs satisfactorily,
agreed to confer degrees on such students as should be examined and
recommended by the several professors of the College whose charter had
been abrogated. By this arrangement, at the first public commencement
of the University, held in Philadelphia, June 27, 1780, the degree of
Pachelor of Medicine was conferred on William W. Smith and Ebenezer
Crossly, and that of Doctor of Medicine on David Ramsey, who was in
the service of the American Army, and at the time a prisoner in the
hands of the British. These were the first medical degrees conferred
by any institution created under the auspices of one of the independent
States of Annerica. This state of antagonism between the professors in
the College of Philadelphia and the trustees of the University, con-
tinued until 1789, when, aided by the influence of Benjamin Franklin,
after his return from Europe as foreign minister, the former succeeded
in inducing the State Legislature to repeal the act of abrogation, and to
restore to the College all its rights and privileges. This was done in
March, 1789, but it left the University in existence, with its endowments
from confiscated estates the same as before. The officers and faculty of
the College of Philadelphia were immediately reinstated, with Dr. Ben-
jamin Franklin himself as president of the Board of Trustees.
In October of the same year, Dr. John Morgan died, and Dr. Adam
Ruhn resigned, leaving the chairs of Practice of Medicine, and Materia
Medica and Botany, vacant. The vacancies were immediately filled,
and the Medical faculty of the College as reorganized for the session of
1789–90, was composed of William Shippen, Jr., M.D., Professor of
Anatomy, Surgery, and Midwifery; Benjamin Rush, M.D., Professor of
the Theory and Practice of Physic; Caspar Wistar, M.D., Professor of
Chemistry and of Institutes of Medicine; Samuel P. Griffiths, M.D., Pro-
268 DAVIS,
fessor of Materia Medica and Pharmacy; Benjamin Smith Barton, M.D.,
Professor of Natural History and Botany. At the same time Dr. Shippen
continued to occupy the same chair in the University of the State of
Pennsylvania, and was joined in that faculty by Dr. Adam Kuhn, in the
Chair of Theory and Practice of Medicine, and by Dr. James Hutchin-
son, in that of Chemistry.
The trustees of the College of Philadelphia not only reinstated a full
corps of medical professors, but they revised their former rules in regard
to medical requirements for graduation. These rules, as adopted in 1767,
provided for the conferring of the degrees of Bachelor of Medicine and
Doctor of Medicine. The student was permitted to apply for the first
after “a sufficient apprenticeship to some reputable practitioner in
Physic,” attendance on “at least one course of Lectures on Anatomy,
Materia Medica, Chemistry, the Theory and Practice of Physic, one
course of Clinical Lectures, and attendance on the practice of the Penn-
sylvania Hospital one year.” It was expected by the founders of the
College, that those who took the Bachelor’s degree would return after
three years of study and practice, and take the higher degree of Doctor.
Experience, however, had proved this expectation fallacious, as very few
of those who entered into practice after receiving the first degree, ever
returned for the second. For this reason the Bachelor's Degree was
abolished, and the revised regulations adopted for the College by the
trustees, November 17, 1789, and published in the Pennsylvania Gazette
were as follows:—
“I. No person shall be received as a candidate for the degree of Doctor of
Medicine until he has arrived at the age of twenty-one years, and has applied
himself to the study of medicine in the College for at least two years. Those
students, candidates, who may reside in the city of Philadelphia or within five
miles thereof, must have been the pupils of some respectable practitioner for
the space of three years, and those who may come from the country, and from
any greater distance than five miles, must have studied with some respectable
physician there, for at least two years.
II. Every candidate shall have regularly attended the Lectures of the follow-
ing professors, viz.: of Anatomy and Surgery ; of Chemistry and the Institutes
of Medicine; of Materia Medica and Pharmacy; of the Theory and Practice
of Medicine ; the Botanical Lectures of the Professor of Natural History and
Botany; and a course of Lectures on Natural and Experimental Philosophy.
III. Each candidate shall signify his intention of graduating to the Dean of
the Medical Faculty, at least two months before the time of graduation, after
which he shall be examined privately by the professors of the different branches
of medicine.
If remitted to his studies, the professors shall hold themselves bound not to
divulge the same ; but if he is judged to be properly qualified, a medical ques-
tion and a case shall be proposed to him, the answer and treatment of which he
shall submit to the medical professors. If these performances are approved,
the candidate shall then be admitted to a public examination before the Trus-
tees, the Provost, Vice Provost, Professors and Students of the College; after
which he shall offer to the inspection of each of the Medical Professors a
Thesis, written in the Latin or English Language (at his own option) on a
medical subject. This Thesis, if approved of, is to be printed at the expense
of the candidate, and defended from such objections as may be made to it by
the Medical Professors at a commencement to be held for the purpose of con-
ferring degrees, on the first Wednesday in June every year.
Bachelors in Medicine who wish to be admitted to the degree of Doctor in
Medicine, shall publish and defend a Thesis agreeably to the rules above men-
tioned.
A D D R ESS O N M E DIC A. L E D U C A TI O N. 269
The different Medical Lectures shall commence annually on the first Monday
in November, the lectures in Natural and Experimental Philosophy about
the same time, and the lectures. on Botany on the first Monday in April.
BENJAMIN FRANKLIN, President of the Board of Trustees.
WILLIAM SMITH, Provost of the College and Secretary of
the Board of Trustees.”
The Trustees of the University of the State of Pennsylvania adopted
very similar regulations regarding courses of lectures and time of study
for the degree of Doctor in Medicine, but they continued also to confer
the degree of Bachelor, as before. One hundred and four medical stu-
dents attended the Lectures in Philadelphia during the College term of
1790–1, and appear to have been nearly equally divided between the
two schools. The disadvantages arising from this division of patronage
were too apparent to be overlooked, and the friends of both schools soon
instituted measures for an amicable union. These measures resulted in
the passage of an Act of the Legislature of the State, September 30, 1791,
uniting the College and the University on the terms which had been
mutually agreed to by both the parties in interest. The name adopted
for the united institution was the “University of Pennsylvania.” Dr.
John Ewing was elected Provost and Professor of Natural and Experi-
mental Philosophy, and all the professors in the medical department of
the two previous institutions were elected professors in the new one.
The full medical faculty of the University, as thus constituted, was ar-
ranged as follows: William Shippen, M.D., Professor of Anatomy,
Surgery, and Midwifery; Caspar Wistar, M.D., Adjunct; Adam Kuhn,
M.D., Professor of Theory and Practice of Medicine; Benjamin Rush,
M.D., Professor of Institutes of Medicine and of Clinical Medicine ;
James Hutchinson, M.D., Professor of Chemistry; Samuel P. Griffiths,
M.D., Professor of Materia Medica and Pharmacy; Benjamin Smith
Barton, M.D., Professor of Botany and Natural History.
The University, as thus reorganized, ceased to confer the degree of
Bachelor of Medicine, and left it optional with the medical students
whether they should attend the lectures on Natural History and Botany,
but in all other respects adopted the “Rules respecting a medical educa-
tion and the conferring of Degrees in Medicine,” which have been already
given as having been adopted by the Trustees of the College of Philadel-
phia in 1789. -
We have thus sketched briefly the progress of medical instruction from
its incipient beginnings in Philadelphia, to the complete establishment
of the University of Pennsylvania by the formal election of the faculty
above named, in January, 1792, not merely because.it was the pioneer
school, and one which still continues to exercise an important influence
over the educational interests of our profession, but because it has served
as the type or pattern for nearly all the medical schools subsequently
organized in this country. While the cause of medical education was
progressing, as we have detailed, in Philadelphia, the profession in New
York was not idle. We have stated that, as early as 1767, a charter was
granted by the Colonial government of New York for the establishment
of a General Hospital in that city; that, chiefly through the efforts of
Drs. Samuel Bard and Peter Middleton, a society was organized, and a
hospital building nearly completed, which was destroyed by fire in 1772;
and that the enterprise received liberal pecuniary aid from Sir Henry
! See History of the University of Pennsylvania, by Joseph Carson, M.D., pp. 95–6.
270 DAVIS,
Moore, the provincial Governor, from the Legislature, from the City
Corporation of New York, and from many private individuals. The
loss of the building by fire, and the speedy supervention of the war for
Independence, prevented all further efforts in that direction until after the
close of that war. Soon after this latter event, the corporation known
as the Society of the New York Hospital was revived, its work re-
sumed, and adequate hospital buildings completed ready for occupation
in 1791. The same persons who had been influential in the primary
effort to establish the New York Hospital, also induced the trustees or
governors of King’s College, located in New York City, to establish a
Medical Department of that institution, and to appoint a full medical
faculty in 1768. This faculty was composed of Samuel Clossy, 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., Professor of Chemistry and Materia Medica; John W. B. Tennent,
M.D., Professor of Midwifery; and Samuel Bard, M.D., Professor of
Theory and Practice of Physic.
Some important differences will be noticed in comparing this faculty
Organization with that of the faculty just previously organized in Phila-
delphia. First, it makes a more complete division of labor, and at once
gives a full recognition to the departments of Surgery and Midwifery,
assigning to each a separate professorship on an equality with all other
departments, instead of making them appendages to the more prominent
departments of Anatomy and Theory and Practice of Medicine. In this
respect the New York faculty was in advance, not only of that of the
Philadelphia College, but also of that of the University of Edinburgh.
Second, it makes no mention of the departments of Botany and of Natural
and Experimental Philosophy. Third, as the number of chairs and the
consequent division of labor was greater, the annual college term was
made shorter by one month ; the term closing in May instead of June in
each year. In all other respects the regulations were very similar to those
adopted by the school in Philadelphia. The first courses of lectures
were given in the autumn and winter of 1768–9, at the close of which,
in May, 1769, the degree of Bachelor in Medicine was conferred by the
Trustees of the College on Samuel Kissam and Robert Tucker. And at
the close of the succeeding college term, in May, 1770, the degree of
Doctor in Medicine was conferred on one or both of the same persons.
These are stated by Dr. J. B. Beck, and several other writers, to have
been the first medical degrees conferred by any college in America. This
is true, however, only as it relates to the degree of Doctor in Medicine.
Por, as a matter of fact, the College of Philadelphia conferred the degree
of Bachelor in Medicine on ten students in June, 1768, but did not con-
fer the degree of Doctor in Medicine until June, 1771.
The regular annual courses of medical instruction were continued, and
attended by small classes of students, until they were interrupted by the
war. During the war, the name of King’s College was changed to that
of Columbia College, which it still retains. Soon after the close of the
war an effort was made to re-establish the medical department connected
there with. By some misfortune connected with the procuring of sub-
jects for dissection, a violent popular outbreak, called the “Doctors'
Mob,” was induced, during which the dissecting-room of the college was
broken up, and for three days law and order were trampled under foot.
To counteract, as far as possible, the evil influences thus brought to bear
upon the profession, and to improve medical science, several of the more
A D D RESS O N M E DIC A. L E D U CATIO N. 271
enterprising and younger members of the profession formed a private
Society, and in 1787 succeeded in inducing the magistrates of the city to
establish a public free dispensary for the sick poor. Among the more
prominent of those engaged in this enterprise were Drs. William Moore,
Nicholas Romaine, Benjamin Kissam, Wright Post, and Valentine Sea-
man. They not only gave gratuitous attendance on the poor in the dis-
pensary, but in connection there with gave lectures on most of the
branches of medicine; thereby making it the first institution connected
with practical instruction in medicine under the corporation of the City
of New York.
So great was their success that, in 1790, more than fifty students
attended their instruction, and an unsuccessful attempt was made to
organize an independent school under the name of the College of Physi-
cians and Surgeons. In the autumn of 1791, the private association intro-
duced not less than sixty students into Columbia College, and thereby
induced the Legislature of the State to make a grant of $30,000 to the
trustees, for the purpose of enabling them to enlarge their buildings, etc.
In the following year the medical faculty was reorganized by the appoint-
ment of Drs. Bailey, Post, Rogers, Hammersly, Nicol, and Kissam, as
professors, and of Dr. Samuel Bard, as Dean of the Faculty. Some of
these appointments were very unsatisfactory to the students, and were
followed by such a degree of opposition as to greatly interfere with the
prosperity of the College, and to lead many members of the profession in
the city to use their influence in favor of the establishment of another
and independent medical school.
In accordance with their wishes, the regents of the University of the
State of New York granted a charter for a new college in 1807, to be
located in the city, and called the College of Physicians and Surgeons
of New York. It was placed under the control of a board of trustees,
consisting of the whole Medical Society of the city and county of New
York, and the degree of Doctor of Medicine was to be conferred by the
regents of the University of the State, on the recommendation of the trus-
tees and faculty of the College. The first course of lectures was given in
the winter of 1807–8, to a class of fifty-three students. In 1810 the
medical department of Columbia College was finally discontinued, leav-
ing the College of Physicians and Surgeons the only one in the State,
with a class of students numbering eighty-two, and the following very
able faculty, viz.: Samuel Bard, M.D., President; David Hosack, M.D.,
Vice President and Professor of the Theory and Practice of Medicine and
of Clinical Medicine; William James Macnevin, M.D., Professor of Chem-
istry; Samuel L. Mitchill, M.D., Professor of Materia Medica and Bot-
any ; Valentine Mott, M.D., Professor of Surgery; John W. Francis,
M.D., Professor of Obstetrics and Diseases of Women and Children ;
Wright Post, M.D., Professor of Anatomy.
But instead of that rapid prosperity which the friends of the institu-
tion and the regents of the University now anticipated, the very numer-
ous board of trustees, being mostly medical practitioners in the imme-
diate vicinity of the College, soon became distracted by opposing councils,
and jealousies arose between them and the members of the faculty, which
caused much difficulty and greatly retarded the prosperity of the college.
These defects were corrected in subsequent years, and the institution has
maintained a good reputation and leading influence down to the present
time.
In 1783, the medical department of Harvard College, in Cambridge,
272 DAVIS,
near Boston, was organized by the appointment of John Warren, M.D.,
Professor of Anatomy and Surgery; Aaron Dexter, M.D., Professor of
Chemistry and Materia Medica; and Benjamin Waterhouse, M.D., Pro-
fessor of the Theory and Practice of Medicine. The medical department
of Dartmouth College, at Hanover, New Hampshire, was organized in
1797, chiefly through the influence of Dr. Nathan Smith, who was ap-
pointed Professor of Medicine, and for ten or twelve years taught all the
branches of medicine with signal ability. The medical department of
the University of Maryland, at Baltimore, was incorporated in 1807, and
was supplied with an able faculty, consisting of John B. Davidge, M.D.,
Professor of the Principles and Practice of Surgery, and Nathaniel Pot-
ter, M.D., Professor of the Theory and Practice of Medicine, assisted by
T}rs. Shaw, of Maryland, and Cooke, of Virginia.
I3y the foregoing brief historical statements it will be seen that during
the first thirty years after the close of the war for Independence, which
included the first decade of the present century, seven medical schools
had been organized, namely, two in Philadelphia, two in New York City,
one in Boston, one in Hanover, and one in Baltimore. The two in Phila-
delphia had been speedily united into one, and one of those in New York
had been discontinued. We find, therefore, only five medical schools in
existence in the United States in 1810, with an aggregate number of
medical students in attendance of about 650, of whom about 100 received
in that year the degree of either Bachelor or Doctor of Medicine. Two-
thirds of this whole number were in the University of Pennsylvania.
Only two public general hospitals had been established, namely, the
Pennsylvania Hospital in Philadelphia, and the New York Hospital in
New York City." The former was a very important aid to the Univer-
sity in attracting students to Philadelphia, by the clinical instruction
which it afforded, as inaugurated by Dr. Thomas Bond soon after it was
opened for the reception of patients.
All but one of these medical schools were organized as departments of
colleges or universities of literature and science, already established, and
all but the one began with a small number of professors, making it neces-
sary that one man should teach two, and sometimes three, branches of
medicine during each annual college term. For this reason more than
any other, the medical college terms were made to commence generally
on the first of October, and to continue until the following May or June.
All these schools adopted, at first, the policy of conferring the degree of
Bachelor of Medicine on students who had studied medicine with some
reputable practitioner not less than two years, and had attended the
medical instruction in the college one year, or rather one college term ;
and the degree of Doctor of Medicine after three years of study and two
annual college terms. It must be remembered that, during the colo-
nial period of our history, and for thirty or forty years subsequent to
the achievement of our National Independence, it was the universal cus-
tom for young men who entered upon the study of medicine to become
regularly apprenticed to some practitioner for a term of three or four
years, during which time the preceptor was entitled to the student’s ser-
| Since the above was written, we have learned that, in 1784, Don Andras Almonaster
commenced the erection of a public or general hospital in the city of New Orleans, on the
site of the one blown down in the great storm of 1779. It was called the New Charity
Hospital, and cost $114,000. As Louisiana became one of the States of our Union, by pur-
chase, in 1803, this Charity Hospital should have been included with those of Philadelphia
and New York mentioned above.
A L) D R E S S O N M E DIC A.T., E D U C A TI O N . 273
vices in preparing and dispensing medicines, extracting teeth, bleeding,
and other minor surgical operations, and, when more advanced in studies,
in attending on the sick ; and, in return, the preceptor became obligated
to give the student detailed and thorough instruction in all the branches
of medicine. Many of the more eminent practitioners often had several
students in their offices at one time, constituting a small class who were
drilled almost as regularly in their studies as they would be in a college.
In some instances the term of apprenticeship was extended to six and
even seven years, and was made to commence at the early age of fifteen
or sixteen years. All these customs were brought by the emigrants from
the parent country, and their perpetuation here was rendered more neces-
Sary by the sparseness of the population and the difficulty of access to
medical schools."
In the midst of such customs, and at a period in the world’s history
when railroads, steamboats, and other means of speedy transit were un-
known, and even post-coaches were rare, it was entirely reasonable that
the first idea of a medical college should be to furnish the means for a
rapid review of the several branches of medical science, aided by such
experiments and appliances for illustration as could be commanded, and
the whole concentrated into as small a part of the year as possible. The
idea of the founders of medical schools, both in Great Britain and in this
country, was to make them supplement but not supersede the work of the
preceptor and the medical apprentice. The study of anatomy by dissec-
tions, the illustration of chemistry by experiments, the clinical observa-
tion of disease at the bedside, were capable of being carried on in the
offices of preceptors, only to a very limited extent. But by combining
several preceptors, each eminently qualified in some one department, in
a college faculty, with access to anatomical rooms, chemical laboratory,
and hospitals for the sick, all the branches of medicine then recognized
could be very well reviewed in the form of didactic instruction, in five
or six months of the year. It was expressly to supply the wants here
indicated, with the greatest economy of time and labor, that the medical
department of the University of Edinburgh was founded in the beginning
of the eighteenth century, and conferred its first degree of Doctor of
Medicine in 1705. It rose rapidly to distinction among the schools of
Europe, and furnished the model after which the first medical schools in
this country were organized ; as it was the Alma Mater of nearly all their
first professors.
Assuming that the student would serve from two to four years of his
apprenticeship to his preceptor, before resorting to a medical school, the
several professors very naturally arranged their courses of instruction to
begin nearly at the same time, generally in September or October, and to
be completed in timé for the public commencement and conferring of de-
grees in the following May or June. And as the Bachelor's degree was
generally conferred after attendance on one full course of college instruc-
tion in the several branches taught, no gradation or consecutive order of
studies could be incorporated into the college course. The addition of
one or two years more of study, including a second course of college in-
struction, entitled the applicant to an examination for the degree of Doc-
tor of Medicine. At the first organization of all the medical schools to
which we have thus far alluded, provision was made for conferring the
degrees of both Bachelor and Doctor of Medicine. But, as already men-
! See Contributions to the Annals of Medical Progress, etc., by J. M. Toner, M.D.
18
274 DAVIS,
tioned, the degree of Bachelor was abandoned by the College of Phila-
delphia in 1789, and by the University of Pennsylvania in 1791, and by
all the medical colleges in the country after 1813. The whole number
of medical degrees conferred by the seven medical schools whose origin
we have traced, prior to 1810, did not exceed six hundred. Very many,
however, served their regular apprenticeship with the preceptor, attended
one course of college instruction, and entered upon practice without a
college degree; and there were not a few who entered upon the respon-
sible duties of practice with simple certificates from their preceptors,
without ever having seen the inside of a college building.
We shall not fully appreciate,the relations of the medical schools to
the needs of the profession at that time, unless we consider also the coin-
cident condition of the different branches of medical science. To the
active workers of the present generation, a medical college with only
three or four professors, or one professor attempting to teach anatomy,
surgery, and midwifery, all in one college term of five or six months,
would appear hardly less than absurd. If we remember, however, that
down to the commencement of the present century, the principal medical
works in use were the writings of Sydenham, Boerhaave, and Cullen,
the Physiology of Haller, the Anatomy of Cheselden or Monro, the Sur-
gery of Sharp, Pott, or Jones, the Midwifery of Smellie or Hunter, and
the Materia Medica of Lewis, we shall readily see that the field of med-
ical study was limited in comparison to that which now opens before the
student.
At that time, surgery had only begun to be recognized as a distinct
branch from anatomy. We learn from an introductory lecture by James
Spence, F.R.C.S.E., Professor in the University of Edinburgh, that “so
late as 1777, when the College of Surgeons petitioned the patrons to in-
stitute a separate professorship of surgery in the University, they were
opposed by Monro, then Professor of Anatomy, as interfering with his
branch ; and he succeeded in getting his commission altered so as to in-
clude surgery, which was thus made a mere adjunct of the anatomical
course, and continued to be so taught (if it could be said to be taught)
until the institution of the chair of Surgery in 1831.” It was not until
June 4, 1805, that Surgery was separated from the chair of Anatomy
by the appointment of Dr. Philip Syng Physick as Professor of Surgery,
on an equality with the other professors in the University of Pennsylva-
nia. The department of Midwifery was still later in gaining recognition
as a distinct branch of medicine. At the request of Dr. Caspar Wistar,
who had succeeded to the professorship of Anatomy and Midwifery in
the University on the death of Dr. Shippen, in 1808, the trustees sepa-
rated the chairs, and in 1810 appointed Dr. Thomas Chalkly James the
first Professor of Midwifery in that College. And yet it was not until
three years later, October 11, 1813, that he was formally recognized as
a member of the faculty, and attendance on his lectures rendered obliga-
tory upon the students who applied for graduation. In New York, how-
ever, midwifery was recognized as a distinct branch at a much earlier
period than in any of the other cities in which medical schools had been
organized ; for in the first medical faculty appointed in connection with
Ring’s College, in 1768, Dr. John W. B. Tennent was made Professor of
Midwifery, apparently on an equal footing with all the other professors.
The foregoing facts are sufficient to show the limited field of medical
science at the beginning of the present century, compared with the same
field at the present time. If this is borne in mind, it will be seen that
A D D RESS O N M E DIC A. L E D U CATION. 275
the five medical schools, embracing the medical departments of the
University of Pennsylvania, Harvard College, near Boston, Dartmouth
College, at Hanover, the University of Maryland, at Baltimore, and the
College of Physicians and Surgeons, at New York, which were either re-
organized or founded de novo during the first thirty years of our history
as an independent nation, were established on as liberal a basis, and were
as well adapted to the then existing wants of the profession and the peo-
ple, as any that have been organized since. As a general rule, they com-
menced with a small number of professors, but as the different depart-
ments of professional knowledge became better developed, and the work
of instruction better systematized, there was manifested that tendency to
make divisions of labor by the creation of new chairs, which has con-
tinued to the present time. In this respect the University of Pennsyl-
vania, as the leading School, may be taken as a representative of all the
rest. Commencing with only two professors, Drs. Morgan and Shippen,
aided by the clinical instruction of Dr. Bond in the Hospital, in 1765,
the number was increased by the addition of the chairs of Chemistry and
Materia Medica, in 1768–9; and on the merging of the College of Phila-
delphia with the University of the State of Pennsylvania, in 1791–2, the
number of chairs was increased to six, by the addition of professorships
of Institutes of Medicine, and of Botany and Natural History. A fur-
ther addition took place by the creation of a separate chair of Surgery,
in 1805, and one of Midwifery, in 1810. From the year just named the
number of medical schools began to increase with great rapidity.
A medical department was established in connection with Yale Col-
lege, in New Haven, in 1810, but the first course of instruction was not
commenced until 1813. In 1812, the Regents of the University of the
State of New York incorporated the College of Physicians and Surgeons
of the Western District, located in Fairfield, Herkimer County. The
Vermont Academy of Medicine, located at Castleton, Vermont, received
a charter from the Legislature of that State in 1818. The same year, a
medical school was organized as a department of Transylvania Univer-
sity, at Lexington, Kentucky, chiefly through the influence of Drs. Dud-
ley, Richardson, and Blythe. In January, 1819, the Legislature of Ohio
passed an act incorporating the Medical College of Ohio, in Cincinnati.
In 1820, the Medical School of Maine was organized as a department of
Bowdoin College, at Brunswick, Maine, with a faculty consisting of Drs.
Nathan Smith, John D. Wells, and Parker Cleaveland. In 1821, a medi-
cal school was organized in connection with Brown University, at Provi-
dence, Rhode Island, but was soon after discontinued. The medical
school of the University of Vermont was established in Burlington, in
1822. A school called the Berkshire Medical Institute, was organized
in Pittsfield, Massachusetts, under the charter of Williams College, in
1823. The Medical College of South Carolina was established in Charles-
ton, in 1824, and supplied with a full corps of professors, including the
well-known names of Drs. Ramsey, Holbrook, Dickson, Prioleau, Frost,
Ravenal, and Elliot. The Medical Department of Columbian College, in
the District of Columbia, was organized in 1825, chiefly through the in-
fluence of Drs. Thomas Sewall and Frederick May, of Washington.
In the winter of 1825, the Legislature of the State of Pennsylvania
passed an act under which a new medical school was organized in Phila-
delphia, in connection with a literary institution called Jefferson College,
at Canonsburg; and hence the new medical school took the name of Jef-
ferson Medical College, and, in its progress since, has attained a prosper-
276 DAVIS,
ity and influence equal to that of the best medical colleges in this country.
The Medical Department of the University of Virginia, located at Char-
lottesville, in that State, was organized in 1825, and has continued to the
present time, teaching the different branches of medicine in the same man-
ner as the various branches of science are taught in other departments of
the institution. The medical school of the Valley of Virginia was estab-
lished at Winchester, Virginia, in 1826, on nearly the same plan as the Med-
ical Department of the University, at Charlottesville. It attracted but a
small number of students, and appears to have been discontinued several
years since. In 1827, the Washington Medical College was organized in
|Baltimore, on the same plan as the majority of American medical colleges.
The Medical College of Georgia, located at Augusta, was incorporated by
an act of the Legislature of that State in 1830, and the first course of
instruction was given in 1832–3. The Willoughby University, in Ohio,
was chartered in 1834, and its first course of instruction commenced in the
autumn of 1835. The Medical Department of the University of Louisi-
ana, at New Orleans; the Medical Institution of Geneva College, at Ge-
neva, New York ; the Medical Department of Cincinnati College, Cin-
cinnati, Ohio ; and the Vermont Medical School, at Woodstock, Ver-
mont, were chartered by the Legislatures of the respective States in which
they were located in the year 1835.
The Medical Department of the University of Louisville, Kentucky,
was organized in 1837, and the Medical Department of the University
of the City of New York, the same year. The Medical Department of
Hampden Sidney College, at Richmond, Virginia, was organized in 1838.
The Albany Medical College, at Albany, New York, and the Medical
Department of Pennsylvania College, at Philadelphia, in 1839. The Mis-
souri Medical College, at St. Louis, Missouri, was organized in 1840, and
the St. Louis Medical College, in the same city, in 1841. The Legisla-
ture of Illinois granted a charter for the Rush Medical College, in Chi-
cago, in 1837, but a faculty was not organized for instruction until 1843.
The Cleveland Medical College was organized at Cleveland, Ohio, in
1843. The Medical Department of the University of Buffalo was organ-
ized in Buffalo, New York, in 1846. The Starling Medical College and
Hospital was organized at Columbus, Ohio, in 1847. The Medical De-
partment of the University of Michigan, at Ann Arbor, was instituted
in 1849. The Medical Department of the University of Nashville, at
Nashville, Tennessee; the College of Physicians and Surgeons, at Keo-
kuk, Iowa ; and the Woman's Medical College of Pennsylvania, at Phila-
delphia, were organized in 1850.
The Medical College of Virginia, at Richmond; the Medical Depart-
ment of Georgetown University, at Washington; and the Cincinnati
College of Medicine and Surgery, at Cincinnati, were created in 1851.
The Savannah Medical College, at Savannah, Georgia, and the Miami
Medical College, at Cincinnati, were established in 1852. The Atlanta
Medical College was commenced at Atlanta, Georgia, in 1855. The
Medical College of the Pacific, at San Francisco, was organized in 1858.
The Chicago Medical College, Medical Department of the Northwestern
University, was organized in 1859. The Medical College of Mobile, Ala-
bama, and the Long Island College Hospital, in Brooklyn, New York,
were organized in 1860. The Bellevue Hospital Medical College was
established in the city of New York in 1861. The Woman’s Medical
College of the New York Infirmary, located in the city of New York,
was created in 1864. The Medical Department of Willamette University,
A D D R E SS O N M E DIC A. L E D U C A TI O N . 277
located at Salem, Oregon, was commenced in 1866. The Medical Depart-
ment of Howard University was organized in 1867. The Medical Depart-
ment of the University of South Carolina, at Columbia, and the Detroit
Medical College, at Detroit, Michigan, were commenced in 1868. The
Medical Department of the University of Wooster, at Cleveland, Ohio;
the Kansas City College of Physicians and Surgeons, at Kansas City,
Missouri; the Louisville Medical College, at Louisville, Kentucky; the
Medical Department of the Iowa State University, at Iowa City; and
the Medical Department of the Indiana University, at Indianapolis, all
had their beginning in 1869. -
The Woman’s Hospital Medical College, at Chicago, and the Medical
Department of Lincoln University, at Oxford, Pennsylvania, were organ-
ized in 1870. The Free Medical College for Women was organized in
the city of New York in 1871. The Medical College of Evansville,
Indiana, was chartered in 1846, and reorganized in 1872. The College
of Physicians and Surgeons of Syracuse University, at Syracuse, New
York, and the College of Physicians and Surgeons at Wilmington, North
Carolina, were incorporated in 1872. The Medical Department of the
University of California, at San Francisco, was first organized under the
name of the Toland Medical College in 1864, and became a department
of the University in 1873. The Medical College of the University of the
State of Missouri, at Columbia, Missouri, and the Texas Medical College
and Hospital, at Galveston, Texas, were organized in 1873. Medical
schools have recently been established in Portland, Maine, and in Balti-
more, Maryland, the exact dates of the formations of which are not at
hand.
From the foregoing statistics we learn that, during the thirty years
intervening between the close of the war for Independence and 1810,
seven medical schools were organized ; in the thirty years intervening
between 1810 and 1840, twenty-six new medical colleges were added to
the list; in the thirty-five years since 1840, the number of new medical
schools created is forty-seven ; making the whole number of medical edu-
cational institutions established in the United States, during the first
century of our history as a nation, eighty. We have not included in
these numbers five or six mere abortive attempts to form medical schools
in different localities, but which were so transient as to leave a record
difficult to trace. Of the eighty which have been established, seventeen
have been discontinued or suspended, leaving, at this date, sixty-three
medical colleges now in active operation in this country. Of these, Maine
has two, New Hampshire one, Vermont three, Massachusetts one, Con-
necticut one, New York nine, Pennsylvania three, Maryland three, Vir-
ginia two, South Carolina one, Georgia three, Alabama one, Louisiana
two, Texas one, Tennessee one, Kentucky three, Missouri three, Califor-
nia two, Oregon one, Iowa two, Illinois three, Indiana three, Ohio seven,
Michigan two, and the District of Columbia three, leaving thirteen
States without any medical college now in operation. Four of the
schools included in the foregoing list, namely, two in New York City,
one in Philadelphia, and one in Chicago, are established for the exclusive
education of women in medicine. The whole number of students attend-
ing the medical colleges in 1810 was about 650, of whom about 100 gradu-
ated at the close of the college terms for that year. The population of the
United States at that time was 7,239,881. In 1840, the whole number
of students in the colleges was about 2500, of whom about 800 received
the degree of Doctor of Medicine. The population of the United States
278 DAVIS,
in that year was 17,069,453. During the college terms for 1875–6, the
whole number of medical students in attendance on the colleges was
6650, of whom 2200 received the degree of Doctor of Medicine. The
population of the States at this time is over 40,000,000. Without
claiming absolute accuracy for the foregoing figures, they are sufficiently
close for all the purposes of comparison. And they show clearly, notwith-
standing all that has been said about the rapid multiplication of medical
schools, and the increased numbers of students and graduates, that the
colleges and the students, during the last thirty-five years, have increased
in a ratio only about equal to the increase of the population of the country.
The whole number of those engaged in teaching as professors in the several
medical colleges, at this time, is about five hundred."
As has been already stated, the origin of medical schools in this country
was solely from individual efforts, put forth from time to time, as the
ambition of the individuals or the supposed wants of the country
demanded, and not from any well-digested scheme or official plan of
professional education adopted either by the States or by the General
Government. The same remark is true, not only of their origin, but
also of their continuance and multiplication to the present time. When-
ever and wherever the Legislature of any one of our States has been asked
to grant a charter for a medical college, as a rule the request has been
complied with. And in the few instances in which such requests have
been denied, the parties interested have seldom found difficulty in forming
a connection with some literary college or university, already having
authority to grant degrees in medicine, as well as in general science.
Some of the State Legislatures, in addition to liberally granting charters
for medical colleges, have also occasionally appropriated a few thousand
dollars to aid in the erection of suitable buildings, but rarely, if ever, to
endow professorships, or to defray any of the current expenses of such
institutions. In the State University of Michigan, and possibly in one or
two other State Universities, the medical professorships, like those of the
other departments, are sustained by the income from the general endow-
ment, independent of the fees derived from the medical students. We
may say, in general terms, therefore, that the whole system of medical edu-
cation in this country, represented to-day by sixty-three medical colleges
distributed among twenty-four different States, sustained by the active
work of over five hundred professors, and annually aiding in the education
of nearly seven thousand students, is the spontaneous outgrowth of the
profession itself, self-reliant, and almost wholly self-sustained. Originating
among a free people, under the aegis of various educationally independent
States, apparently striving to keep pace in the increase of their number
and efficiency with a population which, in one short century, has increased
from three millions to forty millions, and extended over a territory from
the Atlantic to the Pacific, and from the great interior Lakes to the Gulf,
under circumstances of the freest competition, these schools constitute a
subject worthy of the most careful study.
To what extent have these schools been adapted to the real wants of
the profession and people of these States? Wherein have they failed to
keep themselves adjusted to these needs or wants, as the country has
1 In the above statistics we have not included colleges or schools for teaching exclusively
dentistry or pharmacy, or exclusive dogmas in medicine. Of the first there are eleven ; of
the second, thirteen; of the third there are three, called Eclectic, and eight or nine, Homoeo-
pathic.
A DDRESS ON MEDICAL EDUCATION. 279
advanced to the present time? If failures in adjustment have taken
place, in what do they consist, and how can they be remedied ? Let me
ask a continuance of your patient attention, while I answer as briefly
and directly as possible these most important questions, and my task will
be done. - -
We have already seen that our medical colleges had their origin at a
time when medical science and art occupied a far narrower field than
at present. A time when obstetrics was yet mostly in the hands of
unlettered midwives; surgery an appendage to anatomy; organic che-
mistry, histology, and even physiology, as now recognized, hardly known.
A time, too, when it was the universal practice for regular students of
medicine to apprentice themselves to private preceptors of reputation,
from whom they expected to receive the greater part of their professional
education. The great and pressing need, at that time, was for schools in
which, after gaining a knowledge of the text-books, the rude pharmacy
of his preceptor's office, and the individual experience of the preceptor
himself, during two or three of the first years of his study, the student
could review the whole in connection with such experimental demonstra-
tions as could be given only in the laboratory, the dissecting room, and
the clinical wards of the public hospital. It was to supplement, not
supersede, the work of the private preceptor.
Precisely this was what the medical schools were adjusted to do, and
they fulfilled the object well. Hence, although originating in different
States, wholly independent of each other, and in direct rivalry for patron-
age on which they depended for support, they were remarkably similar
in their organization and requirements. At first, the number of profes-
sors was small, and the college term eight or nine months, offering the
Bachelor's Decree after three years’ study, and ome college term, and the
Doctor's Degree after one or two more years, and a second course of col-
lege attendance. But as most of the students lived in small towns and
country districts remote from the colleges, making attendance on the
lectures both tedious and expensive, only a part of those engaging in the
study of medicine ever reached a medical college, and most of these, after
taking the Bachelor's Degree, never returned to take a second course and
the higher degree of Doctor. These circumstances constituted a strong
inducement for the colleges to concentrate the annual period of instruc-
tion into as short a time as possible, both for the purpose of increasing
the number of students who could afford the means of attending, and
the number who would take the second degree. Under these influences,
the first thirty years sufficed to cause the Bachelor's Decree to be aban-
doned by all the schools, the number of professors in each to be doubled,
and the length of the annual college term to be shortened one-third.
And in twenty-five years more, from the same causes, aided efficiently
by the fact that the degree conferred by the colleges became practically
recognized everywhere as a sufficient license to practise medicine in all
its departments, the colleges, with but one exception worth noting, had
each from five to seven professorships occupied by as many different pro-
fessors, and an annual college term of only from twelve to sixteen weeks,
during which the students, in one class, listened to from five to six lec-
tures daily, on as many different topics, besides attending to dissections
and clinical instruction when such were accessible.
The requirements for the Doctor's Degree were, three years study with
some regular practitioner of medicine, including attendance upon two
such courses of college instruction, the one being chiefly a repetition of
280 DAVIS,
the other; the writing of a thesis on some medical subject; the possession
of a good moral character; the attainment of twenty-one years of age;
and the sustaining of a creditable examination in the several branches of
medicine at the close of the second course of lectures. It will be seen
that, in these requirements, there was no reference to any standard of
preliminary education to be attained by the student before entering upon
his professional studies, except the ability to write a thesis. The require-
ment of a knowledge of the ancient languages, and the writing of a thesis
in the Latin language, were abandoned on the full reorganization of the
University of Pennsylvania, in 1792. The relinquishment of natural
philosophy, natural history, and botany, as requirements, soon followed,
leaving only the single indirect trace of any non-professional education,
to which we have alluded. Under these conditions and tendencies, by
the end of the second thirty years of our history, the number of medical
colleges had increased from five to forty-one; the number of students
attending them from six hundred and fifty to twenty-five hundred, and
the ratio of those graduating, each year, from less than one in six, to one
in three.
Here we see a system of medical colleges originating spontaneously to
supply the wants of a free and rapidly increasing people, and open to the
most free and unrestrained rivalry, actively developing two apparently
opposite results. In one direction, the schools justly vie with each other
in increasing the number of their professors in full consonance with the
rapid advancement of medical sciences; they sagaciously seek out and
enlist the services, as teachers, of the most learned, eloquent, and indus-
trious men to be found in the profession ; they spend time and money
freely in filling laboratories, anatomical rooms, and museums with all the
means for efficient teaching and illustration. So far their free rivalry
has reference only to their office as teaching bodies—institutions for im-
parting instruction—and is productive only of the highest good to the
profession and the people. But the anomaly consists in the fact that, at
the same time, the same institutions have been rapidly shortening their
annual courses; cutting off all collateral requirements; failing to grade
the branches of medical study, as they have increased in number and ex-
tent, so as to adapt them to the several years of pupilage ; and even re-
ducing the final examinations to the simple process of asking a few oral
questions in the mysterious “green room.” This most unfortunate ten-
dency of our experiment in permitting the freest rivalry in the estab-
lishment of medical schools, results directly and necessarily from the
fact that the degrees they confer, and the diplomas they give, have been
permitted throughout the whole country, with only a few temporary ex-
ceptions, to have all the force and effect of a license to practise medicine.
It requires but a moderate familiarity with the motives that govern
human actions, to see clearly that in a country where there are no entail-
ments of estates, and where the great body of young men who seek the
profession are without pecuniary fortune, and largely dependent on their
own industry for the means of education, as well as reputation and for-
tune in after life, the question “where can I get the degree of doctor,
which is equivalent to a license to practice, and a full admission into the
ranks of the medical profession in the shortest time, and consequently
with the least expenditure of time and money º exerts a very great, if
not controlling influence, in determining where the student shall attend
his college instruction.
Not that medical students are a whit less conscientious, in their desire
A D D R E SS O N M R. DIC A. L. E L) U C A TI O N . 281
to fully qualify themselves for the responsible duties of our profession,
than those who seek any other calling in life. But present necessity, or
even convenience, easily controls when there comes with it the flattering
thought that, at another time, after having earned a little money by
practice, all deficiencies can be supplied by a season of reviewing in a
school of the largest facilities. Just on this half-unconscious delusion,
hundreds are induced to go where the requirements in time and money
are least, regardless of all other advantages. The medical college in a
country village, remote from all facilities for clinical instruction in
hospital or dispensary, and but scantily supplied with subjects for dissec-
tion, can issue to its graduates just as large a diploma, couched in just
as unintelligible Latin, and having much the same influence with the
people, as the school in a metropolitan city, where its students can have
the largest facilities for clinical and practical study. IIence it is not
strange that, before the end of the seventh decade of the past century of
our existence as a nation, about forty medical colleges had been organized,
only sixteen of which were so located as to afford their students any
proper facilities for clinical instruction ; and that these sixteen were
attended by little more than one-third of the whole number of those who
attended medical colleges.
The general acceptance of the college diploma as full admission into the
profession, thereby uniting in the hands of the same men the business of
teaching and the power of licensing, has continued to the present day; and
is wholly responsible for the fact that, while we have sixty-three medical
colleges to-day, one third of them are so located that they can afford
their students no advantages for clinical instruction worthy of mention;
and all, except three or four, still attempt to crowd instruction in all the
departments of medicine upon the attention of mixed or ungraded classes,
in annual college terms of from sixteen to twenty weeks, and exact only
two such strictly repetitional courses for graduation. This state of things,
in regard to our medical schools, is made still worse by the fact that,
during the century under consideration, the system of private medical
pupilage has undergone a complete change. At the beginning of that
period, as we have already seen, the private study, under a master, was
a protracted and serious work, and the resort to the college was simply
to review and more fully illustrate that work. But steadily, as medical
colleges increased in number, as populations became more dense, and as
steamboats and railroads increased a thousand fold the facilities for travel,
the work of private pupilage relaxed. Indentures of medical students, as
pupils. to the more noted practitioners, long since ceased, and the relations
of student and preceptor have become merely nominal in practice, in nine
cases out of ten consisting in little more than the registry of the student's
name in the doctor's office, permission to read the books of his library or
not as he chooses, and the giving of a certificate of time of study for the
student to take to the medical college where he expects to graduate.
The relative position of the private pupilage and the collegiate studies
has undergone a complete practical reversal. The latter, instead of
reviewing and supplementing the former, has become the student’s chief
reliance for the acquisition of medical knowledge; and hence, to have
maintained its adaptation or adjustment to the needs of the profession,
should have not only increased the number of its professors and its means
for communicating knowledge, but also the length of its annual courses,
and the division or gradation of its classes in accordance with their period
of study, and in proportion to the greatly enlarged field of medical know-
282 DAVIS,
ledge to be acquired. And such would have been, to-day, the grand
result worked out by our experiment of self-originating, self-sustaining,
and unrestricted competition in the establishment and maintenance of
medical schools, had they been restricted to their only appropriate func-
tion as institutions for imparting medical instruction and advancing
medical science, instead of being hampered and perverted from their
natural course by assuming the office of licensing institutions. And
could this incubus be removed to-day, another quarter of a century would
not pass before every medical college in our country would have its annual
course of instruction extended to six months; its curriculum and classes
so graded that the attention of each student should be restricted to such
branches as are adapted to his period of advancement in study ; and nine-
tenths of all our medical students would be in attendance on those colleges
only that could afford proper facilities for full clinical and demonstrative
instruction.
Let the only question presented to the mind of the student, when
choosing the college he shall attend, be where can he most certainly
obtain that amount and variety of medical knowledge which will enable
him successfully to pass the examination of an independent board of
examiners, acting under liberal and enlightened rules and modes of
testing the student’s knowledge, and we shall have nothing to fear either
from the number, or the rivalry, of our medical schools. The injurious
tendencies of our system of uniting the work of teaching and that of
licensing to practise, in an unlimited number of independent medical
colleges, was seen at an early period, and clearly pointed out; and by
none more clearly and forcibly than by some of those engaged in the
colleges themselves.
So true is this that the Legislatures of some of the States, in organiz-
ing and regulating their respective State Medical Societies, made some
ineffectual attempts to lessen the evil by legislation. This was particu-
larly true in South Carolina, Maryland, Delaware, Massachusetts, and
New York. As early as 1839, at an annual meeting of the Medical So-
ciety of the State of New York, the following resolution was reported
by a committee, and, after free discussion in the Society, was adopted
by a vote of fourteen to four: “Resolved, That the right of teaching
ought to be separated as much as possible from the power of conferring
degrees or licenses.” The following year a committee, consisting of T)rs.
James R. Manly, of New York City, T. Romeyn Beck, of Albany, and
John McCall, of Utica, submitted to the same Society an able and inter-
esting report on the whole subject of medical education, in which occurs
the following cautious but significant language: “Put in view of the
diploma becoming depreciated by the rapid establishment of new schools,
it may well become a question deserving serious consideration, whether
at no distant period the rights of teaching and licensing should not be
disjoined. An incidental difficulty to the adoption of this suggestion, is
the fact that we are surrounded by institutions in other States, which
might or might not follow it, and thus our students be induced to desert
our own colleges.” -
In 1837, the same view was advocated by some of the ablest members
of the profession in Philadelphia, and they proceeded so far as to organ-
ize an institution for the purpose of examining eandidates and of confer-
ring degrees, wholly independent of the business of teaching. A petition
* See Transactions of the New York State Medical Society for 1840.
A. I.) D RESS ON ME DIC A. L E D U CATION . 283
signed by one hundred and twenty-six physicians, residents of that city,
was presented to the Legislature of the State, asking for a charter giving
legal effect to their organization, but the charter was not granted and the
project failed.
In 1844, the subject was again brought prominently under discussion
in the meeting of the New York State Medical Society, by him who now
addresses you. The discussion of the same subject was continued in the
annual meeting of 1845, and resulted in the call issued by that society
for a convention of delegates from all the medical colleges and societies
in the United States, which was held in New York, in May, 1846, and
from which originated the American Medical Association. I make these
historical allusions to show that neither those engaged in medical teaching
nor the profession at large have been unmindful of the evil to which I
have attached so much importance. Yet it still exists in all its force. That
the colleges have failed to keep themselves adjusted to the needs of the
profession in regard to the length of their annual courses of instruction,
the systematic classification of the branches included in their curricu-
lums, the corresponding grading or division of their classes, and the exac-
tion of a reasonable standard of preliminary education, has been still
more fully appreciated and acknowledged.
Not only is this appreciation indicated by the criticisms in our medical
periodicals and the discussions in our medical societies, and by the more
general efforts of the colleges, since 1850, to increase the number of their
professors, and the fulness of their curriculums, by piecing out their
annual courses of instruction with two or three weeks of preliminary
lectures at the beginning, and short spring courses at the end of the reg-
ular terms—all of which the student might attend or not as he chose—
but in a still more formal manner by the proceedings of two or three
conventions of delegates from the various schools, in which all the defects
here stated relating to preliminary education, inadequate length of the
annual courses of instruction, and the urgent need of a systematic division
of the branches taught into groups appropriate for each year of study,
and the consequent grading of the classes, with annual examinations of
each class, have been fully stated, and a thorough plan of remedying them
devised and urgently recommended to the schools for their adoption.
The first of the conventions to which I allude was held in Cincinnati,
in May, 1867, and was presided over by the learned Prof. Stillé, of the
medical faculty of the University in whose buildings we are assembled
to-day. The second was held in the city of Washington, in May, 1870,
and was presided over by the justly distinguished head of the faculty of
the Jefferson Medical College of this city. A third convention of less
formal character was held in this city, in June of the present year. If
you ask me why these reasonable and highly important recommendations
have not been adopted by the greater part of the schools, I can only point
you for answer to the paragraph already quoted from the report on med-
ical education made to the New York State Medical Society, in 1840, by
that learned trio composed of Beck, Manly, and McCall. Or, more di-
rectly, to the fact that while the faculty of each school frankly acknowl-
edges the defects in adaptation to the present enlarged field of medical
science and art, and the urgent needs of the profession, each waits for
the other to move first, lest, by placing higher requirements upon the
time and resources of the student, it should cause its own halls to be de-
serted for those of its less exacting neighbor.
The efforts in this direction, however, have not been entirely fruitless
284 DAVIS,
of practical results. In 1859, the Chicago Medical College, now the
Medical Department of the Northwestern University, was organized for
the express purpose of testing the practicability of establishing a school
with a thoroughly graded and consecutive system of instruction. Its
curriculum was made to embrace thirteen professorships, arranged in three
groups, one appropriate for each of the three years of study required. The
students attending were correspondingly divided into three classes,
junior, middle, and senior. Each class was required to devote its time
thoroughly to the group of branches and lectures belonging to its year of
advancement in study, and to be examined fully in those branches at the
end of the college term. Each of the three courses was continued six
months of the year, and actual attendance on hospital clinical instruction,
and practical work in the chemical, anatomical, and microscopic, or his-
tological laboratories, was added to the requisites for eligibility to gradu-
ation. The very satisfactory success of this institution during the past
fifteen years, and its present prosperity, certainly demonstrate the prac-
ticability of the scheme.
In 1871, the medical school of Harvard University, one of the oldest and
most influential medical institutions in our country, also adopted a fully
graded system of instruction, dividing her classes, and extending her
courses of instruction throughout the collegiate year, and has continued
this plan to the present time, adding annually to the perfection of its
details, and adding also to her own prosperity and influence. The new
medical school of Syracuse University, New York, has practically adopted
the same scheme; and the annual announcements of several other medical
schools, for the present year, including some of the most influential and
important institutions in the country, give unmistakable evidence of
their having taken initial steps in the direction of this most desirable
change.
But our medical schools, aided by the work of the private preceptor,
do not constitute the whole educational force or influence operating upon
the profession in this country. Our social or society organizations, City,
County, District, State, and National, have exerted, throughout the whole
period of our history, a most potent influence over the educational inter-
ests of the profession. We had intended to sketch briefly the history of
the more important of these organizations, but must not trespass further
upon your time and patience on this occasion. It is sufficient to say that
these society organizations, by their annual reunions of the profession in
almost every State and important city in our wide domain ; by the oppor-
tunities they afford for the presentation of papers, and comparison of
views in free discussion, not only in relation to scientific and clinical
matters, but in relation to every interest whether of medical science or
medical polity, have exerted indirectly an influence over the progress, the
education, and the general character of the profession, hardly second to
that of the organized schools. And if the profession, as represented in
these social organizations, would boldly move on in the exercise of its
own most important right and duty—by fixing for itself both the stand-
ard of preliminary and professional education necessary for young men to
attain before admittance into its ranks, and by appointing the necessary
tribunals for enforcing that standard, thereby leaving the colleges to their
only legitimate work, that of imparting instruction—the latter would
speedily adjust themselves perfectly to the actual educational needs of
the profession.
|Because we have endeavored, in reviewing the progress of our educa-
A D D R E S S O N M E DIC A. L E D U C ATION . 285
tional institutions during the past century, to indicate what we regard
as their most important defects, let no one infer that we belong to that
class, who, in any degree, undervalue the past work or present influence
of our medical schools. We do not agree with those who would compel
every young man who desires to spend his life in alleviating the suffer-
ings of the sparse populations of our mountains and prairies, to spend the
best part of his youth in the vain endeavor to become an adept in the
native languages of Cicero and Hippocrates; nor would we discourage
the laudable ambition of that large and most valuable class of our young
men, who are largely dependent on the proceeds of their own labor for
their education, as well as for their advancement in after life, nor foster
the indolence of the more wealthy by copying the five, six, or seven years
of professional collegiate study from the institutions of Europe. Neither
do we agree with those who regard the establishment of a National pro-
fessional school by our general government, or the endowment of State
colleges, with professors salaried out of public funds, as the panacea for
our ills. To invoke the patronage of either National or State Govern-
ments, in this country, in the regulation and support of medical schools,
is simply equivalent to asking that the lobbies of every legislative body
in the country shall be annually filled with the log-rolling satellites of
every “pathy” and “ism” of the day, that the professorships of our col-
leges shall be transformed into political sinecures, and that the colleges
themselves shall become the foot-balls of partisan politicians.
On the contrary, we believe that our system of medical college instruc-
tion, with all its defects, has developed in strict consonance with the
spirit of a free and enlightened people, in the comparatively short period
of one hundred years, a body of medical men as enlightened, enterprising,
industrious, and self-sacrificing, as faithful to the interests of the people,
and animated by as noble an esprit de corps, as is to be found in any country
on the globe. And not only so, but that these same schools have done
their full share in creating and sustaining that progress in medical science
and literature, which has been demonstrated to this Congress so fully in
the most intersting Addresses to which we have listened, on the various
departments of medical science and art.
Let us, then, in the same self-reliant, independent spirit, which actuated
those who founded, and with the same untiring zeal and generous emu-
lation which characterized the host of others who have sustained and
developed, the medical institutions of our country thus far, endeavor to
manage wisely the high trust they have left us. Let us neither be blinded
by reverence for the past, nor be fretful with impatience because clearly
perceived evils will not flee at our bidding, nor yet, with childish weak-
ness, call on the Hercules of government to do our work for us; but let
us with boldness yet persevering steadiness of purpose, carry forward our
educational organizations, both collegiate and social, enlarging their
foundations, improving their adjustments, and adding to their super-
structure; and we shall thereby most certainly enable those who come
after us in celebrating the next centennial anniversary of our national
progress, to review our work with the same pleasure and profit that we
derive to-day, in contemplating the works and characters of those whose
names are an honor to the century which has just passed.
286
ADDRESS ON THE MEDICAL STAFF OF THE UNITED STATES
ARMY AND ITS SCIENTIFIC WORK.
BY .
J. J. WOODWARD, M.D.,
SURGEON, UNITED STATES ARMY.
GENTLEMEN: The Centennial Medical Commission having requested
the Surgeon General of the Army to depute an officer of the Medical
Staff to occupy an evening during the session of the International Medi-
cal Congress by giving some account of the scientific work of the Medi-
cal Department of the Army, the Surgeon General has designated me as
the officer to undertake the task, and, in obedience to his commands, I
am here to-night to comply with the invitation of the Commission.
In the discharge of this duty, I wish first of all to explain, as briefly
as possible, how it happens that a certain class of scientific work, inti-
mately connected in its nature and results with the progress of practical
medicine and surgery, is undertaken by the Medical Bureau, and I hope
to make it clear to you that the kind of work to which I refer is of na-
tional importance, and that it can be better and more economically done
by the Medical Bureau of the Army than in any other way. I shall,
then, endeavor to lay before you in a sketchy way, for a single evening
will not suffice to go into any branch of my subject in detail, the charac-
ter of the work already done, and of that actually in progress, with some
hints as to matters which might profitably be undertaken in the future,
did the means placed at our disposal permit.
It is the duty of the Surgeon General to provide for the maintenance
of the health of the Army, as well as for the humane treatment of its sick
and wounded. The first duty is, if possible, more important and more
delicate than the second, and both are rendered much more difficult to
discharge efficiently than might be anticipated in view of the small num-
ber of men in our little army, by the comparatively great number of sepa-
rate military posts, and by the vast extent of the territory over which
they are scattered. . -
The total strength of the Army, officers and men, is, after all, less than
twenty-eight thousand, hardly the strength of an army corps of the army
of the great German Empire, but it is broken up into little detachments,
so that there are nearly two hundred permanent garrisoned posts, and
almost half as many more detached parties, of variable strength, requiring
medical care. I think it quite safe to affirm that the actual strength of
the army might be increased tenfold without materially increasing the
labor of its medical administration, provided the number of posts and
detachments remained the same as now.
These posts and detachments are scattered over all parts of our wide
territory. They are most numerous in the great interior wilderness,
remote from the comforts and facilities of more settled communities.
Many of them on the southern coast and the Mexican frontier are exposed
to frequent visits of epidemic yellow fever, the scourge of our southern
MEDICAL STAFF OF U. S. ARMY. 287
seaboard, which, as late as 1867, destroyed in a single season nearly one
per cent. of the whole strength of the army of that year. Moreover, the
troops stationed on the Indian frontier are most of the time exposed to
all the hardships and privations of a state of actual war. I know that a
great statesman has recently declared that Indian conflicts are not war,
and that it has been decided that gallantry in these bloody struggles
shall, no longer receive the poor reward of brevet rank ; but the bullet
wounds that are received are none the less dangerous because they are
inflicted by a savage foe, and the privations and hardships of campaigns
in the wilderness against a well-armed enemy who greatly out-numbers
our little force, have precisely the same tendency to produce disease and
death that the same conditions would exert could they exist in a war
against a civilized foe. In a recent disaster, which is only too fresh in
the memory of my hearers, about one per cent. of the whole strength of
the army, among them two medical officers,' perished in a single day.
Let us hope that such a catastrophe may never occur again; but similar
incidents, though the total loss in each case was less, have happened be-
fore, and almost every year since the close of the civil war has had its
share of victims fallen in obscure but bloody conflicts.
Now, it is self-evident that the officer charged with the medical and
surgical care of any army must keep himself informed as to its sanitary
condition ; as to the number and character of the cases of disease actually
occurring, and the circumstances under which they are developed ; as to
the number and character of the wounds, and the circumstances under
which they are sustained. This information would be indispensable to
the intelligent action of the Surgeon General of the Army, even were he
charged with no other duties than the assignment of the medical officers
and the purchase and distribution of the medical supplies required for
the treatment of the sick and wounded ; it is still more necessary if he is
expected to supervise the sanitary condition of the army with a view to
the suppression, as far as possible, of all preventable diseases. In the
army of every civilized nation in modern times, therefore, the medical
officers actually serving with troops are required to keep a record of the
cases of sickness and wounds under their care, and to report them at
stated intervals to a central bureau. It is, furthermore, self-evident, that
if these reports are at all numerous or voluminous, as they must be, either
if the army is large, or if it is scattered in numerous detachments, the
Surgeon General will be physically unable to perform the task of person-
ally examining them with any thoroughness, and must assign this duty
to others, distributing it among a sufficient number of competent assist-
ants, who must analyze the reports received, and bring to the attention
of the Surgeon General such facts and deductions as require his official
action. In other words, the Surgeon General of an army, to act effi-
ciently, requires a personal staff of medical officers who enjoy his confi-
dence, and who must be competent to analyze thoroughly the various re-
ports assigned to them, and, if necessary, to advise intelligently on any
matters as to which their opinions may be required by their chief.
In our own army, the system of reports established for the purposes
just indicated is briefly as follows:—
The medical officer of each post or station is required to keep a register
of the sick and wounded under his care, in which each patient is entered
Assistant Surgeon George E. Lord, United States Army, and Acting Assistant Sur-
geon James M. De Wolf.
288 WooDw AR D,
by name, with the date at which he is taken on sick report; the diagnosis
of his disease or injury, and the termination of the case, being subse-
quently entered in appropriate columns. From this register a monthly
report of sick and wóunded is prepared, and forwarded to the Surgeon
General from each post or station. It contains a statistical statement
of the number of cases of each kind of disease or injury under treatment
at the commencement of the month, the number taken on sick report
during the month, and the number of each recovered, died, discharged
the service, or otherwise disposed of, and the number remaining under
treatment at the close of the month. The report also includes a list of
the deaths and discharges from the service on surgeon’s certificate of
disability, giving in each case the name of the soldier and the cause of
death or discharge, and has a place reserved for any necessary explanatory
remarks.
These reports, consolidated and analyzed at the Surgeon General’s
Office, keep the Surgeon General constantly informed as to the health of
each individual post, of each military department, and of the whole army;
acquainting him with the actual amount of sickness, its nature, mortality,
and relationship to strength, with the number of wounds and injuries,
their character, mortality, and the localities at which they have occurred.
The deaths and discharges for disability are recorded in alphabetical
registers for convenient reference, and subsequently serve to give neces-
sary information to the accounting officers of the Government, and es-
pecially to the Commissioner of Pensions, in case discharged soldiers,
or the heirs of the deceased, make application for pensions or other
allowances due under the laws of the land. The medical officer of each
post or station is required, besides, to make special reports of interesting
cases, giving the full histories of such as appear to him of sufficient
importance, and in case of the outbreak of epidemic diseases, giving
monthly, besides the usual statistical report, a list of all the soldiers
attacked, with the date of attack and the date of recovery or death. In
such epidemic outbreaks the medical officer is required to investigate the
cause of the outbreak; to ascertain, if possible, the mode of introduction,
if the disease is introduced from without, and to record the circumstances
under which it has originated if it appears to have resulted from local
causes. These investigations serve as the basis of a special report, which
is required of the medical officer in charge of any post or detachment in
which an epidemic outbreak may occur.
As intimately connected with the question of the causes of disease,
the medical officer in charge of each post is required to keep a meteoro-
logical register, a transcript of which must be furnished to the Surgeon
General at the close of each month. Moreover, at the close of each year
the medical officer of each post is required to make to the Surgeon
General a general sanitary report on the health of the post, with remarks
on the diseases which may have prevailed, and suggestions, if any occur
to him, as to the improvements or changes which in his opinion may be
advantageously introduced, with the view of improving the health of the
garrison. g
Injuries, wounds, and surgical operations are made the subject of
separate special reports, giving the names of the soldiers, and the par-
ticulars of each case.
Medical officers examining recruits are obliged to record the name
and physical description of each recruit examined, and in the case of
ME DIC A. L S T A FF O F U. S. A. R. M. Y. 289
rejected recruits, the cause of rejection. A transcript of this record is
furnished to the Surgeon General at the close of each month.
Now, I think, it will be understood without argument, that such a
mass of reports as I have just indicated, embracing annually the observa-
tions and experience of several hundred well-educated medical men,
stationed at as many different places, must contain a great deal of
information which, besides its administrative value, must have no little
significance in connection with the interests of progress in scientific
medicine and surgery. I wish, on the one hand, to insist that all these
reports are indispensable from the mere administrative point of view.
Without them, and especially, I may add, without their intelligent
analysis, the Surgeon General of the Army, whatever his personal ability,
would be but a figure-head, powerless for any efficient interference in
behalf of the health of the army. On the other hand, I wish also to insist
On the fact, that by a very small additional expenditure of labor, clerical
force, and money, beyond what would be indispensable for the intelligent
administrative use of the facts collected, they can be made to subserve a
much wider purpose, and the usefulness of the work, which is indispensa-
ble to the army itself, for the sake of which primarily it is done, can
be vastly extended so as to benefit the medical profession at large, and,
through the medical profession, the sick and injured in every walk of life.
These considerations would afford a sufficient motive for much of the
scientific work that has been done by the Medical Bureau in the past,
and for much that is still in progress; but there are other circumstances
to be considered of equal, indeed, as I think, of even greater significance.
A few years ago our country was convulsed by a great civil war which
lasted for four long years. During this time about a million of men
were constantly under arms in defence of the national flag; about two
hundred thousand of them died of disease, about one hundred thousand
of wounds. The Confederate armies, though somewhat smaller, were
numerous enough to resist effectively till the very close of the struggle.
Their losses can hardly have been much less than those of the national
armies. After the close of the war the national armaments were dis-
banded ; the great general hospitals, several hundred of which were in
operation, were closed as rapidly as the patients under treatment could
be provided for, and it became necessary, for administrative reasons, to
order that as each was closed its books and records should be sent
to the Surgeon General’s Office in Washington. In that office there
had also accumulated during the war a vast quantity of reports of sick
and wounded, and other records which had been required for adminis-
trative purposes during the war. The records thus accumulated em-
braced over sixteen thousand folio volumes of manuscript record books,
and, I suppose, several tons of manuscript reports and papers. Urgent
administrative reasons demanded that these records should be examined,
classified for convenient reference, and, to a certain extent, that their
contents should be analyzed. The pension laws of the United States
are so framed that it became necessary, in almost every one of the hun-
dreds of thousands of applications for pensions, to apply to the Surgeon
General for the hospital history of the soldier concerned. Subsequently,
liberal laws were adopted granting artificial limbs and other prothetic
apparatus to those who had lost limbs or been otherwise mutilated, and
trusses to those who had been ruptured during the war. This bounty
was to be dispensed under the direction of the Surgeon General, and
again the records of his office came into requisition, both to protect the
19
290 WO O DWARD,
Government against fraudulent claims and to secure the rights of honest
applicants. For all these strictly administrative purposes a vast amount
of clerical work became necessary, and that this work might effect its
end, it was absolutely necessary that it should be directed at every step
by competent medical officers.
Now, it became evident from the very first, that by the expenditure of
a comparatively small amount of additional labor in the supervision of
this work, by a comparatively small increase of the clerical force, and
other expenditures absolutely required for mere administrative reasons,
results might be attained the publication of which would be beneficial
to mankind, and it seemed as though it would have been indeed a great
national crime to have lost this opportunity to utilize, in the service of
humanity, the experience which it had cost so much blood and so many
tears to acquire.
The work of analyzing these records for the double purpose just indi-
cated was entrusted to the very same medical officers who have charge
of the current work of the bureau to which I referred a little while ago.
Even if no intention of publication had been entertained, these officers
would have required for the efficient discharge of their duties, supposing
them to have been limited to mere administrative ends, the use of a good
consulting library ; and if they had simply preserved for subsequent
comparison the pathological specimens with which special medical and
surgical reports were frequently accompanied, and without which these
reports would often be only partially intelligible, an Army Medical
Museum would have gradually been built up, however slow the process
might have been.
At the time the war broke out nothing deserving the name of a Medi-
cal Library existed in Washington ; and the incipient medical libraries
in other cities, even at such great medical centres as Philadelphia, New
York, and Boston, were exceedingly deficient in the very class of books
which were most frequently needed for consultation. Indeed, these
medical libraries, built up by the voluntary contributions of a generous
profession which numbers but few wealthy men in its ranks, were defi-
cient in every direction, and, had the best of them been situated in
Washington, it would but imperfectly have satisfied the necessities of
the case. There was, therefore, no hope of supplying the want unless
the Surgeon General’s Office should be able to accumulate a library of
its own. In like manner, the correct interpretation of many of the patho-
logical specimens received implied the ability to compare them with
others, such as Ought to be found in a General Pathological Museum.
But no considerable pathological museum existed in America. Small
museums had indeed been created by the industry and liberality of the
professors of several of the medical schools in the great northern cities,
but these had been founded with special reference to the needs of the
elementary instruction of medical students, and contained no wealth of
accumulated material such as is often needed for purposes of comparison
in arriving at the intelligent interpretation of an individual case. Such
museums had been built up in the older civilized countries of Europe
for the most part by Government aid, and without Government aid it
was and still is impossible that any considerable collection of the sort
should ever grow up in America. It was evident, therefore, that if the
officers on duty in the Surgeon General’s Office were to enjoy the advan-
tages of consulting such a collection, it must be created by the office
itself. Now, here again, it was clear from the first that by a small addi-
M E DIC A. L S T A FF O F U. S. A. R. M. Y. 291
tional expenditure beyond what would have been necessary to create
such a library and museum as would be thoroughly efficient for the
merely practical purposes of the Medical Bureau, a National Medical
Library and a General Pathological Museum might be created, which
would meet a want long felt by every medical man in America who has
ventured into the domain of original research.
The considerations hitherto presented are, let me hope, sufficient to
make it plain that it was the bounden duty of the Surgeon General’s
Office to undertake that scientific work of which enough has already
been published to enable the medical profession throughout the world to
form a judgment as to its character, and as to the fitness of the medical
officers to whom it has been intrusted to accomplish the task which they
have undertaken. The medical criticism of the old world has already
proclaimed its verdict as to both points in an outspoken manner, and I
will not be deterred by any false modesty, on behalf of my colleagues or
myself, from making the statement that the verdict has been altogether
favorable. As for the medical profession of our own country, my fellow-
citizens—so many of whom I see around ºne to-day—how shall I find
words to express my feelings? Your generous sympathy and encourage-
ment have sustained us from the very first. Many of you served with us
during the war, and aided in accumulating those vast stores of experience
which we are now endeavoring to utilize. We were so fortunate as to
secure your co-operation at the beginning, and your support has never
failed us yet; I believe it never will, if we continue to deserve it. It is
largely owing to your influence that the National Legislature has been
induced to supply us with the funds, without which our work could not
have been carried on ; and however scanty these funds have appeared to
some of us, when compared with the sums devoted by other civilized
governments to similar purposes, we have never forgotten how liberal the
appropriations have been when compared with any ever made before by
our own National Government for any medical purpose. Not merely have
you constantly strengthened our hands, and supported us in our endeavors
to accomplish our work, but, ever since the close of the war, you have
labored with the National Legislature to secure for the officers of the medi-
cal staff a reasonable share of rank and pay, and these efforts were at last,
during the recent session of Congress, successful in securing legislation
which, if it did not do for us all you had hoped, at least placed us on a
better footing than we had ever hitherto enjoyed. It is, therefore, alto-
gether an appropriate thing that I should explain, as I am now doing in
your presence, the character of the work we are endeavoring to perform.
I have now to present to you, as briefly as possible, some details with
regard to the nature and extent of the scientific work of which I have
been speaking; but first, let me remark that the observations and reports
which form the basis of this work are due to the intelligence and industry
of the whole medical staff. This fact must never be lost sight of in esti-
mating the character and importance of the work. It represents no mere
individual observations and opinions, but the conjoined and systematic
labor of a considerable body of trained and trustworthy medical men.
The officers entrusted with the labor of digesting these observations, and
preparing them for the press, have constantly endeavored, in all their
publications, to give full credit to their brother officers at the various
military posts, whose original labors are the foundation of all the scien-
tific work that has been done, and of all that can be done at the Surgeon
General’s Office. I refer you confidently to any of our publications in
292 WOOD WAR D,
illustration of this statement. This work of the officers of the Medical
Staff deserves the appreciative recognition of all who are interested in the
progress of Medical Science. Not merely have they made with alacrity
the observations and reports required of them in the discharge of their
military duties, but their voluntary labors have been meritorious and
important. Those of you who practise medicine in cities, and enjoy all
the stimulus of converse with intelligent fellow-laborers and of competi-
tion for success, can hardly realize the difficulties under which most of
the work of these medical officers is done, at remote and usually isolated
stations, or amidst the hardships and perils of campaigns in the wilder-
ness against the Indians, with no special stimulus to investigation except
the love of Science and desire for usefulness.
Next, I have to remind you that the work of analyzing these observa-
ions, comparing them with each other and with similar observations
in other lands, preparing the results of these studies for publication, and
seeing them through the press, has been from the beginning to the
present time, with the exception of two or three publications, to which
I will refer specifically hereafter, performed by but three medical officers;
and it may be of interest to those who love to see economy in adminis-
tration above all other things, for me to state that these three officers
have received as remuneration for their labors during the last ten years
nothing more than the modest emoluments belonging to the rank of
Assistant Surgeons in the Army. One of them was, it is true, promoted
to the grade of Surgeon a few months ago, but this was simply the
accidental consequence of his place on the Army Register; the others
remain as before. The three officers to whom I refer are my colleagues,
Drs. Billings and Otis, and myself.
Now, it would not be just to these officers if I did not state that they
have never been, and are not now, free to devote their whole time to the
scientific work entrusted to their care—each is also charged with certain
administrative duties which demand a portion of his time and attention.
Thus, my colleague, Dr. Billings, besides the charge of the Library
and various special duties connected especially with the sanitary con-
dition of barracks and hospitals, has always had to do a good deal of
administrative work in connection especially with the purveying of med-
ical supplies and the accountability of medical officers for supplies issued
to them.
My colleague, Dr. Otis, besides his duties as Curator of the Army
Medical Museum, as the officer in charge of its Surgical, Anatomical,
and Miscellaneous sections, and as the officer entrusted with the prepa-
ration of the Surgical History of the Civil War, has had administrative
work to do in the way of furnishing information from the Surgical
records with regard to the numerous applications for artificial limbs and
prothetic apparatus, and other current work connected with the Division
of Surgical Records.
For myself, besides the charge of the Medical, Comparative Anatomy,
and Microscopical sections of the Museum, the Chemical Laboratory of
the Surgeon General’s Office, and the preparation of the Medical History
of the Civil War, I have had charge, since its organization, of the Record
and Pension Division of the Surgeon General’s Office, a purely adminis-
trative bureau, which for several years employed about one hundred
clerks, and which still has thrust upon it ample work to employ the same
number, although parsimony in legislation has reduced the force to less
than half, so that the work is rapidly falling behind hand. Some notion
ME DIC A. L S T A FF O F U. S. A R M. Y. 293
of the responsibility attaching to this bureau can be formed when I state
that, since 1865, the hospital histories of about three hundred thousand
deceased or disabled soldiers have been traced through the record books
and furnished to accounting officers of the Government, especially to the
Commissioner of Pensions, and the insufficiency of the clerical force
now authorized, will be appreciated, when I state that between twelve
and thirteen thousand such applications are lying unanswered on the
table of my chief clerk as I speak these words.
Now, you will readily understand that the administrative duties to
which I refer must not merely increase the responsibilities, but must
necessarily occupy a portion of the time of the officers concerned, with
the inevitable effect of diminishing the amount of scientific work which
it is possible for them to perform. Yet my experience in the office has
convinced me that it would not be wise to relieve these officers of this
administrative responsibility and throw it upon a different set of officers.
The same records are to be used both for administrative and scientific
purposes, and the double work can best be performed under the same
heads. The most economical, and at the same time the most efficient
means of diminishing the burdens of these officers, and of increasing
both the quantity and the value of the scientific work which it is possi-
ble for them to perform, would be to provide them with a really ade-
quate clerical force, and with a sufficient number of competent assistants.
I do not speak to-night in any complaining spirit, but it would be worse
than useless to pretend that adequate clerical and other assistance has
ever been supplied to us. This is a naked fact, which it is my duty to
make known, and which you must constantly bear in mind in appreci-
ating the amount of work which we have as yet published. That under
the circumstances we should have been able to do as much as we have—
that since the close of the war we should have been able to prepare for
publication the various works with which you are acquainted—the pub-
lications of the Surgeon General’s Office, edited by us and already issued,
constituting over six thousand quarto pages"—could only have been
achieved by tireless industry and a genuine devotion to our task.
Coming next to the details of this scientific work, I may remark that
a portion of the reports received at the Surgeon General’s Office which
are susceptible of scientific treatment, refer to the conditions under which
the soldier lives. Here belong the meteorological reports and a large
portion of the annual sanitary reports.
Prior to the civil war, the meteorological observations made by the
medical officers of the army were published from time to time by the
Surgeon General’s Office, the greater portion having been edited by the
lamented Coolidge. All students of the Climatology of the United
States are familiar with these works, which long furnished the only re-
liable information with regard to the climate of our western territories,
and, indeed, contain information with regard to many districts which is
still the only information printed.
During the civil war the fierce necessities of the struggle caused the
suspension of these observations, but they were resumed after its close,
and, at the present time, observations of the temperature three times a
day, the rain-fall, appearance of sky, and direction and force of the winds,
are recorded under the direction of the medical officer of every perma-
ment military post, and barometrical, and other special observations, at
* See Appendix.
29.4 WOOD WAR D,
selected posts. Since the Signal Service has been conducting its exten-
sive meteorological observations in the more settled portions of the
country, however, it has been thought by the Surgeon General that the
interests of science, as well as of economy, would be best subserved if
he should discontinue the publication of the meteorological observations
made by the medical officers of the army, and accordingly an arrange-
ment has been made by which the monthly means and other portions of
the meteorological reports needed for reference in the Surgeon General’s
Office are briefed in convenient books, and the original reports are then
turned over to the Signal Office, for use in conjunction with the observa-
tions made under the supervision of that bureau.
The annual sanitary reports received from the several military posts,
since the close of the war, have served as the basis for the preparation
by my colleague, Dr. Billings, of two bulky volumes, which contain de-
scriptions of the several military posts, their barracks and hospitals,
embracing a good deal of new information with regard to the medical
topography of many parts of our country, especially the western terri-
tories, and also containing abstracts, prepared under my own supervision,
of the sickness and mortality, and of the meteorological conditions, of
the various posts for several years.
Another portion of the reports contains information with regard to
the physical characteristics of the men who become soldiers; I refer to
the monthly reports of the officers entrusted with the physical examina-
tion of recruits. These reports contain the name, nativity, former occu-
pation, age, social condition, height, weight, chest measurement, com-
plexion, and color of eyes and hair of each recruit examined, and in the
case of rejected recruits, the nature of the disability on account of which
enlistment is refused. These reports, if subjected to scientific treatment
at stated intervals, say every five or ten years, would give valuable hints
as to the improvement, deterioration, or stability of the physical char-
acteristics of our population. I know that a very great number of these
recruits are of foreign birth, but, as this is carefully specified in each
case recorded, there would be no difficulty in the way of the separate
analysis of the facts with regard to the native born, and the total number
of observations which have accumulated since the war is large enough to
be of considerable importance. The two splendid volumes recently pub-
lished by Colonel J. H. Baxter, U. S. A., recently Chief Medical Officer
of the Provost Marshal General’s Bureau, and now Chief Medical Pur-
veyor of the Army, contain an analysis of a vast number of similar facts
observed by the examining surgeons in the course of the several drafts
made during the civil war. I am clearly of the opinion that the analysis
of the subsequent observations would possess sufficient scientific value to
warrant the comparatively small amount of labor and expense requisite
to do the work and publish it; but I regret to say that the office has not
yet been able to secure enough clerical aid to assign the necessary force
to this work, and nothing has as yet been done in this direction. I must
hope that it may be possible in the near future to undertake the analysis
of the reports received during the last ten years.
Still another portion of the reports received contains information with
regard to the diseases and injuries from which our soldiers suffer while
in actual service. Here belong the monthly reports of sick and wounded,
the special reports of cases, the reports relating to epidemic diseases, and
the various reports of wounds and surgical operations.
The monthly reports of sick and wounded are analyzed and consoli-
IM E DIC A. L S T A F F O F U. S. A. R. M. Y. 295
dated by districts as soon after their reception as possible, and constantly
furnish information as to the actual condition of the health of the army.
From the statistical tables produced by their consolidation the brief
statements made by the Surgeon General in his annual reports are pre-
pared. They have also furnished the data for the abstracts published in
the volumes prepared by Dr. Billings, mentioned a few moments ago.
With these exceptions, these valuable statistical tables remain unpub-
lished. I am decidedly of the opinion that they contain a great deal of
information much too useful to be lost. Indeed, I think, if the Surgeon
General’s Office could obtain the necessary force of clerks and assistants
to make an annual publication of these reports, accompanied by the
accounts of interesting medical and surgical cases received during each
year, it would be an important contribution to medical science; but with
the means at our disposal, and the other demands made upon us, this
has been hitherto quite out of our power. The special reports upon
epidemics have, however, been utilized to some extent in the publication
of two works prepared by myself, on the Epidemic Cholera and Yellow
Fever in the Army during the years 1866 and 1867, and my colleague,
Dr. Otis, has prepared a large volume, published in 1871, containing a
report of 732 surgical cases treated in the Army from the close of the
war to the date of publication. Thus the material in question has at
least been partially utilized, but I think that the portion which as yet
remains unpublished fully equals in value, and certainly exceeds in
quantity, that which has thus far been printed. In connection with the
subject of epidemic diseases, just alluded to, I Ought also here to men-
tion the investigation of the Epidemic Cholera which in 1873 afflicted
the civil population of the United States. By an act of Congress the
Surgeon General was directed to detail a medical officer of the army for
this investigation, and Assistant Surgeon (now Surgeon) Ely McClellan,
U. S. Army, was designated for this purpose. This officer made an
elaborate report, which was published as a Congressional document.
With it was printed a bibliography of cholera, prepared at the Surgeon
General’s Office by Dr. Billings, which is, I believe, the most complete
list of the works on this subject that has yet appeared.
Perhaps it would be most convenient, in this connection, to say a few
words with regard to the Chemical Laboratory of the Surgeon General’s
Office. The creation of this Laboratory was one of the necessities of the
civil war. In mense purchases of medical supplies were being made, and
it very frequently happened that efforts of the most ingenious kind were
employed to defraud the Government. Moreover, among the great num-
ber of medical officers in service, there were many who were inexperi-
enced, and some who were ignorant, and complaints were often made as
to the quality of the medical supplies issued which were not justified by
the facts. Under these circumstances it was constantly necessary that
the Surgeon General should have the opinion of a chemical expert on
whose advice he could rely, and it was this that led to the organization
of the Chemical Laboratory. Soon other bureaus, especially the Subsis-
tence department, began to apply to the Surgeon General for advice in
the matter of supplies purchased or about to be purchased, and it is safe
to affirm that the Laboratory of the Surgeon General's Office was the
means of saving hundreds of thousands of dollars to the Government.
The Laboratory was established on the most economical basis, its person-
nel never having exceeded two individuals, a chemist and an assistant,
both employed as acting assistant surgeons. Their time has been almost
296 WooD WAR D,
exclusively occupied in the examination of supplies about to be pur-
chased for the army, or of supplies already purchased, with regard to
which complaints had been made. If this Laboratory could be more
liberally provided for, it might have a much wider field of usefulness.
Scientific questions of a chemical character constantly arise in connection
with the medical service of the Army, which might then profitably be
investigated.
I have next to present a few remarks with regard to the Medical and
Surgical History of the late Civil War. The project of such a work was
conceived early during the struggle, suggested, no doubt, by the volumes
published by the British Government on the Medical and Surgical IIis-
tory of the War in the Crimea. As early as June 9, 1862, the intention
to prepare such a work was announced to the Medical Staff by a circular
from the Surgeon General’s Office, and all medical officers were requested
to co-operate in the undertaking by collecting details of cases, and other
material for the work. The supervision of the work of collecting surgi-
cal material was assigned, by the same circular, to Dr. J. H. Brinton, at
that time Surgeon U. S. Volunteers; that of collecting medical material
was assigned to me. Dr. Brinton was relieved from this duty in Octo-
ber, 1864, and his place supplied by my present colleague, Assistant Sur-
geon Otis, U. S. Army, then Surgeon U. S. Volunteers, who, for the three
years previous, had served continuously in the field as Surgeon of the
27th Mass. Regiment of Infantry. Both my colleagues and myself did
our best to collect material for the work in view, and our efforts were
constantly sustained and encouraged by the Surgeon General.
In November, 1865, the Surgeon General issued a document, now well
known as Circular No. 6, which was accompanied by two somewhat de-
tailed reports, prepared by Dr. Otis and myself, “On the extent and
nature of the materials available for the preparation of a Medical and
Surgical History of the Rebellion.” The object of this circular was to
acquaint the medical profession with the character of the materials col-
lected, and to secure, if possible, favorable public opinion in behalf of
the legislation necessary to provide means for preparing the work and
completing its publication. This merely preliminary document was
widely circulated, and effected the end for which it was designed, Con-
gress, in July, 1866, making an appropriation for the preparation of
plates and illustrations for “A first part of the Medical and Surgical His-
tory of the Rebellion;” but it was not until March 3, 1869, that Congress
at length authorized the actual printing of five thousand copies of the
first part of the work. -
Meanwhile, anxious that the information collected on some of the more
important surgical points should be made public, the Surgeon General
published, in 1867 and 1869, two important monographs prepared by Dr.
Otis; the first on Amputations at the IHip-joint, the second on Excisions
of the head of the Femur for shot injury.
The labor of preparing the first part of the Medical and Surgical
History for publication had now so far advanced that it went to press
soon after the necessary authority was obtained, and in December, 1872,
the first part of the Medical and Surgical History was issued from the
Government Printing Office. This part consisted of a medical volume,
a surgical volume, and an appendix, the whole occupying 1800 pages
quarto. The Medical volume, edited by myself, was devoted to the
medical statistics of the war. Some necessary explanatory remarks were
offered in the introduction to this volume, but detailed comments on the
M E DIC A. L S T A F F O F U. S. A. R. M. Y. 297
statistics were reserved for the second part of the work. The appendix
consisted of the reports of the Medical Directors of armies and depart-
ments, and of other medical officers, which were believed to be of histori-
cal value. The Surgical volume, edited by Dr. Otis, contained a chrono-
logical summary of losses in battles and engagements, and a detailed
discussion of the statistics and reports relating to special wounds and
injuries of the head, face, neck, spine, and chest.
It was not until June, 1872, that legislation was obtained for continu-
ing the publication of the work. Congress then passed an act for its com-
pletion and publication, in two parts, of eighteen hundred pages each, in
addition to the parts already published.
In accordance with this legislation the publication of the second part
of the work was commenced, and the Surgical volume of my colleague,
treating of special wounds and injuries of the abdomen, the pelvis, the
back, and the upper extremities, has, as you know, been brought success-
fully to its completion, and was issued from the Government Printing
Office during the present summer. This volume contains 1024 pages
quarto. I had hoped that its companion Medical volume, which will
embrace a discussion of the symptoms, pathology, and treatment of those
diseases which were the chief causes of the sickness and mortality among
our soldiers during the war, would have appeared simultaneously. In
this hope I was doomed to disappointment. In the winter of 1873 and
1874 my health unexpectedly gave way, and for several months I was
incapacitated for any literary work. For a long time subsequently, I
was obliged in accordance with the counsel of my medical advisers, to
limit my hours of labor to a minimum, so that, with all my other duties,
I made during the two years which followed my first illness but little
progress on the Medical History. I am thankful to say, however, that
my health appears at length fully restored, and I trust, when my labors
in connection with the Centennial come to a close, that I will be able to
resume the printing of the volume and to bring it to a conclusion in a
reasonable time.
The third part of the History is expected to consist, like the others, of
two volumes. The Surgical volume will treat of the wounds and injuries
of the lower extremities; of luxations and fractures from other causes
than gunshot; of burns, scalds, and frost-bites; of generalities on gunshot
wounds, amputations, etc.; of the use of anaesthetics; of the materia chi-
rurgica, and of the transportation of the wounded. The Medical volume
will treat of the hospital system inaugurated during the war, the system
of medical supplies, and other kindred matters.
I3efore passing to another topic, I desire to say a word with regard to
the work of my colleague, Dr. Otis, on the Surgical History. How pains-
taking and accurate it has been, how laboriously he has collected the
former experience of other lands to throw light on our own, and to aid
in its interpretation, is well known to all of you who have looked into
his volumes. But I wish to remind you, in connection with the state-
ments I have made, as to the time required for the preparation of this
work, of the extent of the data to be handled as compared with those of
any former war. The previous surgical histories of wars, published under
government auspices, were that prepared by Dr. T. P. Matthew, on the
Surgery of the English Army in the Crimean War, and those of M.
Chenu on the Surgery of the French Army in the Crimea, and during
the Italian War. Dr. Matthew had to deal with 12,166 surgical cases;
Chenu with 40,586 for the Crimean, and 19,590 for the Italian war.
298 WOOD WAR D,
The reporter for the American war had to deal with the reports of over
270,000 cases of wounds. Moreover, my colleague undertook a task
comparatively new in military surgery, which certainly appears to me of
the greatest importance. In the T3ritish and French reports, when a
wounded man was invalided or pensioned his history was terminated.
T)r. Otis attempted to trace all the more important cases down to the
date of publication, and this the organization of the Pension Bureau
enabled him to do successfully in the majority of instances. At the time
this plan was determined upon, it was believed to be altogether new. It
is now known, however, that Professor Hannover, of Copenhagen, had
conceived a similar plan, and applied it in the case of the invalids of the
war of 1864.
Similar investigations have since been made by Loeffler, Mossakowsky,
and Berthold, though in connection with a much smaller number of cases
than occupied my colleague.
I cannot dwell longer to-night on the Medical and Surgical IIistory
of the War of the Rebellion. I pass to a few remarks concerning the
Library of the Surgeon General’s Office. I have already indicated the
reasons for the commencement of this Library. The first appropriation
of money for the purpose was made by Congress not long after the close
of the war. For two or three years ten thousand dollars, subsequently,
however, only five thousand, were appropriated annually. This has been
expended with great economy and discretion, under the supervision of
my colleague, Dr. Billings. A great many books have also been acquired
by exchange, or have been presented to the library. As a result, this
library now contains about 40,500 bound volumes and 41,000 pamphlets.
Although, for obvious reasons, under the charge of the Surgeon General,
this library is essentially the Medical Section of the Library of Congress.
For several years the Librarian of Congress has not purchased medical
books, leaving that branch of the subject to the Surgeon General’s Office.
In 1874, the Government Printing Office issued a small edition of a
Catalogue of Authors, prepared by Dr. Billings, which formed three
quarto volumes of about 2000 pages, similar in style to the Catalogue
of the Congressional Library. This Catalogue is in the possession of
every public medical library in the country, and is very useful, as far as
it goes, to students who desire to avail themselves of the resources of
the library in connection with medical researches of any kind. The
library itself is thrown open to all medical men who choose to use it.
Although far from complete, this library is now one of the great medi-
cal libraries of the world ; and right here I wish to say, that even double
the money expended upon it would not have made it as valuable as it
now is but for the generous assistance of the profession of this country.
Many of our physicians have ransacked their own libraries to supply us
with works which, in many instances, we could not otherwise have ob-
tained, especially the older American books and journals. The extent to
which this has been done is the best proof of the general desire of the
medical profession of the United States that this library should speedily
become a complete library of reference on medical subjects.
I know that a few individuals have objected that Washington is not
the best place for a great medical library, and seem to think it a pity that
it cannot be established in Philadelphia or New York, where the number
of physicians is so much larger; but the usefulness of such a library is
not to be measured by the number of casual readers, but by the number
of original investigators who consult it in connection with their own work.
MEDICAL STAFF OF U. S. ARMY. 299
It is only through the work of these men that a great library becomes
generally useful to the whole profession. These original investigators
are comparatively few in any city, but almost every city has some of
them. Wherever the National Medical Tibrary might be, the majority
of the medical investigators of the country would have to travel to con-
sult it. Until very lately, such men had to travel to Europe for the
same purpose. It is important that this should no longer be necessary.
It is important that there should be in at least one place in our country
a complete medical library, and this we will make at the Surgeon Gene-
ral’s Office, if we can get the means. There is no probability that such a
library will ever be built up in the United States except by Government
aid. This is also what has happened in all other countries. If we could
secure for the purposes of the library exclusively an annual appropriation
of ten thousand dollars, we could in a very few years make this library
the most complete in the world.
One point further I desire to mention. To give the library already
collected the highest degree of usefulness, a subject catalogue is now im-
peratively demanded. Dr. Billings has undertaken such a work. With
dauntless industry he has not merely arranged the cards representing the
separate treatises in the library according to their subjects, but he has
undertaken to make separate cards for all the original essays contained
in all the medical periodicals in the library. About 275,000 such cards
have already been prepared. IIe now desires to obtain the authority to
have the Government Printing Office publish a Subject Catalogue pre-
pared from these cards. A specimen fasciculus of this catalogue has
already been issued, and most of you who are specially interested in med-
ical bibliography have already seen it. Dr. Billings estimates that the
catalogue, if completed on the plan of this fasciculus, would make about
five volumes of a thousand pages each. IIe is abundantly willing to un-
dertake the labor if Congress can be induced to authorize the printing of
the work. An appeal will be made to Congress on this subject at its
next session, and if the medical profession of the country agree with me,
that the publication of such a catalogue would be a work useful to every
medical investigator in the land, I feel sure that by an expression of their
views they can secure the success of the undertaking.
Lastly, I have to say a few words with regard to the Army Medical
Museum. I have already indicated the circumstances under which it
originated. It has now acquired very considerable extent, containing
very nearly 19,000 specimens. The specimens collected during the civil
war were almost all illustrations of military surgery and of camp dis-
eases. But, since the war, it has begun to acquire a broader Scope, and
we now aim to make it a National Medical Museum. The collection now
embraces, besides the Medical and Surgical sections, a Microscopical sec-
tion, sections of Human and Comparative Anatomy, and a Miscellaneous
section.
The section of Comparative Anatomy is yet in its infancy, and almost
all the specimens have been collected by medical officers of the army, so
that it has cost altogether but a few hundred dollars. There are about
1500 skeletons and crania, almost all of American vertebrates, in this
section. A check list of them, prepared by Dr. H. C. Yarrow, has recently
been published in pamphlet form. Those interested in this special sub-
ject can obtain copies of it at the Hospital of the Medical Department
of the Army at the Centennial grounds.
The section of Human Anatomy is chiefly remarkable for its collection
300 WOOD WAR D,
of human crania, which now number about 1600. These chiefly repre-
sent the native American races, including the prehistoric mound-builders,
and the various modern tribes, from the Esquimaux at the North to the
Patagonians at the southern extremity of South America. The careful
measurement of these crania, under the Supervision of Dr. Otis, consti-
tutes a genuine addition to the science of ethnology. An abstract of
these measurements has been prepared by him, and recently published
in pamphlet form. Ethnologists can obtain copies at our hospital on
the Centennial grounds, or of the Surgeon General.
Catalogues of the Medical, Surgical, and Microscopical sections were
published in 1867. That of the Surgical section was prepared by As-
sistant Surgeon A. A. Woodhull; that of the Medical section by myself;
and that of the Microscopical section by Assistant Surgeon E. Curtis.
Since these catalogues were published the collections have doubled in
size. The publication of a catalogue of the additional specimens, or a
revised catalogue of the whole, would be a useful work.
It gives me pleasure to state that the interest taken in this collection
by the medical profession of the country is being annually more and
more frequently displayed by the presentation of valuable medical and
surgical specimens from all parts of the country. Such specimens are
always acceptable, and especially, I may remark, that those which have
served as the basis of original communications published in the medical
journals have especial interest. You can all appreciate how useful it
would be; how many misunderstandings would have been prevented if
the actual specimens which have served for certain pathological descrip-
tions could have been somewhere preserved and accessible to the criti-
cism of subsequent investigation. Dut no medical museum that is not
national in its character will ever serve as the central point for such a
collection.
The actual appropriations of money for our Museum have never ex-
ceeded five thousand dollars a year. The sum is not a liberal one, and
much more could be advantageously expended if it could be obtained.
The Centennial Medical Commission, in giving the invitation to which
I have responded to-night, expressed the wish that I would endeavor to
represent to your eyes in some way the character of some portion of our
collection. In compliance with their request, I have naturally selected
my illustrations from the Medical and Microscopical sections, which are
under my own immediate direction. I have made use of photography
for the purpose, and Mr. Edgerton, of J. W. Queen & Co., 924 Chestnut
street, has kindly undertaken to exhibit the pictures on the screen. First,
I exhibit a series of photographs, novel, I think, in character, represent-
ing certain pathological conditions of the intestinal canal.
[Twenty-five lantern slides, representing pathological alterations of the intestinal mu-
cous membrane, were here exhibited, and briefly commented on.]
My other illustrations are taken from the Microscopical section. This
section was originally established for the purpose of preserving the speci-
mens acquired in the study of the pathological anatomy of some of the
diseases of soldiers. Sections of morbid growths, and other specimens
sent to the Surgeon General’s Office by the medical officers of the Army
for an opinion as to their nature, have been added, with a certain number
of other specimens, especially in the direction of normal and pathological
histology. The collection now contains about 7000 permanently mounted
microscopical slides. A single assistant, paid as a clerk of the first class,
ME I) IC A. L S T A FF O F U. S. A. R. M. Y. 301
constitutes, under my direction, the whole personnel available for the
work.
The process by which the photographs I am about to exhibit were pre-
pared, was, as most of you are aware, brought to its present state of per-
fection by my own original investigations. A complete misconception
exists in certain quarters as to the time I am able to devote to work of
this class. It has been simply my amusement—my relaxation from the
daily routine and toil of the other labors which I have outlined to you
to-night. For years all the work of this kind I have been able to accom-
plish has been done on Sundays and holidays.
A part of this work was undertaken for the sake of the Medical His-
tory of the War.
[Twelve photo-micrographs were here shown, exhibiting perpendicular sections of dis-
eased intestines, the magnifying power with which the slides were taken ranging from 50
to 200 diameters. This was multiplied by 50 by the lantern projection.]
Another portion represents incidental histological work.
[Here fifteen micro-photographs were shown, including nine of blood-corpuscles, to demon-
strate the impossibility of discriminating between the blood of man and certain other
mammals. These slides were taken with 150 to 1000 diameters.]
Still another portion represents work undertaken in connection with
the investigation of attempts to defraud the Government.
[Here fourteen slides, each magnified 150 diameters, were exhibited, illustrating an inves.
tigation into the so-called “ calf-hair goods,” undertaken at the request of the Honorable
Secretary of the Treasury.]
In connection with these investigations, the question of the scientific
certainty of microscopical appearances has constantly been thrust upon
me, and I have been forced to the conclusion that not unfrequently,
especially when high powers are used, the false appearances resulting
from diffraction and interference have been mistaken for real structure.
This would be a melancholy conclusion, were I unable to point out how
such misinterpretations may be avoided. It is impossible to do this in
detail on such an occasion as this, but I will show you a few pictures in
illustration of my meaning."
[The address was concluded by the exhibition of a series of slides representing the real
and spurious appearances of certain diatoms often employed by microscopists as test objects,
the slides being magnified from 500 to 2500 diameters, and this increased by the lantern
fifty times.]
APPENDIX.
PUBLICATIONS OF THE SURGEON GENERAL's OFFICE.
[1863–1876.]
Circular No. 9. War Department, Surgeon General's Office, July 1, 1863.
Consolidated Statement of Gunshot Wounds. By Surgeon J. H. Brinton, U. S.
Volunteers, 11 pp. 8vo.
Circular No. 15. War Department, Surgeon General's Office, Washington,
September 8, 1863. Sickness and Mortality of the Army during the first year
of the War. By J. J. Woodward, Assistant Surgeon, U. S. Army, pp. 8, 8vo.,
with 6 diagrams.
! [The descriptions of the several slides would require for their clear understanding the
reproduction of the pictures referred to, and are therefore, at the request of the author,
omitted.—EDITOR.]
302 WooD WARD,
Circular No. 6. War Department, Surgeon General's Office, Washington,
March 10, 1864. Reflex Paralysis. By Acting Assistant Surgeons S. Weir
Mitchell, George R. Morehouse, and W. W. Keen, Jr., pp. 17, 16mo.
Circular No. 1. War Department, Surgeon General's Office, Washington,
June 10, 1868. Report on Epidemic Cholera and Yellow Fever in the Army
of the United States during the Year 1867. By Brevet Lieutenant Colonel J.
J. Woodward, Assistant Surgeon, U. S. Army, pp. 156, 4to.
Circular No. 2. War Department, Surgeon General’s Office, Washington,
January 2, 1869. A Report on Excisions of the Head of the Femur for Gun-
shot Injury. By Brevet Lieutenant Colonel G. A. Otis, Assistant Surgeon,
U. S. Army, pp. 141, 4to.
Circular No. 3. War Department, Surgeon General's Office, Washington,
August 17, 1871. A Report on Surgical Cases treated in the Army of the
United States from 1865 to 1871. By Brevet Lieutenant Colonel G. A. Otis,
Assistant Surgeon, U. S. Army, pp. 296, 4to.
Circular No. 4. War Department, Surgeon General’s Office, Washington,
December 5, 1870. Report on Barracks and Hospitals, with Descriptions of
Military Posts. By Brevet Lieutenant Colonel J. S. Billings, Assistant Sur-
geon, U. S. Army, pp. 494, 4to.
Circular No. 5. War Department, Surgeon General’s Office, Washington,
May 4, 1867. Report on Epidemic Cholera in the Army of the United States
during the Year 1866. By Brevet Lieutenant Colonel J. J. Woodward, Assist-
ant Surgeon, U. S. Army, pp. xviii., 65, 4to.
Circular No. 6. War Department, Surgeon General’s Office, Washington,
November 1, 1865. Reports on the Extent and Nature of the Materials avail-
able for the preparation of a Medical and Surgical History of the Rebellion.
Medical Report by Brevet Major J. J. Woodward, Assistant Surgeon, U. S.
Army; Surgical Report by Brevet Lieutenant Colonel G. A. Otis, Surgeon,
TJ. S. Volunteers, pp. 166, 4to.
Circular No. 7. War Department, Surgeon General’s Office, Washington,
July 1, 1867. A Report on Amputations at the Hip-joint in Military Surgery.
By Brevet Lieutenant Colonel G. A. Otis, Assistant Surgeon, U. S. Army, pp.
87, 4to.
Circular No. 8. War Department, Surgeon General's Office, Washington,
May 1, 1875. A Report on the Hygiene of the United States Army, with de-
scriptions of Military Posts. By Brevet Lieutenant Colonel J. S. Billings,
Assistant Surgeon, U. S. Army, pp. lix., 567, 4to.
Catalogue of the Surgical Section of the United States Army Medical
Museum. Prepared, under the direction of the Surgeon General, by Brevet
Major A. A. Woodhull, Assistant Surgeon, U. S. Army. Washington: Gov-
ernment Printing Office, 1866, pp. 664, 4to.
Catalogue of the Medical Section of the United States Army Medical
Museum. Prepared, under the direction of the Surgeon General, by Brevet
Lieutenant Colonel J. J. Woodward, Assistant Surgeon, U. S. Army. Wash-
ington: Government Printing Office, 1867, pp. 136, 4to.
Catalogue of the Microscopical Section of the United States Army Medical
Museum. Prepared, under the direction of the Surgeon General, by Brevet
Major E. Curtis, Assistant Surgeon, U. S. Army, Washington: Government
Printing Office, 1867, pp. 161, 4to.
[For Catalogues of the section of Human and Comparative Anatomy, see
Centennial pamphlets infra.]
Catalogue of the Library of the Surgeon General’s Office. By Brevet Lieu-
tenant Colonel J. S. Billings, Assistant Surgeon, U. S. Army. Washington :
Government Printing Office, 1872, pp. 454, 4to.
Catalogue of the Library of the Surgeon General’s Office. By Brevet
Lieutenant Colonel J. S. Billings, Assistant Surgeon, U. S. Army. Vol. 1,
A—L, pp. 1193, 4to. Vol. 2, M-Z, pp. 956, 4to. Supplement, pp. 31.9, 4to.
Washington: Government Printing Office, 1873–4.
M E DIC A. L S T A FF O F U. S. A R M. Y. 303
Specimen Fasciculus of a Catalogue of the National Medical Library under
the direction of the Surgeon General of the U. S. Army, at Washington, D. C.
By Brevet Lieutenant Colonel J. S. Billings, Assistant Surgeon, U. S. Army.
Washington: Government Printing Office, 1876, pp. 72, 4to.
A Medical Report upon the Uniform and Clothing of the Soldiers of the
United States Army. By Brevet Major A. A. Woodhull, Assistant Surgeon,
U. S. Army. Washington : Surgeon General's Office, 1868, pp. 26, 8vo.
Report on the Pathological Anatomy and Histology of the Respiratory
Organs in the Pleuro-pneumonia of Cattle, with 6 lithographs from photo-
micrographs. Washington, June 15, 1870. By Brevet Lieutenant Colonel J. J.
Woodward, Assistant Surgeon, U. S. Army, pp. 9, 4to. In the Report of the
Commissioner of Agriculture on the Diseases of Cattle in the United States.
Government Printing Office, 1871. e
Report of Results of Examinations of Fluids of Diseased Cattle, with reference
to the presence of Cryptogamic Growths. By Brevet Lieutenant Colonel J. S.
Billings, Assistant Surgeon, U. S. Army, and Brevet Major E. Curtis, Assistant
Surgeon, U. S. Army, pp. 12, 4to. In the Report of the Commissioner of Agri-
culture on the Diseases of Cattle in the United States. Government Printing
Office, 1871.
Photographs of Surgical Cases and Specimens, taken at the Army Medical
Museum, with histories, of 296 cases. By Brevet Lieutenant Colonel G. A.
Otis, Assistant Surgeon, U. S. Army. Washington, 1866–71. 6 vols., 4to.
Reports accompanied by Photographs of Microscopic Objects. By Brevet
Lieutenant Colonel J. J. Woodward, Assistant Surgeon, U. S. Army, viz.:
Report on the Magnesium and Calcium Lights as applied to Photo-Micro-
graphy. 6 pp., 4to., l l photographs. Surgeon General’s Office, 1870.
Report on the Oxy-calcium Light as applied to Photo-Micrography. 3 pp.,
4to., 2 photographs. Surgeon General’s Office, 1870.
Report on an Improved Method of Photographing Histological Preparations
by Sunlight. 10 pp., 4to., 11 photographs. Surgeon General's Office, 1871.
Report on the Histology of Minute Blood vessels. 8 pp., 4to., 11 photo-
graphs. Surgeon General's Office, 1870.
Report on the Minute Anatomy of Two Cases of Cancer. 10 pp., 4to., 2
photo-lithographs. Surgeon General’s Office, 1872.
Memorandum on Pleurosigma Angulatum and Pleurosigma Formosum. 4
pp., 4to., 8 photographs, Surgeon General's Office, 1871.
Memorandum on Surirella Gemma. 1 p., 4to., 2 photographs. Surgeon
General's Office, 1871.
Memorandum on the Test Podura. 3 pp., 4to., 5 photographs. Surgeon
General’s Office, 1871.
Memorandum on Amphipleura Pellucida. 1 p., 4to., 2 photographs. Sur-
geon General’s Office, 1871.
Memorandum on the Nineteen-band Test Plate of Nobert. 4 pp., 4to., 9 pho-
tographs. Surgeon General's Office, 1872.
Four Letters to the Surgeon General, accompanying Photographs of the
Mosquito, certain Parasites, the Proboscides of certain Flies, and miscellaneous
photographs of Insects and parts of Insects. 8 pp., 4to., 35 photographs. Sur-
geon General’s Office, 1872.
The Medical Department of the United States Army from 1775 to 1873. By
Brevet Major H. E. Brown, Assistant Surgeon, U. S. Army. Washington :
Surgeon General’s Office, 1873.
The Medical and Surgical History of the War of the Rebellion, 1861–65.
Prepared under the direction of the Surgeon General. Part I., Vol. I., Medi-
cal History, by Brevet Lieutenant Colonel J. J. Woodward, Assistant Surgeon,
U. S. Army, pp. xliii., 726; Vol. II., Surgical History, by Brevet Lieutenant
Colonel G. A. Otis, Assistant Surgeon, U. S. Army. pp. clv., 650. Appendix,
containing Reports of Medical Directors, etc., pp. 365. Washington : Govern-
ment Printing Office, 1870. [Actually issued in December, 1872.] Part II.,
304 Woo DWARD, MEDICAL STAFF O F U. S. ARMY.
Vol. II., Surgical History, by Brevet Lieutenant Colonel G. A. Otis, Assistant
Surgeon, U. S. Army, pp. 1024. Washington : Government Printing Office,
1876.
A Report on a Plan for Transporting Wounded Soldiers by Railway, etc.
By Brevet Lieutenant Colonel G. A. Otis, Assistant Surgeon, U. S. Army.
Surgeon General Office, 1875, 56 pp. 8vo.
Pamphlets issued in connection with the exhibit in the Hospital of the Medi-
cal Department, U. S. Army, International Exhibition of 1876, viz.:
No. 1. List of Skeletons and Crania in the Section of Comparative Anatomy
of the U. S. Army Medical Museum, for use during the International Exhi-
bition of 1876. By Dr. H. C. Yarrow. Washington, 1876, pp. 52, 8vo.
No. 2. Description of the Models of Hospital Cars. By Brevet Lieutenant
Colonel J. J. Woodward, Assistant Surgeon, U. S. Army, 10 pp., 8vo.
No. 3. Description of the Models of Hospitals. By Brevet Lieutenant Colo-
nel J. J. Woodward, Assistant Surgeon, U. S. Army, 22 pp., 8vo.
No. 4. Description of the Models of Hospital Steam-Wessels. By Brevet
Lieutenant Colonel J. J. Woodward, Assistant Surgeon, U.S. Army, 12 pp., 8vo.
No. 5. Description of Perot & Co.'s Improved Medicine Wagon. By the
manufacturer, 16 pp., 8vo.
No. 6. Description of the U. S. Army Medicine Transport Cart, Model of
1876. By Brevet Lieutenant Colonels D. L. Huntington and G. A. Otis, As-
sistant Surgeons, U. S. Army, 16 pp., 8vo.
No. 7. Description of Selected Specimens from the Surgical Section of the
Army Medical Museum. By Brevet Lieutenant Colonel G. A. Otis, Assistant
Surgeon, U. S. Army, 22 pp., 8vo.
No. 8. Check List of Preparations and Objects in the Section of Human
Anatomy of the U.S Army Medical Museum, for use during the International
Exhibition of 1876. By Brevet Lieutenant Colonel G. A. Otis, Assistant Sur-
geon, U. S. Army, Washington, 1876, pp. 135, 8vo.
No. 9. List of Selected Microscopical Preparations from the Army Medical
Museum. By Brevet Lieutenant Colonel J. J. Woodward, Assistant Surgeon,
U. S. Army, 7 pp, 8vo. *
No. 10. Description of Selected Specimens from the Medical Section of the
Army Medical Museum. By Brevet Lieutenant Colonel J. J. Woodward, As-
sistant Surgeon, U. S. Army, 21 pp., 8vo.
No. 11. Typho-Malarial Fever: Is it a Special Type of Fever? Being re-
marks introductory to the discussion of the question in the Section of Medi-
cine, International Medical Congress. By Brevet Lieutenant Colonel J. J.
Woodward, Assistant Surgeon, U. S. Army, 44 pp., 8vo.
OTHER OFFICIAL PUBLICATIONS OF THE MEDICAL STAFF.
Teport on Quarantime on the Southern and Gulf Coasts. By Brevet Major H.
E. Brown, Assistant Surgeon, U. S. Army. Washington: Government Print-
ing Office, 1873, 42d Congress, 3d Session, Senate, Executive Document No. 9.
Cholera Epidemic of 1873 in the United States. Reports prepared under
the direction of the Surgeon General of the Army. A. History of the Cholera
Epidemic of 1873 in the United States. By Brevet Major E. McClellan,
Assistant Surgeon, U. S. Army, 513 pp., 8vo. B. History of the Travels of
Asiatic Cholera. By John C. Peters, M.D., of New York, and Brevet Major E.
McClellan, Assistant Surgeon, U. S. Army, 192 pp., 8vo. C. Bibliography of
Cholera. By Brevet Lieutenant Colonel J. S. Billings, Assistant Surgeon, U.
S. Army, 320 pp., 8vo. Washington : Government Printing Office, 1875, 43d
Congress, 2d Session, House of Representatives, Executive Document, No. 95.
Statistics, Medical and Anthropological, of the Provost Marshal General’s
Bureau, etc. By Colonel J. H. Baxter, Chief Medical Purveyor, U. S. Army,
Washington: Government Printing Office, 1875, Vol. I., pp. lxii., 568; Vol. II.,
pp. xxviii., 767.
305
SECTION ON MEDICINE.
P R E S I D E N T OF T H E S E C T I O N .
ALFRED STILLE, M.D., LL.D.,
OF PHIL AD EL PHIA.
W I C E - P R E S I D E N T S .
R. P. HOWARD, M.D., J. J. WOODWARD, M.D.,
O F M O N T R E A L. U. S. A R MY.
S E C R. E. T. A. R. Y .
J. EWING MEARS, M.D.,
O F PHIL AD EL PHIA.
TYPHO-MALARIAL FEVER: IS IT A SPECIAL TYPE OF
FEWER 2 •
BY
J. J. WOODWARD, M.D.,
SURGEON, UNITED STATES ARMY.
SINCE the earliest times Pestilence has followed in the footsteps of
War. It has been the consequence of Ignorance as much as of Necessity.
Its causes are to be sought, not merely in fatigues, exposures, and priva-
tions necessarily incurred during the performance of heroic deeds; not
merely in the morbific influences of strange climates; not merely in the
miseries of besieged places; they are equally to be sought in the thou-
sand preventable abnormal conditions to which armies are exposed when
huddled together in ill-selected, over-crowded, and filthy camps, fed by
ignorance or cupidity on scanty, improper, ill-cooked food, drinking
water contaminated by human exeretions, and breathing air poisoned by
human effluvia. Hence arises a brood of camp diseases more destructive
than the improved small-arms or rifled cannon of any foe; which, on
memorable occasions in times past, have annihilated whole armies, and
yet more frequently decided the fate of campaigns in spite of the mili-
tary genius of generals or the heroism of their followers.
The humane spirit of modern civilization, revolted at horrors which
modern science has shown to be to a great extent preventable, has made
of late years earnest efforts at prevention, and the intelligence of modern
administration has perceived that the success of such efforts is an indis-
pensable condition to success in war. It is this double motive that has
called into existence the Medical Staff, which has become of late years
an essential component part of the army of every civilized nation.
The work to be done cannot be performed by a band of hired barber-
surgeons employed to bind up rudely the wounds received in battle;
it cannot be performed by the voluntary assistance of the crowd of edu-
cated civil physicians who may be led by motives of humanity to the
306 WOODWARD,
scene of suffering, after the mischief is done and pestilence has actually
broken out; for its efficient performance it requires the existence of a
trained Medical Staff.
To possess the desired efficiency such a staff must be a component part
of the army in time of peace. It must enjoy such rank and pay in its
higher grades, and offer to its lower grades such prospects of reasonably
rapid promotion as to secure the life-long services of the ablest medical
men. These must devote themselves in times of peace to the study of
the sanitary conditions which affect the health of armies, and war must
find them ready to point out with authority the precautions which cannot
be neglected without peril. The demands of philanthropy, the impulses
of humanity, are best fulfilled by such a staff when it best discharges
its military duty, which is to see to it that of a given number of soldiers
on the rolls, the largest possible number shall always be ready for duty.
This proper duty of the Medical Staff is as much a military duty as
that of the artillery or the infantry. It is the business of these to maim
and destroy till the strength of the enemy is so diminished that he can
no longer resist ; it is the business of those to aid in keeping the fight-
ing ranks full until their work is done. For the efficient discharge of
this military duty the medical staff requires military rank as much as
any other branch of the army service. It requires it, not merely because
it is otherwise impossible to secure the continuous service of an efficient
personnel, but because, without military rank, no personnel, whatever
its qualifications, can be really efficient. It requires rank, because it
requires authority. If its wise counsels can be thwarted at every step
by the obstimacy of ignorance, it becomes a mere witness of evils which
it is impotent to prevent.
This is not the time or place to discuss the question as to whether the
conditions just indicated as necessary to secure the most efficient medi-
cal staff possible have yet been completely fulfilled in any army. I must
leave that question to the thoughtful consideration of my hearers of all
countries. It is enough for my present purposes to point out that coin-
cidently with the elevation of the medical staff in modern times the
camp diseases of modern wars have notably diminished in malignancy.
We no longer hear of armies destroyed by pestilence within the first few
weeks or months after taking the field. The old bubo-plague and spotted
typhus no longer figure in the history of wars between civilized nations.
I admit that much remains to be done by Preventive Military Medi-
cine. I admit that much remains to be learned with regard to the causes
of disease. But this is no reason why armies should not enjoy to the
uttermost the knowledge we already possess. And it is after all but a
partial application of this knowledge which has brought about the ame-
lioration to which I have just referred. I think it is safe to affirm that
no army ever yet took the field, even in the most modern times, that did
not campaign in daily violation of well-established hygienic laws. And
hence it will be found that if in any modern war the mortality from
disease has been very small, it has been because the struggle has been very
brief. We shall deceive ourselves if we overlook the element of time in
the production of the diseases of modern armies. An army may very
well escape with trifling mortality from an exposure of a few weeks or
months to influences which would have proved fearfully destructive if
continued for a year or longer.
This was well illustrated by the experience of the Armies of the United
States during the civil war by which this country was recently convulsed.
TYPHO - M. A. L. A. R.I.A. L. F. E. W. E. R. 307
Notwithstanding the want of discipline among the newly-levied troops;
notwithstanding the lack of experience in military medicine on the part
of the newly-enrolled medical officers; notwithstanding all the faults of
administration and the necessity of reform, of which so much has been said
in certain quarters, the mortality from disease did not exceed 2.2 deaths
per 1000 of strength monthly, during the first six months of the strug-
gle'—a death-rate which, if it had continued, would have represented an
annual loss from disease of 26.4 per 1000 of strength. But in point of
fact a rapid increase in the mortality took place after the first of Novem-
ber, 1861. The deaths from disease during the year ending June 30,
1862, were at the rate of 49.3 per 1000 of strength, and, in spite of in-
creased discipline and increased experience, the reorganization of the
Medical Staff, and other reforms, rose to 63.2 per 1000 of strength during
the year ending June 30, 1863. During the year ending June 30, 1864,
the improved discipline and sanitary management of the white troops
were at length accompanied by a diminished mortality, and the death-rate
from disease fell to 48.2 per 1000 of strength, or very nearly what it was
during the first fiscal year of the war. Subsequently, however, it rose
again, in spite of every effort, and was 56.5 per 1000 of strength during
the year ending June 30, 1865. These figures, it must be remembered,
refer only to the white troops, who constituted the bulk of our forces.
They include both the regular army and the volunteer troops. And I
may remark that I have shown in the introduction to the first volume
of the Medical History of the War,” after an analysis of the records of
the Surgeon General’s office, and a careful comparison with the records of
the Adjutant General and the Quartermaster General, that the average
annual mortality from disease among the white volunteers, during the
four years of the struggle, must be fixed at 55 per 1000 of mean strength,
while it was only 32 per 1000 of strength for the small regular army
during the same period.
But what shall I say of the mortality among the colored troops?
The statistical tables in the first volume of the Medical History show it
to have been 211 per 1000 of mean strength, during the year ending June
30, 1864, and 139.8 during the year ending June 30, 1865. Even if we
extend the view to cover the whole period from the day the first volun-
teer colored regiment was mustered into service to the day the last was
mustered out, a period of five years and four months, and distribute the
mortality over the whole term, it will be found, as I have shown in the
Introduction to the first volume of the Medical History,” that it repre-
sents an average annual mortality from disease of 133 per 1000 of mean
strength—a proportion which it is impossible to consider without emo-
tl On.
It is only just to express my conviction that a large part of this ex-
cessive mortality was due to circumstances from which the colored men
suffered before they were enlisted, rather than to mismanagement or
maltreatment afterwards. It must be remembered that a large part of
these colored soldiers were fugitive slaves. They fled into our lines
literally naked and starving. The diseases which destroyed them were
to a great extent engendered by the miseries they had suffered before
they found a refuge under our flag.
| These figures and those in the following paragraphs are deduced from the Statistical
Tables of the first Medical volume of the Medical and Surgical History of the War of the
Rebellion (1861–5). Washington, Government Printing Office, 1870.
* Op. cit., Introduction, p. xli. * Op. cit., Introduction, p. xl.
308 Woo D WAR D,
In all—embracing in the count all arms and all colors, officers and
men—the total mortality of the armies of the United States from dis-
ease during the war (including the deaths during the year following, in
which a large part of the mortality was from diseases contracted during
the struggle), may be fixed at a little over 200,000 men, while battle and
wounds destroyed rather more than 100,000." This estimate of 200,000
men dead of disease embraces, it must be remembered, not only about
30,000 of the colored soldiers, upon whose mortality I have commented,
but a nearly equal number of white soldiers, who died while prisoners
of war in the hands of the enemy, under circumstances upon which I
refrain from comment at this time, but for which the Medical Adminis-
tration of the United States army can assuredly in no wise be held re-
sponsible.
These circumstances no doubt increased the mortality of our armies
greatly beyond what it would otherwise have been. On the other hand,
it must not be forgotten that discharges from the service for disability
took place with a freedom—perhaps in strict justice I ought to say, with
a recklessness—never before exhibited in any army. The total number
of soldiers thus discharged may be estimated as not far short of three
hundred thousand.” No doubt very many of these men only went home
to die. No doubt, also, many thousands of them, epecially those suffer-
ing with lame backs and general debility, rheumatic pains, and cardiac
palpitations, needed only a short sojourn in a northern climate, with a
generous diet, to have fitted them again for the field. I cannot dwell
here on this shameful story. It is one of the scandals of the war. I
have never been able to collect data to justify even an approximate esti-
mate of the proportion of these men who died. I believe it to have been
comparatively small. Removed from the theatre of war, returned to the
healthier circumstances of their homes, I doubt not that a large propor-
tion of these men recovered their health, and that thousands of them,
induced by the large bounties which were offered for recruits, found their
way again into the ranks.
Certainly the statistics I have cited afford food for earnest thought.
But if their study is to be profitable, it must be undertaken with a
careful consideration of all the circumstances. Above all, when these
figures are compared with the results of other wars, the element of
time must be taken into account, or the gravest misunderstandings will
arise. A striking illustration of this possibility has been brought to
my notice.
In an oration delivered on the 2d of August, 1874, on the anniversary
of the Military Medical School of Berlin,” Professor Rudolph Virchow,
In the Introduction to the first Medical volume of the Medical and Surgical History
of the War, I have fully discussed the various official records, and arrived (see p. xxxviii.)
at the following results, which are probably very near the truth:—
T)eaths from battle, wounds, and other violence . e e . 93,969
Deaths from disease - e º º e © © º . 186,216
Deaths, the causes of which are not recorded . º © g . 24,184
304,369
On the reasonable supposition that those deaths in which the causes are not recorded were
distributed between wounds and disease in the same proportion as those whose causes are
recorded, we shall arrive at the results expressed in the text.
* See Introduction to the first Medical volume just cited, p. xlii.
* Die Fortschritte der Kriegsheilkunde, besonders im Gebiete der Infectionskrankheiten.
Rede gehalten zur Feier des stiftungstages der militar-ārztlichen Bildungs-Anstalten, am
2, August, 1874, von R. Virchow. Berlin, verlag von A. Hirschwald, 1874.
TYPHO - M. A. L. A. R.I.A.L FE W E R . 309
one of the ablest medical thinkers in Europe, alluded to this enormous
mortality from disease during our war, and contrasted it with the com-
paratively small losses of the German army during the late war with
France. After reciting the American figures, and, I may add, after
speaking of the publications of the Surgeon General's office in language
so complimentary that, as one of the officers concerned in their prepara-
tion, my modesty will not allow me to repeat it, the distinguished
orator continued as follows: “The German army had, during the last
French war, out of a strength of 913,967 men, a total loss of 44,980.
Of these, 17,572 fell before the enemy, 10,710 died later of their wounds,
12,253 fell a sacrifice to disease and pestilence; certainly a very favora-
ble proportion. But we had before us the experiences of two recent
wars, which had been well discussed and taken advantage of, both scien-
tifically and administratively. We possessed the inestimable experience
of the Americans, and, finally, we had German science.”
Truly, I will not yield even to Virchow himself in my appreciation
of German science. I know well the debt of gratitude which modern
medicine owes to German investigation. For myself, I have drawn
much of the knowledge I value most from German sources. I admire
German science for its industry, which is without parallel ; for its origi-
mality, which has already pushed discovery so far ; but most of all, for
the truly catholic spirit which knows no nationality, and for the manly
independence, which never hesitates to weigh authority by a comparison
with the actual facts.
Something of this spirit I have tried to catch, and I will not therefore
allow myself to be misled as to the matter under discussion, even by the
authority of Virchow. I cannot avoid interpreting the facts otherwise
than he has done, and I feel that I am but performing a necessary duty
when, standing here before you to-day, I declare it to be my opinion
that not even German science would have sufficed to save the German
army from a greatly increased percentage of mortality if the war had
lasted a few years instead of a few months.
The figures given by Virchow are from the official report of Dr. Engel.”
They represent a period of seven months. They must not be compared
with the losses of our whole civil war, but with the losses of the first
seven months. Let us make the comparison. Virchow's figures repre-
sent a mortality of 13.4 + per 1000 of strength for seven months, or
1.9 + per 1000 monthly. Now I have already shown you that the mor-
tality from disease in our armies during the first six months of the war
averaged 2.2 per 1000 monthly. During the following month, viz.,
November, 1861, the mortality increased very greatly, so that, indeed,
almost as many died during that month as during the whole six months
preceding. Including these deaths, I find, on a discussion of the official
data, that during the first seven months of the civil war, viz., from May
1 to November 30, 1861, the mortality from disease was at the rate of
18.8 per 1000 of strength, or 2.7 per 1000 monthly.” You see that the
1 Op. cit., S. 7.
* Zeitschrift des Königlich Preussischen Statistischen Bureaus. Redigirt von dessen
Director Dr. Ernst Engel. Zwölfter Jahrgang, 1872. Berlin, 1872, S. 293.
* These ratios are deduced from the Statistical Tables in the first Medical volume of the
Medical and Surgical History quoted above. I may add here, that the total number of
deaths from disease from the commencement of the war to November, 1861, recorded on
the alphabetical registers of the Surgeon General's Office, is 3206. There are also 160
deaths recorded during the same time, the causes of which are not specified. If we sup-
310 WOOD WAR D,
mortality of our army from disease, during equal times, was really but
about one-third greater than that of the German army in the French
war; whereas, as Virchow presents the subject, it is made to appear
more than fifteen times greater.
Now, I am perfectly willing to admit that a part of the actual differ-
ence in favor of the German army was really due to better discipline and
a wiser application of preventive medicine. But I do not believe that
this is the only reason for the difference. The raw levies of the North-
ern States were sent at the very first to the South, and campaigned or
lay in camp during the time in question in the miasmatic valleys of the
Mississippi, the Ohio, and the Potomac, while the German army did its
work on the comparatively salubrious plains of France. What would
have happened had the scene been exchanged 7 How much of the dif-
ference was really due to the wisdom of man, how much to a more
favorable climate, and the absence of the intense malarial poison to
which all were exposed who bore our arms?
This malarial influence, and the pathological processes to which it
gives rise, demand the most careful study of those who would endeavor
to comprehend the problem of the health of armies in America. It is
not merely manifested by the frequency of ordinary ague, of which very
nearly a million cases' were officially reported in our armies during the
war; it colors and complicates other diseases to an extent which can
hardly be credited by those who have not been eye-witnesses to its effects.
Especially does it demand the consideration of those who may attempt
the study of the fatal continued fevers which have been, and will be, the
pose all of these to have been deaths from disease, the number will be 3366. Of this num-
ber, 1457 died during the month of November, viz.: 1413 of disease, and 44 of causes not
specified. The absolute number is but a little more than one-fourth of the German figures;
but the average strength of the troops in service during the time referred to was also about a
fourth of the German army, so that the ratios are as stated in the text. The compara-
tively small mortality at the commencement of our civil war is strikingly illustrated by the
Medical History of the three-months' volunteers. It will be remembered that at the com-
mencement of the struggle President Lincoln called out 75,000 men to serve for three
months. This call was issued April 15, 1861. According to the records of the Adjutant
General’s Office, the actual number of men who were mustered into service on this call was
91,816. Through the kindness of Assistant Adjutant General T. M. Vincent, I have
ascertained from the death and disability records of the Adjutant General's Office that the
actual mortality of these troops during their three-months’ service was as follows:–
I)eaths from battle, wounds, and other violence . º º º . 221
“ from disease • & e o e º º e º . 151
“ from causes not recorded . e º º º º e . 231
Total . º e e e º & e 603
If all the deaths of which the causes were not recorded were from disease, the total num-
ber of deaths from disease would be 382, or 4.2 per 1000 of strength for the three months.
This would correspond to a mortality of 1.4 per 1000 monthly, or less than three-fourths of
the monthly rate which I have shown in the text for the first six months of the war.
* The number of cases and deaths reported as due to ague was as follows:—
WHITE TROOPS. CoLoRED TRoops.
Cases. Deaths. . Cases. Deaths.
Quotidian intermittent fever . 447,258 452 63,992 58
Tertian intermittent fever . . 375,170 381 51,045 54
Quartan intermittent fever . . . 41,223 84 3,923 15
Congestive intermittent fever . 13,673 3,370 2,536 794
Total . e e . 877,324 4,287 121,496 921
The grand total for both white and colored troops is 998,820 cases, and 5208 deaths.
See the first volume of the Medical History, cited above.
T Y. P. H. O - M. A. L. A. R.I.A. L. F E V E R . - 31||
scourge of the camps of every army that operates in the valleys of the
Mississippi and its tributaries, or of the rivers that flow into the Gulf of
Mexico, and into the Atlantic ocean south of the fortieth parallel.
These camp fevers occupy a conspicuous place among the diseases
which produced the mortality of our armies during the civil war. They
caused more than one-fourth of all the deaths from disease. In fatality
they proved second only to diarrhoea and dysentery. I suppose it is safe
to estimate that diarrhoea and dysentery produced about 60,000 deaths
in the armies of the United States during the civil war, and camp fevers
rather more than 50,000." A right comprehension of these two groups
of diseases must therefore be regarded as the most important task of
Military Medicine in America.
It is my purpose in the present discourse to discuss certain points con-
nected with the pathology of these camp fevers, and especially the com-
plication of the typhous process by the malarial influences to which I
have just referred.
Already in the fall and early winter of 1861 reports began to come in
from various quarters that a new form of fever was prevailing in our
camps. The great majority of our army surgeons at that time were
fresh from civil life. Many of them had been engaged in extensive pri-
vate practice. Almost all of them were well acquainted with ordinary
typhoid fever (enteric fever, typhus abdominalis) as it annually prevails
in the Northern States, and it was precisely these men who first called
attention to the fact that the fevers they were now called upon to com-
bat differed in many important particulars from those to which they
were accustomed at home.
This circumstance was noticed in both the Western and the Eastern
armies; but, so far as I have been able to ascertain, official attention was
first directed to it in the Army of the Potomac, then encamped just
beyond the banks of the river in front of Washington. By an order
from the Adjutant General’s office, dated December 6, 1861, a Board of
Medical Officers was convened for the purpose of visiting the camps of
the Army of the Potomac, and inquiring into the nature of the prevail-
ing fever, especially endeavoring to ascertain—to use the language of
the order appointing the Board—“whether it is to be considered an
intermittent or bilious remittent fever in its inception, assuming in its
course a typhoidal type, or a typhoid fever primarily.” This Board
consisted of Surgeon A. N. McLaren, U. S. A.; Brigade Surgeon G. H.
44,558 deaths from diarrhoea and dysentery were reported during the war, out of
156,885 deaths from disease, the causes of which were specified in the reports. If we sup-
pose these diseases to have caused the same proportion of those deaths from diseases the
causes of which are not specified in the reports, we shall obtain the estimate of the text.
The cases and deaths of the several forms of camp fevers reported to the Surgeon General's
Office were as follows:–
WHITE TROOPS. CoLoRED TRoops.
Cases. Deaths. Cases. Deaths.
Typhus fever . & gº * . 2,501 850 123 108
Typhoid fever . & * e . 75,368 27,056 4,094 2,280
Common continued fever & . 11,898 147 ...... ......
Typho-malarial fever & & . 49,871 4,059 7.529 1,301
Remittent fever . & º . 286.490 3.853 30,645 1,002
Total g e . 426,128 35,965 42,391 4,691
This gives a total of 40.656 deaths from these fevers out of 156,885 deaths from disease,
the causes of which are specified in the reports. On the supposition just mentioned we
obtain the estimate in the text.
312 WOOD WAR D,
Lyman, U. S. Volunteers, and Assistant Surgeon M. J. Asch, U. S. Army.
It convened December 16, at the quarters of Brigade Surgeon Lyman,
who was chief medical officer of the division commanded by General
Fitz John Porter; and during its subsequent labors examined the hospitals
of this and other divisions, and collected a great deal of valuable infor-
mation, in writing, by means of written questions addressed to the
brigade and regimental medical officers of parts of the army which its
members were unable conveniently to visit. As might have been expected,
some diversity of opinion was expressed in the replies received. But in
their general tenor the great majority of these replies confirmed the
opinion formed by the members of the Board on the basis of their own
personal observations. This opinion was that, while a certain number
of cases of ordinary typhoid fever existed in the army, the large majority
of the febrile cases were “bilious-remittent fevers, which, not having
been controlled in their primary stage, have assumed that adynamic type
which is present in enteric fever.”
In the following spring, after the Army of the Potomac commenced
its Peninsular campaign, this mixed form of fever increased in frequency.
It assumed formidable proportions during the siege of Yorktown, and
reached its greatest intensity while the army lay encamped on the
swampy borders of the Chickahominy. The hospitals of Washington
and Alexandria, of Baltimore, Philadelphia, New York, and other
Northern cities, were crowded to overflowing with the sick. Among
the attending physicians were some of the best instructed medical men
of the Northern States. They have shown that they recognized that
they had to deal with an unusual pathological complex, by perpetuating
the name of Chickahominy fever, which appears so often in their reports.
It was under these circumstances that I was ordered, early in the
summer of 1862, to serve on a Board of Medical Officers, who were
directed to revise the form of sick report in use in the army. I was
fresh from the Army of the Potomac, which I had accompanied from its
camps before Washington, where I had spent the winter with it. I had
lain in camp at Yorktown, and followed the army up the Peninsula. I
had formed the opinion that the prevailing fevers of the Army of the
Potomac were hybrid forms, resulting from the combined influence of
malarial poisoning and of the causes of typhoid fever. I believed that
individual cases received their characters in accordance as the one or
the other of these influences preponderated in the individual, and that
very often the picture was still further complicated by the coexistence
of a scorbutic taint. Full of these opinions, I proposed to the Board,
as I had previously suggested to the Surgeon General, to designate the
complex condition in question by the name typho-malarial fever, and I
induced the Board to add this term to the list of diseases printed on the
blank form for the monthly sick report. I often regret that I did not
also urge upon the Board the preparation of a circular letter to accom-
pany the new sick report, explaining why this term had been adopted,
and calling for special reports with regard to the cases which it was
intended to designate. As it was, the term went upon the sick report
without any explanation or a word of comment. But even under these
circumstances, 23,346 cases were reported as typho-malarial fever during
the following year, showing how widely the opinions I had formed were
shared by the medical officers of the army.
In September, 1863, I published in Circular, No. 15, of the Surgeon
TYP HO - M. A. LA RIAL FE W E R. 313
General’s Office, a short statement with regard to the sickness and
mortality of the army during the first year of the war, in which I stated
the meaning I designed to attach to the term typho-malarial fever, and
in November of the same year completed the publication of my Outlines
of the Chief Camp Diseases of the United States Armies,” in which I
presented my views at some length. I also gave a short account of the
subject in Circular No. 6, Surgeon General’s Office, 1865.” And now, after
a careful study of all the pathological and documentary material accu-
mulated during the war, I still hold substantially to the same views,
and hope in the second volume of the Medical History of the War to
present the facts upon which my opinion is based in such a manner as
to command universal assent. In so doing, I shall, of course, present
many additional matters of detail not contained in any of my former
publications; and also, I may frankly say, I shall correct some errors of
detail (particularly with regard to the pathological anatomy of the intes-
times in these fevers), into which I fell during my earlier studies, and
which were incorporated in the account presented in my book on Camp
Diseases.
In the same connection I hope to present historical proof of a proposi-
tion, which I do not hesitate even now to announce to you, that such
hybrids between malarial fever and typhus, of one form or another, are
no new thing in the history of armies. They were not first begotten on
American soil. In fact, in every great army that ever yet campaigned
for any length of time in a malarial region the prevalent form of fever
has been a hybrid between malarial fever and some form of typhus. By
a malarial region I mean simply a region in which ague and remittent
fevers are the common endemic diseases. The causes of these fevers act
always with peculiar intensity upon strangers; and an invading army is,
therefore, peculiarly prone to suffer from them. At the same time the
uncleanliness and overcrowding of camps favor the spread of some form
of typhus, whether originating de movo or introduced from without by
contagion. In some cases it has been spotted typhus which has made
its appearance; in others it has been abdominal typhus (typhoid fever),
and as the typhus poison has been of one or the other variety, and as
the malarial influence has been more or less intense, the complex result
has varied—at times the malarial phenomena, at times the typhous
phenomena being the more prominent. The morbid conditions resulting
from these twofold causes have usually also been still further modified
by the existence of actual scurvy, or at least of a scorbutic taint, the
result of an improper and often scanty supply of food.
It would be impossible, in the time allotted to me, to re-examine to
| Circular No. 15, Surgeon General's Office, Washington, D. C., September 8, 1863.
Sickness and Mortality of the Army during the First Year of the War. The language
used in this preliminary report was as follows: “Moreover, while a certain amount of
uncomplicated enteric and remittent fever certainly did occur, especially at the commence-
ment of the war, the vast majority of the camp fevers of the army were of a mixed cha-
racter, exhibiting undoubted enteric phenomena, variously combined with the periodicity
and other peculiarities of malarial disease, and still further modified by the tendency to
incipient scurvy, which is the ordinary concomitant of camp diet. To indicate this mixed
nature, the term typho-malarial fever, which I had the honor to suggest to the Department
in June, 1862, appears appropriate, and, at the present time, is coming into very general
use.”
* J. J. Woodward. Outlines of the Chief Camp Diseases of the United States Armies,
as observed during the present war. Philadelphia: J. B. Lippincott & Co., 1863. 8vo.
. 364.
P. Circular No. 6, Surgeon General's Office, Washington, November, 1, 1865, p. 109 et seq.
314 WOOD WAR D,
any great extent the history of armies from this point of view. I can
only bring to your notice a few striking illustrations. First, let me recall
the pestilential fever which destroyed the French General Lautrec and
the army of thirty thousand men with which he besieged Naples, in
1528. Hecker' has analyzed the chronicles of the time with his usual
eloquence, and has arrived at the conclusion that it was simply petechial
typhus which raged in the French camp. After an examination of the
authorities he cites, I cannot agree with this conclusion. The siege
began May 1. Almost the first act of the French General was to cut
the aqueducts which supplied the city with water. TXy this rash act
the plains on which he was encamped, intensely malarial at the best,
were converted into a vast series of bogs and stagnant pools, from which
the heat of the sun raised clouds of vapor, which hung around his camp
like a pall. I must believe that Jovius” was right in attributing the
destruction of the French army chiefly to this act of madness. No coll-
temporaneous physician has described the pestilence that followed, but
the chroniclers of the siege have recorded symptoms which are incom-
patible with the theory of Hecker, Jovius tells us that many of the
patients were affected with swellings of the belly and legs. They became
so pale and death-like in their complexions that their friends were hardly
able to recognize them. Scarcely able to crawl, and without attendants
to nurse them, they often died in their tents of hunger and thirst.
Sandoval” describes the same death-like faces, and applies to them the
epithet amarillos (yellow). These are not the symptoms of spotted
typhus, but of intense malarial poisoning. We saw just such cadaver-
ous yellow faces, with swelled legs and bloated bellies, crawling about
in the camps at Young’s Point on the Mississippi, and at other swamp-
beset localities, during our own war.
I agree, however, with Hecker, to whose work I must refer you for
particulars, that spotted typhus was no doubt also present in the camp;
and I suppose it complicated the acute fevers very much, as it did later
in the same century in the Austrian armies in Hungary. Moreover,
Guicciardini" relates that after Lautrec first fell sick, during the month
of July, things fell into confusion, the enemy cut off the convoys of
provisions, and some of the soldiers actually died of starvation in con-
sequence. These circumstances, I doubt not, also played their part in
destroying the French Army. By the second of August there were but
four thousand men fit for duty. Lautrec died August 15, and, the
mortality still continuing, his successor thought only of flight. This he
attempted August 29, but was pursued, and capitulated at Averse a
few days later. Crowded into the stables of la Madeleine, the pestilence
continued its ravages among the prisoners, and when, a little later, they
were released by the conqueror, but a handful remained to find their
way back to France.
Next let me ask your attention to the story of the celebrated Hunga-
* J. F. C. Hecker. The Epidemics of the Middle Ages. Transl. of Sydenham Soc.,
London, 1844, p. 212 et seq.
* Jovii (Pauli, Novocomensis, Episcopi Nucerini) Historiarum sui Temporis, Tomi II.,
Florentiae, 1550–2, Lib. XXVI. I have not obtained access to the original, but find in the
Congressional Library a German translation, printed at Frankfort, 1570.
* Sandoval. Historia de la vida y hechos del Emperador Carlos V. Pamplona, 1614–18.
Part. II., Lib. XVII., 3 XI., p. 12 et seq.
* Guicciardini. Della Istoria d'Italia. Lib. XX., Venice, 1738. I have used the
lºnglish translation of A. P. Goddard, 3d ed., London, 1763.
TYPHO - M A. L. A. R.I.A. L. F E V E R . 315
rian fever, which for at least three centuries played so formidable a part
in the campaigns undertaken by the House of Austria against the Turks.
The valleys of the Danube and its tributaries are still the home of agues,
remittent and continued malarial fevers, big spleens, and malarial
cachexias. Lying further to the north than our own Mississippi valley,
the climate is nevertheless such that the marshy borders of the streams
and pools give rise to a malaria scarcely less intense than that with
which we are familiar in the lower Mississippi. I may refer you to the
papers of Müller, Wenmaring, and Läntz' for graphic descriptions of
the characteristics of the country and of its prevailing diseases in our
own day.
Now, in every considerable campaign against the Turks, in which the
armies of the German Emperors invaded the Hungarian plains, from the
beginning of the sixteenth century to the end of the eighteenth, a form
of fever prevailed among the troops so unlike the ordinary European
fevers that it has always been known as the Hungarian fever, and so
fatal as to occasion the proverb that “ Hungary is the grave of the Ger-
mans.” This IIungarian fever has exercised some of the best medical
minds of the last three centuries. It is now generally admitted to have
been a hybrid between the endemic remittent fevers of the Hungarian
soil and spotted typhus. The attention of civilized Europe was first
directed to it when, after the luckless IIungarian campaign of Maximil-
ian II., in 1566, his pest-stricken soldiers returned to their homes.
They scattered the contagion of spotted typhus throughout Germany
on their way. The disease bred by that contagion was also called the
Hungarian fever, but it was simply spotted typhus, and the student of the
voluminous older literature of the IIungarian fever finds no little con-
fusion growing out of this circumstance, and no little difference between
the descriptions of such eye-witnesses as Thomas Jordan and Tobias
Cober, who described the Hungarian fever as they saw it on Hungarian
soil, and the descriptions of those who merely observed the spread of
spotted typhus in the German towns, and gave it the name of the Hun-
garian fever because the contagion had been spread by soldiers returning
from Hungary.
The army of Maximilian, however, was not the first German army
which had suffered from the Hungarian fever. In 1542 a pestilential
fever broke out at the camp before Ofen, in the Imperial German army
which Margraf Joachim von Brandenburg had led against the Turks.
It became still more fatal during the disastrous retreat, and according
to Haeser” destroyed 30,000 men. Johannes Langius,” who accompanied
the Count Palatine, Frederick II., in this campaign, as well as in the
* Jos. Müller. Die k. k. Militaergraenze, mit besonderer Berucksichtigung der ver-
einigten Carlstadter, Banal und Warasdiner Graenze. Med. Jahrb. desk. k. oest. Staates.
Bd. 35 (1843), S. 89,231, 361. Bd. 36 (1843), S. 110, 235, 338. F. Lántz. Phys. Med.
Beschreibung der Barangaer Gespannschaft in Ungarn. (Same Journal.) Bd. 55 (1846),
S. 98, 231, 361. Bd. 56 (1846), S. 99, 221, 349. B. Wenmaring. Ueber die Sumpf.
wechselfieber. (Same Journal.) Bd. 57 (1846), S. 11, 129. Consult, also, J. M. Minderer.
Das Halbdreitagige Fieber (Hemitritaeus), in den Sudlichen Provinzen des Russischen
Reichs. Hufeland's Journal, Bd. 28, st. 2 (1809), S. 1. Müller, cited above, speaks of this
fever as the Hemitritaeus Daciae. Op. cit. Bd. 36, S. 343.
* Haeser. Geschichte der epidemischen Krankheiten. 2te Aufl. Jena, 1865. Bd. II, S.
340.
* D. Johannes Langius. Med. Epist. Basel, 1554. Epist. 4 (p. 17). In Cura Causonis
Chirurgicorum temeritas.
316 WOODWARD,
campaign of 1526, has left an epistle, in which he describes this fever in
such a manner as to leave no reasonable doubt of its identity. He tells
us, also, that the camp surgeons, whose ignorance he pictures with
bitter sarcasm, gave the disease the name of Bhreiine (Bräume) on account
of the condition of the tongue, which they supposed to be the most
essential symptom. According to Haeser,” the Chronicler Wintzenberger
gave the same epidemic the name, “pestartige Bräune.” These names
long continued in use among the designations by which the Hungarian
fever was known to the vulgar.
The epidemic of 1566 is famous both on account of the manner in
which typhus was spread through Europe by the disbanded soldiers, and
on account of the classical description of the Hungarian fever by Thomas
Jordan,” who accompanied the army of Maximilian as his chief medical
officer. The spring had been exceedingly wet, and the great Hungarian
streams had overflowed their banks; the summer was unusually hot and
dry; the German army was scantily supplied with food. When the
fever first appeared the army was encamped at Komorn, at the point of
junction of the Waag and the Danube—a marshy, intensely malarial
plain. It became still more destructive in the camp at Raab, where the
Raab and Rabnitz empty into the Danube. Such was the devastation
caused by it that Maximilian, though his force when he went into camp
at Raab was about 80,000 men, did not venture to take the offensive,
and saw the gallant little garrison at Zigeth captured by the Turks after
more than twenty vain assaults, without daring to strike a blow in their
behalf. In the early autumn he ignominiously retreated with the re-
mains of his army. After the retreat the pestilence was especially
destructive at Vienna. The hospitals could not accommodate all the sick,
and the dead and dying were scattered through the streets. Throughout
all this devastation it was the German troops that suffered ; the native
Hungarians almost entirely escaped.
The Hungarian fever broke out anew during the siege of Papa, in the
year 1597. The Italian allies suffered most. According to Haeser, of
more than 8000 of these troops, less than 1500 found their way back to
Italy. This is the epidemic described in the admirable work of Tobias
Cober.”
Again it made its appearance, as we learn from Esslinger and Haeser,
among the 12,000 German troops who occupied Hungary under the
celebrated General Montecucculi,” in the year 1661. The disease broke
Out in the swampy camp between Komorn and Neuhäusel, and soon
brought the fruitless campaign to an end.
Once more it appeared in the army with which Prince Eugene besieged
Belgrade in 1717. The Grand Vizier advanced to the relief of the be-
sieged with a great army. The Turks took the offensive, and shut up
Eugene, with his army of 60,000 men, in the marshy plain between the
Danube and the Save. It was here that the IHungarian fever broke out,
! See Hecker. Art. Hungarica febris. In the Encycl. Woerterbuch der Med. Wiss.
Berlin, 1838, Bd. XVII, S. 164; with which compare the Dissertation by G. Agats. De
Morb. Hungarico. Berlin, 1840.
* Op. cit., S. 341.
* Thomae Jordani, Pestis Phenomena. Franckfort, 1576. Cap. XIX. p. 219. De Lue
Pannonia.
* Tobiae Coberi, Obs. Med. Castrensium Hungaricarum. Decades tres. (Edition of H.
Meibomius.) Helmstad, 1683.
* See Mémoires de Montecucculi. Nouv. ed. Amsterdam et Leipsic, 1756. Livr. III.,
ch. i., p. 321.
TYPHO - M A. T. A. R.I.A.T. F. E. W. E. R. 317
accompanied by a fatal dysentery. A large number of men had perished,
when the gallant Prince, venturing all on the fortunes of a day, attacked
the Turkish army and routed it after a desperate battle. The surrender
of Belgrade followed, and the peace of Passarovitz was the result.
Still more terrible were the ravages of the Hungarian fever during the
disastrous campaign which the Emperor Joseph II. undertook against
the Turks in 1788. Disappointed with regard to the help he had antici-
pated from Russia, and his troops decimated by pestilence, the feeble
campaign terminated in a humiliating retreat. The imperial army at
the commencement of the season numbered about 200,000 men; its losses
from disease have been estimated at between 30,000 and 40,000.
The symptoms of the Hungarian fever have been described at great
length by numerous writers. I can only refer to a few leading points.
The patients were seized, usually during the afternoon or evening, with
a slight, short chill, followed by a burning fever. This was accompanied
by a headache so intense that the vulgar called the disease sometimes
the head disease (Haupt-krankheit); the raging brain disease (Hirnto-
bende-krankheit); or the head misery (Kopfwehe). So prominent was
this symptom that in the earlier autopsies medical men sought for the
cause of the affection chiefly in the encephalon, and, deceived either by
the congested appearance of the choroid plexus, or by the presence of
vermiform clots of blood or fibrin in the ventricles or in the great sinuses,
actually supposed they had discovered worms in the brain, and gave to
the disease the designation “Cerebri vermis” or “Hirnwurm.” With
the headache came on a pain in the epigastrium so intense that the
appellations “Herzbräune” and “Herzbreun,” were widely employed.
Soon the fever was accompanied by a raging delirium; the tongue be-
came dry and covered with a brown coat, from whence the vulgar names
“Bräune” and “pestartige Bräume,” already mentioned. Hemorrhages
from the cracked tongue or from the gums were common. Then, there
was also the characteristic typhus eruption of the skin, accompanied by
petechiae, whence the disease was called “Febris Lenticularis,” especially
by the Italian physicians. In cases which recovered, the favorable crisis
usually occurred on the fourteenth or twenty-first day, but fatal cases
often terminated much earlier. In some cases gangrene of the extremi-
ties occurred.
All these symptoms, together with the unmistakable contagion, cer-
tainly point to spotted typhus; but from a very early period, cultivated
physicians, like Sennertus, for example, have pointed out that this fever
differed in several marked particulars from ordinary spotted typhus.
The most striking differences were its tendency to present a decidedly
remittent type in its earlier stages, and the accompanying gastric symp-
toms, bilious vomiting and the like. Even Rulandus," who was disposed
to identify the disease with the febris lenticularis of the Italians, was
obliged to admit that during its early days it frequently presented, in a
decided manner, the type of a simple or double tertian fever. A com-
| Martin Rulandus. De Morbo Ungarico. Leipsic, 1610. Consult Cap. I. p. 9, where,
after intimating that these remissions are deceptive in their character (falsa specie), the
author admits that in the case of Baron Reinhard, who died of the Hugarian fever, he
supposed, during the earlier history of the case, that he was dealing merely with a double
tertian. For his argument in favor of the identity of the Hungarian fever with febris
lenticularis, see Cap. VIII., 3 XX. p. 376. Consult further, Cap. VIII., quaestio 39, p. 510,
for argument against the supposition that the Hungarian fever has truly a tertian or quar-
tan type.
318 WooDWARD,
mon form was the semi-tertian, to which the old Greek physicians gave
the designation Hemitritaeus; and hence the Hungarian fever has some-
times been described as the Hemitritaeus Daciae.
So marked were these symptoms that Sauvages, the great Nosologist,"
classes the “Amphimerina Hungarica,” as he calls it, among the remit.
tent fevers. The learned Naumann” goes so far as to declare that the
Hungarian fever is at the bottom merely the common summer fever
which occurs every year in Hungary, the valley of the Danube, and
Southern Russia, and attains malignity only in epidemic years. Among
modern epidemiologists, while Ozanam 4 still clings to the notion that
Hungarian fever was merely typhus, both Hecker and Haeser” express
the opinion that it was typhus, modified by the intense malaria of the
Hungarian plains.
Side by side with the Hungarian fever a chronic affection occurred
among the German soldiers in Hungary, which, like the Hungarian fever,
was often spoken of as the Hungarian disease. (Morbus Hungaricus, or
Lues Pannonica.) This was the celebrated Languor Pannonicus, or
Asthenia Pannonica." It was a profound debility, accompanied with a
disgust for food, unwillingness for exertion, diarrhoea, and pains in the
back. It attacked large numbers of men, and not unfrequently proved
fatal. I suppose it to have been the joint effect of chronic malarial
poisoning and a scorbutic taint. Much in the old descriptions reminds
me of a certain group of cases of general debility which were common
enough in our own war. These, too, were rebellious to treatment so
long as the patient remained in the malarial region, but recovered
promptly, like some of the cases of Languor Pannonicus described by
Tobias Cober, so soon as the patients escaped to a healthier atmosphere
and better diet.
Dysentery was another camp disorder which proved fatal in the Iſun-
garian campaigns. It is mentioned by various writers, as for example,
by Cober, but does not appear to have attracted as much attention as it
probably deserved. .
I cannot dwell further in this discourse on the story of the Hungarian
camp diseases. I have said enough to indicate that the chief difference
between these diseases and those of our own camps during the war of
1861–5 consisted in the prevalence of spotted typhus in Hungary in-
stead of abdominal typhus, which was the form from which our armies
suffered. The degree of malarial complication must have been very
similar. The extent to which any scorbutic complication existed is
difficult now to ascertain. Almost all the writers complain of the food
and cooking of the Hungarian camps; but the soldiers would appear to
have had fresh meat in some abundance, for one of the constant com-
plaints is that they persisted in cooking it too soon after killing. Scurvy,
of a marked kind, however, does not appear to have occurred, and the
most significant evidence of the frequent existence of a scorbutic taint
is, after all, the constant development in every army, after a few months’
campaigning, of numerous cases of the Languor Pannonicus.
F. Boissier De Sauvages. Nosologia Methodica. Amsterdam, 1768, tom. i. p. 327.
* Moritz Ernst Adolph Naumann. Handbuch der Med. Klinik. Bd. III., Abth. I. (Ber-
lin, 1831), S. 233.
* Ozanam. Hist. Méd. des Maladies Epidémiques. 2me. Edit., Paris, 1835, tome iii. p.
127. * Cited above.
* For a description of the Languor Pannonicus, see particularly the work of Cober, cited
above. Consult, also, Sauvages, op cit., tom. i. p. 802.
T Y. P. H. O. M. A. L. A. R.I.A. L. F. E. W. E. R. 319
Of late years we have heard but little of this once dreaded scourge,
which only now and then attracts the attention of some medical writer
whose tastes incline to historical studies. I cannot but believe, how-
ever, that whenever a German army goes again into the valley of the
Danube, as perhaps may happen before long unless the present disturb-
ances in the Danubian provinces are fortunately brought to a peaceful
termination, the old Ilungarian plague will once more appear in its
ranks—a more formidable foe to be encountered than the sword of the
Turk.
I have thus presented to you a couple of striking illustrations of the
hybrid disease resulting from the complication of malarial influences
with the causes of spotted typhus. Let me next refer to some examples
of the similar complication with typhoid fever.
The first instance to which I shall refer is the epidemic of the so-
called morbus mucosus, which occurred at Göttingen during the years
1760–61, and which has become famous, less on account of the extent
of the mischief done than because of the admirable description which
we owe to two teachers in the Medical Department of the Göttingen
University, Röderer and Wagler." The summer of 1760 was warm and
rainy ; the winter which followed was wet, with notable vicissitudes of
cold and mild weather. Besides the inhabitants, a garrison of French
troops, numbering, with the camp followers, about 8000, was shut up in
the town. Röderer and Wagler have drawn a striking picture of the
want of food, the uncleanliness, the general misery that prevailed. Al-
ready by the middle of July, 1760, intermittent fevers, sometimes of
mild type, sometimes, however, of marked malignity, Occurred to a
degree unusual in that region. During August the intermittents con-
tinued to be prevalent, but malignant forms became more numerous,
and many of the cases assumed a continued type. At the same time a
malignant dysentery made its appearance, and raged with fatal results
till the month of November. The intermittents meanwhile had con-
tinued, but during the month of November both these and the dysente-
ries were gradually replaced by the morbus mucosus, which became the
prevailing disease, and continued as an epidemic all winter. During
April and May, 1761, it was again, to a great extent, replaced by inter-
mittents, bnt still scattered cases continued to occur during the summer.
In the autumn, interfmittents again became the common disease, occur-
ring often in a malignant form ; and smallpox, which had first appeared
during the summer of 1761, assumed epidemic proportions during the
winter of 1761–2.
The mucous fever was a continued fever, which in severe cases was
often prolonged beyond the twenty-first day, sometimes till after the
thirtieth, though fatal cases often perished as early as the ninth. In
its earlier stages it usually presented a decidedly remittent type, tertian,
double tertian, or semi-tertian being the most common varieties. Some-
times, as the patients convalesced, the continued fever passed into an
ordinary intermittent before recovery took place. After the fever was
fairly under way it presented many of the symptons of ordinary typhoid
fever. Delirium, frequent, feeble pulse, diarrhoea, meteorism, in the
worst cases petechiae, made their appearance. At the beginning the
tongue was furred, and its swollen, red papillae projected through the
fur; it became brown and dry as the disease progressed. Hemorrhages
! J. D. Röderer et C. G. Wagler. De Morbo Mucoso. Göttingen, 1762.
320 WooDWARD,
from the nostrils sometimes took place, especially about the sixth day;
still more frequent were hemorrhages from the bowels. . It is a signifi-
cant fact that the extract of Peruvian bark often proved highly effica-
cious in those cases in which the remissions were most marked.
The disease derived its designation from the belief that an excessive
secretion of mucus from the alimentary canal was its most characteristic
phenomenon. This was manifested by the frequency with which mucous
vomiting, with or without bile, occurred at the inception of the cases,
just as we know it does in ordinary remittent fever. The diarrhoea was
interpreted as but another expression of the excessive mucous secretion,
and the dead lumbricoid worms which were often noticed in the stools,
or during the progress of autopsies, were supposed to have been bred in
consequence of the morbid excess of mucus in the alimentary canal. In
the autopsies, the closed glands of the stomach and small intestines
were usually found tumefied to a marked degree. This was erroneously
supposed to be the consequence of an accumulation of the mucous secre-
tion in their interior. Röderer and Wagler have published three remark-
able copper etchings of the appearances they observed. The lesions they
have figured are not those characteristic of typhoid fever, but of ordinary
intestinal catarrh. In one of the autopsies (No. V.) they describe the
agminated glands, near the ileo-caecal valve, as marked with black pig-
ment, quite like the condition often observed in our own war, and de-
scribed as “the shaven-beard appearance.” The mesenteric glands were
enlarged. The anatomical evidences of peritonitis were often present.
Dysenteric sloughs frequently existed in the colon. Nowhere, however,
do I find any description of the bulky tumefaction, ulceration, and
sloughing of the glands of Peyer, which is characteristic of typhoid
fever. Nevertheless, I am by no means sure that this essential lesion
did not exist in some of the cases at least. It must be remembered that
the typhoid lesion was not then known as we know it now. Perhaps
some of the gangrenous spots, of smaller or greater size, which our
authors describe as having been observed in the small intestines of some
of their cases, were really of this nature." This appears to me the more
probable, because in the case of the very similar epidemic which Sarcone”
observed in Naples in 1764, and which, in the circumstances under which
it occurred, its course, symptoms, and the anatomical lesions observed
after death, appears to have been identical with the morbus mucosus of
Röderer and Wagler, I read that these gangrenous spots were again
observed in the alimentary canal of some cases, and that they occurred
chiefly in the small intestines. Dut even if this interpretation is correct
——and I believe it is—I cannot think that the characteristic typhoid lesion
was present in all the cases in which Röderer and Wagler made autopsies,
or it surely would have received greater attention from those acute obser-
vers, and I must think that in part, at least, of their cases, there was no
other lesion of the small intestine than a smart intestinal catarrh.
The doctrine of the mucous fever, as taught by Röderer and Wagler,
took firm root in the medical mind of Europe.” It figures largely in
| Op. cit., p. 162.
* Michael Sarcone. Istoria ragionata dei mali osservati in Napoli, nel corso dell' anno
1764. Naples, 1764. There is a German translation by Fuesslin, Zurich, 1772, and a
French translation by Bellay, Lyons, 1804. Our library contains the German translation
only.
º Ozanam, op. cit., tome i., p. 257 et seq., gives an excellent abstract of the works of
Röderer and Wagler, and of Sarcone.
TYP HO - M. A. L. A. R.I.A. L. F E V E R . 321
many of the text-books of the first half of the present century, and you
will even find the descriptions reproduced without criticism, under the
head of “Mucous or pituitous fever,” in the admirable Dictionary of
Copeland." Some writers have expressed the opinion that this mucous
disease was after all neither more nor less than ordinary typhoid fever.”
I cannot agree with them. I see in the story, as told by the original
observers, unquestionable marks of malarial complications; indeed, also
of scorbutic complications. I do not marvel that the Göttingen ob-
servers should have devoted sections of their work to the discussion of
the relationship of the mucous disease with intermittent fever, and of
its relationship with scurvy, and should have arrived at the conclusion,
to use their own striking language, that the epidemic which they observed
was the corrupted and degenerate progeny of intermittent fever. They
thought they saw also a causal relationship between intermittent fever
and dysentery, an opinion which I cannot discuss here, but which I
must confess I share to a certain extent. No doubt, since their time,
the term mucous fever has often enough been applied to simple typhoid
fever, and although of late it has been banished from the books, it still
survives among certain practitioners who were educated thirty or forty
years ago, and I myself have heard it applied by old practitioners to
unmistakable cases of typhoid fever within the last five years. The
misuse of terms in medicine is, however, a common consequence of im-
perfect knowledge, and we must not allow ourselves to be led astray by it.
I cannot dwell longer now upon this interesting epidemic. Det me
turn next to another illustration, in which the malarial element was still
more potent, and with regard to which I need only present a few salient
points, because it is so often cited in connection with the diseases of
armies that most of the leading facts must be well known to you all. I
refer to the Walcheren fever, which decimated an English army in the
year 1809.
The previous experience of English armies in the Netherlands had
shown the malignant character of the malarial influences which prevail
in that region. It had been described in striking language in the excel.
lent work of Sir John Pringle.” He had recorded that all the flat region
between the rivers Lys and Scheldt and the sea, was marshy and un-
healthful, the home of periodical fevers; that a great part of IIolland,
including Dutch Brabant, was subject to the same disorders, and that
the air was worst of all in Zealand. He has left graphic descriptions of
the fevers which prevailed among the English troops operating in these
low countries between 1742 and 1748. He had observed especially that
when the troops were encamped near stagnant waters the “marsh fevers
are not only apt to begin with little remission, but, after intermitting
for some days, to change into continued fevers of a dangerous nature.”
Especially was this the case during the summer and autumn of 1748,
when the troops were encamped near the inundations of Dutch Brabant.
An epidemic of such fevers occurred among them. Pringle writes:
“At the height of the epidemic it appeared that both intermittents and
remittents, by extending or doubling their paroxysms, frequently changed
| James Copeland. Dict. of Pract. Med., London, 1858, vol. i., p. 988.
* As for example, W. Griesinger. Infections-Krankheiten. Virchow's Handbuch der
Spec. Path. u. Therapie. Bd. II., Abth. 2. Erlangen, 1857, S. 118.
* Sir John Pringle. Observations on the Diseases of the Army. 7th Edit., London,
1774, p. 1 et seq.
* Op. cit., p. 173.
21
322 WOODWARD,
into a continued and dangerous form, and that most of those we lost
died in this way. These men, as we remarked, had a corrupted smell
for a day or two before their death, and soon after, their bodies putrefied.
Some had petechial spots, though the place where they lay was neither
crowded with sick nor too close ; and to these spots were added some
other symptoms, the same with those of the hospital fevers.”
The expedition of 1809 renewed the experiences of Pringle on a more
formidable scale. The English army, of between 42,000 and 43,000 men,
was quite healthy when it set sail from the Downs, July 28, but as
early as the middle of August the number of the sick was so great as
to excite alarm. By the 26th the number was 5000. By the 7th of
September it amounted to 10,948. According to Sir Gilbert Blane,”
26,846 men were sent to hospital in Zealand between the 21st of August
and the 18th of November. The expedition was paralyzed by these
misfortunes, and after the surrender of Flushing, August 15, was
unable to continue offensive operations. In spite of the fact that a large
part of the sick who were sent home to England began to improve so
soon as they escaped from the pestilential regions in which their diseases
had originated, and ultimately recovered, the total mortality was large.
It has been estimated at about 8000 men. I must refer you to IIan-
sard’s Parliamentary Debates, the Annual Register, the Edinburgh Re-
view, and the Essays of Marshall, Sir Gilbert Blane, Dawson, T)avis, and
Wright,” for the particulars of this disastrous expedition. I can only
pause to emphasize a few facts.
The diseases of the Walcheren expedition were diarrhoea, dysentery,
intermittents, and a form of fever which began as a remittent, and sub-
sequently assumed a continued form, and which at that time was desig-
nated the Walcheren fever, or the Walcheren remittent. Sir Gilbert
Blane, who visited the island of Walcheren during September and
October, reported to the Government “that he found so great a propor-
tion of the sick to consist of those affected with the intermitting and re-
mitting fevers peculiar to marshy countries, that there could be no doubt
that the sickness of the army was owing to that cause.” He admits,
however, that he found a certain number of cases of a fever which he
called “typhus,” and of dysentery, particularly at Flushing, where “the
prevalence of these two diseases was very remarkable, particularly in one
regiment, of which all the medical officers were either absent or dead,
and of which the sick, originally affected with the endemic disease,
were suffering also from typhus and dysentery in consequence of the
want of cleanliness, as well as of proper medicines, diet, and attendance.”
Dorland and Lempriere,” two other medical officers serving with the
| Op. cit., p. 181.
* Sir Gilbert Blane. Facts and Obs. respecting Intermittent Fevers, and the exhalations
which occasion them. Med. Chir. Trans., vol. iii. (1812), p. 11.
* Hansard's Parliamentary Debates. Series I., vol. 15, Appendix 22 and 23, and vol.
16, Appendix “Papers relating to the Expedition to the Scheldt.” The Edinburgh Annual
Register for 1809. Edinburgh, 1811, vol. ii., part 1, p. 660. The New Annual Register for
1809. London, 1810, p. 316. Observations on the documents, including the evidence heard
at the bar, laid before Parliament on the subject of the late Expedition to the Scheldt.
The Edinburgh Review, vol. 17 (1810–11), p. 331. Henry Marshall, Contribution to Sta.
tistics of the Sickness and Mortality which occurred among the troops employed in the
Expedition to the Scheldt in the year 1809. Edinburgh Med. and Surg. Journ., vol. 48
(1837), p. 305. Sir Gilbert Blane, op. cit. Davis. Wright, and Dawson—works cited below.
* Op. cit., pp. 2 and 3. - e
* J. Borland and W. Lempriere. Report on the prevailing Malady among his Majesty's
Forces serving in the Island of Walcheren. The Med. and Physical Journal, vol. 23
(1810), p. 183. -
TY PHO - M. A. L. A. R.I.A. L. F. E. W. E. R. 323
troops on the island, reported, in the same spirit, that the malady was
“the endemic fever of marshy countries; the effect of miasmata from a
soil the most productive in deleterious exhalations of any perhaps in
Europe;” stated that it prevailed also among the natives of the island
as an intermittent or remittent fever, and that among the British troops
it assumed “a character of greater malignancy.”
But the most elaborate studies of the Walcheren fever were made by
the medical men whose duty it became to treat the sick who were sent
home to England. Dawson tells us that the Walcheren soldiers were
affected with intermittents in a number surpassing those who were
attacked by the continued fevers; that many of the soldiers who were
subjects of the continued fever had already labored under the intermit-
tent, and that on the other hand intermittents were common among
those who had recently recovered from the continued fever. Davis,”
whose account of the fever is more elaborate, tells us that at the begin
ning it assumed the quotidian, tertian, double tertian, or quartan type,
but that the most common of all was the double tertian. It assumed,
however, the characters of a continued fever of typhoid type as it
progressed, with muttering delirium, small rapid pulse, dry, black
tongue, sordes-covered teeth, fetid odor, and black discharges from the
bowels.
On account of the frequency with which this fever was associated
with dysentery, the characteristic lesions of dysentery were frequently
found in the colon during the autopsies which were made. But Davis’
has also recorded the significant fact that “the ileum and jejunum were
frequently interspersed with tubercles, inflamed and ulcerated in differ-
ent parts.” This description would seem to indicate beyond doubt
that the lesions, which we have now learned to recognize as character-
istic of typhoid fever, were frequently present in the cadavers of
those who had perished from the Walcheren disease. After a thought-
ful study of the evidence, no doubt is left in my own mind that this
fever was not, as has often been asserted, simply a malignant remittent,
but that it was a genuine hybrid between malarial and enteric fever."
Did time permit, I might bring forward other interesting illustrations
from the history of the British Army in the East and West Indies and
elsewhere, from the Algerine experience of the French, and from other
sources; but I fear that I have already occupied too much of your time
with facts of this class. I cannot, however, leave the subject of the
experiences of other armies without bringing to your notice an unex-
pected corroboration of the views I am urging upon your attention,
which I find in an essay published by Virchow in 1871 on the fever and
dysentery of the German army" during the recent war with France,
which he contrasts with the similar diseases of our own civil War, as
described by me in my book on Camp Diseases, and in Circular No. 6..
Virchow hesitates to acknowledge “typho-malarial fever” as a special
' G. P. Dawson. Observations on the Walcheren Diseases. London, 1810, p. 70.
* J. B. Davis. A Scientific and Popular View of the Fever of Walcheren. London,
1810. See also Thomas Wright. History of the Walcheren Remittent. London, 1811.
* Op. cit., p. 192.
* Essentially the same opinion with regard to the Walcheren fever has been expressed
by J. J. Levick. Miasmatic Typhoid Fever. American Journ. of the Med. Sciences,
April, 1864, p. 409.
* R. Virchow. Kriegstyphus und Ruhr. Virchow's Archiv., Bd. LII. (1871), S. 1.
Note pp. 5 and 30. -
324 WOOD WAR D,
f
group of diseases, and exclaims, with cautious conservatism : “It seems
to me we ought to be very careful in this direction.” Yet, in the same
essay, while contending that the prevalent fever of the German army
was simply abdominal typhus, as proved by numerous post-mortem
examinations made at Berlin on soldiers brought back sick from the
front, this cautious but acute observer finds himself compelled by the
facts under his eyes to use the following emphatic language:–
“Nevertheless, abdominal typhus affords such numerous diversities in
its course that it is in the highest degree imperative to preserve every
precaution in the interpretation of individual cases. Especially does
the admixture (Zumischung) of the malarial element, which also in this
war has shown itself active, by numerous cases of intermittent fever,
confuse the picture of the so-called normal course of typhus in a some-
times very deceptive manner.”
Now, I must protest that these words represent the very essence of
the doctrine I am here to defend, and if the comparatively mild malaria
of the plains around Metz was capable of complicating the course of the
abdominal typhus which occurred in the German army to a sufficient
extent to justify this eloquent language, what think you would the
great pathologist have written could he have observed for himself the
fevers of our own army in the valley of the Mississippi or by the banks
of the Chickahominy 7
I have occupied the greater part of my hour with these preliminary
matters; but not, let me hope, in vain. I come now to a rapid sketch
of the principal facts with regard to the typho-malarial fever of the civil
war of 1861–5.
The characters and distribution of the malarial fevers of the region in
which that colossal struggle took place have been described in a most
original and interesting work by our countryman, Dr. Daniel Drake,
who has embraced them under the general designation of autumnal
fevers. This term serves very well to express the greater prevalence of
intermittents and remittents during the autumn months; but it must
be distinctly understood that their occurrence is not limited to these
months. In the regions in which they are endemic, they may occur at
any season of the year, and their course gan by represented by a curve
in which the abscissas begin to lengthen early in the spring, and grow
longer and longer, till they attain their maximum most generally at
some time during September or October, after which the curve rapidly
drops to a minimum during the winter. Sometimes the curve presents,
also, a slightly irregular elevation during the early spring, justifying
the term vernal intermittents, which has often been used ; but most
generally the increasing frequency of these fevers in the spring simply
represents the commencement of the annual rise in the curve which
culminates in the autumn. This is well illustrated by curves which I
have had constructed to represent the monthly number of new cases of
agues and remittents reported in our armies in the Atlantic and Central
regions during the civil war. These I hand you for examination, but I
cannot pause to discuss them at this time. Doubtless the winter and
vernal cases are to be regarded in part as relapses, in part as illustra-
tions of the postponed development of the consequences of previous
Daniel Drake. The Principal Diseases of the Interior Valley of North America.
Cincinnati, 1850. The same, second series, edited, after the death of the author, by S. H.
Smith and Francis G. Smith. Philadelphia, 1854.
TYP HO - M A. I. A. R.I.A. L. F E V E R . 325
exposure; but, however you may choose to interpret them, I wish to
insist upon the point that they occur with much greater frequency than
some of the systematic writers would have us believe.
Dr. Drake has shown that in a general way these fevers are most in-
tense in the States that border on the Gulf of Mexico, and gradually
diminish in frequency and severity as we go to the north, so that they
no longer prevail in epidemic form beyond the 44th parallel, and cease
to occur even sporadically at about the 47th. To the southwest, the
Cordilleras of Mexico and the Southern Rocky Mountains constitute
their boundaries, while in the higher latitudes they cease on the great
plains, long before we reach the mountains. On the Atlantic slope they
prevail with constantly increasing severity as we go southward from
New York, and though they do not occur on the table-lands and higher
ground of the Appalachian chain, yet they ascend high up the valleys
of the streams which flow out of the flanks of those mountains.
In the volume of the Ninth Census of the United States, which is
devoted to Vital Statisties,' there is an interesting map which exhibits
the distribution of the mortality from intermittent and remittent fevers
during the year 1870. Doubtless this mortality, which is but at best
incompletely represented in the Census Report, can only be regarded as
a very imperfect measure of the frequency and severity of these fevers;
but, imperfect as it is, its indications are valuable. It shows in a general
way the almost complete exemption of New York, the New England
States, and the mountainous parts of Pennsylvania, Maryland, West
Virginia, and Virginia, and a gradual increase in severity indicated by
an increasing mortality in the river valleys as we go southward from
the fortieth parallel. It illustrates, also, in a striking manner, a fact
which arrested the attention of Drake,” that in various scattered districts,
from the influence evidently of strictly local causes, the malarial fevers
display greater prevalence and malignancy than they exhibit further
South and on a lower level.
It would be altogether foreign to my purpose to enter in the present
discourse into any discussion as to the causes of these fevers. I simply
urge upon you to-day the great fact of their endemic existence, in some
localities more frequently and with greater severity than in others,
formidable even to the natives of the soil, but still more formidable to
strangers, throughout the whole region in which our great armies ope-
rated during the civil war. The characters of the fevers thus distributed
are too well known to you all for any description to be necessary here.
I need only remind you of the frequent occurrence throughout the
Southern States, side by side with ordinary ague, of malignant forms,
the so-called congestive chills or pernicious fever; of the severity of the
remittent fevers which prevail; of the frequency of big spleens, dis-
ordered livers, and malarial anaemias, and of the great frequency with
which, in these regions, an intermittent type is impressed on the ordi-
nary acute phlegmasiae, and even on chronic disorders.
Drake has also presented an interesting account of the distribution
throughout the United States of typhoid or, as he calls it, typhous
! Ninth Census, vol. ii., Vital Statistics of the United States. Washington, 1872. See,
also, Statistical Atlas of the United States—based on the results of the Ninth Census,
1870. By F. A. Walker, 1874; in which the map in question is given on a larger scale,
and better engraved, as Plate 42.
* Op. cit., First series, p. 704.
326 WOODWARD,
fever." This fever is the usual form in which typhus manifests itself in
the United States. The spotted typhus of the Old World never appears
on our soil except as isolated cases, imported, as “ship fever,” into our
seaports. Drake has correctly pointed out that while in a general way
the typhoid fever of the United States is more prevalent in the Northern
than in the Southern States, it nevertheless does occur both sporadically
and in local epidemics even in the southernmost portion of our territory.
This fact is strikingly illustrated by a map in the volume of the Ninth
Census already referred to, which” represents the distribution through-
out the United States, during the year 1870, of some 24,000 deaths
from typhoid fever. In constructing the map a few hundred cases of
cerebro-spinal fever were included, but their number is too small to
vitiate its value” in illustrating the distribution of typhoid fever during
the year in question. This map, while exhibiting in a general way a
gradual decline in the mortality from typhoid fever as we go to the South,
displays also a number of limited areas of high mortality, representing
the endemic prevalence of the fever during that particular year in certain
localities. Several of these areas of local prevalence are situated in the
Southern States. In one of them, in Georgia, which embraces the region
drained by the Altamaha and Satilla rivers, typhoid fever caused about
one-fifth of all the deaths—a greater mortality than it produced in any
part even of the New England States. In another almost equally re-
markable area, embracing parts of the States of Mississippi and Alabama,
having near its centre the town of Columbus, Mississippi, the propor-
tionate mortality from typhoid fever was nearly as great.
Drake has urged, as one of the distinguishing marks between typhoid
fever and the autumnal fevers, that the former is not limited like the
latter to a particular portion of the year, “between the summer and
winter solstice, but occurs, though unequally, at every season.” But he
believes that “on the whole, however, they are most prevalent in autumn
and winter,” an opinion which has been shared by several careful
writers.”
Liebermeister" has recently compared the statistics of the monthly
prevalence of typhoid fever in some of the great European cities, and
shown that in London, Berlin, and Basle, the curve which represents the
course of the disease is distinctly autumnal in character. “The mini-
mum is in February and April (in the Berlin curve a little later); the
maximum is in September and October. (In Berlin, the maximum is in
October.)” Munich alone presented an exception, the maximum falling
in February. Now, I must say, my study of the sick reports of our civil
war inclines me to believe that the autumnal curve observed by Lieber-
meister represents also the usual annual distribution in this country. I
have constructed curves representing the monthly ratio of new cases to
strength in each of the three regions. These curves present certain irre-
gularities in the Atlantic and Central regions corresponding to the
| Op. cit., Second Series, p. 358 et seq.
* See also Walker's Statistical Atlas, cited above, Plate 46.
* Ninth Census, vol. ii., cited above. Special tables of Mortality, p. xxiii. The
number of cases is, enteric fever, 22,187; typhus fever, 1770; cerebro-spinal fever, 650.
The cases reported as typhus were simply misnamed, and are to be regarded as enteric.
* Op. cit., 2d series, p. 358.
* See, for example, G. B. Wood. Treatise on the Practice of Medicine. 6th ed.
Philadelphia, 1866, vol. i. p. 383.
° Liebermeister. Typhoid Fever, in Ziemssen's Cyclopædia of the Practice of Medicine,
Amer. transl., vol. i. New York, 1874, p. 65.
TYP HO – M A. L. A. R.I.A. L. F E V E R . 327
varying circumstances in the fortunes of the great armies, but on the
whole they represent the disease as most prevalent during the latter
part of the summer and autumn, rather than during the autumn and
winter. In the Pacific region the curve is strictly autumnal. The
maxima are as follows: October in 1861, September in 1862, November
in 1863, September in 1864, October in 1865. The minima were in April
and May for 1862 and 1863, April, 1864, and March, 1865. In the At-
lantic region the maximum for 1861 was in November. In 1862 there
were two maxima, one during the Peninsular Campaign in July, fol-
lowed by a great reduction on the withdrawal of that army, and a second
maximum in October and November. In 1863 and 1864, the maxima
were during July and August. In 1865, during October. The minima
fell in March, 1862; June, 1863; February, 1864; and April, 1865. In
the Central region the maximum for 1861 fell in November; in 1862, in
May. During 1862 the curve was quite irregular ; it rose to a maximum
in May, then diminished in frequency during the summer, and steadily
increased after September through the winter, attaining its maximum in
February, 1863, after which it diminished until June, and then again
increased to a second maximum in August. The maximum for 1864
fell in September; in 1865, during September and October. The minima
were in March and September, 1862; June, 1863; February in 1864 and
1865.
I find from the Annual Reports of the Board of Health of the city of
Boston, for 1874 and 1875, that the mortality from typhoid fever during
those years pursued a markedly autumnal course, the maximum being
during September in 1874, and during October in 1875. In the District
of Columbia the registration returns show that the greatest number of
deaths since 1872 have always occurred during the months of August
and September.
I incline, therefore, to the belief that typhoid fever presents in fact
in this country an annual autumnal curve very similar to that of the
so-called autumnal fevers. I base upon this circumstance no argument
as to the relationship or nature of either disease, but press it upon your
attention as a fact which must not be overlooked.
Next, let me remind you of the important fact that intermittent and
remittent fevers often disappear more or less completely from neighbor-
hoods in which they have long prevailed, and are replaced by typhoid
fever. This circumstance could not escape such a faithful observer as
Drake. He has described it in the following language:—
“Far in the North, remittent fever often presents, almost from the
beginning, a tendency to the continued type, displaying the characteris-
tics of the synochus of Cullen's Nosology. It is properly called au-
tumnal fever, because it prevails most in that season, and is an equivalent
for the true remittent fever of the warmer climates. Nearly the same
remark is applicable to this fever when, in the middle latitudes, it ap-
pears in the long-cultivated and drier portions of Tennessee, Kentucky,
Western Pennsylvania, and Ohio. Formerly it often abated into an
intermittent; latterly, it is apt to degenerate into a continued type.”
Whatever criticism you may choose to bestow on the wording of some
! See Second Annual Report of the Board of Health of the City of Boston, 1874, and
Third ditto, 1875. Both volumes give charts representing the weekly mortality from
typhoid fever. Also, Annual Reports of the Board of Health of the District of Columbia
for 1872, 1873, 1874, and 1875.
* Drake. Op. cit. First Series, p. 781.
328 WOOD WAR D,
parts of this remarkable passage, it is an honest attempt by a keen
observer to describe a class of facts which he had had the opportunity
of observing on a great scale. The substantial truth, that, in numerous
districts throughout this land intermittents and remittents were the
prevailing form of fever when the first settlements were made; that as
time passed by and cultivation progressed, the intermittents diminished
in frequency, the remittents exhibited more and more a disposition to
pass into continued forms, and finally were replaced by ordinary typhoid
fever, which became the prevailing epidemic fever—all this, I suppose,
has occurred under the personal observation of many of the American
physicians who listen to me to-day, and I need not weary you by multi-
plying authorities in proof of a fact with which you must all be familiar.
But next let me observe that the change thus effected is not always a
permanent one. Often in individual years the intermittents and remit-
tents reappear in epidemic-wise in regions such as I have just described,
and then the typhoids vanish for a time, to return once more when the
temporary prevalence of the periodical fevers comes to an end.
Existing thus side by side, replacing each other in this intimate—if
you will, in this intricate manner—it is evident that the unknown causes
of the periodical fevers, and of typhoid fever, whatever they may be,
must frequently coexist. Ought we not, then, to anticipate that indi-
viduals exposed to both would often suffer with fevers in which phe-
nomena belonging to both affections would also coexist?
I suppose the once popular belief that diseases are entities, and that
a man can suffer from but one at time, is now so completely dead that
it is quite unnecessary for me to bring forward facts and arguments to
disprove it. I suppose it to be now well established that individual
cases of disease are always more or less complex, representing in every
instance the total effect of all the morbific causes acting upon the in-
dividual, and modified always by his individual resisting power, the
result of his own individual organization and his own previous history.
Even Sauvages, the greatest of all the systematic nosologists of the last
century, already recognized this fundamental fact when he exclaimed, in
the introduction to his work: “Genera and species of diseases are ab-
stract notions. Throughout the universe neither genera nor species
exist, but only individuals.” Is it wonderful, then, that hybrid forms
of disease, exhibiting the ordinary symptoms of malarial and of typhoid
fever, variously combined, should long have been observed in this coun-
try : In fact, such hybrid forms have long been observed in Europe
also. In the first volume of his Institutes, published in 1781, Burserius’
recognized them as a group; “the Proportionata,” which he defines as
a compound species composed of the synochus and intermittent fever.
This union, he says, occurs especially “when intermitting fevers prevail
epidemically, or at least constitute the prevailing and stationary disease;
for then almost all diseases bear some resemblance to intermittents, or
sporadic, or intercurrent fevers, of whatever other kind, are combined
with the intermitting fevers.” -
Hermann Schmidt,” in his account of the so-called Summer fever, which
was epidemic throughout Europe during the year 1827, has still more
! Sauvages. Nosolog. Method., Amsterdam, 1768, vol. i. p. 26.
* J. Bapt. Burserius. Institut. Med., vol. i., Milan, 1781. I quote ftom Hecker's edi-
tion, Leipsic, 1826, vol. i. p. 512.
* Hermann Schmidt. Uber des Europaeische Sommerfieber, Paderborn und Arnsberg,
1830.
TYP H O - M A. L A-RIA L FE W E R . 329
elaborately described as the form of fever then most generally prevail-
ing, a combination of intermittent fever with the endemic typhus of
Europe (our typhoid fever). He has subdivided the resulting hybrid
forms into two chief classes: 1. Typhus intermittens subintrams, which
he defined as a combination of typhus and intermittent fever, with a
predominance of the typhus element. 2. Febris intermittens typhosa,
which he defined as a similar combination, with a predominance of in-
termittent fever. I would refer you to his elaborate treatise for many
suggestive details.
Naumann' has quoted, with approval, the views of Burserius and
Schmidt, and mentions corroborative observations by several other,
writers, to which I might add many more did the scope of this discours
permit.
Recurring to the American experiences, I would recall to your memory
the fact that the existence of the hybrids under consideration did not
escape the practical eye of Drake : “When remittent fever terminates
fatally in one or two weeks,” he observes, “a certain amount of subsul-
tus, a dryness of the tongue, and intestinal hemorrhage, are sometimes
present, although no typhus fever may be prevailing in that locality,
and this brings us to inquire, not into the distinctive peculiarities of
these two forms of fever, but into their combination, into the hybrid or
mongrel diathesis which results from the joint impress, in ever-varying
proportions, of the causes which produce true typhous and true remittent
fevers.” For these hybrid forms he proposes the designation, “Remitto-
typhous or secondary typhous fever.” “I do not recollect,” he says, “to
have seen a case of fever well-marked as typhous in the early stages
terminate as an intermittent, nor a decided intermittent degenerate into
a typhous. The union is between remittent and typhous.” And this
certainly is the most common combination ; but the combination with
intermittent does also occur, though less frequently, and both the possi-
bilities which Drake tells us he never observed were seen often enough
during the civil war.
The same combination of remittent and typhoid fever which was ob-
served by Drake has also been described by the late Professor Dickson
of this city. Dickson continually emphasized the doctrine of the fre-
quent blending of those febrile types which are “connate in cause and
analogous in symptoms.” He tells us that “it is a matter of familiar
remark, that in long-protracted cases of the ordinary remittent of mala-
rious regions, there is a domination of the palpable contrast or alterna-
tion of the period of febrile exacerbation and unison—a tendency in the
former to continuousness, the latter being less an alleviation of the
symptoms–-and the several symptoms themselves approaching more
and more in appearance those which belong to simple continued fever,
nervous fever, or typhoid fever. In common professional language, such
cases “take on the typhoid character.’” “On examination, typhoid
lesions will sometimes be found in the body dead of bilious remittents.
The mucous membrane of the stomach and intestines is highly injected
in severe and short attacks. In more protracted cases, follicular ulcera-
tion may be found throughout the whole extent of the bowel.”
1 Op. cit. Bd. III., Abth. ii., S. 235.
* Drake. Op. cit., Second Series, p. 556.
3 Samuel Henry Dickson. Elements of Medicine. Philadelphia, 1855, p. 196. See also
his Essay On the Blending and Conversion of Types in Fever. Trans. of the Amer. Med.
Association, vol. v. (1852), p. 127. -
X
330 WOOD-WAR D,
Similar opinions were long entertained by my revered preceptor, Dr.
George B. Wood. He has told you that remittent fever “is sometimes
of a low, adynamic or typhous character from the commencement. This
may be the result of a previous exposure to causes calculated to depress
the vital powers and to deprave the blood; but it probably most fre-
quently arises from the co-operation of a typhoid epidemic influence with
miasmata.” He did not believe that the characteristic lesions of typhoid
fever ever occur in pure remittents, as some have reported, and explained
their observations by the remark that “there is reason to believe that
enteric fever has sometimes been mistaken for bilious or remittent fever,
and lesions belonging to the former been placed to the account of the
latter; and not unfrequently, in all probability, the two diseases are in
greater or less degree mingled together.”
Now, under the conditions which existed in the camps of our armies
during the late civil war, these hybrid combinations, which had already
attracted the attention of such men as Drake, Dickson, and Wood, in
civil life, made their appearance, as might have been predicted, on a
great scale, and produced, as I have already shown, a formidable mor-
tality. It was for these hybrid forms that I proposed the term typho-
malarial fever. I never meant this term to represent a specific type of
#.i.a it to designate all the many-faced brood of hybrid
forms resulting from the combined influence of the causes of malarial
fevers and of enteric fever. The term corresponds essentially to the “Pro-
portionata” of Burserius. It includes both the “Typhus intermittens
subintrans” and the “Febris intermittens typhosa,” of Herman Schmidt,
and the “Remitto-typhous” of Drake. These are merely varieties of the
group of hybrids, all of which I intended to embrace. I pointed out,
in my book on Camp Diseases, that this whole group might be conve-
niently divided, for the purpose of study, into—1. Fevers in which the
malarial element, without being the only pathological condition present,
is the predominant one ; and, 2. Fevers in which the typhoid element
is evidently predominant, although the others are also present in a more
or less distinct manner. To these I felt compelled to add a third group,
namely, “Fevers of either of the first two varieties, in which from the
first, or at Some time during the progress of the affection, the scorbutic
element becomes predominant.” To this general grouping of the cases,
with all the light of subsequent experience, I must still substantially
adhere.
In the group of cases in which the malarial phenomena predominated,
the disease began as a simple intermittent or remittent fever, of quoti-
dian, tertian, or quartan type, the most frequent form being a simple or
double tertian ; but after a week or ten days the fever assumed a more
or less completely continued type, with many of the phenomena char-
acteristic of typhoid fever, such as diarrhoea, abdominal tenderness,
meteorism, muttering delirium, subsultus tendinum, dry, brown tongue,
and the like. But even when the typhoid phenomena were most pro-
nounced, some of the most characteristic of them were often wanting.
Thus, sometimes there was no diarrhoea at all, but constipation instead.
The characteristic tache rouge, or rose-colored eruption, was generally
entirely absent; gastric disturbance, hepatic tenderness, and an icteroid
hue of the countenance were much more generally present than in simple
typhoid fever.

| Wood. Op. cit., vol. i., pp. 307 and 309.
TYP H O - M.A. L. A. R.I.A. L. F. E. W. E. R. 331
Now, a large proportion of these cases terminated favorably, especially,
as I think, because quinine was so freely used in their treatment; the
occurrence of ordinary paroxysms of ague was a frequent accident during
the convalescence. And, just because of the frequency with which they
recovered, I suppose, the number of autopsies in cases of this kind which
I have been able to collect is much less than in cases of the second group,
of which I shall presently speak. Still, I have collected a number of
autopsies of cases of this kind, in which diarrhoea had been present dur-
ing the fever, and in which, after it had assumed a continuous type, it
had strikingly resembled typhoid fever, but in which dissection showed
no other lesion in the alimentary canal than a smart intestinal catarrh.
Patches of inflammation, scattered irregularly throughout both small and
large intestines, and enlargement of the closed glands, often associated
with pigment deposits, were the characteristic lesions. The solitary
glands of the small intestine appeared as little projecting tumors the size
of pinheads, which often had constricted necks, so that they resembled
tiny polypi. The agnminated glands of Peyer, slightly prominent, were
often the seat of pigment deposit, which gave them the so-called shaven-
beard appearance. Sometimes the villi of the small intestines were hyper-
trophied ; sometimes they had pigment deposits at their apices. In the
large intestine the slightly swollen solitary glands were often the seat of
pigment deposits, seated either in the glands alone, or sometimes also in
the surrounding mucosa, in which case the central dot of pigment was
surrounded by a little pigmentary ring. When the fever had supervened,
as often happened, upon a chronic flux, or where dysentery had been de-
veloped during the course of the fever, or of the convalescence, and had
been the immediate cause of death, the characteristic follicular ulcera-
tions of the colon or the phenomena of the diphtheritic process compli-
cated the picture. Great enlargement of the spleen and congestion of
the liver, with or without fatty degeneration, were frequent concomi-
tants. The condition of the intestinal canal in these cases closely resem-
bled that which has been emphasized by Röderer and Wagler, and by
Dickson. Between the simple inflammatory enlargement of the closed
glands, which I have pictured, and the more luxuriant process which
occurs in ordinary typhoid fever, and which most pathologists believe to
be specific, every possible transition existed. I, for one, confess myself
unable to draw a line between the two conditions. Anatomically they
appear to pass into each other by insensible gradations. The essential
element of both is the accumulation of a swarm of migrated white cor-
puscles in the closed glands, in the surrounding lymph passages, and the
adjacent connective tissue, associated, doubtless, as we must infer from
the study of other inflamed tissues, with multiplication of the lymph
cells of the parenchyma of the closed glands by division, though it is dif-
ficult, if not quite impossible, to demonstrate this latter phenomenon in
the present case. The sloughing and ulceration of the so-called typhous
process is, I think, sufficiently well explained by the intensity of the
process and the nutritive disturbances which thence result, without
conjuring up in our imaginations an undemonstrated specific something
to account for it.
The group of cases in which the typhoid phenomena predominated
more closely resembled ordinary typhoid fever. They began more like
it; they ran their course like it; like it, they refused to be cut short by
quinine; after death they presented the characteristic lesions of the
patches of Peyer. But even these cases presented, also, many phenomena
332 WOODWARD,
s
which did not belong to ordinary typhoid fever. First of all, I must
emphasize the manifestation of an unwonted tendency to periodicity.
This was not merely an exaggeration of the daily exacerbation and re-
mission, which we all know as a part of the history of the early stages of
typhoid fever. The exacerbations assumed with great frequency a ter-
tian or double tertian type, which has no parallel in the ordinary typhoid
history. With this tendency to periodicity, the gastric and hepatic dis-
turbances common in remittent fever were often associated in the early
stages, and ordinary ague paroxysms often occurred in the convalescence.
The autopsies in these cases disclosed the ordinary lesions of typhoid
fever. During my earlier studies I believed that I had observed certain
peculiarities in the character of the ulcers in these cases, by which they
might be distinguished from the lesions of simple typhoid." A larger
experience, especially the examination of a large number of specimens
received by the Medical Section of the Army Medical Museum, has con-
vinced me that this opinion was premature. I renounce it as erroneous.
There is really nothing in the lesions of Peyer's glands, in these cases, to
distinguish them from ordinary cases of typhoid fever ; and it was just
these lesions, so well known to you all that I need not pause to describe
them, which were observed in the vast majority of those fatal cases of
fever occurring during the late war in which autopsies have been re-
corded or specimens preserved. As for the other lesions observed in these
cases, tumefaction of the spleen, far beyond the degree ordinarily ob-
served in typhoid fever, was common enough, and the pigment deposits
in various tissues and organs, which are so frequent in malarial diseases,
were very often encountered. Moreover, the colon lesions, characteristic
of chronic fluxes or of acute diphtheritic dysentery, were frequently asso-
ciated, as is well shown by numerous specimens in Our Museum.
I will not for a moment, however, countenance the sophism that, be-
cause the lesions of ordinary typhoid fever were those most frequently
encountered during the war in fatal cases of fever, uncomplicated
typhoid fever was the prevailing febrile form. On the contrary, as I
understand it, though this was the lesion in the majority of fatal cases,
the slighter lesions described in connection with the first group were
those which most probably existed in the majority of the cases which
recovered. Nor will I admit the fallacy that, even in those fatal cases
in which the typhoid lesion was most marked, the patients are thereby
proved to have died of simple typhoid fever. I will not emphasize the
big spleens, pigmentary deposits, or other anatomical evidences of ma-
larial complication. I will even admit the uncertain diagnostic value
of all these phenomena in the present state of our knowledge. But I
cannot ignore the facts of clinical observation. I cannot but see in the
periodicity and other clinical evidences of malarial complication to which
I have briefly alluded, proof of the action of an additional morbid
agency, to which I doubt not we must look for one reason of the great
mortality of the fever cases in our armies.
It often happened that, in fevers belonging to either of the classes I
have just described, scorbutic phenomena complicated the picture, and
sometimes even took a commanding place in determining the course
and issue of the disease. I have affirmed, and shall elsewhere bring
forward satisfactory evidence in proof of the assertion, that a mild but
distinctly recognizable scorbutic taint was wide-spread among our
| Camp Diseases, p. 102.
TYP HO - M. A. L. A. R.I.A.T. F. E. W. E. R. 333
soldiers. It manifested itself as a peculiar anaemia, accompanied by
muddy complexion, large, smooth, flabby tongue, and by neuralgic or
pseudo-rheumatic pains in various parts of the body, especially in the
back. As a rule, it was only after this scorbutic anaemia had existed
for some time, either alone or variously complicated with symptoms due
to malarial poisoning, that the characteristic scorbutic conditions of the
gums, the scorbutic indurations about the joints of the lower extremities,
and the well-known scorbutic purpura made their appearance. These
easily-recognizable symptoms of fully-developed scurvy were but mod-
erately frequent. The preliminary anaemia, however, was common
enough, though often overlooked or misunderstood.
Now, when either of the forms of typho-malarial fever, which I have
described, occurred in individuals suffering under the scorbutic taint, the
symptoms were modified to a degree corresponding to the intensity of
the scorbutic condition. The effect of the complication was to increase
the tendency to mental and bodily prostration during the disease, to
tardy convalescence subsequently, and to increase the frequency of pe-
techial and purpuric eruptions, and of hemorrhages from the nose and
bowels. Sometimes the characteristic scorbutic condition of the mouth
was developed during the progress of the fever, when it had not pre-
viously made its appearance. When the characteristic typhoid process
was developed in individuals laboring under a marked scorbutic taint,
the symptoms closely resembled those of spotted typhus. Fatal hemor-
rhages from the bowels were common in such cases, and on the dissec-
tion, the lower patches of Peyer were found converted into dark-red or
black pultaceous sloughs of considerable size and thickness. I suppose
the scorbutic condition to have modified the typhoid ulceration in such
cases, just as we often see it modify the condition of superficial ulcers
or of gunshot wounds.
The outlines of the chief phenomena of typho-malarial fever which I
have thus endeavored to present to you to-day are necessarily incomplete,
for it is, of course, impossible to go into the details of so large a sub-
ject in a paper like this. I hope to be able to fill up these outlines
in a satisfactory manner in the second volume of the Medical History
of the War.
And this brings me, at length, to answer the question—Is typho-mala-
rial fever a special type of fever ?—and I reply, unhesitatingly, that it
is not. I, at least, am free from the blame of that error, if any one has
fallen into it. In my first published account of typho-malarial fever, I
expressly denied that it could be regarded as a new disease. “Much
rather,” I said, “should it be considered simply as a new hybrid of old
and well-known pathological conditions, in which the exact train of
symptoms is as variable as the degree of preponderance attained by each
of the several concurring elements.” And this is the view which I ad-
vocate to-day. The essential point which I desire most to impress upon
you is the recognition of the group of hybrids between typhoid fever
and the malarial fevers. The scorbutic complication was a mere acci-
dent of the war; its existence is by no means essential to the idea of
typho-malarial fever, but in dealing with the typho-malarial fever of the
war I could not omit it from the picture.
It was, and still is, my belief that the mixed forms of fever which I
have thus sketched constituted the great majority of the continued
* Op. cit., p. 111.
334 WOODWARD,
fevers of our army during the civil war. I still, however, adhere to the
opinion which I expressed in Circular No. 15 of 1863, and in Circular
No. 6 of 1865, that simple typhoid fever and simple remmittent fever did
also occur, though the statistics fail to show to what extent; and I still
adhere, also, to the view then expressed, that a large portion of the cases
actually reported during the war “ as typhoid and remittent fevers are,
to a great extent, to be regarded simply as those in which the typhoid
or the paroxysmal phenomena predominated.”
It would follow, from the views I have advanced, that typho-malarial
fever ought to be encountered also in civil life, particularly in our Southern
States; not, indeed, to the same extent that it existed during the war,
when hundreds of thousands of soldiers, born and bred in the Northern
States, campaigned in the malarial valleys of the South, but to an extent
which deserves thoughtful recognition. And this, I must believe, from
my own observations, and from facts communicated by professional friends
in various parts of the South, is actually the case.
Since the close of the civil war my doctrine of typho-malarial fever
has been accepted with approval in many quarters, and the term has been
extensively used. Dr. Meredith Clymer" has adopted it as a synonym of
“American Camp Fever” in his edition of Aitken’s Science and Practice
of Medicine. Dr. George B. Wood,” though unwilling to adopt the
name, has fully recognized the great prevalence during the civil war of
“this mixture of the two fevers.” In the sixth edition of his work on
Practice of Medicine, published in 1866, he remarks: “Since the last
edition was published this complex affection has been much more preva-
lent than before, probably because great numbers of young men engaged
in the armies at an age when the predisposition to enteric fever is strongest,
have been in an unusual degree exposed to the joint action of the causes
of the two fevers; to that of enteric fever, in the almost unavoidable
filth attendant upon great encampments, and to that of bilious remittent
or intermittent in the low grounds from which miasmatic effluvia are so
abundantly extracted in our Middle and Southern States in the latter
part of summer and in autumn.”
Dr. Austin Flint,” whose former experience in the South makes me
regard his opinion in this matter as particularly valuable, in his Treatise
on the Practice of Medicine, has adopted the term typho-malarial fever
as a convenient designation to represent the hybrids which had been
indicated by Drake and Dickson, and which Flint himself tells us he has
recognized in his own lectures to medical classes for twenty-five years.
His article on simple remittent and typho-malarial fever is an admirable
one, to which I refer you with pleasure.
With this intelligent corroboration and support of my views on typho-
malarial fever, there has been, I must admit, some indiscriminate use of
the term, which is well calculated to bring it into discredit. I have
myself known it to be erroneously applied to simple typhoid fevers, in
the clinical history of which I at least could see nothing to indicate a
malarial complication, and to simple remittents in which I could perceive
no typhoid symptoms. I think I have observed, also, a tendency in
certain quarters to bestow the term upon almost any obscure febrile affec-
1 Wm. Aitken. The Science and Practice of Medicine. With additions by Meredith
Clymer. Philadelphia, 1872, vol. i. p. 607. -
* Op. cit., vol. i. p. 377.
8 Austin Flint. A Treatise on the Principles and Practice of Medicine. Philadelphia,
1866, p. 749; also Fourth Edition. Philadelphia, 1873, p. 934.
TYP H O - M. A. L. A. R.I.A.T., F. E. W. E. R. 335
tion which offered diagnostic difficulty. May I not hope that the publi-
cation of this paper may serve to diminish abuses of this kind hereafter 7
But although widely accepted, my views with regard to typho-malarial
fever have not escaped criticism. Dr. Roberts Bartholow, formerly an
Assistant Surgeon of the Army, and now a successful practitioner in
Cincinnati, has attacked them with a good deal of acrimony in an article
on the Camp Fevers of the Civil War, which he contributed to the Medi-
cal Volume of the Memoirs of the United States Sanitary Commission.
Led away by the energy of his attack, he goes so far as to affirm boldly
“a typh element did not in my experience exhibit itself as a modifying
condition in remittent fever.” He declares the camp fevers of the army
to have been remittent, simple continued, typhoid, and typhus, and affirms
that “these several forms of fever preserved as distinct clinical features
in the army as the same forms of disease in civil life.” To give force to
his criticism, he even goes to the extent of misrepresenting my views,
and says: “There were, therefore, according to Woodward, really no
cases wholly typhoid, or wholly remittent, in the army”—although I had
distinctly affirmed the occurrence of such cases in all my publications on
the subject. I will not pause in this place to answer these criticisms of
Dr. Bartholow in detail. I would merely remark that, although he
makes typhus one of the forms of camp fever, he himself admits that he
has no knowledge of it from personal observation. And though he is so
ready to deny that the typh element, as he calls it, can complicate malarial
fevers, he is compelled to concede that the malarial influence can com-
plicate typhoid fever. This he has explicitly affirmed to be a common
occurrence in civil life, in another article contributed to the same volume
of the Memoirs of the Sanitary Commission. His language is: “I have
already adverted to the fact that, as populations increase in malarious
districts, typhoid supplants the intermittent and remittent fevers. Dur-
ing the transition period a mixed fever prevails; it is a typhoid fever
with a malarial complication.” He admits, therefore, the combination
of malarial and typhoid fevers, but holds that the typhoid element is
always dominant. Against this, I maintain that sometimes the one and
sometimes the other of the two elements predominates, and I must believe
that the facts are on my side. I may add that the distinguished editor
of the volume of Memoirs in question, Dr. Austin Flint, felt himself
called upon to append to Dr. Bartholow’s essay the following remark:
“The general favor with which the term typho-malarial has been received,
and the readiness with which it has come into vogue, show that it
expresses a pathological doctrine consistent with clinical experience.”
In his hasty criticism, Bartholow falls into another error—so mis-
chievous, that I cannot permit it to go unchallenged. He denies the
frequency of a scorbutic taint among our soldiers during the civil war,
and thinks that even the cases reported as actual scurvy include many
of “ordinary stomatitis.” He says: “In a pretty extended course of
observation, I did not meet during the war a single well-marked case of
scorbutus.” A general belief that Bartholow’s opinions as to this mat-
ter are correct would be a serious obstacle to any attempt to improve the
alimentation of our soldiers in any future war. In fact, however, this
opinion is so far wide of the truth, that I can only understand it as an
! Roberts Bartholow. Camp Fevers, being chap. 2 of the Medical Volume of the
Memoirs of the U. S. Sanitary Commission. New York, 1867, p. 193 et seq.
* Op. cit., p. 126. * Op. cit., p. 214. * Op. cit., p. 196.
336 WOODWARD,
illustration of the extent to which one may be led astray by the eager-
ness of controversy. It is not necessary to leave the volume in which
Bartholow’s paper is printed to find evidence to contradict him. You
will find such evidence in the paper by Dr. Sandford B. Hunt, which
constitutes the third chapter of the volume; and in the first chapter of
the volume, by Dr. Bartholow himself,” he makes a series of statements
which fully justify my views. Thus, he affirms that the amount of
aliment furnished to the various armies was too often “determined by
the transportation available for bringing it forward, and by the so-called
military necessity;” and that “the armies operating in the interior region
were more affected by deficiencies in commissariat supplies than those
on the Atlantic coast,” of which fact he gives several striking examples.
He explicitly states that “the diet was not sufficiently varied.” “Anti-
scorbutics came to be furnished after the first year of the war, but the
chief antiscorbutic—the potato—was practically unavailable, from the
difficulty of transporting and preserving it.”
Is it wonderful that, in this connection, Dr. Bartholow, adopting the
very term he criticizes when used by me, should have felt compelled to
write : “A scorbutic taint was to be observed in troops who had served
in the South for a considerable period;” and, further on, that “an im-
poverished state of the blood, due to defective alimentation, undoubtedly
existed to a large extent. It exhibited itself in various forms, but espe-
cially in increasing the fatality of diseases and in impressing an adynamic
character on those of mild and tractable forms.” Still further : “The
camp fever of the army was essentially typhoid. It was modified by
various accidental and specific causes. We have just alluded to Cne of
the specific modifying causes—malaria. The most important of the
others was scorbutus.”
It would occupy too much time for me to attempt to bring forward
even a small part of the evidence on which my belief of the wide-spread
existence of a scorbutic taint among our troops during the late war rests.
My own observations and opinions have been corroborated by those of
numerous capable medical officers. As for actual pronounced scurvy, so
fully developed that it could be recognized by the average regimental
surgeon, 30,714 such cases, not of the scorbutic taint, but of “scuRVY,”
were officially reported among the white troops during the war, and
16,217 among the colored troops.”
The other critic to whom I desire to refer is Dr. Jerome Cochran, of
| Op. cit., p. 64. * Op. cit., pp. 16–19.
* The ratio of these cases to strength greatly increased during the latter part of the war,
and attained formidable proportions among the troops sent to Texas during the year fol-
lowing the war. The following ratios are computed from the tables published in the first
volume of the Medical History of the War :—
Ratio of Cases of Scurvy per 1000 of mean strength.
WHITE TROOPS.
Year ending June 30, 1862 . tº e © * º gº 4.7
{ % & 4 “ “ 1863 . § o e & º tº 12.6
4 & 66 “ “ 1864 . 9.6
§ { $$ $ 6 “ 1865 . 22.4
4 & § { “ “ 1866 . 28.4
COLORED TROOPS.
Year ending June 30, 1864 . e ſº e gº g ſº . 66.5
& 4 & C “ “ 1865 . o & te º & tº . 65.0
( & £ 6 { % “ 1866 . e e ſº e * > © . 141.6
TYP H O - M A. L. A. R.I.A. I. F. E. W. E. R. 337
Mobile, whose objections I find in the Transactions of the Medical Asso-
ciation of the State of Alabama for 1875. This gentleman's service as
a surgeon in the Confederate Army inclines me to regard his somewhat
grotesquely presented criticism with a respect I could not have felt had
it proceeded from a less reputable source. Singularly enough his objec-
tions precisely contradict the objections of Bartholow ; so that I might
readily call upon either gentleman as a useful witness to contradict the
asseverations of the other. Bartholow will see nothing in the continued
fevers of the war but the typhoid element; Cochran will see nothing in
the fevers around Mobile but the malarial element.
“During the last six months,” he writes, “several cases of protracted
fever, primarily of malarial origin, but assuming in their course certain
typhoid symptoms, have been related to the Society under the name of
typho-malarial fever.” He objects to this term and the theory which it
implies. He thinks the fevers in question are purely malarial. “The ma-
larial mother is easily found, the fruitful mother of many children, but
for the typhoid father I have looked in vain through all the streets and
alleys, in all the wards and suburbs of the city;” and again: “I can
only continue to say that if we have typhoid fever here, I have never
seen it.”
Now, the very same volume in which Dr. Cochran publishes this, con-
tains a tabular statement of the deaths in Mobile during the year 1874.
Among these I find three from intermittent fever, twelve from remittent
fever, seven from congestive fever, one from typho-malarial fever, six from
yellow fever, one from hemorrhagic-malarial fever, and five from typhoid
fever.” Dr. Cochran himself tells us in the course of his remarks that his
antagonists among the Mobile physicians declare the existence in that
town of “a continued fever with diarrhoea, dry tongue, frequent deli-
rium, a rose rash, running a persistent course of three weeks or more,
and defying all treatment to arrest its progress;” but he will not admit
that this fever is typhoid. He does not bring forward any dissections
in proof of his views; indeed, he does not appear to have made a single
autopsy in any of the cases in dispute. He bases his opinion entirely
on a priori considerations deduced from his belief in the incompatibility
of the idiopathic fevers. He proclaims that “ there can be no doubt
whatever of the truth of John Hunter's general doctrine, that no two of
them can exist in the same part of the body at the same time.” I can
only express my belief that if Dr. Cochran had spent a part of the time
which he has employed in criticizing my views, in making, with his
fellow-practitioners, some autopsies on the cases of fever, which he tells
us they persist in calling typho-malarial and typhoid, he would have
arrived at results quite at variance with the opinions he has expressed.
And now, one word before I close, as to the question of nomenclature.
Is it convenient to bestow a single term, as I have done, upon the whole
brood of hybrid forms resulting from the simultaneous aetion of malaria
and of the causes of typhoid fever; or, is it best to use several designa-
tions according as the one or the other of the two elements predomi-
nates? We might give the cases in which the typhoid element pre-
dominates the name miasmatic-typhoid fever, suggested by Levick,”
| Jerome Cochran. Note B. Typho-malarial Fever. Trans. of the Med. Association of
the State of Alabama, 28th Session, 1875. Montgomery, Ala., 1875, p. 337.
* Op. cit., p. 314.
* Op. cit. Supra; also a lecture by the same author, Miasmatic Typhoid Fever. Med,
and Surg. Reporter, June 21, 1862, p. 283.
22
338 WOOD WAR D,
and call those in which the malarial element predominates typhoid-
miasmatic fever. Such a double momenclature we have already seen
was suggested by Hermann Schmidt. We might go still further, and
apply special names, in accordance as the malarial element showed itself,
by giving to the early stages of the case an intermittent or remittent
type. I do not think this is at all necessary. I think a single term
which shall include all the hybrids quite sufficient; but I shall not
Quarrel with any one who wishes to make further subdivisions.
If we agree to represent all these hybrid forms by a single appel-
lation, is the designation Typho-malarial the best for the purpose ?
Would it be an improvement to adopt the term “entero-miasmatic,”
suggested as a substitute by Dr. George B. Wood " I confess to a
preference for the term I have suggested. It is easy enough to pro-
nounce, and seems to me to express its meaning very well; but I attach
far less importance to the employment of the name which I have sug-
gested than I do to the recognition of the compound forms of fever
which I intended to represent by it. The name is, after all, a mere
matter of choice. But if I have rightly presented the subject, a just
appreciation of the hybrid forms which I have urged on your atten-
tion to-day is a matter of grave practical importance. Not merely as a
question of Military Medicine, though most important in that connec-
tion, for I take it that whenever again hereafter an army recruited in a
comparatively non-malarial region shall campaign on a malarial soil,
these hybrid forms will appear once more in epidemic proportions; but
meanwhile, I suppose, in sporadic or endemic-wise, we shall continue
to have these cases to deal with in civil practice in all the miasmatic
regions of our Middle and Southern States, and their right compre-
hension is, therefore, a question of serious moment to every Ameri-
can physician engaged in practice in such localities.
T)ISCUSSION ON DR. WooDWARD’s PAPER.
After the reading of the preceding paper, Dr. RoberTS BARTHOLOW, of
Cincinnati, said:—I have listened very attentively to the paper just read, and
as it refers to some criticisms of mine, I feel called upon to reply. I have
studied Dr. Woodward's writings, and, with many other physicians of the
United States, have labored under the impression that he had attempted to
erect the Typho-malarial fever into a distinct type of disease. Now he recalls,
denies, and repudiates what he has formerly published. In the paper which I
had the honor to contribute to the volume issued by the Sanitary Commission,
and to which allusion has been made, I simply stated that there were distinct
cases of simple typhoid and of remittent fever in the army of the United States.
As a practitioner in the Ohio Valley, I have seen cases of fever in some of
which the malarial, and in others of which the typhoid element predominated.
The paper just read throws no new light on the subject. The form of disease
referred to has been long since known. I must repudiate the idea that the
statements in my paper were made in an acrimonious spirit. When eminent
medical men publish their views, the most obscure member of the profession
has a right to express a difference of opinion, and should not be stigmatized
as acrimonious simply because he utters his opinions in a determined and fear-
less manner.
Dr. WooDwARD said:—I wish simply to say that Dr. Bartholow under-
took to write a history of the fevers of the Civil War for the Sanitary Com-
| Op. cit., vol. i. p. 377.
TY PEI O - M. A. L. A. R.I.A. L. F. E. W. E. R.
mission. He criticized my views, as I thought, in an acrimonious spirit, and
I resolved at the time to reply, but have not till the present occasion had
a convenient opportunity. If after reading my paper, Dr. Bartholow still
thinks that I have misrepresented his criticism, I will offer him an apology for
having done so.
Dr. N. S. DAVIs, of Chicago, said:—I had not supposed that the term
“typho-malarial” was intended to indicate any specific form of fever, and am
Surprised that the author of the paper seems to combat the idea that it should
be so received. I supposed that it meant simply the intermingling of the
Causes of two distinct forms of fever, in such a way that they influenced the
human system at one and the same time. This phenomenon of intermingling
has been familiar to me ever since I took up my residence in Chicago, in 1849.
Then it was almost universally believed that our fevers were of a malarial
character; very few recognized typhoid fever as such. The locality was highly
malarious. The population was about 30,000, and there was not a foot of
sewerage. The supply of water was drawn from superficial wells, and the
prevalence of intermittent and remittent fevers was very distinct. Ten or
twelve years later, when sewerage had extended, and a supply of lake water
had been supplied, the intermingling was observed. Cases of fever at their
onset were regarded as malarial, but, not yielding to the influence of quinia,
were ultimately recognized as of a typhoid character. As time passed on, the
typhoid element predominated, and we now find no difficulty in recognizing
the intermingling of types.
Dr. W. SCOTT, of Cleveland, Ohio, said:—I rise to bear testimony to some
of the facts set forth in Dr. Woodward’s paper. Physicians of thirty years'
standing in the Ohio Valley, and especially in the southern portion of the
State, remember the time when this complex condition was unknown. Our
experience is that the typhoid element is not affected by the use of quinia.
When I have recognized this mixed form of disease, I have given quinia in
sufficient doses to destroy the intermittent character of the affection, when the
fever persists in the continued form. In 1864 I was in Nashville, and observed
many cases of scurvy among the soldiers in the Nashville hospitals.
Dr. W.M. PEPPER, of Philadelphia, said:—At the time I first read Dr. Wood-
ward's publications on the subject of typhoid and malarial fevers, they made a
clear impression on my mind ; and I think his views as now expressed are the
same with slight modifications as to the anatomical relations of these two
affections. I confess, however, to some hesitation as to the propriety of em-
ploying a special term to distinguish a disease which is not itself specific. A
great deal of confusion has resulted from the use of such terms; and I have
found many who regard typho-malarial fever as wanting the specific characters
of typhoid fever, and as, therefore, not requiring the same care as the ordi-
nary uncomplicated form of the disease. We meet with cases of typho-mala-
rial fever in this city, and I have myself become very familiar with it. It is
found itself, however, to present so many forms and varieties, partly depending
on the relative proportion in which the typhoid and the malarial elements are
combined, as to render it very difficult to give a clinical definition of it. More-
over, I have not found that the symptoms which are usually given as indicating
the coexistence of the two poisons, are as constant and reliable as appears to
be thought by many, and as they certainly must have been in the army cases
upon which Dr. Woodward founded his classical memoir. Thus, for instance, it
is true that in the malarial form of typhoid fever an initial chill and an early rise
in temperature are more common than in the uncomplicated form. But there
are so many irregularities in the mode of onset and course of typhoid fever,
apart from any complication, as to render this of uncertain value. And in
this connection I would add that careful study of the irregular and abortive
forms of typhoid fever has convinced me that the fixed rules for the tempera-
ture curve in this disease adopted by many authors, must be very considerably
modified. What I have said of the initial chill and the fever-curve, I might say

340 WOODWARD, TYPHO-M A LARIAL FE VER.
of the kind of tongue thought to be characteristic ; of the relative frequency
of eruption, diarrhoea, epistaxis, etc., in the two forms of the disease. We
are not in the habit of erecting into special types of disease the cases of other
affections which are complicated with malaria—as, for instance, pneumonia,
dysentery, etc., and, although in the case of typhoid fever this complication is
certainly more frequent than in any other affection, it appears doubtful to me
whether it would not be better to include typho-malarial fever under the general
head of typhoid fever, and to merely designate it as the “miasmatic form” of
that disease. Still, there is a feeling among physicians that the use of the term
“typho-malarial” is convenient, and it is perhaps desirable that for the present
at least it should be recognized.
The Secretary read the following remarks contributed by Dr. J. A. ESTLAN-
DER, of Finland :- At certain periods, malarial fever is very common along the
southern coast of Finland; at other periods it disappears altogether. During
the last years of the decade 1850–60, it reigned over the whole coast, but from
1860–68 it disappeared so completely that not one single case was to be met with
at the hospital. From the last-named year until the present time, it has again
plagued this part of the country very severely, but seems now to be fast decreas-
ing. This periodicity seems to depend on the atmospheric pressure, for when
during our short summer the average range of the barometer is high, the water-
level is low, and the bottom of the sea, in the numberless small creeks and bays
penetrating the shores of the Gulf of Finland (where, by the way, no tide is
perceptible), lies uncovered and exposed to the sun. When, on the contrary,
the mean barometer is low, all is covered with water, and the summer is rainy
and cold, but free from malaria. The abdominal form of typhoid fever may be
called endemic in my country, for cases of that fever occur every year and at
every season, although sometimes with more, sometimes with less, intensity
and frequency. At such periods, when the malarial fever is very intense, we
often see cases exactly like those so well described by Dr. Woodward. These
cases most frequently appear in spring and autumn, and particularly in the
early part of the last-named season, to wit, the month of August, for such, in
this land of short summers, this month is designated. For this reason, this
fever is in my country commonly called “Augusti-feber.” Dr. Woodward has
riamed this form of fever “Typho-malarial,” to define it as a hybrid of the
typhoid and the malarial fevers, and I gladly accept this name and its signifi-
cation. It is a well-known fact that during a period when the malarial consti-
tution is predominant, many diseases combine in a curious manner with this
fever, as for instance diarrhoea and bronchial catarrh, particularly in children,
and therefore such a concurrent action of separate intoxications, as the name
“Typho-malarial” implies, has many analogies in pathology.
On motion of Dr. WooDwARD, seconded by Dr. PEPPER, the following was
adopted as expressing the opinion of the Section:—“Typho-malarial fever is
not a specific or distinct type of disease, but the term may be conveniently
applied to the compound forms of fever which result from the combined influ-
ence of the causes of the malarious fevers and of typhoid fever.”
341
ARE DIPHTHERITIC AND PSEUDO-MEMBBANOUS CROUP
IDENTICAL OR DISTINCT AFFECTIONS:
BY
J. LEWIS SMITH, M.D.,
PHYSICIAN TO THE INFANT HOSPITAL, NEw York, ETC.
THE term Pseudo-membranous Croup, Membranous Croup, or, for brev-
ity, Croup, is applied to a sporadic inflammation of the larynx, which is
accompanied by the formation of a pseudo-membrane upon the laryngeal
surface. It is attended by no symptoms. except such as are referable to
the local disease, and it destroys life by the mechanical effect of the exu-
dation. Croup is universal; Steiner says, “Croup extends over the whole
world, but strikingly diminishes in frequency, according to A. Hirsch,
as we pass from the higher latitudes to the tropics.” Therefore nearly
every physician in general practice meets cases from time to time. My
present purpose is to consider the relation of this malady to an inflamma-
tion of the same parts, which is accompanied by a similar exudation and
with similar local symptoms, but which we know to be a form of, or a
manifestation of, a contagious and epidemic disease, namely, diphtheria.
There are two theories regarding the relation to each other of croup
and diphtheritic laryngitis. The first is that they are entirely distinct,
that the one is a simple, non-specific inflammation, not capable of repro-
ducing itself, while the other is specific and contagious; that, therefore,
they sustain to each other, as one of our writers has well said, a similar
relation to that which exists between ordinary metritis and the metritis of
puerperal fever, having sufficient clinical differences to justify our regard-
ing them as distinct maladies. The second theory is thus enunciated by one
of its foremost advocates (Steiner): “The attempt to distinguish croup and
diphtheria as two entirely distinct diseases has been unsuccessful, both
from an anatomical and a clinical standpoint ; indeed there are many
good reasons for supposing that these two affections are only varieties
and modifications of one and the same process, which, in consequence of
special influences and collateral causes, as yet imperfectly understood,
makes its appearance at one time as croup, at another as diphtheria, now
in a sporadic form, now as a wide-spread epidemic, now as a primary,
now again as a secondary affection.”
The attempt to elucidate the nature of croup, and determine its relation
to diphtheritic laryngitis, is attended by unusual difficulty for one who
makes his observations in a locality where diphtheria prevails, as is the
case with most of us who reside upon the Atlantic coast. The difficulty
alluded to arises from the impossibility of making a clear and certain
diagnosis of croup, where diphtheria is endemic. Has not every phy-
sician in such a locality, now and then, believed, that he was treating a
case of croup, such as he had, perhaps, observed in former years, even ad-
hering to the diagnosis till the death of the patient, when the subsequent
history of contagiousness has taught him that, after all, the case was one
of diphtheria? There is no symptom or anatomical fact observed at the
342 J. L. SMITH,
bedside which will enable the physician to say that the case is croup, and
not laryngeal diphtheria. Absence of a pseudo-membrane upon the fauces
does not, as some seem to think, establish the diagnosis of croup, for I
have treated undoubted cases of diphtheritic laryngitis, ending fatally, in
which there was not only no diphtheritic pellicle upon the surface of the
pharynx, but only a mild degree of catarrhal pharyngitis. Nor is the
absence of glandular swelling under the ears certain proof that the laryn-
gitis is croupous, instead of diphtheritic, for, although it is true that
considerable tumefaction is a sign of diphtheria, yet this swelling is
sometimes absent in cases which are clearly diphtheritic.
For correct and reliable facts in regard to croup I have found it neces-
sary to consult medical literature, and to depend upon my own recollec-
tion, and that of the older physicians of New York, as to cases which
occurred prior to 1857, at which time diphtheria became established as
an epidemic and endemic of the city, and upon the observations of intel-
ligent physicians in localities where diphtheria does not prevail. I am
under obligation to physicians who have thus aided me. The relation of
croup to diphtheritic laryngitis may be conveniently considered under the
following headings—
I. Croup a local malady; diphtheritic laryngitis the expression or manifes-
tation of a general disease.—The late Dr. Hillier, of London, a close ob-
server of diseases, inclined to the belief that croup was a constitutional
malady, but the following facts strongly indicate its local nature. Its
causes, as we shall see, are the same or similar to those of the ordinary
inflammations, which are admitted to be strictly local. There is no evi-
dence, from the symptoms, of any systemic infection or blood disease,
and recovery immediately follows relief of the local malady. The de-
pression which attends cases of diphtheria is lacking. If croup were a
general disease, there should be, it seems to me, in some cases at least,
anaemia, poor appetite, weakness, etc., indicative of the blood change, for
a longer or shorter time after the removal of the laryngeal obstruction
and abatement of the inflammation.
As evidence, also, that croup is not a constitutional disease, is the fact
that the inflammation is almost invariably—I have heard of no excep-
tional case—limited to a single tract of the mucous membrane. It is
the uniform recollection of the older physicians of New York with
whom I have conversed in reference to this matter, that they never ob-
served a case of croup, before the advent of diphtheria, which was attended
by membranous exudation upon other surfaces than that of the pharynx
and air passages. Were there systemic infection, or blood poisoning, in
croup, we should expect that, in some instances at least, the character-
istic inflammation and exudation would occur in other localities also, as
in diphtheria, especially since nearly every mucous membrane in the
system is susceptible of croupous inflammation. Another fact indicative
of the local nature of croup, is its tolerance of depressing remedies, as
we shall see hereafter. Constitutional diseases having inflammatory
lesions, badly tolerate such agents. From clinical and anatomical facts
like the above, the profession has long regarded croup as a local malady,
and I can see nothing in the most recent investigations regarding its
nature to shake the belief in this opinion.
How is it with diphtheritic laryngitis, as this inflammation ordinarily
occurs ? Is it local, occurring independently of blood changes and pro-
duced by the lodgment of the diphtheritic virus upon the laryngeal sur-
C R O U P AN ID DIP HT H E RIA. 343
face; or is it the result of the presence of the diphtheritic virus in the
blood, so that it sustains the same relation to the general disease, that the
pharyngitis of scarlet fever and the bronchitis of measles do to those
diseases? The latter theory, namely that the laryngitis and other in-
flammations of diphtheria are the result and outward manifestation of
an infected or poisoned system, was generally accepted by the profession
of this country and Europe during the last twenty-five years, until the
publication of the bacterian theory. This theory (according to which
it is claimed that a microscopic organism, which is the cause or specific
principle of diphtheria, has been found making its way from the surface,
on which it has lodged or been received from the air, through the tissues
into the circulation) has shaken the belief of many in the constitutional
nature of diphtheria, and they incline to the other view, which certain
experiments seem to support, that diphtheria in ordinary cases begins
locally, and that biood poisoning may or may not result, but that if it
does, it is secondary.
It is a matter of great importance—an importance transcending that
of almost any other subject relating to the pathology of this dreadful
scourge—that we should ascertain clearly and certainly which of the two
prevailing theories is true, since the theory influences practice. Is the
opinion correct, that the primary event is the entrance of the poison into
the blood ; or the other opinion, that the poison is received upon an
exposed surface, where it excites inflammation, and that the blood either
escapes contamination, or receives the poison by absorption or penetra-
fion from the inflamed surface :
Experiments on the lower animals have thus far failed to demonstrate
the primary nature of diphtheria, as it occurs in the human race. Among
the most recent experiments which have a bearing upon this subject, are
those of Dr. Rajewsky, performed with the approval and at the instance
of Prof. Von Recklinghausen. Rajewsky poisoned the blood of rabbits
by injecting diphtheritic matter into it, and then produced catarrhal in-
flammation of the intestinal mucous membrane by injecting a weak solu-
tion of ammonia into the intestine, when the interesting result followed,
that the catarrhal became a diphtherific inflammation. Obviously in
these experiments diphtheria was primarily constitutional. The diph-
theritic inflammation was developed from within—from the poisoned
state of the blood. But in another class of experiments, he first pro-
duced catarrhal inflammation of the intestines in the same manner as
before, and then injected diphtheritic matter into the intestine. The re-
sult was the same as regards the production of diphtheritic inflammation
upon the intestinal surface, for upon the inflamed portion, to which the
poison was applied, the characteristic diphtheritic pellicle appeared. It
may be inferred, that in this class of experiments the primary action was
local, but may not absorption of the poison have preceded the local dis-
ease, as is now believed to be the case in syphilitic inoculations?" (Bum-
stead.)
The fact that diphtheritic inflammations ordinarily occur upon those
surfaces which are most exposed to currents of air, and upon which any
deleterious substance floating in the air would be most likely to lodge,
has been supposed to lend support to the theory that diphtheria is at first
localized in these exposed parts. But if these inflammations were ordina-
rily produced by the direct contact of the poison received from the air,
* Lond. Med. Times and Gaz., Dec. 11, 1875.
344 J. L. SMITH,
coryza ought, it seems to me, to be the primary diphtheritic inflamma-
tion in a large proportion of cases; whereas it is not ordinarily pri-
mary, and in many cases does not occur at all. The fact is that the diph-
theritic virus, in whatever way its reception occurs—whether in the
ordinary manner, or through a wound of the skin—appears to be espe-
cially attracted to the fauces and contiguous parts, or to find in them
the seat of its greatest activity, so that even if the disease is received
through a distant part of the system, pharyngitis is apt to occur. Thus
Hillier relates the case of an eminent surgeon who, performing trache-
otomy on a child supposed to have croup, punctured his thumb. The
puncture was painful, and on the following day a pustule occupied its
site. This was opened and poulticed. “A day or two later, on removing
the epidermis, the subjacent cutis was found in the condition of a pecu-
liar dark slough ; there was an entire absence of suppuration, and exces-
sive pain. This was followed in six days by a diphtheritic deposit on
the tonsils. The wound on the thumb was long in healing.” A month
later, diphtheritic paralysis occurred." In cases like the above, if they
are correctly interpreted, and the poison is received through the skin, it
is evident that the inflammations on the exposed mucous surfaces are not
produced by the direct deposit of the virus, but that they result from the
blood poisoning. And the important and interesting fact appears, that,
in cases thus contracted by inoculation, diphtheria is constitutional, be-
fore the pharyngeal or laryngeal inflammation occurs.
But if we could obtain no farther light in reference to the primary nature
of diphtheria than what is afforded by experiments on animals and acci-
dental inoculations in man, we would probably never know, when called at
the commencement of a case contracted in the usual manner, whether we
had to treat a merely local affection, or a constitutional disease with local
manifestations. We must fall back to the wider field of clinical experi-
ence for help to an understanding of this matter. The following facts,
taken collectively, afford, in my opinion, strong corroboration of the
theory that there is primary systemic infection in diphtheria, as it is
commonly contracted:—
(1) The long incubative stage in certain cases.—Although the incubation
of diphtheria is ordinarily from two to five days, it is sometimes an
entire week, as in the following examples: In April, 1876, a little girl
died of malignant diphtheria in West 41st Street, New York. Her
sister, aged one year, remained with her from April 14 to 17, when she
was removed to a distant part of the city, and placed in a family where
there was no sickness, and had been no diphtheria. On the night of
April 24, seven days after her removal, this infant was observed to be
feverish, and on the following day, when I was called to examine her,
the characteristic diphtheritic patch had begun to form over the left
tonsil. In April, 1875, two sisters, aged seven and five years, resided
with their parents, in a boarding-house, in West 22d Street, New York.
A playmate in the same house had symptoms which were supposed
to be due to a cold, but which were diphtheritic, when one night
severe laryngitis occurred, and ended fatally the next day. The phy-
sician who had been summoned diagnosticated diphtheria, and the two
sisters were immediately removed to a hotel. But seven days subse-
quently, diphtheria commenced in the older child. The younger was
at once removed to a distant part of the same hotel, but on the sixth or
| Hillier on Diseases of Children.
C R O U P AN ID DIP H THE RIA. 345
seventh day subsequent she also became affected with a fatal form of
the disease.
Now according to the doctrine that diphtheria is at first local, and
that the inflammations result from the irritating effect of the virus
which lodges upon the mucous membrane, this virus must remain inac-
tive a week upon the surface where it is received. Such inactivity in a
poison of unusual energy and malignity would be very improbable.
I3ut we have sufficient explanation of the long incubation, if, in what-
ever way the poison is received, it first enters the blood, and the inflam-
mations occur consecutively to the blood-changes. It is a law in path-
ology that those specific diseases which have an incubation of several
days, are constitutional.
(2) Another fact, which indicates primary blood poisoning in diphthe-
ria, is observed in certain cases, namely, the occurrence of severe constitu-
tional symptoms for a longer or shorter time, perhaps for half a day, before the
appearance of the usual inflammation. Thus a girl of five years, having
malignant diphtheria, whom I saw in consultation, was carefully exam-
ined on the first day of her sickness by the attending physician, and
although he closely inspected the fauces, there was no appearance
which indicated the nature of the malady till the subsequent day. In
such cases, a sufficient number of which I have observed, there is apt to
be complaint of soreness of the throat, or difficulty in swallowing, almost
from the beginning of the general symptoms; but the pain and tender-
ness seem to be in the deeper tissues of the neck, and the fact that
redness of the mucous surface does not appear till some hours subse-
Quently, is evidence that the inflammation is developed from within, and
not from the irritating effect of the poison upon the surface.
Again, treatment of the inflammations by the most reliable and efficient
antiseptics and disinfectants which we possess, commenced at the earliest
possible moment and repeated at short intervals, does not prevent the oc-
currence of indubitable symptoms of blood poisoning in cases of a severe
type. Thus I have treated every portion of the inflamed surface, as far
as it was accessible, every second or third hour, with carbolic acid and
other disinfectants, almost from the very commencement of diphtheria,
and so thoroughly that any vegetable or animal poison, with which the
remedies had come in contact, would probably have been destroyed, or
rendered inert, and yet, except in mild cases, symptoms of diphtheritic
blood poisoning have occurred, and as early and uniformly as if less ener-
getic local measures had been employed. While, therefore, I do not fail to
recommend local treatment as calculated to prevent septic poisoning, and
relieve the inflammations, I have lost confidence in it as a means of pre-
venting the entrance of the diphtheritic poison into the blood. Its power-
lessness to prevent contamination of the blood by the diphtheritic virus
is an additional evidence that this contamination occurs independently of
the local disease, and probably precedes it.
(3) The quick succumbing of the system in certain malignant cases is evi-
dently due to diphtheritic toxaemia. We sometimes observe a fatal result
on the second, third, or fourth day, without any dyspnoea, or sufficient
laryngitis to compromise life. Cases of this kind, terminating fatally even
in the first day, have been reported. The system is suddenly overpowered
by the poison, struck down, as it were, by the profound blood change,
while the inflammations are still in their incipiency.
(4) Important evidence of the constitutional nature of diphtheria is
afforded also by the state of the kidneys. No internal organs are so often
346 J. L. SMITH,
affected in diphtheria as the kidneys, and on account of their location
and anatomical relation, it is evident that the poison first passes through
the system before it reaches them. Any clinical or anatomical fact, there-
fore, which indicates that the diphtheritic virus has reached and affected
the kidneys, affords proof that it has penetrated the system, and poisoned
the blood. Now the occurrence of albumen, with granular or hyaline
casts, in the urine, in cases unattended by dyspnoea, affords proof of nephri-
tis, caused by the action of the poison on the kidneys. Dr. West, from
observations made in London, believes that albuminuria is commonly
present in diphtheria, but the frequency of its occurrence varies in dif-
ferent epidemics, according to the severity of the type.
During the latter part of 1875, and in 1876, prior to Aug. 1, I en-
deavored to obtain and examine the urine in every case of idiopathic
diphtheria, having a clear diagnosis, which came under my notice, both
in family practice and in the institutions with which I have an official con-
nection. Ordinarily, during the first week of a case, I found that the urine
deposited urates on cooling, and that the nitric acid test showed a large
relative quantity of urea, but I suspect that this was due to a somewhat
diminished quantity of urine. But the occurrence of albumen was of
chief interest, and the results of the examinations as regards the presence
or absence of this, are recorded in the accompanying table. In most of
the cases the urine was examined several times in the course of the dis-
ease, and, if albumen were present, a microscopic examination was also
made. In nearly all the specimens which contained albumen—all but
three or four—casts, usually granular, but now and then hyaline, and
sometimes both kinds in the same specimens, were observed. In those
cases of albuminuria which recovered, there were comparatively few
casts, or none. If the albumen were abundant, and casts plentiful, the
case was usually fatal, though not perhaps till after the lapse of three or
four weeks, when death occurred with symptoms of exhaustion, paraly-
sis, or feeble heart-action, sometimes with Oedema of lungs supervening
suddenly, and, probably, formation of heart clots. The albuminuria,
unlike that of scarlet fever, seldom occurred except in the grave cases;
and in the majority of instances it did not appear till near the close of
the first week, or in the second, and, in a few instances, not till a later
period. Although the albuminuria of diphtheria is much more grave
than that of scarlet fever, it has in my practice been attended by much
less serous effusion or dropsy, often by none which was appreciable. The
urine, although containing a large quantity of albumen, often had nearly
the normal appearance, instead of the smoky or hazy color so common in
the albuminous urine of scarlet fever.
I. Cases attended with the usual membranous eacudation upon the fauces, with
or without coryza, and without laryngitis or with only catarrhal laryn-
gitis; fifty-eight cases.
Result not
Died. Recovered. stated. Total.
With albuminuria & º . 13 5 l 19
Without albuminuria . tº ... 4 27 I 32
State of urine not recorded ... 3 4 tº º 7
II. Cases attended with membranous laryngitis as the predominant
ºnflammation ; nineteen cases.
Died. Recovered. Total.
With albumimuria e º ... 4 l tº º 5
Without albuminuria . © ... 2 4 tº e 6
State of urine not recorded ... 7 l tº gº 8
C R O U P AN ID DIP HT H E RIA. 347
The mortality of the cases embraced in the above table was probably
larger than the average in New York practice, for several of them were
seen in consultation, and their type was severe. Those in which the
state of the urine could not be ascertained, were usually in children SO
young or so near death that it was impossible to obtain sufficient urine
for examination. It is not improbable, also, that, occasionally, in cases
in which it is stated that there was no albumen in the urine, it may have
been present at a more advanced stage of the disease, or on days when
the examination was not made ; but, as stated above, there were usually
several examinations of the urine made during the progress of each case.
Sir John Rose Cormack, of Paris, in a series of interesting and useful
papers relating to diphtheria, published in the Edinburgh Medical Jour-
mal during the present year, states that albuminuria, and of course the
nephritis on which it depends, sometimes begin as early as the first day.
My observations confirm this statement, as in the following cases:—
CASE I.—L. McD., aged three years, was first visited by me on Feb. 29,
1876. I learnt from the parents that she had been feverish during the preced-
ing forty-eight hours, and her urine very scanty. A moment's examination
was suflicient to show that the case was one of malignant diphtheria, for the
fauces were already nearly covered by the diphtheritic pellicle, the temperature
was 103}*, and the pulse 140. The skin was hot and dry, and there was
moderate swelling under the ears, and a muco-purulent discharge from the
nostrils. On account of the scantiness of the urine, the amount not exceeding
f;iv-v daily, it was impossible to obtain sufficient for examination till the fol-
lowing day. It was then found to have a specific gravity of 1032, to contain a
deposit of urates and hyaline and granular casts, a diminished amount of urea,
and a large quantity of albumen. It can hardly be doubted from the scanti-
ness of the urine, and the large amount of albumen found when the urine was
first examined, that albuminuria had been present on the first day.
CASE II.-The following was a similar case : K., aged four years, living in
West 36th Street, was visited by me in consultation on Jan. 29, 1875. Her
sickness had also continued forty-eight hours; her fauces were swollen, and
covered with the diphtheritic pellicle, which was dark and offensive; respira-
tion guttural; pulse 120; temp. 101° ; she had a free discharge from each
nostril; urine scanty, its specific gravity 1030 ; it contained a small amount
of albumen, with casts, and a large amount of urates, with no apparent dimi-
nution of the urea. Death occurred on the fourth day.
In such severe cases, in which albumen and casts are found in the
urine at the first visit of the physician, there can be little doubt that the
nephritis begins nearly or quite as early as the pharyngitis, and there-
fore, since poisoning of the blood must antedate the renal disease, diph-
theria is in these cases very early, probably from the occurrence of the
first symptoms, a constitutional malady.
Again there are cases, though rare—only one I can recall to mind
during the last two years in my practice—in which the external mani-
festations of diphtheria are very mild, even insignificant, and quickly
cured, but in which the kidneys are severely affected. The occurrence
of such cases is best explained on the supposition that the first departure
from the state of health is in the blood, and that the blood change gives
rise to the inflammation of the mucous membrane externally, and of the
kidneys internally, rather than upon the supposition that the transient
and insignificant inflammation of the mucous membrane is the first
event in the series of morbid changes, and that this inflammation leads
to poisoning of the blood, and the establishment of a much more severe
348 J. L. SMITH,
and protracted inflammation in the kidneys. The following is the case
alluded to :— º
CASE III.—The house, 229 West 19th Street, New York, is an old wooden
structure, and the family, which has occupied it during the last five years, has
been three times visited by diphtheria, the first case, that of the oldest child,
proving fatal. In February, 1876, one of the children had diphtheria in a
moderately severe form. He recovered, and, after my visits had been discon-
tinued, his sister, aged six years, who had had scarlet fever when eighteen
months old, became feverish and complained of her throat. No rash appeared
on her skin, and there was apparently no coryza. Inspection of the fauces by
the parents revealed a small diphtheritic patch over each tonsil. Although
diphtheria was so frightful a malady to this family from their past experience,
the case seemed so mild that the parents treated it without medical attendance,
by the remedies which had been employed for the boy. A mixture of carbolic
acid, subsulphate of iron, and glycerine, was applied to the fauces every third
hour, sufficiently often, apparently, to destroy all bacteria or other vegetable
or animal organisms with which it might have come in contact, and within two
or three days the inflammation of the throat seemed to the parents to be cured.
Nevertheless, with this insignificant inflammation of the fauces, so quickly
subdued, and with no other apparent inflammation of the mucous surfaces,
there was severe internal disease going on as the result of the general infection.
The child did not regain her former appetite ; she had increasing pallor, al-
though able to play about the house; and, finally, in the third week, when I
was called to see her, slight occlema of the face and limbs was observed. Her
urine, which was scanty, was found to contain pus and blood corpuscles, albu-
men, and granular casts, and nearly two months elapsed before, under treat-
ment, it became normal, and her health was restored.
One more clinical fact which I have often observed, may be cited in
support of the opinion that diphtheria is primarily constitutional, and
that the inflammations are secondary, and dependent on the blood poison-
ing. It is this : When the inflammations of the mucous surfaces have
apparently ceased, or only slight catarrhal inflammation remains, and
the apartment in which the patient has been treated has been thoroughly
disinfected, and local treatment discontinued, we are perhaps surprised
to observe the reappearance of the diphtheritic pellicle, though less in
extent and with less severe symptoms than at first. It is highly improb-
able that diphtheria has been contracted a second time. The rational
explanation is that the reappearance of the inflammation is due to the
fact that the blood is still infected; that, as when syphilitic eruptions
reappear, it is not yet fully purified of its noxious elements. I have seen
this return of the diphtheritic pellicle even in mild cases in which there
was no other evidence of general disease. If the second occurrence of
the inflammation is due to the poisoned state of the blood, is it not
probable that the first inflammation is also thus produced ?
I have perhaps occupied too much space in attempting to show, what
indeed many already believe, that croup is simply a local malady,
while diphtheritic laryngitis is one of the inflammations which result
from a general malady. But within the last three or four years, the old
doctrine that diphtheria is local in its commencement, and is therefore,
in at least many instances, amenable to early local treatment, has been
revived, and so promoted by the advocates of the bacterian system, that
it already influences the treatment in many quarters. There are physi-
cians, as I have had opportunity to observe, who attach little importance
to constitutional measures, if they are called early to a case, and who
rely almost entirely on local treatment for the relief of the patient.
C R O U P AND DIP HT H E R IA. 349
But with a correct understanding of the nature of diphtheria, I am con-
vinced that we must continue to regard constitutional remedies as of
prime importance.
The evidence is therefore strong that, while croup is primarily and
constantly local, diphtheria, as it ordinarily occurs, is a general disease
from its commencement, and that the laryngitis and other inflammations
result from and manifest the blood poisoning.
II. Anatomical characters identical in kind, as regards the state of the
larynac, but differing in degree or intensity.—Most of the microscopic exami-
nations of the pseudo-membrane, made during the last twenty years in
this country and Great Britain, in cases of supposed croup, must be re-
ceived with hesitation and distrust, on account of the great difficulty to
which allusion has already been made, of making a clear diagnosis in
localities where diphtheria prevails. For although diphtheritic laryn-
gitis can often be diagnosticated from croup, the reverse, namely, the
diagnosis of croup from diphtheritic laryngitis, is attended by such dif-
ficulty, and is so uncertain, that we can obtain, as already stated, reliable
statistics of croup only from those observers who reside in localities in
which diphtheria does not occur.
Fortunately, for our purpose, there are or have been localities where
pathologists have been able to observe the clinical and histological char-
acters of croup, free from the embarrassment to which I have alluded.
Thirty years ago the great treatise of Carl Rokitansky, on Pathological
Anatomy, appeared, a vast repository of pathological facts, derived from
thirty thousand dissections. No one has ever had better opportunities
than he, for studying the anatomy of diseases, and no opinion has car-
ried, and still carries, greater weight than his, in all subjects relating to
morbid anatomy which do not involve the use of the microscope. I am
informed that even up to the present time, in Vienna, where Rokitansky’s
observations were made, diphtheria is almost unknown, and in his trea-
tise he scarcely makes any allusion to it, so little did he know of it.
We may therefore confidently believe that what this renowned observer
states in relation to croup, relates to the genuine disease.
Says Rokitansky, “The croupy process occurs on all mucous mem-
branes, and sometimes extends over a very wide tract. The mucous
membrane of the respiratory organs shows an especial tendency to it,
and we meet accordingly with laryngeal croup, tracheal croup, bronchial
croup, and croupy pneumonia.” He says, also, which I wish to empha-
size, “Neither during nor after the croupy process does the mucous mem-
brane suffer any material injury to its texture ; the speedy production
of mucus and epithelium prevents any further organization of the plastic
exudation, . . . . and it never enters into an organic connection
with the mucous membrane.” Dr. Heitzmann, now of New York, who
was assistant to Rokitansky till 1874, informs me that diphtheria had
not appeared in Vienna up to the time when he left that city, and that
Rokitansky still held the same views in regard to the anatomical char-
acters of croup.
Prof. Rindfleisch, of Bonn, says of the pseudo-membrane of croup:
“. . . . it spontaneously separates, since it is loosened by a moderate
production of pus, first at the edges, and then raised from its base. . . .
Rarely is a secondary enlargement of the pseudo-membrane perceived,
* Pathological Anatomy, vol. iii., page 56, Sydenham Society's Translation.
350 J. L. SMITH,
never a reproduction at the same spot.” “The boundary between the
mucous and the false membrane is naturally very much obliterated
by this gradual transition of the cells of both sides, although it never
becomes quite indiscernible. It, however, is undoubtedly evident, that
the pseudo-membrane is produced by a secretion of young elements at
the surface of the irritated mucous membrane, and by their gradual in-
duration, sclerosis, vitreous tunnefaction, or by whatever other name we
wish to call the degeneration.” “The pseudo-membrane is of a pecu-
liarly stratified structure, since upon a layer of cells, at tolerably equal
distances, there always follows a layer of fibrin, and this sequence is
repeated from one to ten times, according to the thickness of the mem-
brane. Whether I am correct, in directly calling those second layers
fibrin, must of course remain a question. I do it upon the first impres-
sion which its configuration makes, and with the reservation that there-
with I always have in mind only a fluid albuminate, but indurated by
the transudation into the air.”
Mr. Jabez Hogg, President of the Medical Microscopical Society of
Iondon, in 1873, said, as reported in the Monthly Microscopical Journal
for that year : “A portion of a croupous cast, examined under a power
of 350 diameters, is seen to consist of pavement and cylindrical, or colum-
nar epithelium, and a transparent albuminous substance, entangling the
scattered contents of epithelial cells, molecular matter, fat and mucous
corpuscles, and a few foreign bodies, involved in a homogeneous matrix.
When stained by a weak solution of ammoniacal carmine, or aniline dye,
and carefully spread out with needles, the columnar epithelium retains its
cilia, each cell being filled with clear protoplasmic and nucleated con-
tents. It is therefore highly probable that these cells are not long re-
tained, but are rather thrown off soon after their formation.”
It will be observed that these authorities, from whom I have quoted
(and most microscopists and pathologists agree with them), state that
the pseudo-membrane of croup consists, mainly, of altered epithelial cells,
held together by an albuminate which exists either in the form of layers,
or a network. In the interstices, or meshes of this network, we find, in
addition to the epithelial cells, granular matter, with embryonic and pus
cells. The mucous membrane underneath is more or less denuded of its
epithelium, is thickened and softened, and of a bright red color from
active congestion of its vessels; or the redness is diminished and its
color paler, if the inflammation has to a considerable extent abated.
Does croup produce any other anatomical changes, in addition to those
which have been described above, and which are located in or along the
air passages 7 Apart from those blood changes which occur in all in-
flammations, I believe that there are no other uniform lesions, except
such as result from the passive congestion of organs which is ordinarily
present in advanced cases, and which is proportionate in degree to the
amount of laryngeal, or laryngo-tracheal obstruction. When the dys-
pnoea becomes so great that lividity of the lips and tips of fingers occurs,
a correspondingly severe and dangerous congestion of the internal organs
results. Hence Oºdema of the lungs and albuminuria may supervene in
the last hours of croup. I am convinced from my own observations, and
from the nature of this malady, that those who believe that they have
observed other lesions of croup, as enlarged and altered spleen, enlarged
* Pathological Histology, translated by Kloman and Miles, 33 364, 365, 367.
C R O U P AND DIP HT H E RIA. 351
Peyerian and solitary glands, etc., have observed merely accidental lesions,
or have mistaken diphtheritic laryngitis for croup.
Let us now consider the lesions of diphtheritic laryngitis. In order
to determine their precise nature, I have obtained the help of skilful
microscopists in New York. Dr. Satterthwaite kindly consented to
make microscopic examinations of the organs in the first and second
cases. The specimens were placed in a solution of bichromate of potas-
sium immediately after their removal from the bodies. The following
case occurred in my private practice:–
CASE IV.-H. , aged four years, and two brothers S., who lived directly
opposite in the same street in New York, were daily playmates. On January
27, 1876, H became feverish and complained of sore throat, and four days
subsequently died of malignant diphtheria. This case was carefully examined
by me in consultation, and minute records of it preserved. Before it termi-
nated, the two brothers S. became affected with diphtheritic laryngitis. The
younger brother, aged three years, was for a time in a very critical state from
the dyspnoea, but recovered in about one week. The older brother, aged six
years, died, having the following history: On January 29, two days after the
commencement of diplitheria in his playmate, H
, he vomited and became
feverish, and his voice became hoarse. These symptoms continuing, I was
asked to visit him on Feb. 2. His respiration at this time was harsh, and
audible in the adjoining room, and the cough croupy; pulse 96; temperature in
axilla 100° ; he takes considerable nutriment, and sits quietly, or walks about
the room ; ſauces red, and slightly swollen, but without any diphtheritic
exudation upon their surface ; has slight glandular swelling underneath the
ears; the urine contains no albumen, and the nitric acid test shows no excess
of urea. The constant inhalation of the spray of lime-water is recommended,
with the use of tonics. Feb. 4. Pulse 96, temperature 99°; breathes with
much difficulty at times, but there is still no pseudo-membrane upon the ſauces;
has expectorated since the last record two thick pieces of pseudo-membrane,
each about one inch in length, apparently from the larynx; specific gravity of
urine 1022; it contains a deposit of urates, but no albumen; urea apparently
somewhat in excess of the normal quantity. Feb. 5. Pulse 92; temperature
101*; has a small diplitheritic patch, not more than three lines in diameter,
over the left tonsil. Feb. 6. The pellicle upon the tonsils has disappeared ;
the urine for the first time albuminous, thirty-six hours before death ; its
specific gravity 1024; temperature 103°; dyspnoea great; pulse about 120.
Death occurred on Feb. 7.
Sectio Cadaveris, 19 hours after death; body spare, but not emaciated ;
rigor mortis present; has post-mortem extravasation of blood along the back,
and a thin blood-stained fluid escapes from the mouth ; two or three drachms
of transparent liquid in the pericardial sac ; a large yellowish-white clot fills
the right ventricle, and is prolonged into the pulmonary artery; the right
auricle also contains a large clot, soft and dark in its centre, but firmer and of
a whiter color externally ; left ventricle contains a few soft dark clots, with a
little fluid blood; left auricle partly filled with blood of a tarry appearance;
tonsils not enlarged, but soft, and a yellowish diffluent secretion lies in the
depressions on their surface; subcutaneous glands of the neck slightly enlarged,
one being somewhat larger than a filbert ; under surface of epiglottis, and
entire surface of larynx, covered by a firmly adherent pseudo-membrane which
entirely conceals from view the vocal cords and the sinuses of Morgagni; the
pseudo-membrane is continued over the surface of the trachea, being less adhe-
rent than in the larynx, and, near the bifurcation, it floats freely; it does not
extend into the bronchus or bronchial tubes of the left lung, and this lung is
normal. In the right lung the pseudo-membrane extends as far as the bron-
chial tubes of the third order; the upper lobe of the right lung is in the
second stage of pneumonia, its cut surface being rough and granular, and
352 J. L. SMITH,
liquid escaping from it on pressure; the right, middle, and lower lobes are
congested, and in the lower lobe is a single hepatized nodule ; those portions
of the bronchial tubes which are not covered by the false membrane exhibit
the appearance of catarrhal bronchitis. The liver is large, and not fatty ;
spleen small, moderately firm, and contracted (this is noteworthy, as the spleen
has been found large and soft in diphtheria); kidneys congested and swollen,
and a stellate appearance of the vessels under their capsules; surface of both
small and large intestines congested.
Microscopic Ea:amination.—Red corpuscles of the blood well-preserved, some
of them round, others crenated, and all granular; large masses of transparent
material, containing red corpuscles, floated in the blood. The rod and chain
forms of bacteria were observed in the blood, but not in greater number than
are often seen in other blood the same number of hours after death. (A few
grains of chloral had been added to this specimen of blood immediately after its
removal.) Substance of heart apparently normal, showing no fatty degenera-
tion, nor infiltration ; no bacteria can be recognized in the substance of the
heart. Kidneys : Right kidney examined ; Malpighian bodies congested, and
extravasations of blood throughout this organ; tubal epithelium granular;
increase of connective tissue in points near periphery of kidney, showing inter-
stitial nephritis, but no increase observed in this tissue in other parts of the
organ; no bacteria that could be certainly recognized as such in the kidney.
Spleen : Multitudes of granules in scrapings from the cut surface of this organ,
many of them so small as to be with difficulty recognized with a magnifying
power of over 600 diameters; some of them gave the appearance of the usual
forms of bacteria.
Laryna: ; Thickness of false membrane which covered the entire surface of
this organ varied from rºm to gº of an inch ; thickness of mucous membrane
about ºn of an inch ; epithelial border of mucous membrane could be traced
inwards gºo to rºo of an inch, where it became indistinct, merging into the
other tissues which were more or less infiltrated with embryonic cells and
blood. The false membrane consisted of a network of a homogeneous mate-
rial, most of the meshes being empty, but those nearest the epithelial layer
containing more or fewer epithelial cells. The boundary line between the false
membrane and the mucous surface could not be distinguished by the micro-
scope in many of the sections, the network of the pseudo-membrane extending
into the mucous membrane. But in other places the line of separation could
be distinguished, and here and there the pseudo-membrane and mucous surface
were separated by collections of embryonic cells. The lymph follicles and
racemose glands were apparently normal; mucous surface infiltrated with
granular matter and red blood corpuscles; cylindrical epithelial cells, some of
them with cilia, were distinctly visible both along the free border, and in the
under surface of the pseudo-membrane. Trachea : The false membrane mea-
sures from about 1% o to 5% of an inch in thickness; the mucous membrane 5'6
of an inch, and its epithelial layer rºm of an inch ; the epithelial cells are much
more distinctly visible than in the larynx, and the line of separation of the
adventitious layer and the mucous surface is everywhere distinctly seen under
the microscope; the false membrane has the same general appearance as in the
larynx, but the mucous membrane is in a better preserved state than that of
the larynx; it is nevertheless infiltrated with granular matter, plastic matter,
and red blood corpuscles; lymph follicles and racemose glands apparently nor-
inal; in the trachea, as in the larynx, a large number of embryonic or lymphoid
cells—most of them ho doubt becoming pus cells—lay between the false mem-
brane and the mucous surface. -
CASE W.—A second case, having the following history, occurred in the
Catholic Foundling Asylum in New York. George, aged two years and seven
months, was under treatment for a second attack of measles, the eruption
appearing on March 23, 1876. On March 24, the pulse was 136 and tempera-
ture 104; 9. The fauces presented a deep-red appearance, indicating severe
C R O U P A N D DIP HT H E RIA. 353
pharyngitis, but without any membranous exudation. March 25. Pulse 140;
temperature 103}*; the rubeolar eruption is very thick over the entire surface.
The Sister who has charge of the ward, noticing unusual offensiveness of the
breath, has inspected the fauces and found on them the diphtheritic pellicle.
March 26. Cough becoming croupy, and voice hoarse; pulse 152, temperature
105+ °. From this date the dyspnoea progressively increased, and death
Occurred on March 30.
Sectio Cadaveris.-A considerable part of the interior of the larynx is
coated with the diphtheritic pseudo-membrane, which is firmly attached to the
mucous surface; it extends without interruption over the larynx, and perhaps
Over one-third to one-half of the tracheal surface. It is not attached to this
surface, but hangs over it like a curtain, suspended from its attachment in the
larynx. Further down in the air passages there is the usual catarrhal inflam-
mation of the mucous surface. -
Microscopic Eacamination.— Laryma: ; The false membrane is found to consist
of a network, apparently fibrinous ; in places, in the larynx, it is raised from
the mucous membrane by an accumulation of embryonic or lymphoid cells
underneath ; in other places it is adherent to the mucous membrane, but with
a line of attachment which can be distinctly made out with the microscope;
while in other places still the network extends down into the mucous membrane,
and no distinct line of Separation can be seen. In the upper, or exposed por-
tion of the false membrane, no embryonic or lymphoid corpuscles are observed,
but they are abundant in the deeper portion, and they infiltrate the whole
mucous membrane extensively; upon the mucous surface, wherever the pseudo-
membrane is detached, these corpuscles are abundant ; in parts of the false
membrane they fill so completely the interstices of the network that epithelial
cells can scarcely be distinguished within them ; in places, in the sections
examined, the epithelium seemed to be wholly replaced by granular matter;
in general, the border line between the diphtheritic membrane and the mucous
surſace is marked by a somewhat denser exudation of the albuminate—a fibri-
nous appearing material—than is seen in the false membrane generally ; the
blood vessels in the mucous membrane of the larynx are numerous, and dis-
tended with blood. Trachea : The epithelium, consisting of from two to
three layers, is seen to be intact wherever it is observed ; the surface of the
epithelium is covered with minute markings, probably the cilia in contraction;
the pseudo-membrane is not seen to be reticulated as in the larynx, perhaps from
the contractions which had occurred in it ; it appeared granular and fibrous,
and contained but few corpuscles. Lungs : A portion of one lung was found
hepatized, and the alveoli of this portion contained pus cells, epithelial cells,
blood, and a fibrinous appearing material (croupous pneumonia). Kidneys :
The changes observed in these organs were those of tubal nephritis; the tubes
were highly granular, both in the pyramids and cortex; no increase in the
interstitial connective tissue was noticed ; in places the tubes were not granular.
The muscular tissue of the heart seemed normal.
In the following case, in which the larynx was not involved, Dr. Carh
Heitzmann, late of Vienna, made a microscopic examination of the kid-
neys, in order to determine more exactly the histological changes which
these organs undergo in diphtheria, and how these changes contrast with
the lesions which may result from simple passive congestion, such as is
present in the kidneys in fatal cases of croup.
CASE W I.-J , aged four years, an inmate of the Catholic Foundling
Asylum, began to have sore-throat on March 4, 1876. The fauces were red
and somewhat swollen, but without any membranous exudation, and the diph-
theritic nature of the disease was not at first suspected. My attention was
first called to this case on March 11, on account of almost total suppression of
urine. The fauces were still injected, and somewhat swollen from catarrhał
inflammation; there was a copious muco-purulent discharge from the nostrils;
23
354 J. L. SMITH,
pulse 148. March 13. Pulse 144; temperature 101}9; urine still nearly sup-
pressed, though one drachm of infusion of digitalis is administered every fourth
hour, and bromide of potassium, four grains, every second or third hour, for
the restlessness. Dr. Reid, in using the catheter, observed a diphtheritic patch
on the vulva; there is moderate tumefaction under the ears; the patient vomits
often during the last days; she has livid spots, from extravasation, under the
skin; and vision is much impaired, if not lost ; it is impossible to obtain any
urine for examination. Death occurred without convulsions on March 15. w
Microscopic Eacamination of the Kidneys. (By Dr. HEITZMANN.)—The tubuli
contorti of the first and second order of the cortical substance of the kidney
almost all enlarged ; their epithelium swollen in many places to such a degree
that no calibre of the tubules can be seen ; the epithelium richly provided with
coarse granules, the enlarged living matter; the original cement substance
missing ; instead of this, new transparent lines formed within the protoplasm,
indicating the earliest stage of catarrhal inflammation, with partition and new
formation of epithelial elements; the same changes, though in a less marked
degree, observable in the epithelium of the straight ducts of the pyramidal sub-
stance, while the flat epithelial bodies of the narrow ducts appear almost un-
changed. The connective tissue between the ducts and the enlarged glomeruli
is somewhat increased in size, and it contains newly-formed nuclei in moderate
number, with enlarged blood vessels, some of which are much distended with
blood-corpuscles; no fatty degeneration in kidneys. In a few places, accumu-
lations of dark granules occur within the ducts and their epithelium. These
granules, not being united with each other by threads, nor staining with ear-
mine, are considered to be micrococci, such as occur in any decomposing ani-
mal tissue. Whether they were present during the life of the patient, or were
due to early cadaveric putrefaction (which is common after death from diph-
theria), is uncertain. But since I have seen micrococci and bacteria in the fresh
urine of children suffering from diphtheria, I would not deny the possibility of
the occurrence of micrococci in the uriniferous tubules during life; nay, even,
they may produce the inflammatory process in a way still unknown to us. In
the case under consideration no trace of casts was found within the tubules, SO
that the inflammatory process doubtless was not a croupous one, but a relatively
slight process, termed catarrhal or interstitial nephritis.
The above microscopic examinations in cases of diphtheritic laryn-
gitis and nephritis, correspond with those made by other observers. The
following facts in reference to the histological characters of croup and
diphtheritic laryngitis, we wish especially to call attention to:—
(1) The croupous and diphtheritic pseudo-membranes consist alike of
altered or degenerated epithelial cells, mingled with embryonic, or grow-
ing pus cells and matured pus cells, all held together by an albuminate,
probably fibrin, which exuding in a liquid state from the mucous mem-
brane underneath, surrounds the cellular masses like mortar around the
stones in a wall, and hardens on exposure to the air. The consistence
and toughness, therefore, of the adventitious layer, are largely due to
the albuminate. The exact chemical character of the albuminate, and
the chemical changes which the epithelial cells, of which the pseudo-
membrane is composed, have undergone, have not been clearly ascer-
tained, but so far neither the microscope nor chemical tests show any
qualitative differences which hold good as a means of distinguishing
the false membrane of croup from that of diphtheria. Supposed dif-
ferences, observed by some, have not been noticed by others with other
specimens. The tests of organic chemistry are not sufficiently delicate
for the detection of any uniform difference in the nature of the two exu-
dations, if any difference exist, which seems improbable.
(2) The laryngitis of croup, as compared with that of diphtheria, is
C R O U P AND DIP HT H E RIA. 355
more superficial. Most inflammations of mucous surfaces, which are due
to sudden changes of temperature or exposure to currents of air, as sim-
ple coryza or bronchitis, are more superficial than specific inflammations,
or inflammations due to poisonous principles, acting locally, or through
the blood. Croupous laryngitis is no exception. It produces less infil-
tration in the mucous membrane and submucous tissues, and consequently
less thickening, and less exudation of the albuminate from the deeper
vessels, than occurs in diphtheritic laryngitis.
(3) Croup is a transient inflammation. It commonly begins to abate
when the exudation which relieves the congested vessels has occurred.
Hence the statement of Rindfleisch, that the pseudo-membrane when
detached by suppuration underneath, is never reproduced. The cause of
croup acts only for a brief period, and therefore the effect soon begins to
abate, if there is no fresh exposure. This transitory nature of croupous
inflammation contrasts with the greater persistence and depth of the
laryngitis of diphtheria. It is probably not absolutely true that the
pseudo-membrane of croup is never reproduced. Nevertheless, the dis-
tinction holds good, that there is much less tendency to its reproduction,
and less tenacity of the inflammation in croup than in diphtheritic laryn-
gitis. There seems to be a marked similarity, not only in the nature and
relations of the false membrane, but in the progress of the inflammation,
in croupous phlegmasia, as it occurs in the different divisions of the res-
piratory tract, that occurring in the minute bronchial tubes and in the
alveoli of the lungs, in the common disease croupous pneumonia, being
best understood on account of its frequency. As in this disease the exu-
dative stage soon ceases, and resolution commences with the decline of
the inflammation, so in laryngeal or laryngo-tracheal croup the greatest
danger is from the first exudation, and if the first pseudo-membrane can
be removed by treatment there is a fair prospect of a favorable termina-
tion. In this fact lies one of the chief points of contrast in the anatomy
of croup and diphtheritic laryngitis, for from the persistence of the diph-
theritic inflammation, and longer continuance of the exudative stage, the
diphtheritic pseudo-membrane, if expelled, will probably reform, as in one
of the cases related above, and reform more than once. *
(4) The pseudo-membrane of croup is more or less closely adherent to
the mucous surface underneath, but most microscopists who have ex-
amined specimens removed from the bodies of those who have died of
undoubted croup, agree that it does not penetrate it. The superficial
character of the inflammation, and the fact that the exudation occurs
from the superficial vessels, afford explanation of this fact. In diphthe-
ritic tracheitis, we have found, in the specimens examined above, that
the pseudo-membrane also lay upon the mucous surface without pene-
trating it; and in one of the cases, in which pneumonia had occurred,
the fibrinous exudation also lay free within the alveoli of the lungs.
But in the larynx, the albuminate, which formed the network of the
pseudo-membrane, penetrated the mucous membrane in places so that the
line of demarcation was extinguished; while in other places a distinct
line of Separation of the exudation and mucous membrane was observed
under the microscope, though the two surfaces were in close contact;
while in other places still, the exudation was elevated above the mu-
cous membrane by the secretion of embryonic or pus cells underneath.
This intimate relation of the false membrane to the mucous surface was
long since pointed out by Virchow, and has been confirmed by many
microscopists since. But it is to be remembered that exceptional cases
356 J. L. SMITH,
have been reported, in which the pseudo-membrane lay entirely upon the
mucous surface without penetrating it. This admits of explanation
without impairing the accuracy and truthfulness of the general state-
ment in reference to the intimate relation of the diphtheritic pellicle
with the surface of the larynx. For the adventitious layer is detached
by cell formation or suppuration underneath, so that in most specimens,
as in those described above, there are places in which the detachment
has already occurred. If then the stage has arrived in which there is
more abundant and general suppuration, the detachment of the false
membrane will be in a corresponding degree more extensive. To this
intimate relation of the exudation with the mucous menbrane in diph-
theria, is due the fact that points and patches of ulceration are so com-
monly observed in this membrane when the diphtheritic layer is de-
tached. Perhaps cases occur, which from their commencement are ex-
ceptions to the above statement in regard to the relation of the pseudo-
membranes to the laryngeal surface in croup and diphtheria. Perhaps
there are cases of mild diphtheritic laryngitis in which the exudation lies
entirely upon the surface, as it lay on the tracheal surface in the cases
narrated above, but there can, I think, be little doubt that in a series
of cases of the laryngitis of croup and diphtheria, the anatomical differ-
ence, as stated above, would commonly be observed in the two diseases.
(5) While the lesions of croup, apart from those of the respiratory
apparatus and pharynx, result from the passive congestion which corre-
sponds in degree with the amount of dyspnoea, there are or may be in
diphtheritic laryngitis additional lesions which result from the blood
poisoning, as hemorrhages upon the free surface or in the tissues of
organs, sometimes fatty degeneration of the cardiac muscular fibres, and
frequently desquamative or interstitial nephritis. The last case related
above shows that the renal affection may be an interstitial nephritis,
with almost total suppression of urine, occurring without desauamative
nephritis, and therefore without the formation of casts, while in other
cases the inflammation is largely desquamative, as shown by the presence
of a large number of casts. This frequent occurrence of severe nephritis,
interstitial and desquamative, contrasts strongly with the milder form of
renal affection which occurs in croup. In croup there is passive conges-
tion, with perhaps albuminuria, if the dyspnoea be severe, but I can find
no evidence that there is any liability to those dangerous forms of nephri-
tis with suppression or scantiness of urine, which are so common in diph-
theritic laryngitis as well as in diphtheria when manifested by other forms
of external inflammation. The following case may, I think, be appro-
priately related in this connection, as showing the blood changes and
renal disease to which I have alluded, as common in diphtheritic laryn-
gitis, but as absent or very exceptional in croup. It is true that the case
was one of diphtheritic catarrhal laryngitis, but there is obviously no
essential difference between dipththeritic membranous and catarrhal
inflammations, and, wherever the former occurs, we commonly find at the
same time a border or zone of the latter coexisting with it. This case
is also interesting to the practitioner, as showing the inefficiency of the
antiseptic treatment to prevent the blood changes of diphtheria:—
CASE WII.—M., aged four years, inmate of the Catholic Foundling Asylum,
New York, began to be sick May 6, 1876; was languid and feverish, temperature
104°, had redness of fauces and an exudation over each tonsil, no coryza ;
evening, temperature 103°. May 7. Pulse 120; temperature 100°. May 8.
Pulse and temperature as yesterday; urine scanty; no albuminuria, and no dis-
C R O U P AND DIP HT H E R I.A. 357
charge from nostrils; the membrane extends from the sides of the throat to
the roof the mouth ; sp. gr. of urine 1021, urine contains no albumen, no
excess of urea, and no deposit of urates. May 10. Pulse 140; has considera-
ble oedema of fauces, and breathing guttural in sleep; vomited once since yes-
terday ; the urine contains for the first time a moderate amount of albumen,
with hyaline casts; sp. gr. 1018, acid ; no urea deposited on adding nitric acid;
that alarming symptom in diphtheria, epistaxis, has occurred to-day. The
records which were written daily till death, which occurred on the 14th, show
a gradual increase of albumen with hyaline casts in the urine, increasing scan-
tiness of urine, so that on the 13th not more than half an ounce was passed in
twelve hours; temperature not rising above 100+*, nor pulse above 108; poor ap-
petite, occasional vomiting, and epistaxis. Death occurred from feebleness and
blood-poisoning, notwithstanding that, from the first day, three grains of sali-
cylic acid were given the first hour, two grains of quinine the second hour, and
tincture of iron and chlorate of potassa the third hour, these doses having been
continued night and day in alternation ; with the application of carbolic acid
and subsulphate of iron to the fauces, three times daily ; with nutritious diet,
and the moderate use of stimulants. There were no symptoms referable to
the larynx, unless a slight cough. º
Sectio Cadaveris.—Mucous membrane of larynx, trachea, and bronchial tubes
intensely and uniformly injected, but without any membranous exudation;
lungs fully inflated, as if from commencing vesicular emphysema, and pale in
front ; numerous extravasations of blood in the substance of the lungs and
Other organs; the hemorrhages in and under the mucous membrane of stomach
so abundant that the gastric surface presented a mottled appearance like the
skin in measles.
Microscopic Eacamination. (By Dr. SATTERTHw AITE.)—The mucous mem-
brane of the larynx and trachea was hyperaemic, but was otherwise apparently
normal; muscular tissue of heart normal; spleen soft, but not appreciably en-
larged. The scrapings of the cut surface of this organ contained red blood-
Corpuscles; bodies from two to five times the size of the blood-corpuscles,
holding in their interior oil drops and fine granules, and having a yellowish-
red color; granular lymphoid corpuscles, and granular débris. The walls of
the stomach were congested, but without any noticeable exudation upon the
surface ; the extravasations of blood, described above, were found to be chiefly
in the submucous tissue. In some places the gastric tubes were bare, but in
Other places covered with amorphous matter; but whether the covering sub-
stance was altered epithelium or diphtheritic exudation was not determined.
The epithelium covering the more exposed portions of the tubes was in many
places not distinct, while that covering the deeper portions of the tubes was
clearly defined; at the pylorus, upon the valve, the mucous membrane was de-
ficient; those portions of the true peptic glands lying below the tubes were
normal. The mucous membrane in the lower part of the ileum was congested.
Peyer's patches, and the solitary glands, both in the ileum and large intestines,
were prominent, and surrounded by halos or rings of inflammation. Both the
cortical and pyramidal tubes of the kidneys contained granular epithelium.
In croup the blood certainly undergoes anatomical changes as in other
inflammations, and becomes overcharged with carbonic acid when the
respiration is embarrassed ; but I am not able to find records of any
case of undoubted croup, or of croup occurring in a locality where diph-
theria does not prevail, in which such profound destructive changes
occurred in the blood, as were present in the above case of diphtheritic
catarrhal laryngitis, and as are common in diphtheria whether accom-
panied by laryngeal or other form of inflammation. I must, therefore,
conclude that croup and diphtheritic membranous laryngitis possess such
local and general anatomical differences as justify our regarding them as
essentially distinct.
358 J. L. SMITH,
III. Clinical Facts which indicate the Duality of these two Diseases.—The
season of the year and the weather influence the occurrence of croup.
Exposure to currents of air and sudden changes of temperature are its
common causes. In tropical climates, croup is less frequent than in the
moist and cold climates of higher latitudes. In localities swept by cold
winds, or liable to sudden variations in the atmospheric heat, croup,
as well as pseudo-croup and bronchitis, are common, for these diseases
have a common cause. The following example, which I recall to mind,
may be cited as showing how croup is commonly produced. A little
girl, at a time, and in a locality in which no diphtheria was occurring,
had an ordinary attack of measles. As she was beginning to convalesce,
though still having some cough, she sat for some time in an open window
through which the wind was blowing. On the following night mem-
branous croup commenced, ending fatally in about two days.
The cause of diphtheritic laryngitis is different. It is a contagious
principle which poisons the blood, and produces certain inflammations
quite independently of atmospheric conditions. Exposure to winds and
sudden thermal changes play a very subordinate part in causing diph-
theritic laryngitis. They may sometimes act as predisposing causes, by
irritating or inflaming the mucous membrane, for clinical experience and
experiments on animals show that in a system affected by diphtheria,
the specific inflammation is most apt to appear on such surfaces as are
irritated or inflamed. Only in this respect can diphtheritic laryngitis
be said to have the same cause as croup. In cases which I have observed,
I have rarely had occasion to suspect that the patient had taken cold.
I have frequently seen the laryngitis occur when there had been every
precaution to prevent taking cold, and the proportion of cases of diph-
theritic laryngitis has been, I think, nearly as large in warm and equable
portions of the year, as in seasons of cold and changeable weather.
Again, croup very seldom occurs under the age of eighteen months,
nor over the age of fifteen or sixteen years. Physicians in New York,
whose practice extended over a number of years before diphtheria com-
menced, tell me that they never saw croup after the fifteenth or sixteenth
year. Now diphtheria and diphtheritic laryngitis are not rare between
the ages of six months and two years. I have seen minute white points
over the tonsils, in an infant of six weeks, whose brother was dying of
diphtheritic laryngitis, and there are a few cases on record of new-born
infants affected with diphtheria, though it is the universal experience
that very young infants are less liable to diphtheria than those who are
older. - g
Every physician, again, who has witnessed a severe epidemic of diph-
theria, or who has practised where diphtheria is endemic, knows how
frequently it occurs in youth, and in the first years of manhood. The
statistics of New York epidemics furnish a considerable number of cases
which were fatal from diphtheritic laryingitis between the ages of twenty
and forty years. There is, therefore, a marked difference as regards the
limits of the age in which diphtheritic laryngitis and croup occur.
But the strongest argument in favor of the duality of croup and
diphtheritic laryngitis, and one which, to my mind, is conclusive, is
derived from the fact that the one is non-contagious and the other highly
contagious. Physicians of New York, who saw cases of croup prior to
1 See Bost. Med. and Surg. Journ., March 11, 1875; also Contributions to the Patho-
logy and Therapeutics of Diphtheria, by A. Jacobi, M.D., New York, page 26.
C. R O U P AN ID L) IP HT H E R IA . 359
the time when diphtheria occurred, and country physicians, in localities
where diphtheria has not yet prevailed, have informed me, without an
exception, that they never saw any evidences of the contagiousness of
croup. Would not intelligent physicians, whose united practice in locali-
ties not yet visited by diphtheria gives more than a century of observa-
tion, be able to record a single instance of the contagiousness of croup,
if it possessed in any degree a contagious principle : Contrast this fact
with the fearful contagiousness of diphtheritic laryngitis. Now I hold
that if two maladies are identical in every other respect, but one is con-
tagious and the other non-contagious, it will be necessary to give them
different places in nosology. Contagiousness, although it be a new pro-
perty assumed by an old and well-known malady, so transforms its nature
that it becomes to all intents and purposes new and distinct.
The following is also an interesting fact, as showing an important dif.
ference between croup and diphtheritic laryngitis. In New York City,
statistics of the mortality have been preserved since 1804, and in the long
period from 1804 to 1850, inclusive, no case of diphtheria, or none recog-
nized as such, occurred within the city limits. Now, during this time,
croup was not infrequent, the yearly number of deaths from it never
falling below 60, which was the number in 1817; nor exceeding 356,
which was the number in 1850; the average yearly number being 148.2,
and the total number for the forty-seven years being 6964. Physicians
of New York, whose practice extended over the latter part of this period,
state that they occasionally, at rare intervals, saw cases during this time
which resembled diphtheritic pharyngitis, but which went by the name
of malignant angina, or malignant sore throat. One of the prominent
surgeons of New York lost a child from this sore throat about the year
1833. -
Rokitansky tells us that all the mucous surfaces are liable to croup-
ous inflammation ; and were these pseudo-membranous pharyngeal, or
pseudo-membranous laryngeal, inflammations of the first half of the pre-
sent century, croupous; or were they the inflammations of diphtheria,
which still lingered in the city in a modified form since the great epide-
mic of the eighteenth century, which Colden and Bard described : Cer-
tain facts may be stated which indicate the croupous, and not diphtheritic,
nature of these inflammations: first, the absence of all history of conta-
giousness; and, secondly, the fact that the laryngitis was so much more
frequent and fatal than the pharyngitis. The statistics of diphtheria,
the world over, show, as every one knows, an excess of cases of diphthe-
ritic pharyngitis over the cases of diphtheritic laryngitis; while the
number of fatal cases of diphtheritic pharyngitis and diphtheritic laryn-
gitis is either about equal, or as two to one. From the year 1804 to 1850,
there were in New York 6964 deaths from membranous croup, while the
deaths from all other forms of inflammation of the throat, including the
membranous, for they were all grouped together, numbered only 1387,
or about one-fifth of the number of deaths from croup. Now does not
the wide difference between the frequency and mortality of these inflam-
mations during the half century, when there was no diphtheria to modify
diseases, and of diphtheritic pharyngitis and laryngitis of the present
time, indicate a difference in the nature of the inflammations in the two
periods?
Let us state the argument in different terms. If the croup of New
York, in the first half of the present century, were a modified diphthe-
ritic laryngitis, can any one tell us why membranous pharyngitis, during
360 J. L. SMITH,
*
the same period, was comparatively rare, and fatal membranous pharyn-
gitis so very rare that the majority of physicians did not meet with a
case in years of practice ; when in true diphtheria, the world over, mem-
branous pharyngitis is the most frequent diphtheritic inflammation in
fatal cases, as well as in those which have a favorable issue }
Writers have also very properly called attention to the fact, as showing
an essential difference between croup and diphtheritic laryngitis, that
the former is seldom followed by paralysis, whereas paralysis is common
in those who recover from diphtheria, whatever the form of inflamma-
tion from which they have suffered. -
The results of treatment also indicate a difference in the nature of
croup and diphtheritic laryngitis. In croup, emetics, even those of a
depressing nature, are tolerated. There is rarely any serious depression,
except in advanced cases of croup, from the occasional use, in emetic
doses, of ipecacuanha or tartrate of antimony and potassium, so as to
expel muco-pus from the bronchial tubes, or any portion of the pseudo-
membrane which may be detached. In diphtheritic laryngitis, the
employment of these agents, under any circumstances, is hazardous, and
the profession generally, observing their ill effects, have abandoned the
use of all emetics in diphtheria, even those which are least depressing.
I recollect that, in New York City, soon after diphtheria began to be
prevalent, physicians were sometimes astonished at the rapid sinking of
patients with diphtheritic laryngitis, whom they had treated as they had
previously treated cases of croup. Thus a girl, aged about ten years,
with moderate dyspnoea, but whose case did not seem to be immediately
dangerous, took an emetic of “hive syrup,” by the physician’s advice,
and sank so rapidly that she died in an hour or two later. More recently
I saw a child of three years, whose dyspnoea did not seem to be extreme,
suddenly sink into fatal prostration, under doses of tartrate of antimony
and potassium which the physician in attendance had ordered.
While in croup death results from the obstructed respiration, and con-
sequent imperfect oxygenation of the blood, there is the same source of
danger in diphtheritic laryngitis, but also the additional danger which
results from blood poisoning and structural changes in important organs,
as the heart and kidneys. Hence, fatal as is croup, diphtheritic laryn-
gitis involves greater danger, and is less annenable to treatment. More-
over, as we have seen above, in ordinary cases, there are probably greater
infiltration of the mucous membrane and longer continuance of the exu-
dative process in diphtheritic laryngitis than in croup, and consequently
greater liability to reproduction of the pseudo-membrane. It will be
recollected that in one of the cases related above, the patient expectorated
two pieces of pseudo-membrane, of considerable size, three days before
death, but that the denuded places had been so completely refilled that
the surface from which the detachment had occurred was not apparent at
the autopsy. If the views now expressed in reference to the relative
duration of the exudative period in croup and diphtheritic laryngitis be
correct, and I see no reason to doubt them, it is evident that the expulsion
of any considerable portion of pseudo-membrane affords much stronger
hope of a favorable termination in a case of croup, than in one of diph-
theritic laryngitis.
Statistics of tracheotomy for membranous laryngitis which was sup-
posed to be chiefly croup, derived from the surgical practice in New
York City some years since, before diphtheria became fully established
C R O U P AND DIP HT H E RIA . 361
as an endemic, gave a mortality of about 77 per cent.,' whereas the result
of this operation at the present time, in cases which are believed to be
chiefly diphtheritic, is much less favorable. A prominent surgeon of
New York informs me that in about twenty consecutive cases of trache-
otomy for diphtheritic laryngitis, he has saved only one ; and another sur-
geon has saved only one in thirteen cases; while another still, who has
probably performed tracheotomy oftener than any other practitioner in
New York, has saved only two in about forty operations during the last
four years, and has reason to doubt the genuineness of the disease in one
of the two which recovered. My data are insufficient for positive state-
ment, but I incline to the belief, from cases which have been reported
to me and from conversations with the surgeons, that it is necessary, in
cases which do well, to retain the canula longer on an average after the
operation for diphtheritic laryngitis, than after that for croup. We
would expect this, if there is greater infiltration, and a more protracted
exudative stage, in the former than in the latter disease; and although
I have known the canula to be safely removed, in one case of diphtheritic
laryngitis, at the close of the third day, I think it is oftener necessary
to retain it the greater part of a month, or even longer. Wishing to be
understood as not committing myself to this last statement in regard to
the length of time during which it is necessary to maintain the artificial
opening in tracheotomy for croup and diphtheritic laryngitis, for my
records are too few for a positive assertion, nevertheless the results of
medical and surgical treatment indicate, in my opinion, a wide differ-
ence in the two forms of inflammation.
Those who believe in the essential oneness of croup and diphtheritic
laryngitis, believe, as far as I can learn, that the croup of former times
has been greatly modified to become the diphtheritic laryngitis of the
present day. But how far can a malady undergo modifications and yet
preserve its identity ? Invest a local disease with a specific principle,
or call into activity a specific principle which has hitherto lain dormant
in it, rendering it a constitutional and contagious disease, and its nature
is so transformed that it becomes to all intents and purposes a new mal-
ady. It is not dressing up an old disease in a new garb, but it is chang-
ing its very essence or nature into something new and distinct.
In this connection an interesting fact is suggested. Those who prac-
tise in localities where diphtheria is endemic, often observe other forms of
inflammation becoming diphtheritic. The pharyngitis of scarlet fever,
when the primary disease has continued a few days, is often complicated
by, or transformed into, a diphtheritic inflammation ; and I have seen
diphtheria thus commencing spread as an independent malady. A simi-
lar change in the character of the inflammation is also common in
measles, especially during severe epidemics of diphtheria. And not in-
frequently an inflammation of the air-passages, apparently at first catar-
rhal, and probably so diagnosticated by the physician, presents in a few
days the grave characters of the specific inflammation of diphtheria. It
is, therefore, in my opinion an open question, whether the exudative
inflammation of croup may not afford a favorable nidus for the reception
and development of the diphtheritic virus, so that a case commencing as
croup may become one of diphtheria. Perhaps this may explain the
apparent fact that croup is less frequent in localities where diphtheria is
established, than in former times.
* See the author's Treatise on the Diseases of Children.
36.2 J. L. SMITH,
DISCUSSION ON DR. J. LEWIS SMITH's PAPER.
After the reading of the preceding paper, Dr. WILLIAM PEPPER, of Philadel-
phia, Said :—It seems to me that the recognition of a radical difference between
diseases which possess strong points of resemblance and analogy, is a very
delicate matter, and that the arguments in favor of such separation should be
very clear and unanswerable. In the present case we have to deal with forms
of disease characterized by the production of a peculiar pseudo-membrane
upon the surface affected. Although there are many grades of severity, and
therefore many differences in degree, between the lesions in different cases of
croup and diphtheria, I am confident that no essential difference exists either
in the microscopical or chemical characters of the pseudo-membrane in the two
forms of disease, nor in its relation to the subjacent surface. This form of
exudation is so peculiar and distinctive that a strong presumption would seem
to exist in favor of the relationship of two affections in both of which it is
developed. In considering the arguments against this relationship, which have
been so fully and ably presented by Dr. Smith, I am unable to feel that they
are convincing. We must not think of diphtheria only in its grave epidemic
form, but also in the mild, sporadic form which so frequently occurs. I meet
very frequently with isolated cases of undoubted pharyngeal diphtheria (for I
would carefully exclude all cases of herpetic follicular angina with pseudo-
membranous formation of a different kind), in which the constitutional symp-
toms are not very asthenic, albuminuria is usually absent, glandular swelling is
not very great, there is no evidence of profound constitutional infection, and
paralysis rarely follows. In such cases there is by no means the very marked
difference from the general symptoms of membranous croup that has been
assumed to exist. -
It has frequently been my experience also, as I have stated elsewhere in
connection with Dr. J. Forsyth Meigs, to find that cases which had been regarded
as idiopathic croup, had really been preceded by slight faucial diphtheritic
deposits, and were consequently undoubtedly diphtheritic in nature. It is
true that the pseudo-membrane may first occur in the larynx in some cases, but
I should be glad to see more careful and numerous records of such cases, where
no pellicular formation in nares or fauces was present at any period. In dif.
ferent epidemics, and at different times, the proportion of cases of diphtheria
in which the deposit occurs in the larynx is very variable. At times very few
cases of croup occur; at others, the number is large; in a few epidemics, the
larynx has been, as a rule, the first and only part affected. In these instances
the attendant constitutional symptoms, and the rate of mortality, have been
such as are found in grave epidemics of naso-pharyngeal diphtheria. Last
winter I attended a case of membranous croup with highly sthenic general
symptoms, in the eldest of three children. No faucial deposit was detected, but
there had been nasal catarrh for a few days before the laryngeal symptoms
appeared. The child died from suffocation, the operation of tracheotomy
having been refused. In every respect this case resembled so-called idiopathic
membranous croup; yet, before the child’s death, the youngest sister sickened
with a dangerous naso-pharyngeal diphtheria, from which she recovered with-
out laryngeal implication. I might quote other cases of similar character.
Nor do I think the results of treatment afford a reliable basis of separation.
We cannot regard diphtheria, any more than pneumonia, as though it had a
constant and uniform type. There are cases of the one, just as of the other,
which will bear and justify a treatment which would prove injurious in other
instances, and I believe that the general treatment suitable for cases of sporadic
pharyngeal diphtheria is also well adapted, with the addition of special means
required by the mechanical obstruction of the larynx, to the treatment of
sporadic membranous croup.
I shall add but a word on the argument of contagion. There is still need
C R O U P A N D DIP HT H E R I.A. 363
of careful clinical work here, and the subject is now full of difficulty and
obscurity. When epidemic diphtheria assumes the laryngeal form, the disease
is clearly infectious or contagious, as is the pharyngeal form. When, on the
other hand, pharyngeal diphtheria occurs in its mild sporadic form, any evi-
dence of infectiousness or contagiousness is often wanting. I have known a
mother, affected with an undoubted attack of this form of the disease, to nurse
her child of thirteen months throughout the entire course of the disease with-
out communicating it to the infant. I would refer, on the other hand, to the
case of apparent sporadic membranous croup, above quoted, which was the
cause, seemingly, of severe diphtheria in a younger sister. Is there anything
in the anatomical conditions of the larynx and pharynx respectively—the much
richer lymphatic supply of the latter, and the greater tendency to putrefactive
changes in all exudations in that part—which may influence the liability to
constitutional poisoning, and also to infectiousness, differently in the two
cases 7
I have no desire to assume a partisan position on this subject. I would be
understood only as saying that the evident strong analogies between the two
forms of disease, and the want of conclusiveness, as it seems to me, of the
arguments in favor of their essential dissimilarity, make me feel it hazardous
in the extreme to assert that they are radically distinct affections; and that I
find myself more and more inclining to the view that they are only different
forms or types of one pathological condition.
Dr. HENRY GIBBONs, of California, said:—When you, Mr. Chairman, and my-
self attended lectures in this University, no such word as diphtheria was known
in the English language. Since then we have, by slow degrees, long study, and
diligent practice, become convinced that there are two distinct forms of disease
—one which we know as croup, and the other as diphtheria. Years ago we
invariably bled for an attack of croup, and nearly always cured it.
Dr. J. J. WooDWARD, U. S. A., said:—I would like to ask Dr. Smith if, in pre-
paring his paper, he consulted the first or second edition of Rokitansky’s work 7
I thought from the reference to this eminent pathologist's views that his later
edition, in which he speaks of diphtheria, had not been consulted.
Dr. C. J. HARE, of London, said:—This question of the identity or non-identity
of croup and diphtheria is receiving a great deal of attention on the other side
of the Atlantic as well as on this. At this time there is a sub-committee of the
Royal Medico-Chirurgical Society of London investigating the subject. I ad-
mit that we should search after truth, but I think that medical men spend a
great deal of time in re-determining questions that have already been deter-
mined. I think that after hearing the paper just read, there can be no doubt
about there being two diverse and distinct diseases. The microscope has failed
in other cases as well as in this. There appear to be distinctions which it is
impossible to overlook. The symptoms of the two diseases have been so fully
entered upon by the author of the paper that it would be out of place for me even
to recapitulate those which are, as I conceive, distinctive between them ; but
there are two circumstances or conditions which, taken alone, prove to my mind
the diversity of the two affections. I allude to the contagiousness of diphtheria,
and to the paralytic affections which frequently result from it. Those who
knew croup some thirty or forty years ago, and before the prevalence of diph-
theria, will remember that the disease they then knew was never contagious, and
was never followed by paralytic affections. Nor do the old authors, who de-
scribed so graphically the symptoms of croup, ever mention these points.
Will any one venture to say that if the contagiousness and the affections I
have alluded to had been part and parcel of croup they could possibly have
been overlooked, or could have failed to be described 7 No; they were not
referred to, for the simple reason that they did not exist; and they did not
exist then, because the disease at that time known was true croup and had no
such symptoms; whereas, in recent years, we have also had to deal with an-
other and different disease–diphtheria, of which contagiousness and the
364 J. L. SMITH,
sequelae I have named are characteristic conditions. Our treatment has been
modified, not because one disease has run into the other, but because we have
two distinct diseases to deal with. The result as regards treatment, leaves no
doubt whatever in my mind as to the non-identity of these two affections.
Dr. R. P. How ARD, of Canada, said:—I cannot believe with the last speaker
that this matter is so definitely settled in the minds of the scientific world.
The fact that the Medico-Chirurgical Society of London has just appointed a
committee to inquire into the matter proves this to be so, and the circumstance
that the French school still regards membranous croup as laryngeal diphtheria,
proves that the scientific mind is not agreed upon the question. I think that
there is a good deal of truth expressed in the paper read on the subject, and
that we will have to work honestly and fairly for a long time to come, before
we can controvert some of its statements. If a large number of cases of so-
called membranous croup were investigated after death, we might have the
data by which to arrive at some truth on the subject.
Dr. W. OLDRIGHT, of Canada, said:—In 1865, while I was practising on the
shores of Lake Huron, there was an epidemic of sore throat of a peculiar charac-
ter. During that time I think I met with one case of true diphtheria. On a
Thursday night, a young man became intoxicated, and lay out all night; he
was attacked by the disease, and on Sunday morning gangrene set in, and by
evening the line of demarcation appeared. Shortly afterwards he died of
strangulation. The young man's brother was also attacked, and became para-
lyzed and remained so for about four months. Another remarkable case was
that of a boy about eleven years of age, who on being attacked became per-
fectly black in the face and throat. His face and ears were swollen terribly,
but his intellect remained perfectly clear. He died in two or three hours."
Dr. R. BARTHOLOW, of Cincinnati, said :—As a clinician I have held that the
differential diagnosis of croup and diphtheria rested on three conditions—the
local affection, the constitutional state, and the sequelae. In croup, the exuda-
tion or false membrane lies in contact, merely, with the mucous membrane;
in diphtheria, the exudation extends into and involves the epithelial layer
of the mucous membrane, and the neighboring vessels, especially the lympha-
tics, are crowded with bacteria. Swelling of the sublingual and submaxillary
glands accompanies various faucial inflammations, but in diphtheria the chain
of lymphatics lying under the sterno-cleido-mastoid muscle is involved, while
it is not in croup. As respects the constitutional state, the adynamia is much
more strongly marked in diphtheria than in croup, and bears no proportion,
necessarily, to the extent of the exudation in the fauces. No sequelae follow
croup. When the local process in the air passages ceases, the disease is at an
end. On the other hand, in diphtheria, various sequelae follow—albuminuria,
paralysis, etc. Donders, in his Anomalies of Refraction and Accommodation
of the Eye, makes the capital observation that the ocular and other paralyses
which follow diphtheria are not determined by the amount of the faucial exuda-
tion, and often follow in cases which were supposed to be ordinary cases of sore
throat, and in which no exudation had been observed. The contagiousness of
diphtheria appears to be well established. If this be admitted it constitutes a
fourth means of diagnosis.
Dr. T. L. MADDIN, of Tennessee, said:—In a recent number of the British and
Foreign Medico-Chirurgical Review, the unity or duality of croup and diph-
theria are fully considered : and from this it appears that recent authors of
merit, treating upon the subject, leave the question in doubt. Thus it is evi-
dent that in the minds of many there are intimate links of connection between
the two affections, if indeed, they are not grades of the same disease. With
a large clinical experience, my convictions are clear that pathologically they
have no kinship. Croup is a local disease, and its fever symptomatic ; its
etiology is various, even a common cold often causing it ; its nature a local
inflammation, with a false membrane strictly on the surface, and never under-
going necrosis. Diphtheria has a specific etiology, and is an essential fever.
f
C R O U P AN ID DIP HT H E RIA. 365
Its false membrane, occurring mostly in the pharynx and tonsils, often invades
the nasal, laryngeal, and bronchial mucous membrane. It penetrates the mu-
Cous and often the submucous structure, and undergoes septic decomposition.
It may form on any portion of the body where there is a lesion. The fever is
a dynamic, and the convalescence slow. Albuminuria is present as in Scarlet
fever. The treatment of the two is totally different. I am, therefore, clearly
of the opinion that croup and diphtheria are distinct diseases widely separated
from each other.
Dr. H. P. AYREs, of Indiana, said:—I have seen croup prevail largely, and yet
no diphtheritic symptoms accompany it : but I have never yet seen diphtheria
prevail without croupy symptoms attending it. I do not think the disease is
contagious, although it may be classed as such. I have seen cases in which
One of a family was attacked and died, while the others escaped. Had the
disease been contagious more than one would have been affected.
Dr. C. C. HAMILTON, of Nova Scotia, said:—I have had experience with both
diphtheria and croup, and think there cannot be any very great similarity be-
tween the two. I have had one or two cases which would tend to prove that
croup is contagious, but as a general thing it is not. I have observed that
since diphtheria has prevailed croup has been a much rarer affection than for-
merly.
366
DO THE CONDITIONS OF MODERN LIFE FAVOR, SPECIALLY
THE DEVELOPMENT OF NERWOUS DISEASES 7
BY
ROBERTS BARTHOLOW, M.A., M.D.,
PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE IN THE MEDICAL COLLEGE OF OHIO.
“THE wear and tear of our modern civilization,” is a current phrase
which indicates the general belief, lay and professional, that the struggle
for existence in our time imposes an excessive and consequently injurious
labor on the brain and nervous system of man. That the injury thus
done manifests itself in an increased production of nervous diseases,
seems to be generally conceded. Without having bestowed much reflec-
tion on the subject, I had accepted this popular view ; but when I came
to investigate the facts which are available for the solution of the prob-
lem, in preparation for this paper, I felt obliged to change my opinions.
To the question “Do the conditions of modern life favor specially the
development of nervous diseases 7" I reply in the negative.
At the outset, it must be admitted that the evidence is largely pre-
sumptive. No statistical data have descended from ancient times, and,
indeed, as respects so recent a period as the last and the present century,
an exact numerical expression of the relative prevalence of nervous dis-
eases, is not possible. In the absence of statistical evidence, the inquiry
must be directed into other channels. An approximation to the degree
of current familiarity with mental and nervous maladies, may be made
by a study of the references to such diseases in the ancient secular
writers. The actual state of knowledge of mental and nervous maladies,
as compared with other diseases (of women, for example) will be exhib-
ited by the ancient medical writers.
Insanity is distinctly portrayed in some of the characters of the Greek
drama. The tragic story of Orestes furnishes the material for two of the
most powerful dramas of the Grecian stage. Both by Æschylus and Eu-
ripides, is the hero, Orestes, made to become insane by remorse after the
death of Clytemnestra. The form of insanity which they depict is acute
mania, and after a certain period reason is restored. Probably the best
picture of mania which has descended to us from the ancient world, is
the Ajax of Sophocles. This is delineated with a master hand, familiar
with the malady described. Indeed the three dramatists exhibit a degree
of familiarity with the salient features of an acute maniacal attack,
which could only have been obtained by a personal study of the parox-
ysms. We obtain glimpses from the comedies of Aristophanes, that
cases of senile dementia were not unfrequently subjects of judicial inves-
tigation. In his comedy of “The Clouds,” which was directed against
the sophists, and especially against Socrates, it is indicated that the young
men of Athens employed such means to be rid of troublesome seniors.
It is an historical fact that Sophocles in his old age was the subject of an
inquiry into his mental condition, instigated by his sons who wished
to obtain possession of his property. Even Socrates was the subject of a
delusion—his inward voice, daemonium—which guided all his actions,
M O DE R N LIFE AN ID N E R W O U S D IS E A S E S. 337
however trifling, and to which he invariably deferred. The damonium
of Socrates has been the subject of an immense deal of speculative sub-
tilty. Without presuming to decide a question so surrounded with dif-
ficulties, I may at least express an opinion formed after an examination
of all the sources of information within my reach : To me, this voice, in-
ward mentor, conscience, or daemonium, appears to be a hallucination. It
should be remembered that Socrates was given to introspection, and had
a character full of eccentricities. ** -
In Grecian and Roman mythology, madness is frequently inflicted for
disregard of the commands of divinities, in accordance with the popular
notion that the anger of the gods is thus visited on man. Bacchus was
one of the divinities who most used this means of punishment. He thus
afflicted Lycurgus, of Thrace, and the three daughters of Praetus, be-
cause they declined to worship him. These insane women are represented
to have wandered in the fields like cows, and, quite in accordance with
what we now know of the contagiousness of imitation, many Argive wo-
men went mad and did the same thing. The “heaven-inspired Cassan-
dra” was doubtless insane, as the Trojans believed. It is a very old trick
to feign insanity; Ulysses was the first on record to attempt it.
In the ancient secular writers references to the “sacred disease” are
very numerous. Herodotus chronicles the fact that Cambyses was afflicted
with this malady, and, very remarkably, he attributes the cruelties prac-
tised by this ruler to the mental state induced by the epileptic paroxysms.
Gallius and Macrobius quote from Hippocrates in regard to the “sacred
disease.” In the former occurs the curious statement (attributed to Hip-
pocrates) that the sexual congress is a condition of the body not unlike
the epileptic paroxysm. Horace, in his epistles, describes melancholy
and paralytic tremor.
Erb infers that neuralgia must have been comparatively rare in ancient
times, because “Aretaeus is the first who gives a recognizable description
of it.” Yet Socrates, in the Phaedo of Plato, is made to utter some remark-
able thoughts on the relationship of pleasure and pain. “What an unac-
countable thing, my friends, that seems to be, which men call pleasure;
and how wonderfully it is related towards that which appears to be its con-
trary, pain ; in that they will not both be present to a man at the same
time ; yet if any One pursues and attains the One, he is almost always
compelled to receive the other, as if they were both united together from
one head.” These observations do not, it is true, prove the existence of
neuralgia in ancient times, but they show that the acute-minded philoso-
pher had reflected profoundiy on the nature of pain, anticipating, in his
conclusions, modern knowledge of the functions and attributes of the
sensory nerves. These examples from the secular writers must suffice.
Doubtless most of the members of this learned body will recall other
and, it may be, more pertinent instances; but I must pass to consider the
state of knowledge of nervous diseases shown by the medical writers of
antiquity.
The writings of Hippocrates furnish us with numerous references to
the more important nervous maladies. In the Prognostics, is delineated
with admirable fidelity and brevity that form of delirium in which the
patient picks at the bedclothes and objects in the air. In the Regimen
in Acute Diseases, there is a distinct allusion to trembling delirium due
to vinous excess. In the book of Epidemics, cases of “phrenitis” are
* Ziemssen's Handbook, vol. xi.
368 BARTHOLOW,
given, the main features of which are much like those of modern cerebro-
spinal meningitis. The earlier writers made no attempt to differentiate in
the forms of intra-cranial inflammations, for reasons which are perfectly
obvious; although under the term sphacelus of the brain Hippocrates
probably meant ramollissement. In the Aphorisms, we find a great many
very acute observations on the signs and symptoms of many nervous
affections. The sleep which approaches coma, and the sleep which puts
an end to delirium, are described, and the prognostic value of Sopor and
insomnolence clearly stated. The insensibility to pain manifested by
the insane is recognized. Hippocrates declares that the prognosis of
insanity is more serious after forty years of age, a fact which, we must
admit, is generally true. “It is better that a fever succeed to a convul-
sion, than a convulsion to a fever,” is an undoubted truth, which indi-
cates that Hippocrates recognized the clinical difference between those
convulsions which announced the onset of a fever, and those which came
on at the termination of an acute intra-cranial inflammation. He indi-
cates his acquaintance with aphasia in various aphorisms which refer
loss of speech to injuries of the head, vinous excess, etc. He frequently
alludes to vertigo, apoplexy, and tetanus, and is minute on the subject of
epilepsy, the prognosis of which, he informs us, is more favorable when
the disease occurs in the young than when in the old. In a description
of the effects of venery, Hippocrates draws a picture of nervous symp-
toms not unlike those belonging to the first stage of spinal sclerosis. It
is known to all here present how pronounced are the sexual symptoms
in Duchenne's first stage of progressive locomotor ataxia.
Some of the medical writers subsequent to Hippocrates are more
minute and systematic in their descriptions of nervous diseases. A re-
taeus, who was most probably a contemporary of Galen, describes tie dou-
loureuz (On Cephalaea), vertigo, and the vertiginous sensations which
accompany various intra-cranial diseases, epilepsy, melancholy, mania,
ecstasy, apoplexy, paraplegia, hemiplegia, and paresis, and mentions dis-
turbances of the functions of the cranial nerves such as are produced by
intra-cranial tumors. The most complete account of nervous diseases
that has descended to us from the ancient world is found in Galen." The
different varieties of headache are very admirably depicted by this wri-
ter, and he indicafes his acquaintance with the fact that the symptoms
are associated with various intra-cranial lesions. He treats of abscess,
meningitis, coma-vigil, catalepsy, hysteria, melancholia, mania, imbe-
cility, senile dementia, vertigo, epilepsy, apoplexy, paralysis, local para-
lyses, spasms, tetanus, paralytic tremor, etc. Writers subsequent to
Galen, for many centuries, as is well known, adopted his descriptions.
It would occupy too much time to give a detailed account of the opinions
of other and less authoritative ancient medical writers. It must suffice
to state that Aëtius, Oribasius, Alexander, Caelius Aurelianus, Celsus,
Avicenna, and Rhazes, besides other less important ancient physicians,
treat of nervous maladies at very much the same relative length. It is
quite evident, then, that various diseases of the nervous system were per-
fectly familiar to the writers of the ancient world.
'If we compare the manner in which the ancient medical writers dis-
cussed the various diseases with which they were acquainted, we find
that affections of the nervous system occupied as much space in their
works as the diseases of other parts. Probably the knowledge of the
* De Compositione Medicamentorum secundum Locos.
M O D E R N LIFE AN ID N E R W O U S D IS E A S E S. 369
ancients, as compared with modern acquirements, was more full and
exact on the subject of the diseases of females than of any other group
of maladies. Some instruments of precision which have contributed so
largely to the developmeut of gynaecology, were known to and used by
the most ancient practitioners of whom we have any knowledge. The
Speculum, the uterine sound, and the pessary, were, as is well known,
Only rediscovered in modern times. An attentive examination of the
ancient books on female diseases must convince any one that women
have always suffered from the physical infirmities to which, in our day,
they seem to be specially liable. The ancient physicians had every oppor-
tunity, we may suppose, to become practically familiar with female dis-
eases, and the information conveyed to us in their writings is marked by
the accuracy of detail only secured by faithful observation. When we
compare the amount of space devoted to nervous and female diseases,
respectively, it is evident that the former are treated with as full detail
as the latter. If we take the works of Paulus AEgineta, who, according
to his own statement, “ compiled his collection from the works of the
ancients,” without omitting “any one distemper,” we can see that affec-
tions of the nervous system occupy quite as much space as diseases of
women, and are treated as intelligently.
When the ancient writers allude to the causes of diseases affecting the
nervous system, they are said to be heat, cold, injuries, and excesses in
eating, drinking, and venery—just such causes as in modern times are
held to be influential. The most superficial survey of ancient society
must convince any one that the nervous system of man was, in those days,
exposed to extraordinary trials. The writings of Aristophanes, of Lu-
cian, of Athenaeus, amongst the Greeks, of Martial and of Juvenal amongst
the Romans, give us hints of a licentiousness to which the most debased
societies of modern times afford no sort of parallel. The political status
of the ancient civilized communities was never permanent. Wars and
revolutions, characterized by the greatest atrocities, occupied the restless
citizens of the Grecian and Roman States. At home, games, public
amusements, constantly recurring political excitements, the worship of
Venus and Bacchus with their attendant orgies; abroad, wars, conquest,
and plunder, were the occupations of Athenian and Roman citizens.
The minute subdivisions into which the medical art was parcelled
amongst the ancient Egyptians, and later amongst the Romans, indicated
that in those times diseases were very rife. In Cicero's age the only
divisions were three—physicians, surgeons, and oculists; but when Galen
wrote,” the bad example of Thessalus had filled Rome with a great crowd
of hungry specialists in every possible field of medical practice. There
were specialists in remedies, as well as in diseases, and in the diseases of
every known organ of the body. There were specialists for the globes
of the eyes, and for the eyelids; for the uvula, and for the tonsils; for
the external ears, and for the internal ears; for palsy, dropsy, stone, and
skin diseases; for children, and for old people. There were apostles of
the movement-cure, or those who treated rheumatic and paralytic troubles
by gymnastics, massage, and frictions. Galen contemptuously styled
these multitudinous charlatans, the asses of Thessalus; for this magnifi-
cent, impudent, and successful quack had declared that he could teach
any doctor in six months all that he needed to learn. We obtain from
Pliny a lively picture of the ignorance and rapacity of these specialists:*
! De Oratore. * Methodus Medendi. * Historia Naturalis.
24
370 BARTHOLOW,
“I will not speak of their avarice, their swindling bargains made with
patients in an extremity, the imposition laid on suffering, the earnest
money, so to speak, of death, the secret retainer fees,” etc. Alluding to
the same class, Galen affirms that the doctors in Rome differed from
highwaymen only in the fact that the former lived in the city, and the
latter camped out in the mountains.
These facts indicate, I think, that the diseases incident to Roman life
were very numerous, and hence the demand for physicians; otherwise
the supply had not been so abundant. In this strange medley of special-
ists, there seem to have been as many, comparatively, devoted to mala-
dies of the nervous kind as to other diseases, and certainly during the
times of Galen and Pliny there were in the social and political condition
of the Roman people powerful causes in operation to produce these affec-
tions.
From the thirteenth to the sixteenth centuries, there occurred in Eu-
rope epidemics of purely nervous maladies such as the world had never
before witnessed. In the graphic pages of Hecker, we learn that the
dancing mania, in Germany and Holland, tarantism in Italy, and the
malady of the Convulsionnaires, in France, involved great numbers in the
wildest excesses. Such moral epidemics are possible only in such a state
of society as existed in the mediaeval times—an age of faith and rev-
erence, but ignorant and superstitious. During the same period great
epidemics of cerebro-spinal meningitis devastated various parts of Ea-
rope, notably near the close of the fifteenth and at the beginning of the
sixteenth centuries. No additions during the middle ages appear to have
been made to the knowledge of Galen. In a voluminous work on “The
Generall Practice of Phisicke,” “ compiled and written by the most
famous and learned Doctor Christopher Wirtzung,” and published near
the close of the sixteenth century, the descriptions of Galen are closely
followed. In his commentary on “the braines and all that concerneth
them,” the learned Doctor includes loss of memory, vertigo, phrenitis,
mania, melancholia, dementia, palsy, tremor, spasm, incubus, epilepsy, and
sciatica. It is perfectly obvious that the state of medical knowledge
then existing did not admit more accurate differentiation in nervous
maladies.
The present condition of neurological medicine has been reached only
since the physiology of the nervous system has been adequately studied
within the last fifty years. Until Bichat had laid the foundation of gen-
eral anatomy, physiology had scarcely existed. The brilliant results
attained by the study of the nervous functions by the modern methods of
research, and the great development of morbid anatomy, have stimulated
investigation of the diseases of the nervous system, and to the operation
of these causes must be attributed the remarkable advance in neurological
science. Diseases of the nervous system have been accurately differen-
tiated, and have been elaborately studied both from the clinical and patho-
logical standpoint; but it is more than doubtful if any have been actually
discovered in modern times. Various attempts have been made in France,
England, and the United States, to determine, by the statistical method,
whether an actual increase in the number of insane, relatively to the
growth of the whole body of the population, has taken place in modern
times. It is extremely difficult to make a thoroughly exact census of the
insane. Each succeeding registration is probably more exact than those
which preceded it; but even in England it is not claimed that the re-
turns are more than an approximation to exactitude. It is undeni-
M O DERN LIFE AND NE R V O US DISE ASE'S. 3.71
able that in each decade a small increase in the number of insane has
been noted ; but it is conceded in every report on the subject that the
registration, becoming more and more exact, makes an increase which is
merely apparent. Moreover, a more humane and abundant provision for
the insane, and the increased facilities for communicating with asy-
lums, induce the friends of these unfortunates to entrust their keeping to
the great institutions now provided for the purpose.
If the kind of evidence which I have submitted has any value in
deciding a question of this kind, it must be admitted that the various
forms of nervous disease, including insanity, are not more numerous,
relatively, now than in ancient times. If, as is probable, nervous dis-
eases are not more numerous than they have always been, an inquiry
into the conditions of modern life supposed to have increased them, may
appear to be unnecessary. A candid examination of those conditions
will demonstrate, I think, that their influence has been greatly exagge-
rated. The abuse of stimulants and narcotics, although not unknown
to the ancients, is commonly held to be more extended in modern times.
Certain poisons, dye-stuffs, cosmetics, and deleterious metals of various
kinds, enter more largely into domestic use than was the case in former
ages. Our modern means of intercommunication by railways, subject
the nervous system to a degree and kind of concussion unknown to the
people of ancient times. Modern habitations, with their appliances for
heating and lighting, social customs, diet, and all the methods of an
enlightened hygiene, are very different from those used in the most
polished periods of Egyptian, Grecian, or Roman life.
It is probably an error to suppose that alcoholic excess is more com-
mon in our day. Wine was the beverage chiefly used in ancient times,
as it is now in the wine-growing countries bordering the Mediterranean.
Drunkenness is an uncommon vice in those countries to-day. The feasts
of Bacchus, in ancient times, were scenes of extraordinary drunkenness
and debauchery, which must have initiated thousands into habits of in-
toxication. The god visited madness on those who refused to engage in
the bacchanalian rites. The symposia and orgies, in which the upper
classes, Grecian and Roman, engaged, consisted in an abandonment to
the vinous intoxication. That such indulgences brought upon the vic-
tim the usual punishment, is evident from the references in Hippocrates
to delirium tremens and aphasia from vinous excess. It cannot be de-
nied that the chief factor in the causation of insanity, and an influential
one in the production of other nervous maladies, in our day, is alcoholic
excess, but it must have been equally so in ancient times.
Although the properties of opium were certainly known in the first
century, it was not used as a means of intoxication until the second, and
then, certainly, to a very moderate extent. Its systematic use in civi-
lized communities is a comparatively modern vice, and even now,
although indulged in to an extent which must awaken solicitude, is as
yet confined to an inconsiderable part of the population. Opium smok-
ing has attained to extraordinary proportions in China, and it is esti-
mated that twenty per cent. of the population of that country is now
addicted to it. A recent observer concludes “ that disorders of the ner-
vous system in a general sense, are by no means infrequent amongst the
Chinese, . . . the probabilities are that the prevalence of diseases of
the general nervous system in China bears some proportion to the preva-
lence of the same disease in Europe, and other regions, . . . but
that cases of alienation of mind, idiocy, lunacy, fatuity, and generally
372 BARTHOLOW,
speaking, insanity, are strikingly few, if we leave suicides out of the
reckoning.”
Tobacco has now been used by civilized peoples for three centuries.
The greatest evils were supposed to be produced by it when Sir Walter
Raleigh and his companions first made it the fashion. The large expe-
rience and observation of its effects which have been acquired, demonstrate
that its moderate use produces no ill results, and that the evils which
come of immoderate indulgence are quickly recovered from when the
narcotic is suspended. As the disturbances in the nervous system in-
duced by tobacco are functional, we have in this fact an explanation of
the apparent freedom from injury of those addicted to its habitual use.
Various modes of contamination by poisonous metals—lead, copper,
mercury, etc.—are possible by reason of the employment in domestic
life of articles of necessity and luxury, containing them, and by the va-
rious applications of these metals in the industrial arts. Individual ex-
amples of deleterious results—affections of the nervous system—are not
uncommon, but no general or diffused injury has occurred, or probably
Cºll) () CCUll’.
The daily railway travel of a considerable portion of the population
of civilized countries, has been supposed to exert an injurious influence
on the nervous system. The jar and concussion, the deafening noise which
assails the ear, and the rapid movement of objects which fatigues the
eyes, are supposed to impair the integrity of the nerve centres. One of
the diseases alleged to be caused by railway travel is progressive locomo-
tor ataxia. If ill results are thus produced, they ought to be seen in the
locomotive engineers. On the contrary, the Brotherhood of Locomotive
Engineers is a body of men who are remarkably free from nervous ail-
ments, and who are indeed distinguished for their vigorous health.
As respects the social and domestic conditions of modern life, it can
hardly be disputed that modern man is in every respect more favorably
situated than was his ancient prototype. If statistics are worth anything,
it must be admitted that the improved hygienic conditions of modern
society have lessened the sickness and mortality rates, and have increased
the longevity of man. . The epidemics as described by Hippocrates; the
plague as depicted by Thucydides; the black death of the middle ages;
the ravages of smallpox in the last century, have been imitated, but not
at all equalled by the Asiatic cholera in this century. Those great epi-
demical waves of cerebro-spinal meningitis which formerly overflowed
Burope are no longer possible. A great moral epidemic, like the dancing
mania, would be as much a solecism in this nineteenth century as a
revival of the crusades. -
The Geneva vital statistics, with the observation of four centuries, and
the experience of the great life-assurance societies, based originally on
the Carlisle tables, seem to have established the fact of the increasing
longevity of man. If man is living under more favorable hygienic con-
ditions, and is less vulnerable in his bodily constitution, it must be ad-
mitted that he is improving rather than degenerating. Is it not to the
last degree improbable that one system of the body should manifest signs
of premature decay, and the rest exhibit unwonted vigor? Such a sup-
position is all the more incredible when we come to reflect on the impor-
tant position which the central nervous system holds in respect to the
nutrition and healthy functional activity of other parts of the body. It
| Dr. George Hearn, Journal of Mental Science, April, 1875.
MO DE R N LIFE A N D N E R W O U S ID IS E A S E S. 373
is as little likely that more men, comparatively, are bald in our day than
were so in ancient times. These facts seem conclusive against the views
of those pessimists who maintain that the nervous system of man is
degenerating under the teasing influences of our modern civilization.
Instead of degenerating, it seems highly probable that the brain of
man, like his bones and muscles, is capable of more work than formerly.
Modern thinkers rival the metaphysical subtlety of Aristotle, and an
ordinary man requires to carry an amount of material as the usual furni-
ture of his brain which would have conferred immortality on an Athe-
nian. The brain in its state of functional activity, indeed, illustrates
most aptly what has been styled the principle of least action. A large
part of our mental processes are carried on without our consciousness—a
state of functional activity to which it is the fashion to apply the term
“unconscious cerebration.” So nicely adapted is the organ to the work
it has to perform, that it accomplishes its tasks without any jar, without
indeed disturbing its very sensitive tenant, the Ego. The wear and tear
of our modern civilization no more affects the integrity of this organ
than the discussions in the groves of the academy, nor than the political
dissensions of the Grecian and Roman states.
The following conclusions seem to be warranted by what has gone
before :—
I. Nervous diseases, in the most common forms, have been distinctly
recognized by lay and medical writers from the earliest periods.
II. They appear to have been as prevalent, relatively, in ancient as in
modern times.
III. The sickness and mortality rates having lessened and the lon-
gevity of man having increased in modern times, it is highly improbable
that the nervous system of man has become more vulnerable.
IV. In modern times nervous diseases have been more accurately
studied and differentiated." -
DISCUSSION ON DR. BARTHOLOW’s PAPER.
After the reading of the preceding paper, Dr. TRAILL GREEN, of Easton,
Pennsylvania, said:—No doubt the ancients were well acquainted with nervous
diseases. Apoplexy was well known in Scriptural times, and we find that
many characters in Biblical history suffered from it. When a man is attacked
by apoplexy now, people are apt to say that he has suffered from overstrain.
But we find that the ancients suffered from the same affection, and they had
not the business strain of the present day. Statistics compiled by men familiar
with the subject, and endorsed by mathematicians, show that there is an appa-
rent increase in deaths from nervous diseases among the policy holders of insu-
rance companies; but this is attributed to the fact that more old people insure
now than formerly. The percentage of insanity is just 1% of one per cent.,
and the number of apoplectics is not large. I have closely observed nervous
diseases in my own neighborhood, and out of about fifty persons whom I have
known to die or suffer from apoplexy, or palsy, not one could be said to have
owed his attack to the result of overstrain. The ages of these patients varied
1 Thirty minutes was the limit fixed by the executive committee for the length of papers
read in the sections. The writer regrets that he was not aware that deviation from this
limit would be permitted, for he would otherwise have presented his argument more in
detail, and would have entered more fully into the statistical data which exist as to the
comparative prevalence of nervous diseases in the first and latter halves of the nineteenth
century.
374 BARTHOLOW,
from 58 to 92 years, at the time of attack, and they were from all walks of
life.
Dr. HENRY GIBBONs, of San Francisco, said:—There is nothing in the records
of antiquity nor in modern statistics to settle this question. The statistics of
insurance companies, derived from selected subjects, are of no avail for the
purpose. Mortuary statistics refer only to deaths, and not to the prevalence
of diseases. Even if it were proved that nervous disorders caused as great a
proportionate mortality in former times as now, it would not reach the ques-
tion ; for with the great advance in pathology and treatment, the mortality
ought to diminish. If Dr. Bartholow were to reside a year or two in Califor-
nia, he would change his mind as to the increase of nervous disorders in that
quarter. The increase is conspicuous, and there are causes operating there
which must have that effect. With a large portion of the population, the home
and family influences are wanting, and men in trouble and difficulty are adrift
in the world—no wife, no parents, no children to anchor their troubled spirits.
Passions of all kinds get control. Very recently the wild speculations in
mining stocks, by which fortunes are made or lost in a day, have developed a
notable number of cerebral cases, ending in suicide or insanity. Whether
modern society in old and settled communities exhibits any increase of nervous
disorders, I am not prepared to say ; but as like causes produce like effects,
and as there is every reason to believe that moral and physical causes of a dis-
turbing character are more abundant in modern times than formerly, we might
reasonably infer that disorders of the nervous system would be more frequent,
though their aggregate mortality may not be greater. It must be conceded,
however, without qualification, that in newly-settled countries, and all around
the outskirts of the old civilization, in all parts of the world, the circumstances
of society are more or less similar to those I have pointed out in California,
and that they must lead to similar results.
Dr. WM. B. NEFTEL, of New York, said:—I have no doubt that the causes of
nervous diseases have increased in modern days. The subjects of these affec-
tions transmit them to their descendants in an aggravated or modified form.
We must also consider the law of development. The brain’s intellectual sphere
has been enlarged, and, with increased mental activity, we have greater liability
to nervous diseases. The common use of alcoholic stimulants at the present
day, is, both directly and indirectly, a cause of nervous affections. Syphilis,
another cause of nervous diseases, is not found to have existed in former times,
while now it is very common. The records of the Pathological Institute of
Berlin prove conclusively that many fatal diseases of the brain are due to
syphilis.
Dr. THOMAS L. MADDIN, of Nashville, Tenn., said:—I agree with the author
of the paper that there are no new diseases to which man is subject, for all dis-
ease is but an error of the tissue or function of an organ. But because of edu-
cation and the surroundings of modern life we may have new modifications of
disease, and we often have a physical basis on which to rest those modifica-
tions. The exercise of any organ of the body will increase its size and struc-
ture, and in that way may modify the diseases of an organ. For instance, a
man living luxuriously, and constantly using stimulating condiments and alco-
holic drinks, will in the course of time have his liver in an abnormal condition,
and then there is a physical basis for organic and functional hepatic disorder.
He is predisposed to diseases which another man, living on frugal, plain diet,
while subject to the same affections, is not so likely to have developed. People
are different now from what they were two thousand years ago, or in their
primitive state. People in civilized life differ from savages in reference to the
development of the nervous system. Take a man on a plantation, with no
education, and no elevation of thought, and take another who has been preco-
ciously educated from childhood; the brain of the latter is in a state of hyper-
aemia; his nervous condition has been stimulated from the beginning; and
there is an abnormal condition of his entire nervous system. It is educated
MO DERN LIFE AND NERVO US DISE ASES. - 375
out of relationship to the other organs of his body. It has obtained an
ascendency over his system which influences the functions of the other organs.
Thus the highly educated and civilized man is more subject to nervous disor-
ders than the quiet countryman. -
Dr. A. B. ARNOLD, of Baltimore, said:—The etiology of all diseases is obscure,
but particularly so that of diseases of the nervous system. I believe that the
idea that nervous diseases are more prevalent now than formerly has origi-
nated with specialists. I have practised for thirty years, and am not aware
that I have seen more cases of nervous disease during the latter than during
the former half of that time. If the increase spoken of exists, it must be
attributed to the progress of civilization, to the wear and tear of body and
mind, and to the race for wealth. Intellectual men are generally long-lived. I
believe that shocks are more detrimental than hard study, and, as pointed out
by the reader of the paper, war and turmoil with all their attendant evils were
the almost natural conditions of former times, while now they are compara-
tively rare. In modern civilization, the mind is better trained and disciplined.
It is not so demonstrative in joy, nor so depressed in trouble. Discipline pre-
vents the mind from being affected with shocks. I believe, although it is
rather Darwinian to think so, that the nervous system accommodates itself to
the strain put upon it—an accommodation of the in ward condition to exter-
nal influences, which is in favor of the present time. I am not aware that even
special writers on the subject particularly ascribe insanity to a syphilitic con-
dition; in fact, the subject is so extremely obscure that it is hazardous to
express an opinion upon it. Again, medical men allow themselves to be too
much influenced by the hue and cry of professional temperance orators. It
can not be scientifically proved that alcohol in the form in which it is at present
used has a very marked influence in the production of nervous disease. I
believe that, instead of drunkenness being a cause of mental disease, it is in
nine cases out of ten only the first warning of its approach.
Dr. N. S. DAVIs, of Chicago, said:—This question is One of very wide scope,
and one which it will be extremely difficult to determine with any degree ºf
certainty, with our present knowledge. Even in this discussion, the fact has
been brought out that in certain conditions of society there is to be found a
marked increase of particular nervous diseases. The gentleman from the
Pacific coast has indicated a condition of modern society which has a tendency
to develop that form of nervous derangement that leads to insanity. Go
back to the days of the Crusades, when all Europe was aroused by a religious
mania, and was led forth to the battle field by hundreds of thousands, and you
will find conditions which were likely to, and which doubtless did, produce
special tendencies towards the development of mental disease. People talk
about mental strain being a cause of mental disorder; about the intensity of
our work: I have been led to think that very few brains ever wear out by
work. The physiological law is growth ; strength ; compactness. If there is
not some corroding influence to interfere with the law, you will seldom wear
out your brains with work. Rush tells us of the ten years before the Revolu-
tion, when a large part of the male population of Philadelphia was aggregated
in social clubs, eating four meals a day, and drinking intoxicating liquors at
each ; and he lived to see almost every member of those clubs go to his grave
from the effects of apoplexy, paralysis, or dropsy: there was a development of
nervous disease. The Revolution followed, there was excitement and war;
the people were stripped of their property, and were compelled to labor and
toil mentally and physically ; and that particular class of nervous diseases
almost disappeared.
No doubt some special nervous diseases have diminished, while others have
increased. The reason for this increase of particular classes of disease is not
our high state of civilization, nor our extent of learning ; I doubt whether we
have a student in America, to-day, who studies harder than Some of the stu-
dents of Greece and Rome, or even of the ancient Jews. I doubt whether
376 BARTHO LOW,
Some of them did not think as deeply and persistently. And no doubt some
of them suffered from mental disease, but not from thinking or study. I
think Saul got his paroxysms of mental derangement, as a great many do
to-day, from wickedness; not from study. It is not the hours we spend at
books, or at business, that wear us out; much is attributable to our anxiety
for wealth and show. When we put our whole heart on accumulating wealth,
and the bubble bursts, it produces a severe mental anxiety. Large numbers
of our students become lean and dyspeptic, and disordered in health, before
they get half through college; why Z Because they learn at an early period of
life to go to the breakfast-table, and sip two cups of coffee and nibble a crust
of bread as an apology for breakfast; thus endeavoring to substitute pure ner-
vous excitation for materials to replenish blood and make tissue. It is the
same with many lawyers and doctors, whose friends say they are killing them-
selves, and yet who do not devote to their professional duties as much time, by
one-third, as others do, who are perfectly free from nervous disease. What is
the reason 7 Because as soon as they take their meals they are puffing their
tobacco, or chewing their quids, until they have their entire nervous systems
Saturated with a narcotic that cannot fail to produce retardation of molecular
changes, thus acting upon the false notion that the retention of an old atom is
equivalent to the evolution of a new one ; and in a few years they complain of
being worn out. They have retained the old atoms in the form of inert fat,
which begins to find lodgment in the brain, or liver, or heart. If an artery
gives way, and they fall from apoplexy or palsy, you give your certificate that
they have died from one of these diseases, when the truth is that they have
died from long use of alcohol and tobacco. Take these two influences out of
the community, and you will have less nervous disease than the ancients, be-
cause the other influences are of such a nature that we can guard against them.
We would live longer, the race would be healthier, and we would have fewer
diseases of any kind. These things have stepped in and filled up the places of
some things peculiar to the ancients. No doubt causes have been operating
afl through the world's history, sometimes making one form of mental disease
more prevalent than another. Balance them up, and we may find that we are
very nearly where we were in former years. Our advances in sanitary science,
and in pathology, and in the treatment of disease, have lessened mortality
and increased the duration of human life. If the prevalence is the same as in
former times, then we must have more influences at work.
Dr. R. P. HowARD, of Montreal, said:—I think that previous speakers have
established the fact that nervous diseases are more common than formerly,
owing to the use of stimulants; alcohol was used by the ancients, but tea and
tobacco are modern, and are potential causes of derangement of the nervous
system. Syphilis is another modern cause of nervous disease. One of the
speakers has tried to ignore the importance of this, but its influence is well
established. The undue attention of modern civilization to culture of the
brain, Over-developing it in relation to the other organs, may be another cause.
Hereditary influences will wear themselves out, else every person would inherit,
some taint. A man may have too much work as well as too little. The men
of to-day work faster than men in former times; everything is done in a hurry.
The weight of evidence is in favor of the view that there is a tendency to an
increase of nervous affections.
Dr. H. I. BowdiTCH, of Boston, said:—There are one or two points which
have not been noticed. I am satisfied that the climate of this country is more
stimulating than that of others. I infer this from the general effect it has upon
the English race. The Anglo-Saxon race has grown thin and apparently more
excitable than it was in the mother country. English people have found that
they cannot safely drink to such an extent as they can in England. I have
known cases in which Englishmen in America have been attacked by delirium
tremens, from using quantities of alcohol which they had used with perfect
impunity in England. Yet they were comparatively temperate men. Again,
M O DE R N LIFE AN ID N E R W O U S I) IS E A S E S. 377
there is the perpetual political excitement, affecting both our men and women,
which has no existence in Europe. When an American goes to Europe, he
gets into a state of quiescence which is perfectly delightful, but when he re-
turns, even after spending six months there, the first sight of the pilot boat
puts him into an excitement about the latest scraps of political news.
Dr. GREEN said:—No inference can be drawn from the frequency of suicide,
as Suicides are committed from other causes than the existence of nervous dis-
ease. The Welsh are more predisposed to mental and nervous diseases than
Other people of Great Britain, so that the question of race should be considered
in connection with the subject.
Dr. W. Scott, of Cleveland, Ohio, said:—Our modes of travel induce dis-
eases unknown to our forefathers. The custom of sending children to school
at too early an age also exercises a pernicious influence. Children are taken
from school at the time when they ought to be commencing their studies in
earnest. The medical profession ought to take the subject of education in the
public schools into serious consideratiou. Vicious systems of education are
the cause of many functional disorders, and often lay the foundation for the
development of nervous disease. Another feature of our modern civilization is
the want of vigorous development, and this is more fruitful of nervous affec-
tions than chewing tobacco or drinking coffee. Plants require the light of the
sun in order to grow, and our children should not be denied its blessings.
Many houses, of even luxurious construction, are kept in a state of dun-
geon-like darkness, and children reared in such houses are not nearly so vigor-
ous as the children of a country clown, who have at least the benefits of air
and sunshine.
Dr. BARTHOLOW, in reply, said:—I think that the statements of specialists
should be taken with a great deal of allowance. They seem to base the opinion
that nervous diseases are increasing, upon the fact that they see more cases
than formerly ; but that is only the result of their individual business increas-
ing, as they become settled in practice. Doctors never see as many cases in
their first years of practice as subsequently. It has been asserted that syphilis
is a modern disease; that is doubtful. Many causes of syphilis existed for-
merly, and there is no proof that the disease did not exist too. My great
answer to all the arguments which have been adduced is that men are larger,
stronger, and better in every way than in former times. A modern English-
man cannot put on the old armor. The body is stronger and stouter than it
was, and men are able to do more intellectual work. If the Geneva statistics
are worth anything, they prove that the longevity of man has doubled within
three centuries. As to the effect of the climate of America, it is found that
longevity is greater here than in England.
CONTRIBUTION TO THE ETIOLOGY OF EPILEPSY.
BY
WILLIAM B. NEFTEL, M.D.,
OF NEW YORK.
THE remarkable progress made in our knowledge of epilepsy com-
mences with the classical researches of Brown-Séquard in 1850. As
the results obtained by him are well known to the profession, I shall
merely mention here a few of the more important points. After the
division of one half of the spinal cord, or of one sciatic nerve, in the
guinea-pig, the animal becomes epileptic in the course of several weeks,
exhibiting on the injured side the so-called epileptogenic zone. This
Zone is characterized by a lowered sensibility, and is situated below the
eye, especially at the angle of the lower jaw, and extending toward the
neck and scapula. If the section be made through the entire cord, or
through both sciatic nerves, the epileptogenic zone appears on both
sides, and if the pedunculus cerebri be injured, the epileptogenic zone
appears on the opposite side. The epileptic attacks sometimes occur
spontaneously, but they can be called forth at any moment by irritating,
or even touching, the epileptogenic zone. The artificially produced epi-
lepsy is transmitted by inheritance to the descendants of the animal on
which the experiment has been performed.
These facts are of immense importance for the study of epilepsy in
general, though as yet they do not admit of a direct application to
human pathology, with the exception of the hereditary disposition,
which, however, had been already previously established. It is easy to
presume that epilepsy can be brought on by injury of a sensitive or of a
mixed nerve, and therefore also by injury of the sciatic nerve, or of the
spinal cord, but it is not in accordance with the daily experience of
physicians that affections of the spine or of the sciatic should cause epi-
lepsy, with an epileptogenic zone. Thus amputation of the thigh (sec-
tion of the sciatic) is not followed by epilepsy, with an epileptogenic
zone. Again, W. Müller” has published a case in which the injury of
the cord in the human subject much resembled the experiments of
Brown-Séquard on guinea-pigs. A man received a wound in the back
from a knife that penetrated through the cord ; the patient lived forty-
three days, exhibiting all the symptoms of injury of the cord on one
side, but having no convulsions whatever, though at the autopsy it was
found that the entire left side of the cord had been perfectly divided.”
| Brown-Séquard, Researches on Epilepsy, etc., Boston, 1857; also Journal de la Physi-
ologie des Hommes et des Animaux, 1858–1860; Archivés de Physiologie normale et patho-
logique, 1868–1872. -
* Wilhelm Müller, Beiträge zur pathologischen Anatomie und Physiologie des men-
schlichen Rückenmarkes. Leipzig, 1871.
* I omit giving here examples of epilepsy caused by injuries of sensitive nerves, and will
only mention that it remains as yet undecided whether the epilepsy in these cases is caused
by neuritis ascendens, or by purely functional centripetal excitations. Thus in the case
described by Virchow, the epilepsy was caused by an injury of the median nerve (neuritis
interstitialis prolifera), and in Echeverria's case by a lesion of the ulnar nerve (neuritis).
ETI O L O G Y OF E PILE PSY. 379
In 1871, Westphal, in repeating the experiments of Brown-Séquard,
whose conclusions he confirmed in all particulars, found that guinea-
pigs could be made epileptic by producing a commotion of the brain.
By knocking the animal’s skull against a solid object, or by inflicting with
a small hammer (such as that used in percussion) one or several blows
upon its head, the animal is seized with general tonic and clonic convul-
sions, quite identical in character with the epileptic attacks exhibited
by the animals treated by Brown-Séquard’s method. If the commotion
is very intense, the blow being too violent, the convulsions are generally
followed by the death of the animal from paralysis of respiration, the
action of the heart still continuing for several minutes. If, however,
the blows are moderate, the animals entirely recover from the first
attack, but after the lapse of several weeks exhibit the epileptic state
and the epileptogenic zone on both sides, exactly like the animals arti-
ficially made epileptic by a bilateral section of the cord or of both sci-
atic nerves. In young animals an attack is called forth by a few slightſ
percussions with the hammer, while in grown, vigorops animals a con-
siderable amount of force is required to produck, tº same effect.
When the blows are very slight, no real epileptic attacks follow, but,
instead of them, what may be called abortive attacks, consisting of
peculiar reflex movements. If ºne of the epileptogenic zones be pinched
in such an animal, it scratches the place with the corresponding extrem-
ity, and, closing the eyes, turns the head toward the same side. Ani-
mals exhibiting abortive attacks can easily be made epileptic by repeat-
ing the same operation. The epileptic state and the epileptogenic zones
appear generally four or five weeks after the commotion, and may last
six months or longer, after which they gradually disappear, though a
slight blow on the head can easily bring them on again. Sometimes
the attacks manifest themselves spontaneously, but they can always be
called forth by mechanical irritation of the epileptogenic zone on each
side. The epilepsy artificially produced by cerebral commotion is also
transmitted by inheritance.
In order to ascertain the anatomical lesion which caused the epilepsy
after these experiments, Westphal removed the skin and periosteum,
and, inflicting the blows directly on the bones of the skull, obtained the
same result, viz., an immediate attack, followed later by the epileptic
state and the epileptogenic zones. This shows conclusively that the sen-
sitive nerves of the skin or of the periosteum have nothing to do with
tlese phenomena. Moreover, the autopsy made by Westphal immedi-
ately after the first attack following the blow, did not reveal any lesion
either of the skull, or of the cerebral hemispheres, or of the cerebellum.
IHe found only capillary hemorrhages in the gray and white substances
of the medulla oblongata and of the upper cervical portion of the cord.
Though the experiments of Westphal apparently have some similitude
with traumatic injuries of the head, in man, yet he rejects any applica-
tion of the results of his experimental researches to human pathology.
On the other hand, in Billroth's case there was no neuritis, though the epilepsy was induced
by a traumatic cause affecting the Sciatic nerve. In the same way wounds and cicatrices
may induce epilepsy by the irritation of sensitive nerves. Thus in a case described by
Schnee, the epilepsy was brought on by a wound of the head, which left a very sensitive
cicatrix the slightest touching of which would call forth an epileptic attack. The epilepsy
disappeared after the excision of the cicatrix, in which microscopical examination revealed
the presence of neuritis.
| Westphal, Ueber künstliche Erzeugung von Epilepsie bei Meerschweinchen; Berl.
klin. Wochensch., 1871, No. 38, 39.
380 NEFTEL,
He says: “I am not acquainted with a single observation of cerebral
commotion (in the human subject), in which convulsions are mentioned
among its symptoms.”
Hitzig” has also produced epileptiform convulsions, in dogs, by injur-
ing the cerebral cortex. There is no doubt that epileptiform convulsions
can be called forth in various ways, especially by injuring sensitive parts,
among others therefore some central nervous structures. But the epi-
leptiform convulsions thus produced are by no means identical with
epilepsy, which, besides convulsions, requires the presence of the so-called
epileptic state. In speaking therefore of real epilepsy, we must exclude
such convulsions as are caused by the sequelae of injuries of the cortex
(hemorrhages, inflammation, softening, etc.), as in the experiments of
Hitzig, or in the cases of Hughlings-Jackson.” These latter seem also to
have depended on lesions of the cerebral cortex, whereas the genuine
epilepsy may exist without any palpable textural changes of the brain.
* The ſollowing case, lately observed by me, presents unusual interest,
inasmuch as it resembles in many respects the experiments on animals,
and has besides the great advantage of giving in a precise manner the
subjective feelings of the patient. It is not only interesting as regards
symptomatology and treatment, but especially so as throwing some light
on the etiology of epilepsy. \
Mr. H. W. K., lawyer, 24 years old, of a healthy family, without any heredi-
tary neuropathic disposition, was formerly quite well, intelligent, industrious,
and very regular in his habits. . During a riot in Washington, in July, 1869, a
negro struck him with a loaded cane on the head. The first terrible blow
brought him senseless to the ground, where he received several additional
blows on the head. He was carried to his house in an unconscious state, and,
according to the opinion of the attending physicians, remained during three
days and three nights in a comatose and hopeless condition. The first blow,
which rendered him senseless, was struck on the right side of the forehead, in
the direction from the tuber frontale toward the right crista frontalis externa
and linea semicircularis. Fortunately the patient had long hair at that time,
and wore a straw hat, which undoubtedly weakened somewhat the force of the
blows. To the same circumstance must be ascribed the absence of any injury
to the skull, on which no marks of contusion were noticeable. The greatest
danger that threatened the patient's life was the exceedingly feeble, scarcely
perceptible respiration, which at times seemed entirely extinguished. The
action of the heart was also very weak (pulse 20 in a minute), and immediate
death was undoubtedly prevented only by the strenuous efforts of Surgeon-
General Barnes, who remained day and night at the patient’s bedside, ener-
getically using all possible means of excitation and derivation.
On the fourth day the consciousness gradually returned, though the patient
still remained motionless, and therefore was still considered unconscious. He
could, however, hear and understand everything, and felt the greatest fear of
being buried alive, hearing the physicians express their opinion of his hopeless
condition, and of the fatal termination which must necessarily soon take place.
At the end of the fourth day, he felt in the extremities a pricking sensation
(formication , which gradually extended all over the body, and slowly disap-
peared on the fifth day. At the same time he began to make feeble move-
ments with the extremities, and soon was able to contract all other voluntary
muscles; but he could not swallow or speak until the end of the first week.
During the second week after the commotion, the patient experienced the
* Loc. cit. p. 462. -
* Hitzig, Untersuchungen uber das Gehirn. Berlin, 1874, S. 270.
* Hughlings-Jackson, West Riding Lunatic Asylum Medical Reports, vol. iii., 1873.
E TI O L O G Y OF E PIL E PSY. 381
greatest inclination to sleep, and could not awaken spontaneously. According
to the advice of his physicians, he was awakened at times, and prevented from
sleeping continuously. He was extremely sensitive to noises, easily felt ex-
hausted, and after the slightest exertion would become unconscious, and re-
main so during ten minutes, exhibiting at the same time convulsive move-
ments. He remained in bed during three months, having the epileptic attacks
at first very often, and then once in two or three days. At last his health
Commenced to improve, he had a better appetite, and could exercise in the
open air. But even in the street he was seized several times by an attack,
With pallor, loss of consciousness, and epileptic convulsions.
The most distressing symptom the patient suffered from was an intense
headache, which commenced with the return of consciousness after the com-
motion, and has scarcely ever left him during six years. The seat of the pain
is the right side of the forehead and the right eye, the spot of the intensest
pain corresponding to the right crista frontalis externa, where it passes into
the linea semicircularis. The pain at times increases spontaneously, and be.
comes unbearable, continuing so for days and even weeks, with but short re-
missions, and finally disappearing almost entirely. At the height of the par-
oxysm, the right eye becomes absolutely blind (the patient not being able to
count fingers), the slightest touch of the painful zone is unbearable, and press-
ure upon it calls forth loss of consciousness, and convulsions, considered as
epileptic by physicians who have witnessed them. Occasionally such fits
occur spontaneously, without any pressure upon the painful zone, and the pa-
tient sometimes feels the approach of the attack, and has time to lie down
carefully, though more frequently it comes on suddenly, and the patient falls
without having taken any precaution. All the time the patient suffers from
the violent headache, there is a complete analgesia of the painful zone, and the
whole forehead appears pale and cold.
When the pain is severest, the patient lies motionless, suffering from nausea
and vomiting, and scarcely able to eat anything, as these symptoms are in-
variably increased by food. The patient passes sleepless nights through the
whole duration of the paroxysm, only getting occasional short naps, from
which he awakens with increased pain. At last, under the constant use of hot
applications to the head, the pain gradually disappears and the patient slowly
recovers. He then remains in a comparatively healthy condition for days,
weeks, or even months, with good appetite and the power of sleeping, and with
the vision of both eyes normal. Nevertheless the painful Zone remains sensi-
tive, even during the intervals between the paroxysms, and the slightest
touch, and especially pressure, can bring back the paroxysm of pain with all
its distressing symptoms, the fainting, and the epileptic convulsions. The
patient has always to avoid touching the painful zone, even while washing his
face or wearing his hat. He can hardly read, his head and eyes often feeling
heavy; he has also to avoid the rays of the sun, and every physical and mental
exertion, and as a consequence, has been obliged to give up every occupation.
Of late the paroxysms of pain have become more frequent; his memory, that
used to be excellent, has begun to fail; he cannot always control his ideas
with the former precision, and at times they appear so confused that he fears
the development of insanity. In the course of the last three years, though he
has been treated by many able physicians, and has used among other remedies
a great deal of bromide of potassium and narcotics, nevertheless there has
been a progressive aggravation of the disease, especially as regards the intel-
ectual sphere and the frequency of the paroxysms of spontaneous pain.
Present condition : May 29, 1876. The patient is of middle size, with a well-
developed skull and chest, and moderately developed muscles and panniculus
adiposus; the color of the skin and of the visible mucous membranes is rather
pale ; the thoracic and abdominal organs are normal ; pulse 70; respiration 18;
temperature 37° C. He is now suffering from a comparatively mild attack of
spontaneous pain, and has scarcely slept or taken any food during several days.
382 N EFTEL,
The painful zone extends over the right half of the frontal bone, the anterior
lower portion of the right parietal bone, the upper portions of the greater wing
of the sphenoid bone, and of the squamous part of the temporal bone, the right
eyelids and eye. The slightest touch of this region cannot be borne, and the
patient involuntarily shrinks from the approach of the exploring finger. The
centre of the intensest pain (spontaneous, as well as produced by pressure) is
the upper portion of the crista frontalis externa, and the adjoining lower por-
tion of the linea semicircularis, extending about four centimetres in length, and
half a centimetre in width. The right tuber frontale is also more tender than
the rest of the painful zone, but there is no particular tenderness over the fora-
men supraorbitale. The painful zone does not extend below the eye. The
patient is unwilling, for the sake of an experiment, to have the slighest pres-
sure made upon the painful zone, but assures me that it has been done many
times by mistake or carelessness, and has always been immediately followed
by the intensest pain, with pallor of the face, loss of consciousness, and epileptic
convulsions. The skin of the forehead is cooler than the rest of the face, it is
quite pale, and analgesic; a prick with a needle is not felt. The right eye
looks smaller than the left, and is almost blind. (Only quantitative light can
be ascertained.) The right pupil is somewhat larger than the left, and reacts
sluggishly ; the right retinal vessels are narrower than those of the left side.
The patient speaks very little, and almost without contracting the facial mus-
cles, or moving the eyes; it seems as if he preferred to turn the whole head,
instead of contracting the mimical and eye muscles. His physiognomy there-
fore lacks expression, or rather expresses stupor, though it is evident that he
keeps the facial muscles immovable in order not to increase the pain. The
patient has passed a perfectly sleepless night, and complains of nausea, general
prostration, and heaviness of the head and eyes. -
As every kind of medication that had been resorted to had utterly failed to
benefit the patient, I decided to make a careful trial with the galvanic current.
I applied the cathode of a weak current (two elements of Siemens) to the nape
of the neck, and wanted to apply the anode to the painful zone, but the patient
immediately turned away his head, before the electrode had touched the skin.
Leaving the cathode at the same place, I then applied the button-shaped anode
to the right auriculo-maxillary fossa, and, without interrupting the current,
gradually increased its intensity. When six Siemens's elements had been
introduced into the circuit, the patient remarked that the pain in the forehead
began to increase, whereupon I slowly diminished the intensity of the current,
the whole sitting lasting a little over a minute. He felt somewhat better after
the treatment, and slept that night until 3 A.M., when he awoke with headache
and nausea, the right eye being perfectly blind.
May 30. I tried again the galvanic current, but this time avoiding, as much
as possible, fluctuations of the current-intensity by means of a rheostat, inter-
calated as an accessory current. The current was derived from ten Siemens’s
elements, the flat cathode being applied to the nape of the neck, and the button-
shaped anode to the right auriculo-maxillary fossa; the resistances were gra-
dually augmented in the rheostat, until the full current-intensity had passed
through the body during fifteen seconds, after which the current was again
slowly diminished by means of the rheostat, and imperceptibly broken. The
effect of this treatment was quite surprising. As soon as the current began to
flow with full intensity, the patient exclaimed that the pain had entirely left
him, the head felt quite free, and the eyes became clear. The sitting had lasted
about two minutes. The patient was quite overcome by the sudden disappear-
ance of all the morbid symptoms; his features became movable, and the blind-
ness vanished. He felt quite well the whole day, had a good appetite, could
walk a great deal, and slept six hours. Though he awakened without pain,
still, the next day, the head and eyes were heavy, and he felt the premonitory
Symptoms of an approaching paroxysm.
May 31. I repeated the same treatment, and with the same result; the
ETIOI, O G Y OF EPIL EP SY. 383
batient feeling invigorated, as if, according to his own expression, awakening
from a long and refreshing sleep. I found on examination (which I had
omitted the previous day), after the treatment, the following facts: Slight
touching of the painful zone, with the exception of the most sensitive part
(Crista frontalis, etc.), could be easily borne; there was no trace of anaesthesia
or analgesia in this region, but, on the contrary, a prick with a needle was most
painfully felt (hyperaesthesia). It was quite surprising to find complete anaes-
thesia and analgesia of the left (healthy) side of the forehead, extending exactly
to the median line. Moreover, on this side differences of temperature could
not be distinguished by the patient, and ori applying a piece of lint dipped in
hot water, and another in iced water, he felt no difference on the left, healthy
side, and could easily bear them both ; whereas, on the painful zone, he could
instantly and with great precision discover the least difference of temperature,
the extremes of which were felt most unpleasantly. I ascertained, besides,
that the leſt frontal muscle was paralyzed, the skin of the left (healthy) side
remaining smooth when he wrinkled the forehead; also, that the leſt upper lid
could not be perfectly closed.
June 1. I re-examined the patient, and convinced myself again of the correct-
ness of the above-mentioned facts. I repeated daily the above-described
treatment, applying in addition the button-shaped anode also to the left fossa
auriculo-maxillaris.
June 20. The patient slept ten and a half hours, last night, and the foregoing
nights, six or seven hours, which for years he has been unable to do. He feels
quite well and strong, and has no pain; the head is clear, the vision of both
eyes normal, and he can read very well, has a good appetite, and is able to
walk considerable distances. On examination I find both eyes equal in every
respect, and the vision normal. The painful zone admits of a moderate pres-
sure, and even the most sensitive spot can be touched, though only very gently.
The sensibility and sense of temperature in the painful zone still remain exalted
(hypera-sthesia), and there is no trace of analgesia. However, a stronger pres-
sure cannot be borne, especially by the most tender portion of the zone, and
the patient still wears his straw hat obliquely toward the left side of the fore-
head, thus leaving the right side uncovered. The left side of the forehead
cannot be corrugated, and is still analgesic, though a slight touch with the
finger can be felt ; differences of temperature cannot yet be distinguished.
The galvanic treatment was continued daily as before. viz.: flat cathode at
the nape of the neck, and button-shaped anode at first to the right, and then to
the left, fossa auriculo-maxillaris. Current-intensity seven to ten Siemens’s
elements, increased and decreased cautiously, though fluctuations of one
element could now be easily borne. Current-duration about one minute, or
one minute and a half, for each side.
July 3. The painful zone can now bear a considerable pressure, and even the
most sensitive portion can be touched. The left side of the forehead can be
wrinkled, though less than the right side, and the left eyelid can be perfectly
closed. The senses of touch and temperature on this side have considerably
improved, but are not yet restored. The analgesic area has been progressively
contracting; the patient at first could feel the prick of a needle only at the
lower part of the median line, then at the arcus superciliaris, and now the
region of the left temple alone remains analgesic. The patient complains of
no pain; all his functions are normally discharged ; and his general health is
quite satisfactory.'
I shall not enter into an analysis of the above described symptoms, as
I had not the opportunity of observing the patient at the time of the
accident, nor immediately after. Although the intelligent patient de-
scribed with great minuteness all his subjective feelings, and as much as
After thirty-one sittings of galvanic treatment the patient suddenly and unexpectedly
discontinued his attendance.
384 NEFTEL,
possible gave the opinions of the physicians who then attended him;
still we entirely miss the result of an objective examination as regards
sensibility and motility ; the ophthalmoscopic appearances; the condi-
tion of the pupils; the presence of sugar, albumen, or blood in the urine,
etc. The patient did not even know during six years that the left
(healthy) side of the forehead was anaesthetic and analgesic, with loss of
the sense of temperature and with impossibility of wrinkling it (paraly-
sis of the frontal muscle). On the contrary, he considered the painful
zone as being analgesic, which may have been the case during the parox-
ysms of spontaneous pain, though during the intervals I always found
this zone hyperasthetic.
There can be no doubt, however, that the injury produced a cerebral
commotion of the gravest kind, which threatened to terminate with
paralysis of respiration, exactly as in the experiments of Westphal,
when the blow on the head was too violent. This termination was pre-
vented in our case merely by the energetic and successful interference
of the attending physician. Whether with the cerebral commotion
some transitory affection of the brain had taken place, cannot be decided
with certainty. Thus the vaso-motor phenomena might have been
ascribed to a lesion on the surface of the cerebral cortex, in which
Hitzig' and Eulenburg and Landois” have quite recently discovered the
existence of vaso-motor apparatus. Again, the existence of pachy men-
ingitis might have been assumed with still greater probability in conside-
ration of the somnolence of the patient during the second week after
the accident, and the diagnostic value which Griesinger” attaches to this
symptom, especially when it is found in conjunction with stupor, con-
tracted pupils, and headache. On the other hand, the sudden and almost
complete disappearance of all the morbid symptoms after galvanization,
and their periodical absence, make very plausible the assumption that
no permanent or grave lesion of the brain had been caused by the acci-
dent. This supposition is supported by the researches of Fischer,” who
has shown that a mere traumatic reflex paralysis of the cerebral blood-
vessels is sufficient to produce the phenomena of commotion of the
brain. From the history of the disease, we have every reason to pre-
sume in our case the existence of such a reflex paralysis of the cerebral
blood vessels and not a permanent structural lesion of the brain.
This case therefore elucidates a most important fact, namely, that
epilepsy can be produced in a perfectly healthy person (having no hereditary
neuropathic disposition), by an injury of the head causing commotion with-
out any structural lesion of the brain.
Although the analogy of our case with the experiments of Westphal
is very striking in many particulars, yet there are also apparently some
differences. Thus we find a zone in our patient, the mechanical irrita-
tion of which calls forth at any moment loss of consciousness with epi-
leptic convulsions, and though this zone is here hyperaesthetic, while it
is anaesthetic in the animal, yet during the paroxysms of spontaneous
pain it also appears anaesthetic and analgesic. We must bear in mind
that we generally judge of the presence of anaesthesia in animals by the
absence of expression of pain (screaming); but this was also the case
| Hitzig, Centralbl. für d. med. Wiss., 1876; No. 18.
* Eulenburg und Landois, Ueber thermische von den Grosshirnhemisphären ausgehende
Einflüsse ; Centralbl., 1876; No. 15.
* Griesinger, Archiv der Heilkunde, 1862.
* H. Fischer, Ueber die Commotio Cerebri; Samml. klin. Worträge, Leipzig, 1871.
ETIO L O G Y O F E PIL EP SY. 385
with the patient, who, though suffering intensely when the painful zone
was touched, never manifested any sign of pain, but only became pale
and lost consciousness. Possibly animals artificially made epileptic,
suffer also from paroxysms of pain similar to those of our patient, but
which have escaped our observation. Again, the blindness during the
paroxysms of pain (probably a vaso-motor phenomenon) has not been
noticed in the experiments on animals. Furthermore, the painful zone
in our patient was above the eye, whereas in the animal the epilepto-
genic Zone is situated below the eye. These differences, however, do
not seem to be of great importance, and may depend on the incomplete-
ness of the observations, on some unknown anatomical variations, or on
differences in the localities to which the traumatic irritations are applied.
Of late, cases of epilepsy have been published, in which an epilepto-
genic zone has been observed, though in by far the great majority of
cases this zone is not present. I treated a patient affected with epilepsy,
in 1868, who in several respects resembled the one described in this
paper, especially as regards the blindness and headache.' I regret not to
have paid at that time the necessary attention to the existence of an
epileptogenic zone. Subsequently I received additional information
from this patient, who is now in perfect health, that in his case there
was also great tenderness in the region of the temples, which could not
be touched, and that the affection originated from an injury of the head.
I may add that, in this case too, the disease, which did not yield to the
different remedies employed, nor even to a fortnight's galvanization of
the head, was successfully treated by a method similar to the one above
described. It seems likely that the cases of epilepsy with an epileptogenic
zone are of traumatic origin, and it is therefore advisable in every case
of epilepsy to look carefully for an epileptogenic zone. Of course, in
the human subject the place of this zone may not always correspond
to that observed in animals. It is also probable that in the course of
time the epileptogenic zone becomes reduced, and finally disappears, thus
escaping further observation.
We are now led to inquire whether, in the majority of youthful epi-
leptics, the disease has not been caused by frequent injuries (falling upon
the head), in childhood, especially in individuals with a hereditary
neuropathic disposition. From this point of view it would seem surpris-
ing that comparatively so few are affected with epilepsy and petit mal.
The experiments on animals teach us, however, that not every blow upon
the head even in the guinea-pig–this neuropathic animal par eaccellence—
is liable to produce epilepsy. For the same reason, in the child, the
favorable conditions for producing epilepsy are comparatively rare: it
would possibly be requisite to have the head fixed to a solid immovable
object, striking it repeatedly with a certain force, and perhaps even at a
certain region. If we admit the traumatic origin of epilepsy, we are
then enabled to explain satisfactorily many phenomena which accompany
this disease, as for instance the prevalence of epilepsy in youth, the
hereditary transmission of the disease, the negative results obtained
from the pathologico-anatomical investigation of the brain (at least the
absence of structural lesions of the brain), the vaso-motor and other
phenomena which epilepsy has in common with cerebral commotion, etc.
Lastly, I should like to direct the attention of the profession to the above-
| Neftel, Galvano-Therapeutics. New York, Appleton, 1871, p. 113.
25
386 NEFTEL, ETIOLOGY OF EPILEPSY.
described method of treatment, which may possibly be also found useful
in other cases of epilepsy.
To conclude, Ishall sum up what has gone before in two propositions:—
I. It is made evident by the case described, that in a perfectly healthy
person, free from any hereditary disposition, epilepsy can be brought on
by traumatic influences upon the head, causing cerebral commotion with-
out any structural lesion of the brain.
II. Further investigations will be needed to prove that such traumatic
influences during childhood may constitute a most frequent etiological
factor in the production of epilepsy.
THE INFLUENCE OF HIGH ALTITUDES ON THE PROGRESS
OF PHTHISIS.
BY
CHARLES DENISON, A.M., M.D.,
OF DENVER, COLOR ADO.
IT is assumed that this occasion calls for something suggestive, lead-
ing an inquiring mind to look at an important subject in a new light,
and seeing the errors of former beliefs through a change in the channels
of thought. IIow desirable then, if we are not now perfect (and I
believe the hopeful mind of to-day has more to expect from what we are
to learn, than from what we now know), that a controversy of Opposing
views should here be stimulated in friendly discussion. Believing that
our profession as a body is proving itself an insufficient barrier to “the
progress of Phthisis,” and having convictions which persuade me to
differ from many of the authors' who have written on the subject of
climate and consumption (and I have endeavored to consult them all), I
may be excused for seeking to introduce this discussion by occasionally
emphasizing these differences of opinion.
The subject assigned me is one of the most interesting and important
that can claim our consideration, and all the more so because it has not
hitherto received any special attention from our profession at large. As
to the disease itself—this great and persistent destroyer of mankind—
valuable results have of late accrued from the constant inquiry and patho-
logical research of eminent medical men. Thus this disease has conne,
through the critical analysis of a transitionary stage in professional
opinion, to include, under the one name of Phthisis, various and widely
differing abnormal conditions.
CLIMATE AND CONSUMPTION.
We can define Pulmonary Phthisis as slow death commencing in the
lungs, or, going back of the local affection to the dyscrasia or abnormal
blood state which precedes or accompanies its progress, we can enlighten
ourselves as to the various pulmonary and other defects which have till
of late been considered as one disease. However, the scope of this
report, and lack of time, make the minute consideration of this subject
an unwarrantable digression, so that we will content ourselves with the
generally accepted significance of the term Phthisis in its broadest sense,
including those morbid conditions (chiefly inflammatory”) which favor
1 Dr. Hermann Weber and I)r. Archibald Smith, late of Lima and elevated resorts in
the Peruvian Andes, are notable exceptions.
2 Dr. Hermann Weber. in the Medico-Chirurgical Transactions, vol. lii. (Treatment
of Phthisis by Prolonged Residence in Elevated Regions), gives the credit of first promul-
gating these views to the late Dr. Thomas Addison. “ whose teaching, that inflammation
constitutes the great instrument of destruction in every form of phthisis, was for a long
time either ignored, or regarded as erroneous, by Inost of his contemporaries.” (On the Pa-
388 DENIS ON,
weakening or a breaking down of pulmonary tissue; and refer to special
phases of the disease as the illustration of our thought may seem to
demand. -
In considering the climatic treatment of Phthisis, it is not essential to
dwell upon the first experiences of our medical fathers in this matter.
The conclusion of Dr. Walshe, that “climate takes its occasional share in
bringing about the nearest approximations to real cure therapeutically
obtainable,” has at length come to be very generally held by medical
men. Even before the disease was well understood, while the failure of
medicine to cure or check it was slowly being realized, the considerable
benefit derived from even mild changes of climate must have strongly
suggested a climatic cure. So if the remedy of high altitudes had not
long been utilized, as we now learn it has been in the Peruvian Andes,
the first two cases mentioned by Dr. Hermann Weber, in his excellent
paper “On the Treatment of Phthisis by Prolonged Residence in Elevated
Regions,” would have suggested this most potent means of cure to every
reflective mind. These cases occurred in natives of elevated localities,
who had become residents of London. Prostrated by acute phthisis,
they returned to spend the remainder of their probably short lives in
their early homes, the one to the Black Forest, in Germany, at an eleva-
tion of 2800 feet, and the other to Switzerland, 5000 feet above the sea-
level, and in both the disease was quickly arrested. The evidences of the
therapeutic value of high altitudes are, however, comparatively recent.
Thus it is not strange that, having no better experience to trust to,
the medical profession has hitherto placed confidence in the scattered suc-
cesses furnished by Mediterranean, low continental, maritime and English
health resorts. In England, and on the continent, the description and
classification of favored health resorts have been carried to an exactness
which has hardly been reached elsewhere.” But it is a question, in my
mind, if these analyses are not sometimes made to the exclusion of im-
portant data, notably the moisture of the air, and with undue import-
ance given to less vital points, such as the precise degree of temperature
and the daily variation. Then again the author so often feels it incumbent
on himself to tell you how to get away from a place, if you are not suited,
that often no relief would seem to be expected; while the poor invalid,
usually in some doubt, ekes out a six months’ health trip at as many sepa-
rate resorts. This guessing at the answer to the invalid's conundrum,
“where can I best find relief,” is far from the certainty and confidence
in the course to be pursued, which should characterize the climatic treat-
ment of phthisis. There may be some physicians who are so specially
gifted in the adaptation of these low climates to the consumptive's needs
as to gain very fair apparent success. After studying the descriptions of
numerous low, inland, and seaside Mediterranean health resorts, with all
the phases and symptoms of phthisis so nicely met by the appropriate
thology of Phthisis, by T. Addison, M.D., Guy's Hospital Reports, 2d Series, No. V.,
1845.) The same has recently been emphasized in the works of Dr. Felix Von Niemeyer,
and among others by Dr. Ludwig Buhl (Inflammation of the Lungs, Tuberculosis, and
Consumption, New York, 1874).
' Diseases of the Lungs. W. H. Walshe, M.D. London, 4th edition, page 585.
* Loc. cit.
* Climate, in Williams's Pulmonary Consumption; Lettsomian Lectures, on the influence
of climate in the treatment of pulmonary consumption, by C. T. Williams, M.D.; Con-
sumption, its early and remedial stages, by Edward Smith, M.D.; Diseases of the Lungs,
by Dr. Walshe, 4th edition; The effects of climate on Tuberculous disease, by Edwin
Lee, M.R.C.S., one of the Fiske Fund Prize Essays.
IN FLU E N C E OF HII G. H. A. L TITU DES ON PH THIS IS. 889
climatic remedies, I must confess to a slight feeling of hesitation. It is
well for us to ask ourselves how certain we are of any permanent relief
being obtained by consumptives in low humid climates. Though there
is no lack in the number of “watering places,” the field is so small (with
elevation left out) that one might almost as well think of supplying all
the climatic needs of consumptives within the boundaries of the little
State of Massachusetts. If in these low and narrow limits favorable
qualities are found, then efficiency in the climatic treatment of phthisis
demands more decided proportions of these same qualities, which we
hope to show are to be found, together with additional advantages, at
suitable elevations."
Low Climates.—As I am going to speak positively in favor of the utility
of high altitudes, where not specially contra-indicated, and shall ask you
to concur with me in this favorable opinion, it is well to make mention
of the grounds I have for feeling less confidence in low climates. As
will be apparent when we come to discuss the humidity of the air, we
are deprived of important data with regard to the undesirableness of low
climates, in that we have few positive records of the relative or absolute
humidity of these places in Europe. They all, however, represent more
or less moist climates. Of climates in England, Dr. C. T. Williams, in
his very carefully prepared Lettsomian Lectures, gives valuable statistics
of several localities, mainly along the southern shore of the Island, and
remarks upon the favorable results of 386 winters spent at those places
by 243 consumptives. “Bear in mind,” he says, “that these general
results assign the largest amount of benefit to the most easterly stations,
and follow a course exactly the reverse to that of the warmth of the
localities; Hastings, the coldest, being at the top of the list, and Tor-
quay, the warmest, being at the bottom,” Ventnor and Bournemouth
being between these. This result will be claimed as an argument for
high altitudes, when we come to consider that a cooler temperature, as
well as decreasing humidity, are found to be the natural attributes of
great elevations.
On the continent, there are also warm, moist climates, called sedative,
and more exhilarating resorts, termed stimulating,” which, like Hastings
in England, begin to partake of the best qualities of high altitudes, and
to show, according to Dr. C. T. Williams's excellent tables, a proportionate
improvement for the winters there spent by consumptives. Of the former
group there is Pau, remarkable for the stillness of its climate, where, as
we are informed, a plentiful amount of rain “falls perpendicularly.”
* In Europe, a reason has seemed to exist for sending south to the warm shores of Italy
and to the south of France those consumptives who, from feeble stomachs, are unable to
digest the quantity of food necessary to supply the waste caused by the greater amount of
oxygen inspired in the colder regions of the north. In the warm, moist climate, less car-
bonic acid is given off, and less heat required, so that the feeble digestion is not so heavily
taxed as in the severe climate of England. The plan works well, chiefly as a palliative
measure; but as warm weather comes on it is reasonable to believe that the scales must be
turned, and that the indigestion and enervation felt at the South may be much relieved by
a return to the cool climate of the North. So the consumptives who have shunned a harsh
New England spring, by a sojourn in Florida, hasten back, as warm weather approaches,
to cool seaside and country resorts, and are kept constantly on the move, with considerable
indifferent benefit. This idea of allowing the digestive capacity to decide to what climate
a consumptive should go, may often seem to result in good, but it is founded on uncerta n
premises, and lacks much desired definiteness in results. Like much of the theorizing as
to the treatment of phthisis indulged in by authors for many years, it is not radical enough
to answer our needs in the war we have to wage against one of the greatest of human
destroyers.
* Walshe, op. cit. * C. T. Williams, op. cit.
39() DENIS ON,
There is Valencia, in Spain, which Dr. Walshe characterizes as “probably
one of the warmest, most humid and depressing spots in continental
Europe;” Pisa, a once populous city in Italy, of which the same author
says that it has “completely lost its quondam prestige as a sanitarium,”
though, as we fail to notice positive climatic qualities to greatly recom-
mend it, we are surprised with the further assertion that this “changed
opinion is the result of sheer medical caprice;” and Venice and Rome,
the latter of which Dr. Williams' represents to have “had formerly a
great repute, though for many years its unfitness as a shelter for invalids
has been recognized, and it is now mainly resorted to for pleasure, and
not for health.” Among the latter group (“stimulating”), we find
Hyères, Cannes, San Remo, and Nice (representing the Riviera), Barce-
lona, Gibraltar, Malaga, Lisbon, and the Mediterranean islands (as Sicily,
Sardinia, Malta, and Majorca), which, as before remarked, partake of
more favorable qualities, and are notably less moist, than the “sedative”
group, or which have some peculiar attributes; thus Dr. Edwin Lee says
of Naples, “The frequent variations from dryness to moisture, and from
warmth to coldness, promote the disengagement of electricity.”
There are marine climates which, being wholly surrounded by salt
water, I fancy confer some of the advantages of sea voyages, in that the
air is constantly in motion, and the insensible activity of the skin thereby
promoted, while the air is always pure and bracing, considering the tem-
perature. So that these may be considered better than the moist climates
on the continent of Europe; and yet Dr. Walshe says of Madeira, “ much
of this promising character turns out to be practically delusive. The
damp is so extreme that changes of temperature thermometrically small
—of three or four degrees—prove sensationally great ; a temperature of
58° indoors, without being actually cold, is disagreeably chilly,” etc.”
The Canary Isles, St. Helena, some of the Mediterranean islands, the
Bermudas, Bahamas, West Indies, etc., may also be considered in this
group. There are relatively very dry climates, as Egypt and Syria, whose
enervating quality is the high temperature which would hardly be bear-
able, were the dryness absolute.”
Of American climates, we have the characteristic low resorts of moist
and sedative Florida; the balsamic regions" among the pines in southern
Georgia; the dry and alkaline regions of southwestern Texas, in the
vicinity of San Antonio; and the exceedingly equable and mild Pacific
coast, San Diego, Los Angeles, Santa Barbara, San Luis Obispo, San José,
and San Rafael, in California. Because of the great humidity of the
atmosphere, these last are much like the warm moist climates in the
Mediterranean basin. The favored low resorts in the United States .
might be much better chosen climatically speaking, but then the attrac-
tions have thus far been where the comforts of life are to be found.
| Op. cit. * Op. cit.
* A sea captain of long experience, who now lives in Denver, for the relief of asthma,
tells me he has carried many consumptives to the Sandwich Islands, “but brought none of
them away.”
* In America, in Southwest Arizona, and in the inland portion of Southern California,
notably in the vicinities of the Death Valley and Fort Yuma, the winter months only are
comfortable, and sometimes hardly that, because of the intense radiation from the Sandy
plains. At Fort Yuma, Dr. Geo. S. Rose, of the U. S. Army, has informed me that the mean
annual rainfall has been for nineteen years only 2.95 inches, while the average annual tem-
perature has been remarkably high—about 75°.
* The Pine Forests of Georgia as a Resort for Invalids; by Ezra R. Pulling, M.D.
Reprint from N. Y. Med. Journ., Sept. 1871.
IN FLU E N C E O F H IG H A L TITU DES ON PHT H ISIS. 391
Medium. Altitudes.—America is blessed with advantageous resorts for
cases in which high altitude is not well borne, or rather not permissible.
Notably is this true of the medium altitudes, though the need of them has
yet to be sensibly felt by physicians who guide invalids, before desirable
comforts and accommodations will be assured. Among these should be
mentioned the Cumberland Table Land, in the mountains of eastern
Tennessee, more especially “Walden’s Ridge” (elevation about 2000 feet),
lately described by the facile pen of Dr. E. M. Wight, of Chattanooga ;
western North Carolina (Ashville, elevation 2250 feet);” southwestern
Texas (Fredericksburg, Boerne, Uralde, and Ft. Clarke, elevation 1500
to 2000 feet, valley of Rio Grande); southern New Mexico (the Mesilla
Valley) and western Kansas (elevation 3000 to 4000 feet), the former in
winter and the latter in summer being comparatively warm enough to
be placed in this group. So also northern Minnesota (St. Paul and
JBrainard, elevation 1200 feet), because of its cooler temperature and
northern situation. In Europe, examples of medium altitudes might
be mentioned, as Silesia (Görbersdorf, 1700 feet), Le Mont Dore (3400
feet), Königswarth in Bohemia (2200 feet), Black Forest (2800 feet),
Lower Engadine (about 4000 feet), Eaux Bonnes (2450 feet), Cauterets
(3254 feet), and Bagnères de Luchon (2060 feet). In Brazil, Dr. Walshe
desires to call attention to San Paulo (2300 feet), a short distance inland
from the port of Santos. In Mexico, we have Jalapa (4000 feet).”
High Altitudes.—Coming now to high altitudes proper, a few places
will be mentioned, chiefly those which will serve for our present study,
lying in the region of an altitude of approacimate immunity from phthisis,
which we will consider further on. In Europe we have to content our-
selves with more unfavorable complications than obtain in the chosen
high altitudes of America. The mountains of the Alps present, in the
upper Engadine, such resorts as St. Moritz (6100 feet), Samaden (5500
feet), and Davos (5200 feet). They are high enough for their northern
latitude, but are burdened with an excess of moisture gathered by the
mountains, exposed as they are to the moist Atlantic currents. This is
evidenced by Dr. Walshe's citation from Dr. Hewlett,” that, at St. Moritz,
“in fourteen winter months (seven in 1866–7, and seven in 1867–8) there
were only fifteen clear days, while 148 rainy days, and others more than
half clear, with their admixture of snow, sleet, and rain, made up the
rest.” This is considerably at variance with the excellent reputation
Dr. L. Vacher gives Davos, for the five cold months ending with March,
during which time only the stay of consumptives at this resort is recom-
mended." It is here that the plan, personally investigated by Dr. Vacher
(so novel to us who live at the base of the Rocky Mountains, though
partly exemplified by the invalid's experiences in Minnesota), is presented.
It consists in keeping invalids in the region of continuous snow, until
the thawing season in the spring, when they are quickly removed to a
lower level. Dr. Vacher gives the number of invalids seeking this resort
' A People without Consumption, and some Account of their Country, etc. Reprint,
Trans. Tenn. Med. Society.
* Western North Carolina as a Health Resort; by W. Gleitsmann, M.D. The Climato-
therapy of Consumption; by S. E. Chaillé, A.M., M.D.; from N. O. Med. and Surg.
Journal, May, 1876.
* Influence of Climate in North and South America; by J. Disturnel.
* Walshe, op. cit.
5 St. Moritz; by R. W. Hewlett, M.D. 1871.
* Le Mont Dore—Davos. Etude médicale et climatologique sur les cures d'air dans la
Phthisie Pulmonaire; par Le Dr. L. Vacher. Paris, 1875.
392 DENIS ON,
as eight, in 1865; 55, in 1870; 220, in 1873; and 400, in 1874; which
ratio serves to show the increasing favor which the results of the treat-
ment have warranted, as well as the comparative newness to Europeans
of the special efficacy of high altitudes. I shall have many occasions to
refer to the experiences furnished by Davos. In Asia, the elevated pla-
teaux in Persia and Armenia, and those adjoining the lofty IIimalaya
Mountains, together with other elevated inland and dry localities, would
seem to furnish excellent climatic combinations, but I have not the neces-
sary data for an account of that vast section.
In America, North and South, the great Rocky Mountain and Andes
chains furnish, along and between their variously diverging branches,
almost innumerable resorts of any desired elevation or latitude. From
the north to the south, in the United States, the great plateaux and elevated
basins between the Rocky and the Cascade Range, the Sierra Nevada
and the Sierra Madre Mountains, present variations in altitude, tempera-
ture, and humidity, which would claim our attention could we now
spare the time necessary to study so broad a field. Generally having
favorable climatic attributes, with unfavorable distances and local pecu-
liarities, we pass over this vast section to mention the western slope of
the Sierra Nevada, in California (vicinity of lakes Donner and Tahoe, in
summer), and especially the eastern slope of the Rocky Mountains, in
Colorado and New Mexico. (Cheyenne, in Wyoming Territory, 6100
feet; Boulder, Colorado, 5300; Denver, 5200 ; Idaho Springs, 7540; Colo-
rado Springs, 5980; Manitou, 6200 ; Pueblo, 4630; Canon City, 5260;
Trinidad, 5800. In New Mexico, Santa Fé, 6850; and Albuquerque,
5030.)
It is in Colorado that the Rocky Mountains proper reach their great-
est continuous height, many peaks being over 14,000 feet, and present a
remarkable width of 100 miles. Interspersed with these lofty peaks are
elevated plateaux, or valleys, as North, Middle, and South Parks, 8000
to 10,000 feet; Fairplay, 9800, and San Luis Park (Del Norte), 7000
feet. In Mexico, this vast plateau is continued, being about 1000 miles
wide at the north, and nearly 2000 in length, and is called the Amahuac.
It varies in elevation from 8000 feet on the east, to 4000 feet in some
portions of the western, or Pacific, slope (the City of Mexico, 7400;
Chihuahua, 4640), and includes most of the Tierras Frias, or cool re-
gions. These exceedingly dry, elevated plains, including extensions to
the north into New Mexico and Arizona, would claim much more of
our interest and study were the habits and lives of their greasy original
inhabitants more inviting and congenial to the cultivated American.
The loose sand and fine lime dust, together with the rapidly increasing
growth of the prickly and inhospitable cactus, as you go south and
southwest from central Colorado, may reasonably indicate the undesira-
bleness of much of that southern region." As exceptions to this unin-
viting region, I note the beautiful and favorably-located southern slope
of the mountains, toward the San Juan river, in southwestern Colorado,
where lie the Pagosa springs (most wonderful of the hot springs in Ame-
rica); a genial climate and interesting volcanic region near Fort Bayard
1 Where the cactus grows to the size of trees, as in some parts of New Mexico and
Arizona, Lieut. Philip Reid, of the United States army, informs me, are the most uninviting
places imaginable for the steady abode of man. Yet here, on the advent of railroads, I
predict will be found the extreme climatic remedy which will suit many in winter who are
now without much hope anywhere. Such is the fight the invalid will have to make with
his destroyer.
IN FL U E N C E OF HIG. H. A. L TITU DES ON PH THIS IS. 393
(elevation, 6000 ft.); the foot-hills and possible favored resorts in sunny-
uplands of Chihuahua; and the inviting surroundings of the antique
City of Mexico, almost encircled by the lofty Sierras, which inclose beau-
tiful lakes and favored resorts, and send, among other peaks, the Popo-
catepetl 17,735 feet above the sea, far into the regions of perpetual snow.
The Cordillera de los Andes, which has divided in Guatemala, to
form the eastern and western boundary of the Anahuac in Mexico, ex-
tends into South America, to rise still higher just north and south of the
equator. Here the Cordilleras, lying close to the Pacific coast, diverge
in rangés which inclose elevated valleys or plateaux from less than 8000
to over 12,000 feet in height, while snow-clad peaks like Chimborazo in
Ecuador (21,500 feet), and the Sorata and Illimani, in Bolivia (22,400
and 21,250 feet), tower above." In the central portion of Peru the Mon-
tana consists of a lofty plateau, averaging 12,000 feet in height, which con-
tains many cities and villages, possessing, according to Disturnel, “a
fertile soil, amid the most magnificent scenery on the earth's surface,”
and “enjoying a temperate and delightful climate.” The considerable
amoisture in the air, for such great elevations, as contrasting with the
excessively dry regions on and to the north of the Anahuac, may yet
indicate valuable discriminations for the thousands who will seek a
restoration of their consuming strength in high altitudes.
ANALYSIS OF THE ATTRIBUTES OF HIGH ALTITUDE CLIMATES.
We have now hurriedly, and somewhat superficially, reviewed the
characteristics of low climates, and have geographically indicated me-
dium and high altitudes. In claiming our present consideration, high
altitudes have positive features and effects to contrast with the uncertain-
ties of low levels. Therefore it is to be hoped that the considerable space
given to low climates may not be thought amiss: so much does our ap-
preciation of good, as in fact the enjoyment of life, come to us by con-
trast. I have gladly accepted the invitation to consider high altitudes
in general, rather than any one locality, though I fear that the dry
study of so large a field will tax your patience, and be otherwise unsat-
isfactory. Ilet us then consider high altitudes in the abstract, and seek
to analyze the attributes of its atmosphere, leaving, for the present, geo-
graphical and local considerations mainly in the background.
We may form in our minds an idea of the climates which will best
answer the consumptive's needs. Not that we can fathom the Creator's
plans, and improve on the world he has given us, but that having satis-
fied ourselves of the ideal, for the majority of phthisical patients, we
may then seek the real, among the varied climates of the earth. Here,
it is instructive to remark how various are the visions indulged in by
unsatisfied man, of the most beautiful and desirable country in which to
live. It is of consequence also to note that it is improbable that we
physicians would agree, were we to vote now as to the average tempera-
! When it is considered that, under the equator, the growth of wheat is not established
till the altitude of 4500 feet is reached, and that sugar cane has been grown at 7500 and
the banana at 5400 feet, it is not to be wondered at that the most comfortable existence
for man is to be found at a considerable elevation, and that populous cities lie high up in
the mountains, as Bogota, the capital of the United States of Colombia, 8650 feet; Quito,
of Ecuador, 9540 feet; Cuzco, the ancient capital of Peru, 11,380 feet; and towns bordering
on lake Titicaca, between Bolivia and Peru, 13,000 feet.
394 DENIS ON,
sture, humidity, amount of sunshine, electric tension, elevation, and char.
acteristics of wind, as to direction and velocity, etc., of Our ideal eli-
mate, for the majority of consumptives, or even for uncomplicated phases
of the disease. The attributes of climate just mentioned are so inti-
mately interwoven and dependent on each other, that their separate
consideration is difficult. We will try, however, to avoid repetition by
referring to them in the order named.
Temperature.—The temperature of high altitudes makes life pleasant
under the equator, and gives marked variety to climates north and south
of that line. In general, the decrease in the temperature of the air has
been reckoned at 1°Fahr. for each 300 feet of elevation." But the rule
for the decrease of temperature cannot be arbitrary for all elevations,
because of local peculiarities. For instance, the mean annual tempera-
tures of places along the eastern base of the Rocky Mountains in Colo-
rado, are much higher than their elevations would indicate, judging
from the records of stations in the same latitudes on the Atlantic coast
of the United States. The cause of this is (1) The far inland position.
“The sun's rays passing through the air with but trifling loss, fall on
land or on water. The specific heat of land being only one quarter that
of water, it both absorbs heat and gives it out more rapidly . . . conse-
quently the more land the greater is the heat, and the wider the diurnal
and yearly amplitudes of fluctuation.” (2) The dry sandy soil. The
plains are generally but lightly covered with grass (rivers and trees
being very limited), and this tends to increase the difference between
ordinary clay soil and water, and so furnishes both greater absorption and
greater radiation of heat than the ordinary soil of lowlands. (3) The pro-
tection afforded by the mountains, to the west and northwest. These break
or divert strong winds, and gather moisture from western currents, thus
promoting an increase of sunshine on the plains. (4) The dry and warm
Equatorial and Pacific winds. These prevail at all exposed points on the
mountains, and bring pleasant weather to the plains below.
In considering the variations of temperature referred to above, we
remark that the more rapid absorption and radiation of heat by land
than by water, explains the low fall of temperature at night, and the
considerable rise at midday, away from the sea-coast, and shows, by in-
ference, the equalizing influence on temperature of moisture in the air.
These variations are increased in high altitudes by the lessened capacity
of the air to hold moisture, due to elevation and the resulting loss in
weight. The annual fluctuations, due to the changed angles with which
the sun’s rays fall on the earth, are for the same reason affected by eleva-
tion. Thus the following table is explained, giving the mean daily range,
the average monthly range, the range of monthly means, the annual
means, and the annual range of temperatures of places chosen as nearly
as possible in the same latitudes, on the sea-coast, inland, and at the base
of the Rocky Mountains.
| Under the equator it has been estimated to be 10 Fahr., near sea level, for each 333 ft.;
for each 297 feet at 10,000 feet, and for each 318 feet at 20,000 feet elevation; while recent
observations, in temperate climates, have given the rule of 19 Fahr. for every 400 feet. The
records of Mr. Glaisher's balloon ascension indicated different strata of air, the fall in tem-
perature being under a clear sky 5° Fahr. for each of the first four inches of barometric
fall, then 49 per inch till the thirteenth inch of descent, and 4.5° each for the last three
inches. *
* Parkes, Practical Hygiene, p. 417. 4th ed. Phila., 1873.
IN FLU E N C E OF HIGH A LTITU DES ON PH THIS IS. 395
TABLE I.-Showing Ranges of Temperature from July, 1874, to July, 1875.
Mean daily Mean monthly Range of Annual A nnual
ATLANTIC STATIONs. rä uge. rauge. imonth ly Iſleſſ, Il S. IIł 68t, Il. range.
New Haven, Ct. * . 16C 429 489 48.69 919
Atlantic City, N. J. . . I 5 41–H 44.1 49.7 89}
Baltimore, Md. . g . 18 44 48 53.9 984
Norfolk, Va. . ſº . 18 44 40.7 57.3 89}
Average . . & . 17 43 45.2 52.4 92}
INLAND STATIONs.
Davenport, Iowa t . 18 53.5 68.6 46.8 120
Indianapolis, Ind. . . 22+ 57 58.5 5 1.7 127;
St. Louis, Mo. . e . 20 53 57.4 54.2 | 17
Nashville, Tenn. º . 21. 49 49.7 59.5 108
Average . e tº . 20+ 53.12+ 58.55 53.05 118;
ELEVATED STATIONs.
Cheyenne, Wyo. º . 31 61.5 48.9 43.6 136
I}enver, Col. . e . 3() 6i).5 53.7 49.2 131
Colorado Springs, Col. .. 30 (3.5 47.7 46.8 123
Santa Fe, N. M. & . 29 49.5 45.3 49.2 88
Average . ſº * . 30 38.75 48.9 47.2 1194
PACIFIC CoAst STATIONs.
San Francisco, Cal. . . 12–H 31 11.5 55.5 5()
San Diego, Cal. . º . 13 31 5.6 59.9 (; ()
Average . te ū . 12% 31 8.55 57.7 55
Desides showing the effect of inland position and elevation on the
daily, monthly, and annual ranges of temperature, this table makes evi-
dent certain facts of interest both in reference to the stations separately,
and the groups into which they are divided. (1) The fluctuations in
temperature (notably, of course, in the annual range) decrease toward the
South. This continues till even greatly elevated localities, near the
equator, are quite equable in temperature, as on the elevated plains in
the Peruvian Andes. (2) The comparatively low range of monthly
means, at the “elevated stations,” considering the high mean daily,
monthly, and annual ranges (with the low average relative humidity of
this section, about .45), indicates that there must have been a large pro-
portion of pleasant, even weather at those stations in each month, to have
made up for those other extremes. This preponderance of pleasant,
sunny weather is quite uniform at the base of the mountains. (3) The
extremely low mean range of temperature for all divisions of time, on
the Pacific coast, indicates the existence there of a continuous, warm,
moist wind, which is unobstructed, and only gives up its moisture when
cooled by the winter temperature of that latitude.”
The influence of heat on the activity of several functions of the body
leads us to prefer a cool to a warm temperature. (1) Iſeat is opposed to
stimulation, so far as the nervous system is concerned. “In experiments
Report of the Chief Signal Officer, War Dept., 1875.
* It is unobstructed, for otherwise there would be greater precipitation of moisture, and
accompanying thermal changes. That it only rains in winter, is a fact known to all. It is
a continuous wind, for otherwise terrestrial radiation and absorption would have produced
a much more marked effect on the temperature than the records show. It may be considered
warm, because a cold wind could not carry moisture enough to have produced such thermal
effects in these latitudes. It is moist, because if it was dry the daily and seasonal influences
of the sun would be greater than the records show. We are not surprised then to learn
that the average atmospheric humidity is out of proportion to the amount of rainfall on the
Pacific coast.
396 DENISON,
on frogs, when a temperature much over the natural amount is applied
to nerves, the electrical currents through them are lessened, and at last
stop." E. H. Weber's observations” show that for men the same rule holds
good, the most favorable temperature being 99.5° Fahr.” Then a con-
trast between the temperature of the surrounding air and that of the body
favors the influence of atmospheric electricity, which experience proves
to be an active agent at considerable elevations. (2) Iſeat in the shade
has been shown by Rattray” and others to have a sensible effect in
increasing the temperature of the body, to counteract which a healthy
activity of the skin is required, but is impeded by a coincident high
relative humidity of the air. The experiment of entering a heated oven
(200° to 300°) becomes more difficult when the air is moist than when
it is dry; evaporation is hindered, and the bodily temperature is said to
rise even 7° or 8°." (3) Heat lessens the number of respirations per
minute. According to Rattray’s observations, the variation has been
known to be from 16.5 respirations per minute in England, in winter, to
12.74 and 13.74 in the tropics. Other observers note that the breathing
is also less deep. Dr. Francis (Bengal Army) and Dr. E. A. Parkes"
have both observed that the lungs are lighter after death in Europeans
in India, than the European standard. On the other hand, a healthful
activity of the respiratory function is favored by a cold temperature, and
is an important feature of the high altitude cure. (4) Heat, especially
if continuous, lessens the digestive powers. The stimulation of the appe-
tite which cold is well known to produce, is lacking, especially for much-
needed animal food. So the destruction and formation of tissue is
retarded. This is also opposed to that renovation of system which is
decidedly promoted by both cold and elevation.
Humidity.—To continue our proof that cool, dry climates are better
constituted for the needs of phthisical patients than those which are
warm and moist, we will consider the humidity of the air, bearing in
mind that coolness and dryness are constantly favored by increasing ele-
vation. This brings us to one of the strongest arguments in favor of
high altitudes. It is, however, difficult to thoroughly explain this sub-
ject, because of our lack of familiarity with the precise laws which
govern the various changes of the moisture in the air.
The Signal Service Bureau of the United States Army determines the
relative humidity of the air by the difference in temperatures given by the
wet and dry bulb thermometers, and thus the percentage of saturation
of the air is known. But these humidity records have not been well
distributed, and it would seem either that the officers of this bureau have
little confidence in the reliability of humidity statistics, or that they
do not appreciate their important bearings on scientific and climatologi-
cal investigation. While the relative amount of atmospheric moisture
is most important, as determining the healthful activity of the skin,
the evaporation and quickening of perspiration from the surface of the
! Eckhard, Henle’s Zeitschr., Band x., S. 165, 1851.
? Weber, Ludwig's Phys., 2d ed., vol. i. p. 126.
* Parkes's Practical Hygiene, 4th ed., p. 400.
* On the Effects of Change of Climate on the Human Economy, by A. Rattray, M.D.,
Surgeon R. N. Proceedings of the Royal Society, 1869–1872.
* By inference we find here one cause of sunstroke, which in our experience does not occur
at great elevations in America, notwithstanding that Dr. Vacher (op. cit.) speaks of sun-
stroke occurring on the Alps.
6 On Algide Cholera, by E. A. Parkes, M.D., p. 14 (1847).
IN FLU E N C E OF H IG H A L TITU DES ON PHT HIS IS . 397
body being greatly in proportion to the removal of the dew-point and
temperature of the air from that of the body, yet these records are in a
measure superficial, simply because they are relative and not real. This,
too, notwithstanding that a little more than half the ratio of saturation
is shown by them on the plains east of the Rocky Mountains, to that
which exists in some localities on the sea-coast. This is proof enough
that our temperature is not much in the suspicious company of the dew-
Point. I ann, however, inclined to claim that the importance of a large
annount of atmospheric vapor, as a causative, and of a small amount, as
a curative, element of phthisis, is such that the absolute rather than the
relative amount of moisture in the air needs our special study. If to-day
we were possessed of the knowledge of the average amount of vapor in
a cubic foot of air in all parts of the country, I believe we would have
one, if not the most valuable indication possible, of the best localities
for phthisical patients. With some reservation as to temperature, the
smallest ratios would indicate where consumption originates with the
greatest difficulty, where a low ratio of relative humidity, a small
annual rain-fall (excepting sudden and great precipitation), a large pro-
portion of sunshine, and a favorable diathermancy of the air would be
assured, so much do these favorable conditions accompany real dryness
of the air. This absolute humidity would of course be shown to be
greatest in the tropics, least toward the poles; increased over large bodies
of water, decreased as we go inland from the sea; increased by heat, as
in summer and at mid-day, and decreased by low temperature, as in
winter and in the morning.
To more fully consider the importance of the real atmospheric humid-
ity, it is to be noted that the air is capable of holding moisture, mainly
according to its temperature. The expansion of air under the influence
of heat increases its capacity for retaining invisible vapor from about
half a grain in a cubic foot, the limit at zero, with a barometrical pres-
sure of thirty inches, to 19.84 grains, the limit at 100°Fahr. (See Table
II.) As to a loss due to change in the weight of the air, many compli-
cations present themselves, among which a very slight one is the fact
that dry air weighs from 2 grains at a temperature of 44°Fahr., to 8
grains at 80° Fahr., more in the cubic foot than saturated air." The
elastic force of vapor, or the absolute humidity of the atmosphere, Mr.
Buchan says, “diminishes with the height, but the average rate at which
it diminishes is not known.” The records of balloon ascensions give
some information in this direction, but not sufficient to constitute any
rule of change. The balloonist Croce-Spinelli, who perished in his aerial
flight, recorded before he died that, at an elevation of 16,370 feet, “there
was no longer vapor in the air.” And the experience of many of us
who have ascended great heights, agrees with that of Gay-Lussac, who
recorded in his balloon ascension that, at 14,715 feet, “the air was so dry
that for want of saliva he could hardly swallow bread.” We understand
that the air is twice rarefied at a height of 3% miles, 4 times at 7 miles,
16 times at 14 miles, 64 times at 21 miles elevation, etc. This expan-
sion of the air with increasing elevation is accompanied with a loss of
part of its humid contents, through the coincident cooling which takes
place, so plainly described by Prof. Tyndall.” If, with our “mind's
Smithsonian Meteorological and Physical Tables, by A. Guyot.
* Handbook of Meteorology, by Alexander Buchan, 2d ed., p. 162.
* The Forms of Water, by John Tyndall, LL.D., F.R.S., 1874.
398 DENIS ON,
eye,” we follow a cubic foot of saturated air in its ascent through space,
we notice the loss of most of its moisture through the chilling due to the
expansion ; but there is another portion of the moisture, as well as of the
air, crowded outside the cube by the same expansion. Mr. Glaisher’s
tables, before referred to, which give the weight of vapor in a cubic foot
of saturated air at different temperatures, are made for a barometric
pressure of 30 inches. If these tables are as accurate for places a mile up
in the air as for those at sea level, then there is no diminution of mois-
ture due to elevation independent of temperature, and the saturated air
of such height may retain more moisture in proportion to its weight for
a given temperature than the air at sea level. The air at the School of
Mines, in Golden, Colorado, 5900 feet above sea level, was found by Prof.
B. J. Mallett to contain at 60° Fahr. 331 grains of nitrogen and 99
grains of oxygen, or 430 grains weight for the cubic foot, which is just
about four-fifths the weight of air at sea level.
TABLE II.—Showing Weight of Vapor, in grains Troy, contained in a cubic foot
of saturated air, at temperatures between 0° and 105° Fahrenheit.'
Tempera- Weight of Tempera- Weight of Tempera- Weight of Tempera- Weight of
ture of air vapor in ture of air vapor in ture of air vapor in ture of air vapor in
Fahr. grains. Fahr. grains. Fahr. grains. Fahr grains.
()O . . ().545 36O . . 2,469 ($39 . . 6.361 900 . . 14.8 l ()
4. . . 0.649 39 . . 2.759 66 . . 7.021 93 . . 16.176
8 . . 0.772 42 . . 3.076 69 . . 7.739 96 . . 17.648
12 . . 0.916 45 . . 3.426 72 . . 8.521 99 . . 19.235
16 . . 1.090 48 . . 3.8ll 75 . . 9.372 101 . . 20.357
20 . . 1.298 51 . . 4.234 78 . . 10.292 103 . . 21.535
26 . . 1.674. 54 . . 4.696 81 . . 11.291 105 . . 22.771
29 . . 1.892 57 . . 5.202 84 . . 12.376
33 . . 2.208 60 . . 5.756 87 . . 13.546
Is there no diminution in the capacity of this rarefied air for moisture,
due to this lessened pressure of three pounds to the square inch : The
question is of importance to us as affecting the basis of our judgment of
high altitudes. Besides, the Signal Service weather reports often come
to us with relative humidity noted as “not corrected for elevation,” and
we are left to learn what such correction may be. Now, seeking to avoid
the headache and uncertainty which are induced by the search for suit-
able explanations in Guyot's and Glaisher's complicated tables, we will
simply say that the only correction given is by the former author,” and
adds from two to three per cent. to the relative humidity of places of the
altitude of the Rocky Mountain base. This correction, as affecting the
dryness of air in high altitudes, amounts to but little ; besides, as before
inferred, the comparison of climates by the relative humidity of each, is su-
perficial, when temperature is not taken into account. With temperature,
however, as indicating the capacity for moisture, the question becomes
equivalent to this: Is the comparison of climates by the absolute humidity
of each just 7 Our argument in advance has been that possibly it is
unjust to high altitudes, as far as desirable dryness is concerned. Let
us suppose it just, however, and (adding Guyot's corrections) make one
or two comparisons which will suffice for all, and show the superiority
of the highlands over the lowlands. We are enabled to compute the
weight of vapor from Mr. Glaisher's table already given, or from one of
Guyot's tables. Compare Jacksonville, Florida, with Denver, Colorado.
| Smithsonian Meteorological and Physical Tables, page 93.
* Ibid., page 72. -
IN FLU E N C E O F H IG. H. A. L TITU I) E S ON PH THIS IS . 399
According to Dr. Baldwin, the mean annual temperature of Jackson-
ville is 69.82° Fahr., and the mean relative humidity .696. The Signal
Service records at Denver give a mean annual temperature of 49.2°;
relative humidity .46 (corrected for elevation, .48). Then the average
cubic foot of air in Jacksonville contains 5.6 grains of vapor, while in
Denver the amount is 1.91 grains, about one-third as much. Or again,
to compare the humidity of Jacksonville, Davos, and Denver, for the
five cold months ending with March, the term of the thermal cure at
Davos, we have:—
Mean Mean relative Grains of vapor
temperature. humidity. in a cubic ſoot.
Jacksonville . - e & & º º 60C 68 3.92
Davos . º - e º o º e 23 842 1.24
Denver . º - & e o º º 33 512 1.13
The small amount of absolute humidity compared with the high rela-
tive humidity of Davos, shows the fallacy of judging solely by the relative
humidity, while the whole table shows the remarkable dryness of high
altitudes in winter.
The sensational effect of cold with excessive absolute, as opposed to a
high ratio of relative, humidity, and really little moisture, is conside-
rable. A gentleman, now a resident of Denver, who formerly resided
in Jacksonville, says that he “stands the winter cold better,” and “feels
less chilly,” in Colorado than in Florida; and the temperature of 58°
Fahr., in doors (which is always very comfortable in Denver), is said by
Prof. Walshe to be “disagreeably chilly” at Madeira. Excepting certain
high altitudes where mountains act as constant condensers of moist
currents, it is now incontestably shown that, as to temperature and
humidity, coolness and dryness are progressively concomitants of in-
creasing elevations. The proof that cool, dry climates, or high altitudes,
are better than warm, moist ones, or tropical lowlands, needs no better
conclusion than the evidence furnished by Dr. C. T. Williams's excellent
analysis of 593 winters spent by 251 consumptive patients in foreign
climates. I quote with pleasure (and with thanks for the unintentional
favor) the indisputable evidence which this zealous student of European
and lowland resorts gives for high altitudes.” I have already adverted
to the experience of 243 consumptives who spent 386 winters in English
“home” stations, which resulted in the colder resorts carrying off the
palm." Now as to the experience in foreign climates, Dr. Williams con-
cludes: “As to what class of patients profit most by dry climates, it has
been shown that, taking collectively all forms and degrees of phthisis,
the dry climates are the most likely to arrest the disease. . . . As
to the desirability of moist climates for consumptive patients, the evi-
dence is decidedly against their use in the treatment of ordinary chronic
phthisis. The addition of warmth only makes the damp tell more un-
favorably, though a strong saline element and invigorating breezes do
something to counteract the humid influence. Still even these do not
place a moist climate on the same level as a dry one.”
Diathermancy of the Air.—A striking, and to most people a novel fea-
ture of high altitudes, is the clearness of the air, as shown by the inten-
sity of the sunshine. I was impressed with this characteristic of Colorado
| “An address on the Climatology of Florida.” By A. S. Baldwin, M.D., President.
Proceedings of the Florida Medical Association. Sessions 1-74 and 1875.
* Corrected for barometrical heights by Guyot's Meteorological Tables, 2d ed. page 72.
* Lettsomian Lectures, Lecture lII. * Id. op., Lecture II.
400 DENIS ON,
air on my first arrival three years ago, when, while riding toward the
northeast, on a cold winter afternoon, the exposed portions of my body
became chilled, while the back of the carriage seat, on which the sun
was shining, was very hot ; and I have ever since been curious to under-
stand the phenomenon. After ineffectually endeavoring to get the
Signal Service officers to study this matter, I conceived the idea of deter-
mining for myself the ratio of difference between the temperature in
sunshine and shade, for each decided elevation, believing that, with the
same conditions, excluding the influence of the wind, artificial heat, etc.,
observations at a few stations would serve to establish an approximate
rule for almost all elevations. Accordingly, since February last, the de-
sired temperature has been recorded at Washington, D.C.; at Royalton,
Vt.; at Denver; and more lately by C. S. Richardson, C.M.E., at the
Dolly Varden mine, on Mt. Bross, Colorado. Ordinary thermometers
in metallic frames, and of Fahrenheit scale, have been used, observations
having been taken at 2 P. M., on clear days only; and western rooms,
not artificially heated, and with western windows, having been chosen.
The temperature of the room has been taken in the shade and sun, with
the window closed, and also with the window open, the direction, etc. of
the wind being noted. The results must be taken as only approximate
for general conclusions, because of the many conditions by which they
may be affected, the fewness of the stations, and the short time the ob-
servations have been continued, extending only over parts of March,
April, May, and June.' I have lately found an average of the same kind
as my own, taken at the city of Mexico by Dr. Jourdanet,” which I add
to the accompanying table:–
TABLEs III. AND IV.-Showing Diathermancy of the Air.
Difference between Ditto, window open
STATIONS Elevation temperature in sun Average or out-doors, the A verage
T 4.x tº e above sea. * and shade in-doors, difference, windy days ex- difference.
window shut ; from cluded ; from
Washington, D. C. . . 80 feet. I2O to 37C 230 L7O to 37C 24O
Royalton, Vt. . . . 500 “ 16 to 42 27 23 to 47 28
Denver, Col. . . . . 5200 “ 40 to 48 43 46 to 55 50}
Mexico, Mex. . . . 7600 “ ........ * tº e e 56 to 65 604
Temperature in
w * Elevation Temperature closed box with * {{*, *.
STATIONS. above sea. in shade. glass cover Difference.
(sunshine).
Mt. Bross, Col. . . . . . . . . 13,400 feet. 56O 162O 1069
Alma, Col. . . . . . . . . . 8,800 “ 68 154 86
Denver, Col. . . . . . . . . . 5,200 “ 88 160 72
Besides the increase of diathermancy, the tables show the more uni-
form clearness of the air at high than at low altitudes. From these
! Lately I have been pleased to learn, from Dr. Vacher's brochure on “Davos, Le Mont
Dore,” that others also have been making observations similar to my own. But as
these observations, one with the thermometer in vacuo, and another, that of M. Saussure,
which consisted in “exposing to the rays of the sun a thermometer placed in a wooden box
lined with black cloth, and covered with glass,” were not made under conditions favorable
and usual to human existence, I have more confidence in the utility of my own; though the
contrasts between sunshine and shade are not as great in my observations as in the
others.
* Le Mexique et L’Amérique Tropicale, Climat, Hygiène et Maladies, par D. Jour-
danet.
* Partly from Dictionary of Elevations and Climatic Register. By J. M. Toner, M.D.,
1874.
* Taken in January.
INFLUENCE OF HIGH ALTITU DFS ON PHT HISIS. 401
tables we can approximately arrive at the desired result, the difference
between sunshine and shade, or the heating power of the sun’s rays.
Mr. Richardson has kindly taken many observations for me on Mt.
Bross, the difference between the temperature in the sun and in the
shade out-doors at 2 P.M. being only from 10° to 20°, and not showing
the real diathermancy of the air. This I attribute to the rapid radiation
of heat and constantly moving cold air of that exposed place. As there
was no suitable building in which to try the other test, I prepared paste-
board boxes, with glass covers, and with black velvet lining, in which we
took the temperatures at Denver, Alma, and on Mt. Bross, at 2 P.M. for
a few days, at nearly the same season. The differences between these
records and the temperatures in the shade, noted at the same time, serve
to show the increasing diathermancy of the air at these greater eleva-
tions, notwithstanding the peculiar influence of the cold air and wind of
those heights. Now the differences between these diathermancy tests
tally as follows for the given differences in elevation:—
TABLE V.
Difference in Average difference **ś...”
STATIONS. elevation. * degree of dia-
tº thermancy.
Washington and Denver . . . . . . 5120 feet. 23O 223 feet.
Washington and City of Mexico . . . 7520 “ 36 209 “
Royalton and Denver . . . . . . . 4700 “ 20 235 “
Royalton and City of Mexico . . . . 7100 “ 32 222 “
Denver and City of Mexico . . . . . 1400 “ 9} 148 “
Denver and Mt. Bross . . . . . . . 8200 “ 34 241. “
Denver and Alma . . . . . . . . 3600 “ 14 257 “
Alma and Mt. Bross . . . . . . . 4700 “ 20 235 “
Average g & . 221 feet.
Thus is evolved a general rule, which may be changed by more accu-
rate and extended observations, of one degree greater difference between the
temperatures in sun and shade, for each rise of about 220 feet.
This diathermancy (the increased facility with which radiant heat is
transmitted) explains as clearly as the absolute humidity of the air, the
daily fluctuations in temperature so gradually augmented with increasing
elevation. But the absolute humidity, or elastic force of vapor in the air,
is the main key to its transparency, the elevation only giving an addi-
tional increase in diathermancy to that produced by the decreasing
humidity. So dry, low places, like Fort Yuma, California, will be ex-
ceptions to the rule given. However, this does not disprove, but, on the
contrary, helps to establish the increased diathermancy of high altitudes,
where, as we have already shown, there exists a considerably lessened
absolute humidity. The effect of this diathermancy of high altitudes on
solar and terrestrial radiation is wonderful. The solar radiation is rapid,
and soon after sunrise the temperature rises, because of the slight resist-
ance which the rarefied and dry air offers to the sun’s rays; while, after
sunset, the terrestrial radiation is also rapid, because there is no moist
envelope shrouding the face of the earth to prevent the natural cooling
of the dry ground." The climax of this proof is as follows: Reasoning
from the effects inimical to life in mines, cellars, and ill-lighted abodes,
* The character of the sunlight of high altitudes is a nearer approach, if possible, to
white light, than at sea level, and many find it desirable to wear gray-blue or smoked
glasses to neutralize its effect. -
402 DENIS ON,
to the benefits of sunlight at low levels, where a stratum of moisture
intercepts the sun’s rays like a thin cloud, and thence to the healthful
influence of the unobstructed sunshine of the highlands, we can say,
without fear of successful contradiction, that the beneficial effects of
sunshine increase with increasing altitude. It is further to be noted
that, the sun's rays being less obstructed, there is a proportionately
longer influence of sunshine in each twenty-four hours, besides the excess
due to a usually cloudless sky over such plains as those east of the
Rocky Mountains." Thus, too, is explained a certain degree of incor-
rectness of ordinary temperature records of the Signal Service, which are
taken in the shade and on the north side of the building, with the cold
nine o’clock observation doubled to make up the general average. We
are warmer during the hours in which being out of doors is desirable,
on the elevated western plains, than is indicated by the temperature
records.
Atmospherie Electricity.—The importance of atmospheric electricity as
a curative power in disease is not to be measured by the little we know
about the element itself. The experience in high altitudes of persons of
susceptible nervous temperament goes to substantiate the universal evi-
dence of science that, as a rule, electric tension in the atmosphere is in-
creased with each decided elevation. Leaving out of consideration the
change in electric tension and the negative quality of atmospheric elec-
tricity during storms, we learn from extended observations (Kew obser-
vatory) that with a clear sky the electricity of the air is always positive,
which quality, Alexander Buchan says, becomes manifest “on flat
ground” at a height of five feet. It would seem that, with the increase
of tension due to elevation, the positive electricity of the air, so abun-
dant in dry elevated regions, would be constantly nearing the negative
electricity of the earth. With no other evidence to prove this than the
experiences of our nervous systems, I shall claim that this is the true
state of electric tension of high altitudes, till evidence is produced to
the contrary. Now here is important teaching for the consumptive
multitude, in fact for most of the human family. The houses we live
in, and the piazzas and trees we sit under, are intercepting this vital
fluid, which it is very probable we were intended to utilize more than
we do. The conception and realization of this truth make us pine for
the nomadic life of the travelling Israelites and Arabians, because we
are sick at heart in view of the fact of increasing deaths from consump-
tion with increasing civilization.
High-altitude experience goes towards strengthening the common-
sense idea of the consumptive's course everywhere, which is in favor of
an out-door life. The continued mediumship of the human body between
the negative ground and the positive air, whether a man is on foot or on
horseback, is a constant renewal of his vitality. Here is a secret of the
great utility of camping out and “roughing it” in dry, elevated coun-
tries. You lie down to sleep, as only a tired camper-out can, on the
ground, and get up in the morning from your negative electric bed to
stretch yourself in the positive electric air. I have yet to meet with the
experience which will dissuade me from always giving the advice to
consumptives to live in the open air and sleep on the ground, whenever
conditions are favorable for so doing.
According to records in the Signal Service office at Denver, there have been only
thirteen days since January 1, 1873 (to August, 1876), in which the sun has been invisible
the whole day.
IN FLU E N C E O F HIG EI A. L TITU DES ON PHT HIS IS . 403
Dr. James Henry Bennet, whose personal experience with phthisical
invalids entitles his opinion to great consideration, thus emphasizes the
importance of defective vital or nervous power as a cause of pulmonary
Consumption, which cause even underlies “the most minute anatomical
and histological researches.” “Clinical observation shows that the
manifestation of these forms of lung disease, chronic and acute, must
be looked upon as the evidence and result of a serious, perhaps final,
diminution of vital or nervous energy. . . . . Unless the vitality of the
individual can be roused, the morbid condition will surely progress, and
life will be extinguished sooner or later, according to the state of the
constitution of the patient, and to the type of the disease.” Without de-
laying to add much corroborative proof at hand of the soundness of this
conclusion (more especially the influence of inheritance), we can imme-
diately draw the inference, which is abundantly substantiated by experi-
ence, that the increased electrical influence of high-altitude atmosphere
is one of our most important aids in the successful battle against con-
sumption.”
Ozone.—As to ozone, reliable deductions cannot be drawn from ex-
periments made, because of the many liabilities to error with Schönbein’s
test, which was used—the starch and iodide of potassium paper—and
especially one element of error which is liable to be increased in high
altitudes, namely, the decided dryness of the air. But from the tests
which I have had made on the western plains and in the mountains, the
usual increase of ozone in the mountains is shown, while on the plains
there is a good proportion, considering the lack of moisture and distance
from the Sea. A variation in the amounts observed may, I think, serve
as a profitable indication of the special advantage of living in the moun-
tains during the heat of summer. It is this, that the excess noted dur-
ing the spring months on the plains, came proportionately later in the
season the higher up the observations were made. This utility of going
into the still higher regions in summer is in consonance with the in-
creased benefit of the cooler temperature which we have already shown
elevation insures.
Winds.--While not much can be said of the winds of high altitudes,
independent of local peculiarities, yet two general facts may be men-
tioned, which will not be considered detrimental to elevated climates in
view of the generally admitted healthful influence of a moderate amount
of wind. The total movement of the air at nearly all exposed high alti-
tudes, is of course greater than that at similar places in the lowlands,
yet not nearly so much greater for many points as would generally be
expected. As I have elsewhere explained,” the total movement of air,"
and the number of observations of wind direction, as to winds which
are usually mild and bring pleasant weather,” for some elevated stations
as at Denver, Colorado, compare most favorably, for mildness of results,
with the records of low altitude stations. The winds of high altitudes
being less diverted from their general course, their indication as to the
* Pulmonary Consumption. By James Henry Bennet, M.D., 2d ed., p. 16.
* Some further remarks by the author on this subject may be found in The Archives of
Electrology and Neurology, for November, 1874. “The Influence of the Climate of Colo-
rado on the Nervous System.”
* “The Winds of Colorado.” Report to the Colorado State Medical Society, 1876.
* Plate X. “Total movement of air, with resultants.” Statistical Atlas of U.S. from
ninth census, 1870. By F. A. Walker, M.A., 1874.
* Annual Reports of the Chief Signal Officer, U. S. A.
404 DENIS ON,
character of weather is more constant than at most low stations, and es-
pecially is this the case of inland localities. For instance, according to
excellent charts, in the Annual Report of the Signal Service Bureau for
1876, giving wind directions which are most, and those which are least
likely to be followed by rain, the indications are very strong for Northern
and Eastern Colorado, and Southeastern Wyoming (Denver and Chey-
enne), that the south, Southwest, and west winds bring pleasant weather,
while their opposites, the north, northeast, and east, bring most of the
rainy weather." In Eastern New Mexico (Santa Fé), nearly the opposite
rule holds good; the northwest, north, and northeast winds bringing
pleasant weather, while the southeast, south, and southwest winds bring
most of the rain. The damp atmosphere comes in both cases from be-
low—the Missouri valley and the Gulf of Mexico—while the dry, warm
air comes from over the mountains, which have acted as condensers.
This is proved by the records of the Pike's Peak station, where the rain-
bearing winds are the above-mentioned dry winds on the plains, and
the pleasant weather winds are the rainy winds on the plains.” Another
point is that winds of high altitudes, while they have the same influence
in purifying the air, have proportionately less force, rapidity being the
same, according to the lessened weight of the air due to elevation. It
is to be mentioned, however, that in desirable dry regions, as the East-
ern Rocky Mountain slope, and especially where the adobe soil of New
Mexico, Southern Colorado, and Western Texas, exists, the dust storms
which strong winds raise are a disagreeable element, to be avoided for
the time being by those having weak or diseased lungs.
Altitude.—The physiological effects of high altitude on man are well
understood when we consider the lessened pressure of the air which
obtains at a given elevation. Reckoning the superficial area of a man's
body as sixteen square feet, and the pressure to the square inch as three
pounds less at the base of the Rocky Mountains (6000 feet), than at sea
level, we have this surface relieved of the enormous weight of nearly
7000 pounds. With these figures in our minds, we are struck with the
wonderful adaptability of the normal human organism to changes in
atmospheric pressure, when the limit of danger lies in an atmosphere
almost twice rarefied on the one hand, and five times condensed on the
other.” But when we go further, and learn that Lieberkühn” has com-
puted the area of respiratory surface in both lungs of man to be 1400
square feet, which Dalton avers is not exaggerated,” we find a subtraction
of pressure from those organs which is truly wonderful, even for an
elevation of one mile. The respiratory organs, then, are those which are
chiefly influenced by the lessened atmospheric pressure, the effect on other
organs being mainly secondary to the induced activity of respiration.
Let us analyze the modus operandi of this phenomenon. The proportions
of oxygen, nitrogen and carbonic acid, to each other, do not vary greatly
for habitable elevations. There is then a fifth less oxygen in a given
1 See tables of winds in “The Winds of Colorado,” just mentioned.
* This evidence seems to be opposed to an explanation of sudden changes in temperature
in New Mexico, given by Dr. Gardner as “depending on whether the wind blows from the
dry, parched plains of Texas, or from the snow-crowned summits of the Rocky Mountains.”
“Diseases peculiar to Mountainous Regions.” By W. H. Gardner, M.D., U. S. A., Post-
Surgeon, Ft. Union, N. M. (Am. Journ. of Med. Sciences, July, 1876).
* Parkes's Practical Hygiene, 4th ed., p. 409.
* Simon's Chemistry of Man. Phila. ed., 1846, p. 109.
* Human Physiology. By J. C. Dalton, M.D., 3d ed., p. 236.
IN FLU E N C E OF H IG H A L TITU DES ON PHT HIS IS . 405
space of air a fifth rarefied, as at 6000 feet, and the lungs must inspire a
fifth more air to get the same amount of oxygen. This is favored, first,
by quickened respiration, which as well as the coincident increased
activity of the heart is best shown in aeronauts, who make no muscular
exertion as they rise." Dr. Vacher says that M. Gaston Tessandier, the
surviving aeronaut on the Zenith, gave him the record of his respirations
as 26, at 5300 metres (17,331 feet), and on earth 19 to 23 per minute.
Dr. Vacher himself, when he went to investigate the wondrous effect of
the winter air cure (Cures d’air), at Davos, made careful estimates of his
respirations, which were 18.2 per minute at Davos, while at Paris they
were 16.6, his pulse increasing from 69 to 78 beats per minute.” As I
came to Colorado three years ago, I noted an increase in my respirations
from 20 to 30 per minute, in 24 hours, while rising 4000 feet in Western
Kansas, and an increase of the pulsations from 72 to 82.”
I thought I noticed another of the immediate effects of elevation,
which I have nowhere seen mentioned, but which may yet be of account
in studying the therapeutics of the high-altitude cure of phthisis, an
early and almost constant symptom of which disease is prolonged expira-
tion. I refer to a quicker expiration, which was as though the increased
number of respirations per minute was made up from the time given to
expiration.* As to the effect of altitude on breathing, Dr. Vacher
takes issue with Dr. Spangler, of Davos, and also with Dr. Jourdanet,
formerly of the city of Mexico, the two latter gentlemen claiming
that “the lungs supply a deficiency of oxygen by deeper and slower,”
while the former emphasizes the “more frequent” respirations. I
shall have to differ with these gentlemen on both sides—especially
with Jourdanet—saying the respirations are both deeper and more
frequent, at first the frequence, and afterward the profundity, predomi-
nating. According to Coindet, who made 1500 observations of the
frequence of respirations in French and Mexicans, they were 19.36
per minute for the French, and 20.30 for the Mexicans. The greater
depth and breadth of the lungs of inhabitants of high altitudes has
been noted by all observers who have had favorable opportunities for
testing the question. Our knowledge of the mountain Indians of the
western part of the United States, tallies with the fact noted by Jour-
danet, “that the Mexican Indians, though of medium height, have
unusually large and wide chests, quite out of proportion to their
size.” Even children, born in the Rocky Mountains, have been noticed
while yet young to have chests of unusually large capacity, and the
increased circumference of the chests of consumptives after undergoing
the high-altitude treatment, is shown in many of Prof. Weber's cases,
as well as in my own. M. Jaccound, at Saint Moritz, says there are not
only more frequent, but fuller respirations. “This circumstance brings
| Balloon Ascents; by Parkes:–
Biot and Gay-Lussac, at 9,000 feet, increase of 18 to 30 beats of the pulse.
Glaisher, at 17,000 feet, & 10 to 24 & 6 & &
Glaisher, at 24,000 feet, $ 6 24 to 31 € $ & 4
2 Op. cit.
* This record is of use, as compared with that of Dr. Vacher, who was probably in health,
to show the increased disturbance elevation favors in those whose lungs are impaired; for
at that time, ten months after pulmonary hemorrhages, my right apex and some other peri-
pheral lung tissue showed signs of being clogged with inflammatory or other products, since
happily driven away by Colorado's light air.
* Colorado as a winter resort for invalids, Chicago Med. Examiner, Jan. 15, 1874,
406 DENIS ON,
into use certain portions of the lung I call idle, because in ordinary con-
ditions they take only a small part in respiration.”
The exercise of the will makes a great difference in the frequency of
respiration, and besides, I think, the respirations in high altitudes are
more generally increased in frequency by muscular exertion than in low
countries, as any member of an Alpine club can testify. Lungs of
habituated capacity to high altitudes have little incentive to frequent
respiration when perfectly quiet, as is usual when the respirations are
counted. Dr. Jourdanet evidently expresses this opinion in furtherance
of his theory (Désoxygánation de l’air),” that the deficient oxygen inspired
at great elevations is the cause of the immunity from phthisis. Now as
to both fact and theory I have to differ with this noted author, in refer-
ence to the rationale of high-altitude therapeutics. So I may be excused
for quoting and commenting at length on his views as given in his “Le
Mexique et l’Amérique Tropicale,” page 295. “We have stated that
anaemia is the habitual condition of men who people great elevations,
anaemia by the imperfection of the respiratory act. If it is natural to
admit, d priori, that this anomaly may have a necessary influence upon
the beginning, nature, and progress of maladies in general, with how
much more reason must we acknowledge that the organ which presides
over the respiratory functions would feel the first influence of it? The
lungs in fact find themselves in the presence of a rarefied air, dry, and of
diminished barometrical pressure. The three conditions of rarefaction,
dryness and lightness of the atmosphere, evidently render the endosmose
of oxygen, destined to feed respiration, less easy. But if we are correct
in saying that the most natural stimulant of any organ is the element in
which it acts, we may affirm, without fear of contradiction, that the
lungs are always stimulated in a less degree upon the heights than at
the level of the sea.” After clearly showing evidences of considerable
immunity from phthisis on the Anahuac, and at other elevated stations,
he continues: “Moved by the consoling spectacle of this happy influence
of great elevations upon consumptives, I have sought a reason for it with
the view of turning this fact to a practical account. Several elements
are grouped in my mind, in the resolution of this difficult problem.
Upon one hand I am governed by an incontestable fact, already pro-
claimed as a general fact throughout this work; it is that the chronicity
of inflammatory affections is incompatible with the climate of the heights.
On the other hand, I consider the rarefaction, lightness, and dryness of
the air. The rest which results from these conditions excludes the idea
of any permanent excitation of the lungs. I consider that, in these
circumstances, the lungs find a guarantee against pulmonary phthisis,
while upon the coast, in a heavy and humid atmosphere, which oxidizes
everything with which it comes in contact, a general predisposition to a
chronic inflammatory condition favors the progress of tuberculization.
My mind is struck by the importance of these curious facts, from which
it draws the irresistible inference that an inflammatory element is neces-
sary to pulmonary tubercles, to follow out the divers phases of their
existence, etc.”
Let us briefly dissect these anomalous theories, without objecting to
the ultimate facts they are intended to explain. This “respiratory diet,”
as Jourdanet calls it—the theory which makes a deficient supply and
| La Station de Saint Moritz, p. 34.
* Dr. Vacher's Davos, Le Mont Dore, page 13.
IN FLU E N C E O F H IG H A LTITU DES ON PHT H IS IS. 407
lessened inspiration of oxygen the cause of the immunity of high alti-
tudes—takes no cognizance whatever of the adaptability of the respira-
tory function to changes in elevation. The bare mathematics by which
we get this deficit for high altitudes, which Dr. Vacher reckons is “a
daily deficiency of 139 grammes” of oxygen for an ordinary person at
Davos, throws out of consideration the existence of a pneumogastric
nerve with its reflex function to supply any lack of air, or oxygen its
vital constituent. Even if the deficiency of oxygen is not compensated
for by more frequent and deeper respirations, it is not proved that
endosmose of oxygen has any constant relation to the amount of oxygen
inspired. On the contrary, Dr. Parkes says," “in experiments on animals,
as long as the percentage of oxygen did not sink below a certain point
(14 per cent.), as much was absorbed into the blood as when the oxygen
was in a natural proportion.” This, too, is in addition to any augmented
respiration due to elevation. It is much more probable, in view of the
more perfect combustion (oxygenation) which takes place in consumptives
who move to the highlands, that this deficiency is more than compensated
for in high altitudes. As to the “anaemia by the imperfection of the
respiratory act” which “is the habitual condition of men who people
great elevations” (and so opposed to inflammation), I wish to ask, in all
candor, how long are we to continue the manufacture, in our own minds,
if not by drugs, of one disease to cure another? What, we are inclined
to exclaim, have the much vaunted theories of allopathy (antipathy') and
homoeopathy to do with this question ? Is the improved and more active
circulation of blood in the lungs (even more in them than in the capillary
circulation in other parts of the body), a condition of “anaemia” on the
heights? By no means; it is simply a condition of increased normal
activity.
Let us examine this interesting point further, especially noting the
changes in density of the respired air, while it is in the lungs. I have
already adverted to the wonderful extent of respiratory surface in the
lungs. This large area and the considerable change in atmospheric pres-
sure are two striking factors of the changed respiration due to elevation.
The mechanical effect of this lessened atmospheric pressure is what chiefly
interests us. With the atmosphere say one-fifth rarefied, the respirations
are deeper and more frequent. Then the density of the air in the lungs
during inspiration would seem to be lessened in proportion to the greater
quantity of air which has to be breathed. This increased approach to a
state of vacuum in the lungs is calculated to draw the blood quickly into
the pulmonary vessels. But expiration follows, and it is during expira-
tion that the respiratory muscles have the greater power, greater because
the muscles of expiration are in their normal condition for activity when
the thorax is distended, and the thorax is more distended, because it has
to labor with more air. I have already expressed the opinion that expi-
ration rather than inspiration is shortened by the diminished pressure of
elevation, and this fact would still further show the increased advantage
of the expiratory muscles. Then the density of the air within the lungs
is suddenly made greater than the density of that outside the body. The
blood vessels are pressed upon, and the previously augmented flow into
the lungs is driven quickly on to the left side of the heart. It is possible
that in very great changes of elevation, as in quickly climbing mountains
above 12,000 feet, or rising to an immense height in a balloon, the pul-
* Practical Hygiene, page 407.
408 DENIS ON,
monary vessels may not stand this alternate rarefaction and pressure, and
hemorrhage may result. But we are speaking now of reasonably high
altitudes, which must be considered as varying for different invalids. The
more rapid and perfect renewal of the capillary circulation in the lungs
is opposed to the stasis of blood which is an early stage of inflammation.
Not only that, but chronic hypertrophied tissue, accumulations of mucus,
epithelial débris, and the products of inflammation, are “crowded to the
wall” by this pressure, increased from within outward during expiration,
and the lung thus purified and cleansed of the results of inflammation
and morbid products in the blood, of lingering tendency, has no place for
adventitious products or the deposit of tubercle." Is this exaggerated
activity of the pulmonary vessels and tissue a condition of “anaemia,”
and is it here we find the “rest” which “excludes the idea of any perma-
nent excitation of the lungs?” “There is no rest for the weary” lung,
and in this lies its salvation. Rest is best for a broken bone, but it
offers no special antagonism to progressive degeneration of lung tissue,
even if, as is here erroneously assumed, “the lungs are always stimulated
in a less degree upon the heights than at the level of the sea.”
As to the “endosmose of oxygen” being “less easy” in high alti-
tudes, how, may I ask, if it is so, can the lungs enjoy the “rest” claimed,
whose function it is to promote the endosmose of oxygen : Is it natural
for an organ to be at rest, whose function is obstructed ? I can see no
obstacle to the endosmose of oxygen due to lessened atmospherie press-
ure; on the contrary, almost every effect of rarefaction of the air is to
complete and perfect this process. According to Dunglison, “the ra-
pidity with which endosmose is accomplished varies according to the
nature of the septum or tissue, and of the penetrating body, and to the
penetrability of the tissue.” Now, in high altitudes, the improved con-
dition of the capillary circulation, everywhere shown, but chiefly in the
lungs, the quickened flow of blood on one side of the intercepting mem-
brane, and the proportionately increased pressure and rapid renewal of
the air on the other, all combine to favor the endosmose of oxygen. It
is not then necessary for us to burden our minds with doubtful prob-
lems to understand the healthful influence of the atmosphere of high al-
titudes upon the organs of respiration. This more perfect oxygenation
and capillary circulation of the blood favors a healthy renewal of tissue,
and is constantly washing out of the system and preventing the focus-
ing of impurities or disease germs, of which the consumptive body is
ful].2
The improved respiration and circulation bring demands for increased
digestion and alimentation. Not only the lungs and heart, but the
stomach, liver, and kidneys all contribute a share of this increased labor
| Elsewhere I have given the opinion, which I have never seen mentioned by others, that
this outward pressure of the air within the lungs is chiefly what so generally cures asthma
on the elevated inland plains and mountains of America, by the power it has in stretching
the circular, muscular fibres of the smaller bronchial tubes beyond their easy contraction.
Report to American Medical Association, June, 1876, on the “Climate of Colorado, and
its relation to Pulmonary Diseases.”
* An exception should be here noted, that this purifying process may be too great a task
for the feeble remaining vital-force. Too extensive or far advanced disease in the lungs,
the system being saturated with its accumulating effects, may naturally prove too strong an
enemy for this or any other purifying process, and in the heated contest which is inaugu-
rated the victim is quickly consumed. Such has been the fate of some who have suddenly
risen to great elevations for the sake of restoration to health, when already advanced
in the last stage of consumption.
IN FLU E N C E O F H IG H A L TITU DES ON PHT HIS I S. 409
to sustain a quicker but a more perfect life. The loss of flesh in one,
and the gain in another (the latter especially for those new-comers for
whom to live “is gain”), are but the preponderance of waste and repair
over each other, which come to all with varying results.
ALTITUDE OF APPROxIMATE IMMUNITY FROM PHTHISIS.
The study of the geography of phthisis gives us an additional and re-
markable evidence of the curative influence of high altitudes. For if
a mode of life, or a locality of living, should give a large number immu-
nity from this disease, then there is the strongest inference possible that
the afflicted who could and would adopt the same manner of life or place
of abode might so far enjoy special chances of recovery. Some have
thought that an exact line of immunity from consumption could be
drawn, depending on altitude and latitude. Among these, Küchen-
meister made such close estimates as to give a rule for the altitude of
immunity in any latitude. In Switzerland it was 3000 feet, and at the
equator 9000, the difference for different latitudes in Germany being
375 feet less for each degree from south to north.”
But there are local conditions, variations in the climatic attributes we
have thus far considered, which will greatly vitiate any exact rule of
this kind. For instance, the Coast Range of the Sierra Nevada Moun-
tains, in California, which condenses much of the moisture from the con-
stant Pacific winds, and renders the high altitudes there uncongenial to
most people, would give a very different climate from that of the elevated
portions of the next range, and that in turn from the central range run-
ning through the continent. It is preferable not to try to defend any
positive law, because, if an opponent meets with an instance of the ori-
gination of some type of phthisis above the stated elevation, you have
attempted too much, and can go no further with him. It is not intended
to convey the impression that a given altitude always insures immunity,
nor that an approximate immunity may not exist at some low levels, as
is claimed for certain far northern lands, and by one M. Maydell for a
vagrant and extensive population who inhabit a steppe in Asia, said to
be one hundred feet below sea level. We know nothing further of such
localities, and are somewhat inclined to consider them like some new
gold fields, and many far-off favored localities, where “distance lends
enchantment to the view.” The argument here intended is that, if
twenty to thirty per cent. of all deaths occurring on the coast and bor-
ders of rivers are from phthisis, as on the fortieth parallel in the United
States, ten to twenty per cent. on higher ground under 1000 feet, five to
fifteen per cent. from that height to 2000 feet, two to five per cent. from
that to 4000 feet, one to two per cent. from that to 6000, and seldom a
case above that point, then the proof is conclusive enough as favoring
high altitudes as a resort for consumptives, even though a signal service
observer on the top of Pike's Peak should there suffer a lesion of the
lung which should eventuate in his death from phthisis (a most impro-
bable supposition). We speak then of an altitude of approacimate immu-
| This is too low by one or two thousand feet, according to the valuable statistics of Dr.
Lombard, of Geneva, who, Dr. C. T. Williams states, was one of the first to notice the
rarity of phthisis in the high lying habitable districts of Switzerland.
* “Die hochgelegenen Plateaus als Sanatorien für Schwindsüchtige,” von Dr. Friedrich
Küchenmeister, 1868.
410 DENISON,
nity, which, like the good attributes of high altitudes already discussed,
is found higher up as we approach the equator. And herein lies the
strongest proof imaginable, outside of the experience of a considerable
number of invalids, of the soundness of the combined arguments here
presented, in regard to the climatic attributes of high altitudes.
Drs. Weber, C. T. Williams, and Walshe have given, in valuable
works already quoted, abundant evidence from mortality records of this
gradual decrease of deaths from phthisis originating in high lands. The
corroborative evidence of these authors, with others, as Küchenmeister,
Brehmer, Lombard, Archibald Smith, Füchs, Nühry, Vacher, Spangler,
Jourdanet, Hirsch, and Guilbert, is full and explicit, but would consume
more of our time than can now be spared. In general, the altitudes of
approximate immunity are at or a little above the elevations given in the
first part of this paper for favorable high altitude climates. In America,
Dr. E. M. Wight characterizes the inhabitants of the Cumberland table-
lands as “a people without consumption,” their mode of life probably
having much to do with their immunity. Dr. Archibald Smith, who
practised medicine a long time in the Peruvian Andes, says that phthisis
was unknown above 8000 feet, “except as an exotic,” which evidence
T)r. C. T. Williams well remarks “is important, because we know that,
even up to 13,500 feet, large towns are found in that part of South Ame-
rica, such as La Paz, the capital of Bolivia, and therefore there probably
exist some of the causes specially favorable to the development of phthisis.”
In Mexico, Dr. Jourdanet places the line of immunity at 7000 feet. His
personal observation of the rarity of phthisis in the Anahuac, referred to
the cities of Puebla and Mexico, where he practised medicine respectively
two and eight years. These two cities, comprising a population of
270,000, showed a rarity of the disease, cases occurring only among the
poorly fed and scantily clothed class, or “among those natives of the
heights whom the interests of business induced to visit lower levels.”
During his ten years’ practice in Mexico, he encountered but twelve
cases of phthisis. All occurred among the indigent, a class rendered
quite numerous in Mexico by natural indolence, acquired habits, and
defect of social organization. In New Mexico, Arizona, and Utah, not
a little evidence of an altitude of immunity is shown in communications
I have had the pleasure of receiving from army surgeons who have
served at elevated stations."
| Dr. B. J. D. Irwin reports for Fort Defiance (6500 feet), Northwestern New Mexico:
“Surgeon John F. Hammond, U. S. Army, writing on the diseases of New Mexico, Rio
Grande valley, says, “Phthisis pulmonalis I have never seen in the country, except in two
instances, once in an officer of the U. S. army, and once in an American emigrant. It was
developed in each before he left the United States, and each very gradually improved.
One resided in Lucoro, and the other in El Paso Del Norte.' I can add to the foregoing
[I)r. Irwin writes] that during a service of some seven years in New Mexico and Arizona,
ranging over a region embraced between the 31st and 36th degrees of north latitude—Fort
Union, New Mexico, to Fort Buchanan, Arizona—I never saw or heard of a case of tuber-
culous disease (consumption) amongst the native inhabitants of those territories. When
I went to New Mexico, in 1855, several recruits suffering with well-marked symptoms of
pulmonary tuberculosis were sent along with the detachment destined for the troops then
serving in that region. I kept track of them after their arrival, and had the satisfaction
and pleasure of learning that they all outgrew the tendency to develop phthisis pulmonalis.”
Surgeon E. P. Wollum, from Camp Douglas, Utah, reports “In an experience of three years
and a half in Utah, I have not seen a case of consumption that originated in the territory,
and the Mormon physicians declare that no persons born in Utah——excepting Indians—
have had the disease, to their knowledge.” Among other army surgeons who have written
in corroboration of marked immunity at their stations are B. G. McPhail, Camp Apache,
IN FLU E N C E OF HIG. H. A. L TITU DES ON PHT H ISIS. 411
In Colorado, I will place the altitude of approximate immunity at 6000
feet. There are good grounds for this decision. I have made quite a
thorough canvass of the subject among the physicians of the State, and
have found but one case originating above this altitude, and that not
very well authenticated—said to have been a case of catarrhal pneumonia
of the right apex which afterward improved. Drs. T. G. Horn, of Colo-
rado Springs, and G. S. McMurtrie, of Central, with others who have
practised in the mountain districts for a considerable time, have reported
that they could furnish no cases of the kind from their experience in
Colorado. Between the elevations of 4000 and 6000 feet, however, I
have found a few cases. There have been twenty-two in all up to the
present date, occurring in the practice of physicians who have most of
them resided in Colorado several years. Let us analyze these cases, and
learn that it is greatly due to the looseness of the general term phthisis
that most of them come under this nomenclature.
Dr. H. O. Dodge, of Boulder, reports four cases from that section; two
of the patients have died, and two are not losing ground rapidly ; all
of these cases commenced with severe colds from exposure; three of the
patients probably had pneumonia, and one suppression of menses, which
has since continued : time they had lived in Colorado not stated. Dr.
Joseph Anderson, of Golden, reports a case of general tuberculosis fol-
lowing miscarriage, rapid decline, and death in four months. Also a
doubtful case of abscess following pneumonia in a young man whose
father died of phthisis, and which has resulted in apparent recovery.
Dr. Jacob Reed, Jr., of Colorado Springs, reports a case in a young man
aged 18, three years a resident of Colorado, and with very marked ten-
dency to phthisis by inheritance. Had had slight cough five months
when he received a severe injury to one lung, followed by hemorrhage
and death in one month. Dr. H. B. Tuttle, of Puebla, has seen two
cases “one a sequel to Scarlatina, and one following extreme exposure
during mrenstruation, both badly treated, both fatal.”
For the city of Denver and immediate vicinity, we have the records
of all the deaths occurring since January, 1874, two years and a quarter.
These records require information as to the origin of the disease. We
find thirteen cases recorded as originating in Colorado. They are of
“ phthisis,” “phthisis scrofulosa,” “acute phthisis supervening” as a
sequel to other diseases, etc. I have interrogated most of the physicians
who reported these cases, and find two acknowledged mistakes, in that
the disease existed before the parties came to Colorado; two rapid cases
of Cachezia Africana ; two cases of rapid decline after child-birth; a.
child one month old, whose mother died of the same disease nine days
later; a case of abscess in the base of the right lung following pneumo-
nia ; acute phthisis following pneumonia, and hip-joint disease; a case of
“whiskey consumption”; a fatal result in a very strong man, after hem-
orrhage from severe lifting ; and a case following scarlatina. Now I
cannot see that elevation offers any special antagonism to such cases;
and as to accidental lesions of the lung, causing hemorrhage, and also
acute double pneumonia, the mechanical influence of rarefied air cannot
for the time be considered otherwise than injurious ; while phthisis fol-
A. T. (“Arizona as a Health Resort for Consumptives,” Virginia Medical Monthly, De-
cember, 1874.); W. J. Wilson, Ft. Bayard, N. M.; Oscar A. Woodworth, Mesilla, N. M.;
J. V. Lauderdale, formerly stationed at Tucson, Arizona, and C. B. White, Fort Indepen-
dence, California.
412 DENIS ON,
lowing scarlet fever is not to be wondered at, in that the convalescence
from special fevers is generally noticed to be tedious in the Rocky Moun-
tain regions." g º
An additional evidence in favor of an approximate immunity due to
elevation may, I think, be gained from the low rate of mortality from
pneumonia, as well as from phthisis, as shown by our census statistics,
especially as we are coming so generally to consider phthisis as of inflam-
matory origin; it is that while high altitude increases the unfavorable-
ness of the prognosis of acute pneumonia, the ratio of deaths from the
disease in the Rocky Mountain states and territories is greatly lessened,
showing that there must have been few cases of pneumonia there to
have passed into chronic disease.
ExPERIENCE.
The crowning argument in favor of high altitudes should be the care-
fully recorded results of the extended sojourn in elevated climates of a
good number of consumptives, representing the various types and stages
of the disease. In presenting the following table of the records of such
of my cases as have been kept under observation more than two or three
months during my three years’ practice in Denver, it seems to me the
shortness of the time is greatly compensated for by only recording
the results during the patients’ stay in Colorado. It is to be noted
that the results, after patients left the high altitude, were generally
unfavorable. Those patients who had to be sent away immediately,
and those who were not kept under observation two or more months,
are excluded from the table, which includes all the other uncompli-
cated cases of phthisis I have recorded. Three only of the patients
had been in Colorado longer than three years, the time of observation
specified, while six were in the State the shortest time, namely two
months. The period of sickness previous to coming to Colorado, dating
back to a persistent cough, pulmonary hemorrhage, haemoptysis, or evi-
dent cause, varied from two months to seven years. Some had resorted to
other climates (low altitudes) without benefit. Quite the usual amount
of inheritance, in some cases the most decided in my experience, existed
in these cases.
Almost all types of phthisis are included, the classification as to the
Nature of Disease being quite general, and only of account as indicating
the usually more favorable prognosis for inflammatory than for chronic
tuberculous cases. As to the Stage of Disease, I have endeavored to make
close diagnoses, and may have put some cases in the third stage which
other physicians would have placed in the second. However, the second
stage, in my opinion, does not amount to much in high altitudes, and
for practical purposes may as well be considered with the third. If
lung tissue has become useless, and “softening” commenced, “excava-
tion” is not far off, with the expansion of the lungs due to elevation.
That such a transition is necessarily a part of the high altitude treat-
ment in consumptives So far advanced, will not appear strange to the
reflective mind; though its expediency in some acute cases may well be
! I have known a case of catarrhal and another of chronic pneumonia, contracted in Den-
ver, in negroes who subsequently recovered, but who would undoubtedly have died from
phthisis had they been sick in the East.
IN FLU E N C E OF HII G. H. A. L TITU DES ON PHT HIS IS . 413
doubted. This positive character of the rarefied air prescription leads
me to differ as to part of Dr. C. T. Williams's classification. I refer par-
ticularly to the “stationary” cases which include a good number of his
patients. With the healthful respiratory quickening of high altitudes,
the lungs are either not equal to the strain, or they improve under the
exercise. I prefer to designate the apparently “stationary” cases of
advanced phthisis by what sometimes occurs in them, namely, an exten-
sion of excavation, while the resistance of the system to the general
effects of the disease is favored by the healthful surrounding influences.
As to whether this table represents the average severity of the phthi-
sical patients who seek relief in Colorado, there is a pro and con to the
question, with a preponderance of evidence in favor of its representing
more than the average severity. Invalids whose disease is uncompli-
cated, and with whom the benefit is immediate and continuous, after
their arrival in Colorado, do not, generally, consult physicians there.
A proportion of such cases, including many I know to have improved,
but of which I have no record of examination, are, of course, not in-
cluded in the accompanying table. For instance, in the Pullman car in
which I left Denver, to come to this Congress, there were four returning
health-seekers—three ladies and one gentleman—three of whom went to
Colorado in the first stage of phthisis, and the other in the second or
third; all of them apparently now enjoy a complete arrest of the disease,
and none of them employed a physician in Colorado. On the other hand,
a few months after my arrival in Colorado, I wrote an article dis-
couraging the sending there of consumptives with unfavorable complica-
tions, after the stage of softening, those affected with heart lesions, etc.,
and I am pleased to say that my professional friends in the States have
seldom recommended such cases to me. However, the cases are severe
enough taken as they are, and I am agreeably surprised with the pro-
gress of several having more or less excavation.
* Chicago Medical Examiner, January 15, 1874.
414
DENIS ON,
TABLE VI.—Phthisis in Colorado.
Analysis of 69 years, 2 months, spent by 66 consumptives in Colorado, with results.

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ST A G E OF T IS E A S E O N
COM I N G TO CO LOR A-
D O— |
y, In, |y. Im. y. m. y. Im.
1st stage (deposit). . . . . 25 34 8. 1 4}| 3 || 34 7 || 1 4; 17 | 7 |.... [... 24 1 1 | 15
2d stage (softening)... 11 || 14 4| 1 3}| 3 || 10 11 || 1 2 4 2 2 | 1 8 || 3 |. . . . . ; 4
3d stage (excavation)|| 30 || 69 10 2 4 5 23 8 9}| 5 || 5 8 || 10 || 2 | 18 12 5 2 || 13
Total . . . . . . . . . . . ... 66 his 10]. . . . . . 11 | 69 2 | . . . . . . 24 16 || 10 | 12 4 50 | 16 || 6 || 3 || 32
— *sºme — —
A GE WHEN THEY CAME
TO COLOR ADO-
Under 20.............] 3 || 4 9| 1 7 I 5 4 || 1 9 |.. 1 |.... 2 | . . . 1 || 2 |....'.... 1
20 to 30 .............. 40 | 68 6 1 8}| 6 || 47 3 || 1 2 17 | 8 || 7 || 5 || 3 || 32 || 8 2 1 22
30 to 40 . . . . . . . . . . . . . . . .18 20 3| 1 7#| 4 || 11 6 7#| 7 || 4 || 2 || 4 || 1 || 13 || 5 || 3 || 2 7
40 and over . . . . . . . . . . 5 | 16 4| 3 3 | . . . . . . 5 1 || 1 , |....| 3 || 1 || 1 |' 4 || 1 || 1 2
— —————————
Total . . . . . . . . . . . . 66 118 10! . . . . . . 11 || 69 a tº e s e º g 2 || || 0 12 4 * 16 3 ||3:
- | :
* ———— —
N ATU R E OF DISE ASE—
Inflammatory
(Pueumonic, etc.)... 25 || 25 1 3 23 7 114 | 15 5 1. 2 2 21 4 1 1 | 11
Catarrhal. . . . . . . . . . . . 11 | 12 5| 1 1%| 2 9 2 10 || 3 || 2 || 4 2 | . . . 9 || 2 || 2 || 1 6
Chronic tuberculosis. 30 81 5| 2 8#. 6 36 5 || 1 2;| 6 9 5 8 2 20 10 3 1 | 15
f |
Total . . . . . . . . . . . . | 66 his lo e s & tº is tº 11 | 69 2 |...... 24 16 10 12 4 50 16 || 6 || 3 || 32
FI E MOR R H A G H C C A.S.E.S.–
No.
Hemorrhage or hacmoptysis before coming to Colorado,
probably without cavity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 10 4 || 1 & 15 |.... 1 10
Ditto, probably With cavity... . . . . . . . . . . . . . . . . . . . . . . . . . 6 |.. 1 | 1 || 4 2 || 4 || 1 || 1 || 3
|
Hemorrhage or haemoptysis before and after coming
to Colorado, Without cavity. . . . . . . . . . . . . . . . . . . . . . . . . . 1 | . . . . . . . . . . . . . * 1 |.. I * e
Pitto, with cavity............................. © º º º ſº e º º 5 || 1 || 1 1 || 2 3 || 2 |.. 2
Hemorrhage or haemoptysis after, and not before, with-
out cavity. . . . . . . . . . . . . . . . . . . . e tº e e s e º º • * e º s & tº e º ºs e e s is I 1 * @ I tº e tº º 1
Ditto, with cavity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 |.. 1 I 1 | 1 |........ 1
Total. . . . . . . . . . . . . . . . . . . . . . . . * * * * * * * * * * * * * * = e g º e s e a 30 | 11 || 8 3 I 22 s 2 1 || 17
—— —
Hemorrhage or haemoptysis after leaving high altitude. 4 I 1 2 2 2 2 *

Both lungs affected, 38. Males, 54. Females, 12.
3 for heart disease, 1 irritable cavity, 3 far advanced. Became worse by going to lower
level, 9
Sent away to lower altitude, 7:
IN FLU E N C E OF H IG. H. A. L TITU DES ON PHT HIS IS. 415
Of these analyses, that in reference to the stage of the disease is first
and most important. The twenty-five first stage cases were 38 per cent.
of the whole, and they averaged over a year and a third under observa-
tion in Colorado. Of these, 68 per cent. (17) were much improved or
cured, 28 per cent. (7) gained slight improvement, and 4 per cent. (1) died.
Of the one unfavorable case, an explanation is needed. A beautiful
young lady, age twenty, came to Denver in July, 1875, having chronic
laryngeal phthisis with complete aphonia, which had been coming on
two and a half years; loss of weight, strength, and appetite, increased of
late. Dyspnoea increased, and catamenia absent three months. Grand-
father, father, brother, and aunt and uncle, died of consumption, and
brothers and sisters living, not strong. Dullness with pleuritic adhesions
at base of right lung, and deposit, which I believed to be of true tuber-
cle, at left apex. Slight improvement during the fall. Afterwards she
went to live on a ranche, by my advice, with instructions not to mind
the loss of voice, but to gain in general strength. Gained seven pounds
in two or three months. In February, she followed the meddlesome
advice of somebody, and submitted to “throat treatment” from a man
who claimed to be a physician, in a neighboring town. The local appli-
cation of a sixty grain solution of nitrate of silver was a sample of the
treatment under which this delicate creature lost thirteen pounds in less
than a month. In two months more she died of acute phthisis. I regret
exceedingly to have my list marred by such malpractice. Sixty per cent.
(15) of these cases are now living in Colorado.
The cases of the second and third stages include a variety, the second
embracing several acute, and the third some extremely chronic or pro-
longed third stage cases. Of the 17 per cent. (11 patients) who were in
the second stage, averaging one year under observation, 18 per cent. (2)
were much improved ; 36 per cent. (4) slightly improved ; 18 per cent.
(2) had slight local extension, with general tolerance of the disease; in
18 per cent. (2) the disease extended and advanced ; and 9 per cent. (1)
died in Colorado—or 73 per cent. (8) improved or tolerated the disease, and
27 per cent. (3) became worse or died. Of the 45 per cent. (30 patients)
who came to Colorado in the third stage, averaging nine and a half
months under observation, 17 per cent. (5) were much improved, 17 per
cent. (5) slightly improved, 27 per cent. (8) had slight local extension
with general tolerance of disease; in 33 per cent, (10) there was exten-
sion and advance, and 7 per cent. (2) died in Colorado—or 60 per cent.
(18) improved or disease tolerated, and 40 per cent. (12) worse or died.
Of the whole sixty-six patients, 17 per cent. (11) were lost sight of after
they had been under observation two or more months; 37 per cent. (24)
were much improved ; (24) per cent. (16) slightly improved ; 15 per cent.
(10) experienced slight local extension but tolerated the disease. In 18
per cent. (12), there was extension and advance; and 6 per cent. (4) died
in Colorado—or 76 per cent. (50) improved and tolerated the disease; 24
per cent. (16) became worse or died ; 48.5 per cent. (32) now reside in
Colorado. Thus is shown by evidence, which is abundantly conclusive,
the salutary influence of the elevated plains in Colorado upon phthisis—
a disease eminently progressive in character. Thus too is shown, what
those who live in Colorado have all along believed, namely, that the
first or primary stage is pre-eminently the remedial period for high
altitudes.
As to age, we find 4 per cent. (3 patients) under 20 years old when
they came to Colorado, of whom one was the most remarkable example
416 DENIS ON,
of inheritance I have ever met ; the little fellow weighing two and one-
half pounds at birth, and seventeen pounds when four years old, at which
time he came to Colorado. His father died of phthisis two months be-
fore he was born ; his mother had been subject to a chronic cough ; and
five of her family and six of the father's had died of consumption, with
evidence of its existence in the preceding generations. This case comes
under the head of chronic first-stage, and the duration is estimated as
since birth. The child has been in Colorado four years with gradual
improvement. The other two cases under 20 were advanced acute cases.
T}oth became worse, and were advised to leave. Sixty-one per cent. (40
patients) were between the ages of 20 and 30, of whom 42.5 per cent. (17)
were much improved; 20 per cent. (8) slightly improved ; 17.5 per cent.
(7) experienced slight local extension with general tolerance of the dis-
ease; in 12.5 per cent. (5) the disease was extended and advanced ; and
7.5 per cent. (3) died in Colorado—or 80 per cent. (32) were improved or
tolerated the disease; and 20 per cent. (8) became worse or died ; 55 per
cent. (22) now live in Colorado. Between the ages of 30 and 40, 27 per
cent. of the whole (18), resulted as follows: 40 per cent. (7) much im-
proved ; 22 per cent. (4) slight improvement; 11 per cent. (2) come under
the head of slight local extension with general tolerance of disease ; 22
per cent. (4) extension and advance; and 5 per cent. (1) died in Colorado;
72 per cent. (13) improved or tolerated the disease; and 28 per cent. (5)
became worse or died. Of the 8 per cent. (5) over 40 years old, 60 per
cent. (3) were slightly improved, none being much so ; 20 per cent. (1)
came under the head of slight local extension, with general tolerance of
disease; and 20 per cent. (1) under that of extension and advance; or 80
per cent. (4) improved or tolerated disease ; and 20 per cent. (1) worse or
died. Thus is shown (as would be more clearly indicated if the first-
stage cases were excluded) the less favorable influence of elevation upon
young persons with acute phthisis, and upon old persons with chronic
phthisis, inasmuch as all but one of those over 40 years of age, were of
this latter character.
When we come to analyze the nature of the cases, we find 38 per
cent. (25) which may be classed as essentially inflammatory; of these 25
patients, 60 per cent. (15) were much improved ; 20 per cent. (5) under-
went slight improvement; in 4 per cent. (1) there was slight extension
and tolerance; 8 per cent. (2) advanced ; and 8 per cent. (2) died in Colo-
rado—or 84 per cent. (21) improved or tolerated the disease; and 16 per
cent. (4) grew worse or died, three of the four cases being examples of acute
cheesy pneumonia. The catarrhal group, 17 per cent. (11 patients), included
several in the second and third stages of the disease, and resulted in 28
per cent. (3), being much improved ; 18 per cent. (2) slightly improved ;
36 per cent. (4) undergoing extension with tolerance; and 18 per cent.
(2) advancing—or 88 per cent. (9) being improved or tolerating the dis-
ease; and 18 per cent. (2) becoming worse or dying. The third division,
chronic tuberculous, naturally embracing many of the third-stage cases,
formed 45 per cent. of the whole (30 patients), and resulted in 20 per
cent. (6) being much improved; 30 per cent. (9) slightly improved; 17
per cent. (5) undergoing extension with tolerance; 26.6 per cent. (8) ad-
vancing; and 6.6 per cent. (2) dying in Colorado—or 77 per cent. (20) being
improved or tolerating the disease; and 33 per cent. (10) becoming worse
or dying. Excluding the acute and far advanced cases, this analysis
shows in a remarkable degree the more favorable influence of the climate
IN FIL U E N C E O F H IG H A LTITU DES ON PH THIS IS . 417
upon inflammatory than upon catarrhal, and upon the latter, than upon
chronic tuberculous cases.
It is useful to study the hemorrhagic cases, and to learn what influence
elevation has upon this class. Believing that the pulmonary hemorrhages
seemingly caused by elevation, which have lately been written about,'
have been mainly from cavities, I have arranged the 30 cases (45 per
cent.) which are known to have been attended by hemorrhage or haemop-
tysis, at any time, with reference to the existence or absence of excava-
tion. Seventy per cent. (21 patients) had hemorrhage or haemoptysis
before coming to Colorado; of these, 71 per cent. (15) were probably with-
out cavity and favorably affected, while 20 per cent. (6) were robably
with cavity—four coming under the head of “extension and advance.”
Six patients had hemorrhages both before and after coming to Colorado,
five of whom had cavities when they arrived. One patient, subject to
repeated hemorrhages before coming, which were much mitigated by a
residence in Colorado, subsequently died from metastasis of the disease
to the brain, which, by the way, is not a strange occurrence, considering
the special influence of the climate upon the respiratory functions. Three
had hemorrhage after and not before coming to Colorado. In reference
to these three patients, it is well to explain that one with probably no cavity
had heart disease and complete hepatization of the right lung—at best a
most unfavorable subject for high altitudes. Another had slight haemop-
tysis from a cavity while going over the divide; a third, with probable
cavity, had hemorrhage, following a chill caused by extraordinary exposure
in a storm, and all were evidently little injured by the hemorrhages. On
the other hand, four of these 30 hemorrhagic patients had hemorrhage
on going to lower levels, three of them being much injured thereby, and
two probably dying in consequence. The synopsis of hemorrhagic cases
shows a decidedly favorable effect of the elevated climate upon such
patients as had had previous hemorrhage without cavity, while a some-
what less favorable effect can be inferred upon hemorrhagic patients with
cavity than upon the general average of those with excavation. There-
fore, the advantages of high altitudes are pre-eminently for hemorrhagic
cases in the first stage, while hemorrhagic cases with excavation should
be interdicted from going to great heights.
It would be instructive to compare these results with those in other
climates, but we have none at hand so recorded as to furnish very definite
conclusions. However, allowing for the absence of similar data in the
records of others, the table may be considered as a favorable one, especi-
ally for cases in the early stage of phthisis. It is difficult to compare it
with Dr. C. T. Williams's records of English and continental resorts,
because, in his analyses, those patients who died during the time of obser-
vation do not appear to have been included in the estimate. We are
only told that “since the climatic treatment 45 of the 243 patients (who
spent 386 winters in English stations) have died.” Really it would
seem to be an important inquiry whether any died during the climatic
treatment.
There is strong evidence in favor of high altitudes to be inferred from
the experience of Prof. Austin Flint, Sr., who draws conclusions from
| Some Remarks on Diseases peculiar to Mountainous Regions. By W. H. Gardner,
M.D., U.S.A., Am. Journal of the Med. Sciences, July, 1876.
* Lecture II., Lettsomian Lectures.
* “Phthisis,” by Austin Flint, M.D., p. 239.
27
418 DEN IS ON,
his analysis of 670 cases of consumption, being all he has recorded, but
not all those in which he has been consulted. For though he has not
kept records of cases for the past eight or ten years, he says, “I should not
have omitted to make records of cases of arrested phthisis coming under
my observation.” With this explanation, he continues, “seventy-five
cases must be nearly all in which I have known an arrest of phthisis to
take place, either with or without complete recovery, during a practice
of thirty-eight years.” Now, though there is no analysis of these 670
cases in reference to altitude, several are mentioned, especially among
these instances of arrested phthisis, which may be said to have received
the special benefit of elevation. Among his patients were several who
resorted to the Adirondacks with benefit ; seventeen who went to Min-
nesota, and were, with four exceptions, cured or benefited while there;
one who went to the Peruvian Andes and was cured; and one who passed
eleven weeks in New Mexico with decided improvement while he re-
mained. Since, on the one hand, there is no evidence produced against
high altitudes, and, on the other, so few of those patients who resorted
to elevated stations for relief, we are compelled to present the latter fact
as the only excuse for Dr. Flint's giving high altitude almost no considera-
tion, and for his arriving at the conclusion “that the benefit derived from
the change of climate is due, not so much to a climatic influence per se,
as to the circumstances incidental to the change.” I shall be the last to
take issue with this renowned author, or any one else, as to the import-
ance of out-door life and change of occupation; all the most useful means
we can combine will not be more than enough to make the consumptive
multitude reasonably healthy. Sometimes, by unfavorable cases, the
physician is impelled to agree with Pope, that—
“As man, perhaps, the moment of his breath
Receives the lurking principle of death;
The young disease, that must subdue at length,
Grows with his growth and strengthens with his strength.”
Accepting Dr. Flint's collection of cases of arrested phthisis as the
largest, or one of the largest, that can be made from the experience of
any one man in America, the results of the few cases I have presented
must be admitted as an argument in favor of high altitude, in that the
ratio of improvement is greater, although covering a shorter period of
observation. From my every day experience among the people of
Colorado, I am led to believe that as many cases of arrested phthisis
(75) could now be found among any average collection of 5000 people at
the base of the Rocky Mountains.
One further result of my analysis should not be omitted, so important
is its bearing upon the time invalids should remain in high altitudes.
The facts noted are that of six patients who have died after leaving the
elevation, fatality thereby has evidently been hastened in three; that four
of the hemorrhagic patients (a large proportion of those who left the
heights) had hemorrhage afterward; and that nearly half (9) of all those
who went back to the lowlands, became worse by so doing. Prof.
Weber's cases furnish similar evidence: of thirteen cases arrested in
high altitudes, two were twice relieved, the disease twice returning on
going down to sea level. In six other cases phthisis was rekindled after
a descent to sea level; and two patients, who were residents of high alti-
tudes, moved to the lowlands and became consumptive, were apparently
I N F I, U E N C E OF H IG H A L TITU D ES ON PHT H IS IS . 419
cured on returning to the highlands, and were again taken sick when
they returned to sea level."
Jourdanet, among many striking illustrations of a failing or falling
off of consumptives after leaving the heights, mentions the case of a
young lady who three times went down to a lower level with a return
of active phthisis, and three times, in turn, was decidedly relieved by a
return to Puebla. Dr. C. T. Williams mentions almost as remarkable an
instance of this loss of benefit by the return to low levels. Three of my
:ases show, in a marked degree, the injurious effect of going from Colorado
to Southern California; one patient, in the third stage of the disease,
died in two months after leaving the high altitude, and one in the second
stage, in the vicinity of San Diego, lost ten pounds, had five hemorrhages,
advanced to the third stage, succeeded in getting back to Colorado, and
has improved since. A third patient, in the first stage, was one of six young
men, four of whom, I believe, were consumptive, who went to Southern
California under the restless impulse which often controls such persons.
This young man, with two others of his party, were made perceptibly
worse by their sojourn in California, and returned quickly to Colorado,
considerably disgusted by their experience in the humid air of the Pacific
slope. All of these patients were doing well enough in Colorado, and
most of them assumed the responsibility of going to lower levels contrary to
advice. As Jourdanet expresses it: “I preserve among my notes a great
number of examples of the relief of the malady and of the obstimacy of
the invalids in returning prematurely to the climate which kills them.”
And in reference to those who have returned to a lower altitude, he adds:
“I often ask myself if actual residence would not have finally vanquished
the malady, which a few months’ stay had relieved.” By inference, I
think, an argument might be drawn from the analogous experience of
those gymnasts and athletes who abandon their accustomed exercise and
so render their lungs liable to disease from lack of use; for we are all
the time speaking in favor of healthful respiratory activity as opposed
to the rest which is so desirable in the treatment of most diseases. Such
is the experience which leads to the conclusion that a partial recovery
necessitates a permanent residence. This statement carries with it the
idea, consonant with experience, that complete recovery does not necessi-
tate permanent residence, so that the time invalids should consider it
imperative to remain in high altitudes is less for incipient or first-stage
cases, in which complete recovery may be expected to occur.
Gathering from these arguments the conclusions which may serve as
a guide to the physician in staying the progress of phthisis, many obsta-
cles to successful work may be suggested. Among them, after the
hindrances to the patients’ following the most useful combination of
measures prescribed, comes a difficulty in early arriving at a correct
diagnosis of the existence of the disease. It is referable to ignorance
and neglect on the part of the invalid, and, I fear, too often to inade-
quate knowledge on the part of the physician. Often I find the invalid's.
assertion that his indisposition is slight, that his doctor has examined
him and said so, unverified by a correct and careful examination. The
previous existence of dyspnoea, night-sweats, loss of strength and weight,
are not belied in the real condition of the lungs. We must accept the
conclusion which is inevitable, in view of physicians so often differing
from each other, as they do, in opinion, that the discovery or invention
| Op. cit. * Op. cit., p. 304.
420 -- D ENIS ON .
of new means of physical diagnosis, and the thorough teaching of this
branch in medical schools, should be earnestly encouraged by the medical
profession.
The conclusions of my prolonged, and I fear too tedious, study, I have
embodied in the following deductions, in which I respectfully ask your
COI). CUll’I’ell CG ...—
I. Cool and dry, are better than warm and moist, climates.
II. The most favorable climatic attributes of low altitudes, especially
the diathermancy and dryness of the air, are increasingly found with
increasing elevation.
III. The favorable or positive influence of high altitude upon the pro-
gress of phthisis is best shown in the incipiency of chronic, inflammatory,
and hemorrhagic cases; and in others in proportion as these characteris-
tics exist, the more acute the inflammatory process, or the more active
the pulmonary hemorrhage, the more gradual and tentative should be
the rise in elevation.
IV. Partial recovery necessitates a permanent residence, which is
therefore required either in an advanced stage of the disease, or when
the recovery has been incomplete.
V. The unfavorable or negative influence of high altitude upon the
progress of phthisis, is mainly seen in proportion as the disease approaches
or is complicated with the following conditions: First, cardiac disease,
if associated with increased labor and abnormal activity of the heart.
Second, the stage of softening, in acute cases, associated with extensive
deposit, or with an irritable, nervous state, and lack of desirable will
power aided by the stimulus and hope of youth.
VI. The generally admitted rule that change of climate and mode of
life is favorable to the cure of pulmonary consumption, in proportion to
its early adoption, is rendered more stringent in that the results are more
positive in case of a resort to high altitudes. -
VII. The stimulating effect of high altitude, associated with increased
respiratory activity and power, is opposed to the idea of rest, and con-
stitutes a most important agent in arresting chronic phthisis.
VIII. High altitude is a means of arresting phthisis independent of,
and in addition to, change of occupation and out-door life, and is worthy
to rank with such hygienic measures.
IX. Such is the importance of an early resort to high altitude, that in
incipient cases the patient should receive the benefit of the doubt, and
the physician give affirmative rather than negative advice, in view of
possibility of error in declaring the non-existence of phthisis.
X. High altitude being an important attribute of successful climatic
treatment, a resort to a well-chosen elevated climate should constitute
part of the physician’s advice to every consumptive (who can follow it)
for whom the elevation is not specially contra-indicated.
DISCUSSION ON DR. DENISON's PAPER.
After the reading of the preceding paper, Dr. THOMAS S. DUFFY, of Ruther-
fordton, N. C., said:—The paper is a very interesting one. The subject is
one of experience and observation. The matter of moisture in the atmosphere
is very important. I have known coughs, contracted during dry weather, defy
treatment, and yet disappear spontaneously when the weather became damp.
IN FLU E N C E O F H IG H A LTITU DES ON PHT H IS IS . 421
I have taken observations of the difference in temperature between mountain
and coast springs, and have found the temperature to be 60° at an altitude of
1500 feet above the sea level, and 59° on the coast. Where I live it is very
difficult to find cases of consumption. As this disease is seldom cured, we
should consider preventive rather than curative measures. Perhaps the habits
of the people of North Carolina are as efficient in creating an immunity from
consumption as the climate. North Carolinians are not in the habit of shut-
ting doors to keep out the cold, but increase the heat of their houses, and put
on more clothing instead. Going from a warm to a cold atmosphere will not
give cold, unless the person exposed has been previously exhausted by exer-
tion. It is customary for people in my State to halt while on a journey and
warm themselves, and then proceed in the cold. They do not hesitate, when
warm, to plunge into cold streams. Such an act might kill a man coming
from the harvest field, because he would be exhausted ; but where there is no
exhaustion, there is no danger.
I have been in Southern California, and have observed its climate. In the
daytime, during the dry season, there is a cloudless sky. After the sun rises,
a fog becomes so dense that objects cannot be distinguished at a distance of
twenty yards. The atmosphere is heavily laden; the roofs drip as though
rain had fallen ; vegetation is sustained without rain. It is not observed that
the fog induces consumption, but, on the contrary, the people seem compara-
tively free from it. It is a matter of doubt whether a moist atmosphere is
conducive to disease; a moist, cold atmosphere may be, but a moist, temperate
atmosphere is not.
Dr. A. S. BALDWIN, of Jacksonville, Florida, said:—I am happy to hear the
remarks of the reader of the paper upon a subject which I have studied for
thirty-eight years in my own State, as far as climate is concerned. It is doubt-
ful whether all the beneficial effects mentioned by Dr. Denison are the result
of altitude. I have witnessed the same effects in Florida, where the atmos-
pheric pressure is slightly above 30°, which is assumed to be that of the sea
level, so that it appears to be the change of climate rather than the altitude
that is so beneficial. I have seen, in a post-mortem examination, lungs studded
with obsolete tubercle, the result of disease acquired twenty or thirty years
previously, the patient’s death being caused by exposure following a debauch:
and I have known other cases of consumption, partly cured by the Florida
climate, recur when the patients have exposed themselves carelessly. Some
medical men administer oxygen as a remedy for phthisis, but I doubt whether
this is judicious. By visiting Florida, where the atmospheric pressure is so
great, the patient can get oxygen without the effort required for the same
purpose in Colorado. This would give rest; and I believe in the value of rest
for these diseases, and think that that is one of the reasons why Florida
proves so beneficial.
The rain-fall, taking the whole State, is about 51 inclies. In my section of
the State I have recorded 64 inches in one year, and 31 inches in another. It
is impossible to get the truth about the humidity of the atmosphere without
taking observations extending over a long period of years.
A sick person requires an even temperature, and we always try to keep
them from sudden changes. Experience has taught us this fact. In the ex-
cessively dry climate of the western plains there is a change of 60° between
the atmosphere of the day and that of the night; surely that is harder on a
patient than a change of but 10° or 12°. Therefore, we must have, as one of
the components of a healthy atmosphere, enough moisture in the air to pre-
vent such radiation as to produce violent changes. We have that in Florida;
we have about 14° diurnal variation throughout the year, and a difference of
only 20° in the mean temperature between summer and winter. It seems
cooler in Florida than in other places, even when the thermometer indicates
the same figures. There is no need to avoid the sun ; one can ride or walk in
it with impunity, and sunstroke is unknown.
422 DENIS ON,
Dr. HENRY GIBBONs, of San Francisco, said:—When invalids change their
location and improve in health, the benefit is attributed to the influence of the
new climate and locality, when it is more likely to be due to the mere condi-
tion of change. Removal from a better climate to a worse one often does
much good, for a time. This fact renders it very difficult to form a correct
estimate as to the best resort for consumptives. Our Opinions on this subject
are constantly changing. Twenty-five years ago it was our custom, in San
Francisco, to send consumptives to the Sandwich Islands; but we soon found
that to be a mistake. Then we fixed on other localities from which the best
reports were returned for a while, until it was discovered that they yielded no
permanent good. The climate of Santa Barbara, and of the southern portion
of California, was then selected, and every body was confident of their cura-
tive power, and hundreds of consumptives came there from all parts of the
world. But Southern California is now wearing out. To talk of “the cli-
mate” of California is a great mistake. That country has almost as great a
variety of climates as all the rest of the civilized world combined. You may
journey ten miles across a range of hills, and get from a noonday temperature.
of 65° into an atmosphere of 105°. The Pacific Ocean, along the coast, has a
temperature of 53° or 54°, winter and summer. Put the thermometer in the
bay, at the foot of the wharves in San Francisco, in July or August, at high
tide, and it will fall to these figures. Of course the superincumbent atmos-
phere has the same temperature, and this cold air comes in daily during the
summer towards moon, as soon as the sun has heated the interior. It Often
:arries with it a dense mist. This is the ocean climate, which prevails only
along the coast as far as the first highlands. or where a break in the highlands
allows the cold wind to pour through. This cold ocean wind, as it works
inland, mingles with the heated air, and forms in many localities a climate
highly agreeable and healthful. Farther in the interior, there is a glaring
sun, whose rays are never intercepted by a cloud for five or six months of the
year. Here the temperature is high by day, and the air very dry, with nights
always cool, but never cool enough for discomfort to the invalid. Dr. Denison
is mistaken in speaking of the humid climate of Southern California. At San
Diego, to which he makes reference, there is but a yearly mean of seven or
eight inches of rain. The fact is that consumptives are improved in many
climates where a permanent residence may be injurious. I am consulted habit-
ually by letter, and personally, as to the best health resort; but now, after
twenty-five years of observation and experience in California, I have ceased to
designate any locality. My advice is, to all who have strength enough, “Get
a horse or mule, and seek a climate for yourself. Ride, or lie by, as it suits
you. Eat good, nutritious food, and drink milk or cream; spend all the time
you can out of doors. If you find yourself improving decidedly at any given
point, stay there a while, if so inclined, but do not stay one hour after the
improvement ceases. Keep moving until you find the right climate and the
right place. The chances are that you will get nearly well in searching for
it.” In confirmed and advanced cases, however, my advice is to go home and
die among friends. -
Dr. A. B. STUART, of Winona, Minnesota, said:—Ten years ago I went to
Minnesota as an invalid, accompanied by a brother-in-law suffering from pul-
monary phthisis, resulting from exposure during the civil war. In two years
my brother-in-law recovered, and increased in weight from 125 pounds to 170,
and to-day does not have the appearance of a phthisical patient, though when
he came he had undoubtedly a cavity in the upper lobe of the left lung. I
have often known patients come to Minnesota in the first stages of the disease,
and remain until they have considered themselves well. Beneficial effects may
be lost, however, by staying too long. If a person is unable to take out-door
exercise, Minnesota is no place for him.
Dr. H. A. Johnson, of Chicago, said :—I have known a number of consump-
tives go to Denver, Colorado, to Florida, to the mountains of North Carolina,
IN FLU E N C E O F HIG. H. A. L TITU D E S ON PH THIS IS . 423
to Georgia, to Tennessee, and to the south of France, and come back enthusi-
astic about the beneficial effect of the change of climate. It seems that we are
all agreed as to the advantage of an open air life, exercise, not pushed so far
as to fatigue, sunshine, and good food. Dr. Denison has attempted to estab-
lish the fact that in addition to these beneficial influences there is another, viz.,
altitude. Unfortunately for the solution of the problem he has had to deal with,
altitude is connected with all these other influences. How can we separate
the influence of altitude from the rest ? I believe that in the earlier stages of
the disease, patients are benefited by going to the mountains, but, on the con-
trary, when softening has set in, when cavities exist, I believe that it is hazard-
ous for them to do so. A warm, mild climate is better then. I had about
fifty patients last winter in Florida, and they came back better; even those in
whose lungs cavities existed were better than they would have been had they
staid in Illinois. I therefore think it impossible, in our present state of
knowledge, to prove that altitude, per se, is beneficial, and will continue to
advise patients in the first stages of phthisis to go to the mountains, and in
the later stages to go to Florida or Georgia.
Dr. C. J. HARE, of London, said:—I wish, as a stranger, to thank the author
of the paper for the valuable facts therein contained on the treatment of
phthisis. I have often recommended long sea voyages, and have seen my
patients benefited thereby. I have seen patients come back marvellously im-
proved after a voyage to Australia, and an enjoyment of the wonderful climate
of Queensland. The region in which phthisis exists, gradually descends from
the centre towards the poles. In Iceland and Norway the disease is un-
known. It exists in some of the higher valleys of Switzerland, but at the
same altitude, where there is plenty of fresh air, phthisis is never found. A
winter residence in these places is good, providing the patient can take exer-
cise. To delicate patients I usually recommend a southern, genial climate.
424
ON THE TREATMENT OF SIMPLE ULCER OF THE STOMACH.
BY
M. LE DOCTEUR H. LEBERT, OF VEVEY;
FORMERLY PROFESSOR OF CI,INICAL MEDICIN E AT ZU RICH AND BRESLAU.
|TRANSLATED BY CHARLES WINSLOW DULLES, M.D.,
OF PHILADELPHIA. J
THOUGH the difficulty of treating simple chronic ulcer of the stomach
often renders our efforts futile, yet there are few diseases in which our
art can be of so much service to our patients, both as regards hygiene
and by medicinal treatment, properly so called. We must, at the outset,
consider the general indications to be met.
I. In the first place we should aid the digestive function of the diseased
stomach by selecting for it food easy of assimilation, both from its quality
and its liquid form or slight consistency, and by reducing its quantity to
that strictly necessary for the maintenance of life, whenever we are
obliged as much as possible to spare the labors of the organ. For this
purpose we must not omit to call to our aid the absorbent power of the
rectal mucous membrane to lessen by so much the work of the stomach;
and a suitably regulated diet should always be conjoined with a proper
hygiene, both physical and moral.
II. While thus diminishing the work of the affected organ we must
guard against unnecessarily fatiguing it with drugs. Since, however,
radically curative methods have been, even of late, recommended for this
disease by physicians of eminence, I shall not fail to mention them, so
as to leave to each practitioner an opportunity for free choice; but I
must avow that to this day I incline rather to the expectant method,
advising at the same time most careful symptomatic medicinal treat-
ment, in which the true physician may bring to bear all his knowledge,
his sagacity, and his desire to be of use to his fellows who suffer, or who
are threatened with actual danger.
In the first place, I shall describe the methods proposed by Trousseau,
Ziemssen, and Leube.
(1) Trousseau's plan' is as follows: The patient takes two or three
grammes of the submitrate of bismuth, an hour before meals, three times
a day for ten days, after which time the nitrate of silver is substituted,
in pills containing each one centigramme, taken three or four times a
day for five days. Then the course of bismuth is resumed for ten days,
and followed for four or five days by two daily doses of calomel of one
centigramme each. This routine is repeated again and again for three
or four months, when it is discontinued, to be resumed after a month’s
cessation. Evidently this mode of treatment is too systematic, and does
not allow for the very varied accidents which may arise and call for
modifications during its course.
(2) Ziemssen’s” method consists in the employment of an artificial
| Clinique Médicale, tome iii. p. 96.
* Ueber die Behandlung des Magengeschwiirs, Volkmann'sche Vortraege, 1871, S. 16.
SIM P L E U L C E R O F T H E S T O M A C H . 425
Carlsbad salt, composed essentially of sulphate of sodium, with a little
bicarbonate and chloride of sodium. The patient takes from eight to
sixteen grammes each morning, in water heated to 44° R., and should
have two or three stools in the course of the day, the quantity of the
salt being increased or diminished according to its laxative effect. Grad-
ually small quantities come to suffice.
(3) The method of Leube adds to that of Ziemssen the solution of
meat indicated by the author, in which hydrochloric acid in small
quantity serves to extract from the meat its nutritious principles. Un-
fortunately many patients have a repugnance to this solution, which,
moreover, does not always bear transportation to distant places. Milk
is added to the diet, with Zwieback” (or Einback); and by degrees the
patient can take a more substantial regimen of thick soups, roasted
fowls, etc.
For my part, I prefer to abstain from all radical treatment, placing in
the first rank hygiene, and in the second the treatment of symptoms.
I. Diet and Hygiene.—Absolute diet, or rather absolute absence of
food, should be enforced only exceptionally and very transiently, as after
perforation, or immediately after a violent hemorrhage. Then nutritious
enemata only should be used. In other cases patients do not bear food
well, and we are obliged to give them milk by tablespoonfuls only, every
three or four hours, until a larger quantity can be borne. Under all
these circumstances, absolute rest in bed is indispensable.
Milk Diet.—It is now half a century since Cruveilhier recommended
the use of milk as an exclusive or principal food in the treatment of
gastric ulcer, and experience has perfectly justified his plan. For my
part, I have seen from it effects often so salutary, sometimes so surprising,
that I have, from year to year, become more its partisan. Occasionally
a certain repugnance is met with on the part of patients who pretend
that they cannot take milk in any form whatever. These cases are rare,
and, on the contrary, patients are afterwards grateful to the physician for
not having allowed himself to be checked by their prejudices and objec-
tions which are often ill founded. The exclusive use of milk is, more-
over, rarely necessary for more than from six weeks to two or three
months, and by degrees other articles of food can be added to it. Milk
is sometimes better borne warm from the cow, sometimes heated, some-
times of the temperature of the room ; and iced milk can be taken by
some patients who can bear it in no other form. The quantity is increased
little by little until fifty, sixty, or one hundred grammes every three
hours are successively reached, and total quantities of a litre and a half
or two litres are taken during the day—an amount sufficient for good
nourishment. Patients who bear only thirty to forty grammes at a time,
ought to take it every two hours. At night, feeding should, if possible,
be interrupted.
Cow’s milk is the most useful kind and that generally employed. Some
patients, however, at first bear ass’s milk better. Buttermilk and curdled
milk, preferred by some, are exceptional forms. Where cow's milk of
good quality cannot be had, it may be replaced with goat's milk. Sheep's
milk, much the richest in nutritious matters, is sometimes used with
success by the owners of large flocks and by their families. At the start
! Krankheiten des Chylopoetisches Apparats, V. Ziemssen's Pathologie. Bd. vii., S. 113.
* [Zwieback is made by taking rolls, cutting them in half, and putting them into an oven
until they are brown and crisp. These are much used in Germany and Switzerland, crumbled
and soaked in some liquid article of food. Einback is simple bread or biscuit—TRANSLATOR.]
426 LEBERT,
pure milk is sometimes badly borne, especially if there is a marked
tendency to acid secretions. In such cases I add one-fourth part of lime
water, or as much bicarbonate of sodium as will cover the point of a table-
knife. Patients who at the beginning of the milk-treatment are consti-
pated should take one or two cold water enemata daily. When the
milk habit is once fairly acquired, then may be added to each cup one
or two teaspoonfuls of arrowroot or rice flour; or small quantities of
biscuit, of Zwieback, or of white bread may be taken with the milk.
Sometimes capricious stomachs—-especially in nervous and hysterical
women—bear fat substances very well. To these cream may sometimes
be allowed. They are the patients who at a later period often bear ham
and smoked or salt meat better than fowl, veal, or fillet of beef. It is
always well to mistrust the gastric caprices of hysterical women, since
their sense of veracity is often warped.
When the stomach is habituated to milk, and partially reinstated in
its digestive force, it can be accustomed by degrees to other, forms of
nourishment; to the farinaceous articles already mentioned, to beef-tea,
to Leube's solution of meat; and, better still, to good chicken or beef
broth, to which are added farinaceous substances, or small quantities of
meat very finely hashed or cut; or the yolk of an egg may be beaten in,
or some granulated gluten added—which is very nutritious because of
its azotized constituents. Milk-porridges may also be alternated with
broths.
Every one knows the great difficulty of getting good milk, especially
in large cities, at the seashore, etc. It is, therefore, necessary to have a
substitute for milk which can take its place, and be within the reach of
all purses. Many years ago I learned to appreciate, in this respect, the
excellent milk-powder (poudre lactée) of Nestle, of Vevey, which is recog-
nized as much the best substitute for milk in the nutrition of young
infants. I have likewise come to employ it much in cases of difficult
digestion and embarrassed nutrition, in the treatment of chronic diseases
of the adult, especially in that of chronic affections of the stomach, and
particularly of ulcer. Since I have lived in Vevey I have thoroughly
studied the process of manufacturing Nestle's Farina, and have been able
to satisfy myself that the milk used is of the best quality, and that the
same is true of the other ingredients, and above all of the methods and
manner of manufacture. Fresh milk is first well examined, and then
poured into the apparatus, heated by steam, and evaporated in vacuo at
a temperature which does not exceed 40°–45° C. There is, thus, simple
condensation without change of quality. The bread added to Nestle's
IFarina is made of the best wheat flour, by a plan which preserves its
gluten; and the crust alone being reduced to a very fine flour it is so
much the richer in azotized constituents. The extremely fine division of
the milk in powder, and of the flour of the crust, rich in nitrogen, greatly
adds to its digestibility.
A thousand parts of the milk-powder are found by analysis to contain
49.40 parts of water, 931.10 parts of organic matter, and 19.50 parts of
ash. The azotized constituents form 21.40 parts in 1000. By micro-
scopic examination I have found a division so minute that most of the
molecules do not exceed sºry of a millimetre in diameter, this greatly
increasing the facility of mixing with water.
For each meal ten grammes may be mixed or cooked with fifty grammes
of water, and gradually the quantity is carried up to twenty grammes
in one hundred of water, it being well to warm this mixture to 37° C.
SI M P L E U L C E R O F T H E S TO M A C H . 427
Gradually we may rise to thirty grammes in one hundred, and in place
of two or three little meals give one of a hundred grammes every three
hours, and even oftener, provided always that the preceding meal
appears to have been completely digested. I should be glad if this mode
of feeding, which has already gained an established place in the nourish-
ment of earliest infancy, could be thoroughly tested in that of diseases
of the adult. And as experimentation in such a matter is better than
trusting to any recommendation whatever, I have requested M. Monnerat,
one of the proprietors of the article, to place at the disposal of hospital
physicians the material necessary for this study; to which M. Monnerat,
who is a Syndic at Vevey, has very willingly consented. So that all my
colleagues, who would like to experiment with the lacteous powder in
pathological nutrition, may address him directly to obtain the quantity
required for complete investigation.
In continuing the progress toward a more varied regimen, the stomach
at first often bears better well-prepared mucilaginous soups of barley,
Oatmeal, etc., than broth ; to these sago or tapioca may sometimes be
added with advantage, and if, besides, they have beaten up in them the
yelk of an egg, and contain some finely divided fragments of light meat,
these soups can be made as nutritious as they are savory. When, later,
we come to allow tender and well-roasted meats, such as chicken, veal, or
beef, in small quantity, with a little white bread, it is still needful to enjoin
the patient particularly to chew solid food thoroughly, and to eat slowly.
We may now also permit a little wine, either pure or mixed with water,
at meals. A little later, fish, oysters, and game may be allowed, as well
as potatoes, green vegetables, stewed fruit, etc. Too careful a watch
can never be kept upon the quality and especially the quantity of food
taken. It is well to bear in mind constantly that a single indigestion
may undo the good effect of many weeks of prudent and well-ordered
feeding.
Tea and coffee; in small quantities, diluted with two-thirds or one-
half of milk are allowed comparatively later. The mineral water of
Bilin, or that of Vichy, will serve for some time to dilute the wine at
the principal meals. From my experience I prefer the natural water of
Bilin, in Bohemia, to that of Vichy.
When a patient has become profoundly anaemic in consequence of
violent gastric hemorrhage, there is a strong temptation to soon replace
the severely prudent regimen by a more analeptic diet—a fault which
I have often seen committed. But the more cautiously an increased
allowance of food is provided, the more surely is the patient strength-
ened.
The hygiene which accompanies the diet, ought to be conformed to
the principles announced. There must be repose of both body and mind,
and especially must the patient, after each meal, avoid every rapid or
violent movement; as capable of provoking perforation, and must even
avoid being too long in a carriage or railroad car. In regard to walking,
fatigue must be avoided, and when the patient can resume his occupa-
tion he should do so slowly and gradually. It is very essential that a
daily evacuation from the bowels should be secured, while any great
effort in the expulsion of the contents of the rectum should be avoided.
There are also some periods in this disease in which the examination of
the patient requires precautions on the part of the physician, in avoiding
all strong pressure, and all deep or prolonged palpation.
II. Symptomatic Treatment.— Pain is often advantageously combated
428 LEB ERT,
by the diet and hygiene indicated. But often, also, we cannot dispense
with sedatives; among which opium holds the first rank. The muriate
of morphia may be given in doses of one centigramme internally, or
better still, by subcutaneous injection. Sometimes suppositories of cacao
butter, containing from one to one and a half centigrammes of morphia,
may be used, or clysters of eighty to one hundred grammes of water, with
ten to twenty drops of laudanum. These as well as the bimeconate of
morphia are very soothing, but some patients bear better the extract of
opium in doses of from one to three centigrammes several times a day.
Other sedatives replace opium very imperfectly, because it acts in much
smaller doses, and is equally efficient when combined with alterative
medicines which are themselves efficacious against gastric catarrh, such
as nitate of silver in doses of one to two centigrammes, and the submi-
trate of bismuth in doses of half a gramme, or a gramme, or even more.
Brinton recommends the compound kino powder, which contains fifteen
parts of kino, four of cinnamon, and one of opium ; of this from three
to six decigrammes are given at a time. Locally, wet applications to
the epigastrium often do much good, acting by cold, if frequently re-
newed ; if left in place, as cataplasms. One or the other method is
chosen according to the effect upon the patient. Sometimes large blis-
ters, followed by endermic applications of morphia, give great relief, and
in certain rebellious cases moxa, applied to the epigastrium, have done
me good service.
Haematemesis demands, beside absolute rest, the internal use of small
pieces of ice, and its external application to the epigastrium. Among
haemostatics I place in the first rank the aqueous extract of ergot, given
every hour in doses of five centigrammes, with the addition of one centi-
gramme of extract of opium. If this fails, the solution of sesquichloride
of iron in five-drop doses, given with a mucilaginous liquid, is indicated.
In other cases we may succeed better with tannin, in doses of two or
three decigrammes, or with acetate of lead, three to five centigrammes,
with a little extract of opium added. Alum whey is a good adjuvant
draught. If the patient, exhausted by hemorrhage, is in imminent
danger of death, generous wines should be employed, with large doses of
musk, camphor, etc. When he can again take nourishment, iced milk is
much the best food, while nutritive enemata of milk and yelk of eggs,
or those of Leube, containing meat hashed fine with sweetbread, may
render good service. Enemata of the Nestle's lacteous farina, in doses of
twenty grammes to one hundred of water, repeated three times a day,
may become very useful. Iced solutions of this powder may also take
the place of milk very well, when this cannot be had of good quality.
If the patient gets better, and his appetite returns, we must oppose
too prompt a recourse to restorative diet, the consequence being often a
renewal of pain and dyspepsia. It is the same with iron, the too early
use of which does harm. We should begin with a mild preparatiou,
such as the tincture of the malate of iron, in doses of ten to twenty
drops, or the lactate or citrate of iron, and pass but very gradually
to average doses and to the stronger preparations. I often order an
effervescent ferruginous powder, made up of three grammes of the lactate
of iron, nine of tartaric acid, and twelve grammes of bicarbonate of
sodium ; to be kept in a wide-mouthed bottle, well stoppered, to avoid
moisture. The patient takes from a half to one teaspoonful in a small
wineglassful of water two or three times a day.
Dyspepsia.-The mistake of attempting to aid digestion by the help
SIM P L E U L C E R O F T H E S TO M A C H . 429
of stimulants and a tonic regimen is often committed. On the contrary,
by lessening the quantity and regulating the quality of the food, when
dyspepsia is aggravated, much better results will be obtained. And
here is applicable all that I have said about diet and hygiene. Exces-
sive acidity of the secretions, or acid fermentation, often form an obstacle
to digestion, and in such cases, whatever may be said, the alkalies and
especially the bicarbonate of sodium in doses of from one to four
grammes are indispensable. The alkaline salts of magnesium, of calcium,
and of ammonium, are less well borne in the end, whilst the bicarbonate
of sodium, if of good quality, can be taken for quite a long time. An
effervescent powder made with bismuth has often done me good service
in such cases. It is for these patients, too, that I prefer the natural
water of Bilin, as a beverage at meals, to other mineral waters of the
same kind, as Vichy, St. Galmier, Vals, etc. The water of Bilin is as
alkaline as that of Vichy, and has in it, beside, fixed carbonic acid and
sulphates. It can be drunk pure or mixed with a little Bordeaux wine.
If the bicarbonates neutralize the acids of the stomach too strongly,
the tincture of rhubarb, the extract of orange-peel, the tincture of nux
vomica, the bitter tincture," or that of quassia or calumba, modify the
secretions advantageously, and act in a more lasting manner, so that it
is well to begin their use after that of the alkalies, as soon as the stomach
is able to bear them, which is much facilitated by giving them at first
in small doses. Among the mineral water cures used methodically, I
know none better than that of Carlsbad. When patients are much
weakened I make them go through a course of two or three weeks at
Franzensbad, after a season of four or five weeks at Carlsbad, where they
must take the waters in small quantities, one to three hundred grammes
daily, avoiding also the wells that are too warm, and looking upon a
temperature of 50° C. as the highest admissible. Some patients even
derive more benefit from the use of Carlsbad water when cooled than
when at its natural heat. Anti-fermentatives, such as creosote, hypo-
sulphite of sodium, etc., have been highly praised, but have never done
me much service in this disease.
Vomiting.—Diet is the best anti-emetic, and here iced milk, aided from
time to time by swallowing small pieces of pure ice, may be very useful.
Effervescent powders with the submitrate of bismuth, a mixture of
bicarbonate of sodium with lemon-juice, iced soda-water, and Saturated
alkaline solutions prepared with lemon-juice, with the addition of small
doses of laudanum, are the best medicinal remedies in such cases. Pills
of opium, each containing one centigramme of the extract, sometimes
answer best, three or four being used in the twenty-four hours. Often
the iodide of potassium has seemed to me to stop the vomiting better
than any other means. I cause four grammes of it to be dissolved in thirty-
two grammes of bitter tincture, of which ten to twenty drops are to be
taken three times a day.
Constipation ought not to be permitted. Cold enemata and artificial
Carlsbad water are good preventives. I often direct two or three pills,
each containing five centigrammes of aloes, to be taken before going to
bed. The powder or extract of rhubarb suits better for some patients.
The essential point is to regulate the stools, without provoking either
[The author doubtless alludes to the tinctura amara of the G. P. which consists of
Fructus Aurantii Immaturi, Herbæ Centaurii, Radicis Gentianae, àā partes ii, Rhizomatis
Zedoariae, pars i, Spiritus diluti, partes xxxv.–TRANSLATOR.]
430 LEBERT,
numerous or liquid evacuations. One stool of moderate consistence daily
is enough.
The occurrence of perforation demands the most absolute rest and the
use of opium in full doses—three to six centigrammes of the extract at
first every hour, and afterwards every two hours. The treatment may
further be aided by the use of subcutaneous injections of morphia. Abso-
lute diet should be enjoined, and ice may be applied to the epigastrium.
This mode of treatment has already proved successful in some cases of
this accident, which is one of the most dangerous to which man is
subject.
Constriction of the pylorus is usually beyond the resources of art, even
the best chosen diet furnishing only unsatisfactory results. In such
desperate cases resort may be had to the expedient of washing out the
stomach, after the method of Kussmaul.
In conclusion, the patient’s general condition merits all our attention
during the long course of the disease. Primary chlorotic anaemia, as
well as that which follows upon a severe gastric hemorrhage, demands
the circumspect and prudent use of the ferruginous and bitter prepara-
tions already mentioned. The effervescent ferruginous powder is a
remedy which I am fond of employing under such circumstances. In
summer, the air of the country, of the mountains, or of the sea-shore, may
aid the action of an analeptic regimen and of tonics. It is essential also
that, even when a cure has been obtained, the patient’s diet and hygiene
should still be watched over with the greatest care for years.
T) ISCUSSION ON DR. T.EBERT's PAPER.
After the reading of the preceding paper, Dr. W. Scott, of Cleveland, Ohio,
said :—I have listened with great pleasure to this paper, which treats of the
method of managing a very troublesome disease. I have always treated gastric
ulcer in the manner described by Dr. Lebert. The primary condition to be
observed is to keep the organ completely at rest, and to control pain by the
use of opium or morphia. I have treated a case of this kind for thirty-one
days without having anything nutritious in the stomach during that time.
Dr. H. P. YEOMANs, of Canada, said:—I have found, when treating cases in
the first stage, when there is much vomiting, that nitrate of silver in pilular
form is of service. It may be given in small doses, combined with the com-
pound extract of gentian. I have always found it successful.
Dr. C. J. HARE, of London, said:—Great difficulty is experienced in getting
the stomach to retain anything during the course of treatment. I have found
that milk, boiled for ten or fifteen minutes, and then skimmed, can be borne by
the stomach very often when nothing else can. I think that the language
employed in this and many other papers is adapted to create the impression
that the disease is more frequently met with than is actually the case. Physi-
cians ought always to be sure that the disease is really present before they begin
any particular mode of treatment.
The President, Dr. ALFRED STILLí, of Philadelphia, said:—I think the dis-
ease does occur frequently. While spending the summer at Lake George, N.Y.,
at a place where there is scarcely a village population, I have met with no less
than four cases among the resident population. I am surprised that the con-
densed milk used in this country has not been, as far as Prof. Lebert's paper
indicates, introduced on the continent of Europe. Condensed milk forms one
of the best substitutes for fresh cow's milk that can be found. A gentleman
skilled in infantile diseases has told me that he has been able to use it when
fresh cow's milk was not tolerated, prepare it as he might. I think it rather
SIM P L E U L C E R O F T H E S TO M A C H . 431
objectionable on account of the quantity of sugar usually employed to preserve
it ; but it has seemed to answer better than any other form of milk—even than
boiled milk. In regard to food, I think that a good deal depends upon its tem-
perature. I have known cases in which no other food than that rendered cold
by ice could be retained and digested. A German gentleman, long resident
in this country, had been examined by several eminent physicians who were
unable to determine exactly what was the nature of his disease, but were inclined
to believe it to be cancer of the stomach. After a careful investigation of the
case, I concluded that it was one of simple gastric ulcer, and placed the patient
under a strict dietetic treatment, when his vomiting ceased, and he gained flesh
rapidly, and was able to take long walks and attend to his business as a mer-
chant. He, however, relapsed, and I began to doubt whether I had been right
in my diagnosis. The patient then inquired if a voyage would injure him, and
asked whether I would object to his consulting several medical gentlemen in
Germany. I advised him to consult certain eminent physicians, and wrote out
for them a history of his case. He accordingly visited one or more of these
physicians, who also regarded the case as one of simple ulcer, but whose treat-
ment was not followed by marked advantage. Another, however, advised food
made cold by ice, and no other remedies. The patient immediately began to
improve, and returned home, after an absence of four months, having gained
fifteen pounds of flesh. This confirmed me in my original opinion as to the
nature of the disease. Soon afterwards the gentleman was attacked with
hemorrhage of the lungs, and ultimately died of chronic phthisis. After death
the lung was found to be universally tuberculous. In the stomach there was
no active lesion, but in the greater curvature, and on the posterior wall of the
organ, was a cicatrix, consisting of a white spot entirely denuded of the super-
ficial layers of the lining membrane, from which radiated white bands of a
fibrous aspect.
Dr. MICHAEL O'HARA, of Philadelphia, said:—In a case of gastric ulcer
attended with hemorrhage, I at first used the ordinary treatment with opium
and bismuth. The latter drug was not of much service, but I found oxide of
silver beneficial. The patient recovered, and some time afterward was again
attacked with hemorrhage and recovered a second time under the use of opium
and nitrate of silver. Not long since the same patient has passed successfully
through an attack of typhoid fever.
Dr. HENRY GIBBONs, of San Francisco, said:—In the case of a child under
my care, fresh and skimmed milk were tried unsuccessfully, and nothing but
condensed milk was retained by the stomach. In another case nothing but
milk warm from the cow could be tolerated.
Dr. J. W. SMITH, of Charles City, Iowa, said:—I recall a case in which
nothing could be retained but shavings of ice cut with a plane. The patient
Tecovered, and was able to attend to his business in six weeks.
Dr. DARIUS MASON, of Prairie du Chien, Wisconsin, said:—A good form of
condensed milk is that made simply by the evaporation of its watery portions.
The use of the granulated article can be avoided by the employment of this
condensed milk.
CASES OF PERNICIOUS PROGRESSIVE ANAEMIA,
WITH
SOME OBSERVATIONS UPON THE ANTE- AND POST-MORTEM
CONDITIONS OBSERVED IN THAT AFFECTION.
BY
R. P. HOWARD, M.D., L.R.C.K.,
PROFESSOR OF MEDICINE IN THE M'GILL UNIVERSITY, CANADA.
BEFORE such an audience as the present, and especially in this city, it
is not necessary to make many introductory remarks upon the meaning
of the terms “idiopathic anaemia” and “progressive pernicious anaemia.”
Englishmen are aware that, in 1855, Addison, of Guy’s Hospital, applied
the term “idiopathic anaemia” to a form of “general anaemia occurring
without any discernible cause whatever,” and “with scarcely a single
exception proving fatal.” Germans need not be informed that Biermer,
of Zurich, in 1872, introduced the name “progressive pernicious anaemia”
for the same class of cases, of which he had seen fifteen. And Americans
are well aware that, in 1875, Dr. Pepper, of the city to which belongs the
honor of entertaining the first International Medical Congress held in
America, gave an able resumé of what was known on the subject down
to the month of October last, together with the history of three cases
which he had himself observed.
As the subject is of much importance and interest at the present time,
I beg to invite the attention of the Section to four cases of the disease
that have crossed my own path, and to some observations upon the
ante-mortem conditions which have been observed in sixty-two cases, and
the post-mortern changes found in fifty-one examples of permicious pro-
gressive anaemia.
CASE I.—J. H., aged 41, a shipping merchant, known to me for twenty
years as of light complexion, average nutrition, and strictly temperate habits;
has never had bad health till within two years, during which he has had at
times uneasiness after eating, sore mouth, and a gradual loss of strength and
color. Residence at the seaside for the last two months has not benefited
him; has lost a sister by consumption, but his parents and the rest of his
family are healthy.
On September 4, 1874, first consults me; walks in as if tired, and devoid of
energy and spirit; complexion sallow, white, different from the hue of jaun-
dice; conjunctivae and nails colorless; mucous membrane of mouth and
tongue very pale, with slight abrasions here and there. Careful examination
reveals no disease in thorax or abdomen; liver seems to extend a finger's-
breadth below margin of ribs; appetite poor; sense of oppression felt after
eating ; bowels act every day or two ; urine not jaundiced, free from albumen;
has not lost blood from stomach, nose, or rectum. Malignant disease was
suspected; a careful diet, and pepsin with chlorohydric acid, ordered.
Seen a fortnight later in consultation with Dr. Sutherland, but nothing new
was elicited. Patient had been restless at night, and had rather rapidly lost
P E R N ICI O U S P R O G. R. E. SSI W E A N AE MIA. 433
strength; could no longer walk out, and the ankles had become oadematous
in the evenings.
October 16, Dr. Campbell added to the consultation; no additional facts
ascertained ; agreed that internal carcinoma probably existed; claret and raw
beef to be tried. Under date Nov. 1, it is recorded that patient only gets out
of bed to have it made; is with difficulty induced to take beef-tea and oysters,
which are his only food; sleeplessness persists; slight Oedema of scrotum ;
loud systolic basic murmur; external jugulars pulsate visibly, and fill up from
below; a dull, lemon-colored hue of skin; no patches of discoloration in axil-
lary, inguinal, or genital regions; many moles on right side of neck; urine
copious, not albuminous; blood pale ; no excess of white corpuscles; has not
been able to take iron in any form, but has persevered with the pepsin and
acid. On November 16, signs of effusion into both pleurae were detected; these
increased, and he died chiefly by apnoea on November 22.
Autopsy.—Drs. Campbell, Sutherland, Ross, and Chipman, present with me.
A pint and a half of clear, citron-colored serum in either pleura, and about six
fluidounces in the pericardium ; both lungs healthy, but extremely bloodless,
except at posterior aspect; their bases collapsed ; no coagula in venae cavae or
tricuspid orifice; the latter large, admits three fingers; all the valves healthy.
A few fluidounces of serum in the peritoneum ; the liver, kidneys, supra-
renal capsules, and pancreas, normal ; spleen also, and of usual size; gall-
bladder moderately distended with bile; mucous membrane of stomach ex-
hibits no trace of disease; pylorus and entire intestinal tract in normal state.
All the organs, however, very pale and bloodless. Many of mesenteric glands
rather enlarged, several of them to the size of a wild strawberry. I regret that
as the viscera were not examined microscopically, the existence of fatty de-
generation cannot be affirmed. The diagnosis of “cancer” or “latent ulcer of
the stomach,” was at fault; profound anaemia alone was found to account for
death ; and the case recalled Addison’s description of “idiopathic anaemia.”
CASE II.-T. W., aged 37, a wholesale dealer in fruit, first consulted me on
April 22, 1872, on account of breathlessness and palpitation when walking,
and a gradual loss of strength. Sixteen years ago he had a single attack of
ague for a few weeks; the only one he ever had. He had resided in Toronto
for ten years, and in Montreal for the last eight years; and since then his
complexion has gradually become pale, and a former tendency to short attacks
of diarrhoea from slight causes has increased. Has not been dyspeptic ; has
never lost blood beyond a few drops from the nose a couple of times a year
when suffering from a cold. For the last twelve months his complexion has
been very pale.
He is an only son, and has had but one sister, a healthy woman. His father
died suddenly of heart disease, at twenty-seven years of age, and his mother
of some bowel affection ; she had been subject to rheumatism. Patient is a
large-framed, well-nourished man, but the subject of extreme pallor of the
general surface, lips, and lining of the mouth, without Oedema of ankles or
eyelids. The pulse is small, soft, and regular; a soft-systolic murmur, audible
at mid-sternum, is propagated up the pulmonary artery and aorta; a contin-
uous hum is heard in the jugular vein, and along the right border of the upper
sternal region. The limits of the liver are normal; those of the spleen per-
haps slightly increased. The urine is free from albumen ; the appetite indif.
ferent. A generous diet, claret, and a combination of iron and quinine were
prescribed ; and in June he was sent to the seaside, with instructions to perse-
vere with the above measures. He was very much benefited, and did not re-
visit me till the February following (1873), when he presented the original
symptoms of profound anaemia more intensely than before. A drop of blood
from the finger-point was watery-looking and of a very pale red color, but con-
tained no excess of white corpuscles.
A careful examination in conjunction with Dr. Campbell failed to discover
any disease in lungs, heart, liver, spleen, or kidneys; nor had the patient
28
43.4 H OW A R D,
been suffering of late from diarrhoea or dyspepsia, although his appetite had
been failing for some time. We agreed that the case was probably one of
“idiopathic anaemia,” like the previous one which we had seen together. All
the various remedies, including iron, quinine, pepsin, etc., except phosphorus,
that could be rationally prescribed, failed to meet the increasing pallor and
failing strength. Food was given by mouth and rectum. The pulse grew
smaller and weaker ; faintness followed sitting up in bed; the appetite com-
pletely failed—indeed, food was loathed ; the bowels became very torpid ;
epistaxis, sometimes severe, became a frequent symptom ; a moderate eleva-
tion of temperature was noticed many times; his spirits sank, and towards the
last a feeble delirium and childishness were observed now and then ; Oedema
appeared in the legs, and death by exhaustion took place on April 22, exactly
a year from his first interview with me. No autopsy could be obtained, so
that the diagnosis of “idiopathic anaemia” wants that confirmation. No
other view of the case, however, I submit, appears more rational, neither
“Hodgkin's disease” nor latent carcinoma. This defect does not exist in my
third case.
CASE III.-Mr. T., aged 53, lost his wife very suddenly in her first confine-
ment, about five years ago. Has been known to me for over twenty years as
a temperate and healthy but not robust-looking man, which his occupation as
a book-keeper may perhaps account for. He consulted me first in August, 1872,
for a slight diarrhoea. He next came under observation in April, 1874, suffer-
ing from dyspepsia, which was benefited by pepsine and muriatic acid. On
August 31, he still complained of epigastric uneasiness after eating, and looked
more delicate, paler, and more spare than usual. No local disease in the abdo-
men could be discovered however, and nux vomica and cod-liver oil were ad-
vised in addition to the pepsine mixture. He did not return till Jan. 30, 1875,
when he looked much paler and very sallow, and complained chiefly of weakness,
so that he had of late driven to his office. A few days before he had passed
blood at stool, but the hemorrhage did not recur. The anaemic looking surface
was of natural temperature; the pulse 72; no enlargement of spleen, liver, or
external lymphatic glands could be detected. The urine, free from albumen,
deposited uric-acid crystals freely, and had a sp. gr. of 1030; no discolored
patches on any part of body.
In the latter part of February diarrhoea occurred for a few days; patient's
weakness and pallor were rapidly increasing; a soft systolic basic murmur was
noted, and a drop of blood from the finger was pale and watery. The micro-
scope showed no excess of white corpuscles; nine or ten only could be counted
in the field, and they looked smaller than usual. The surface was very pallid
and of a somewhat light straw color. In addition to pepsine at his meals, a
pill containing reduced iron and nux vomica was prescribed, with beef-tea,
claret, etc.
March 4. Urine still the color of pale sherry, and sp. gr. 1020. Deposits
uric acid ; is free from albumen ; feet and legs oedematous. To have in addi-
tion to the ferrum redactum, so gr. phosphorus (Warner's pills) after every
meal.
He had been seen by Dr. Campbell in consultation with me on March 2, and
no organic disease could be detected to account for the serious anaemia and
prostration. Of course the case reminded us of our two previous examples
of “Idiopathic anaemia,” and as such I told the friends I regarded it. After
this the downward course was rapid. Soon vomiting and a tendency to diar-
rhoea appeared. The appetite failed; the pulse grew gradually more frequent,
78, 84, 90, 102, and became weak and jerking, though regular; a constant
“ beating” in the head was complained of; faintness was experienced on sitting
up in bed; and a mild delirium at night was followed by childishness and want
of purpose in the day. The eyelids became somewhat puffy; the urine re-
tained its high density and color, although the temperature of the body did
not exceed the normal till a few days before death; fewer white corpuscles
were found in the blood on March 18, three in one field and one in another;
P E R NIC I O U S P R O G R E S SIV E A N AF MIA. 435
the red corpuscles were of course deficient, but no attempt was made to esti-
mate their number. The stain made by a drop of blood upon a white hand-
kerchief was very pale. The voice grew feeble ; the body wasted somewhat ;
the bloodless appearance of skin, mucous membrane, and nails, increased ; and,
during the last three days of life, a progressive stupor, dilatation of the pupils,
slackening of the pulse-rate, retention of urine, and labored respiration, indi-
cated a suspension of the cerebral functions. At this time the temperature of
the body became somewhat raised. He died on March 28, 1875.
Autopsy,' twenty-seven hours after death ; moderate cadaveric rigidity; some
subcutaneous fat; no blood escaped while opening cavities.
Thoraac.—About two fluidounces of clear citron-colored serum in left pleu-
ral cavity. Some bridles of adhesion over apex of left lung, in which are found
two or three dry, black and white caseo-calcareous masses, almost the size of a
small bean, and surrounded by a capsule of pigmented and indurated tissue.
The right pleural cavity obliterated by very firm adhesions; in the extreme
apex of right lung a patch of black indurated tissue about an inch in diameter,
and a separate small nodule of mortar-like material. The rest of both lungs
healthy, but occlematous, and very anaemic looking. Bronchial glands not en-
larged. Pericardium contains about four fluidounces of serum ; a good deal of
fat on right side of heart; scarcely any blood in cavities of heart; very small
colorless coagula in both ventricles; valves normal.
Abdomen.—Liver normal ; half a fluidounce of green bile in gall-bladder;
spleen very small, firm, and its capsule shrivelled ; cut surface pale and smooth;
mesenteric and lumbar glands unusually small ; stomach and intestines per-
fectly healthy, but their coats very pale; supra-renal capsules and kidneys
normal; all these organs contain very little blood.
The spleen, a portion of the heart, and blood from the splenic vein and from
the inferior vena cava were taken away for microscopic examination by Dr.
Osler, to whom I am indebted for the following report, as well as for other
valuable assistance in the preparation of this paper:—
“Blood from the inferior cava and the splenic vein: The colorless corpus-
cles did not appear in any excess, averaging in a number of observations from
six to eight in the field of No. 7, ocular 3. They presented slight variations,
in size, and the protoplasm was rather more granular than normal. Clusters.
of from six to ten adhering together were not uncommon. Nuclei variable;
some had only one, others two or three. In the blood from the splenic vein
the colorless corpuscles presented the same characters; a few retained their
amoeboid movements when placed upon the warm stage. Max Schultze’s
granular masses were abundant, and some of large size; the individual ele-
ments composing these masses were very distinct. The red corpuscles looked
natural, a few only were crenated ; a somewhat unusual variation in size was
noticed among them. Many measured scarcely the gºod of an inch in diameter
as seen with the No. 9 (immersion).
“Spleen. Weight one ounce and five drachms. Portions teased in saline solu-
tion and examined with the No. 9 (immersion) showed the ordinary structures
met with in the organ (pulp cells, blood corpuscles, and connective tissue).
The elements of the latter, as might be expected from the diminished bulk of
the Organ, were in excess, and consisted of the fibrous tissue of the trabeculae
and numerous nucleated fibre cells. Examination of their sections yielded the
same results; the elements of the organ appeared normal, there being simply a
disproportion between the connective tissue and the pulp.
“Heart. A small portion of muscle from the left ventricle showed marked
signs of fatty degeneration.”
I regret that the bones were not examined in either of these cases, but
Dr. Pepper's paper had not been published when the last of them termi-
! My friend Dr. Osler kindly assisted me at the autopsy; Drs. Campbell and Chipman
were also present.
436 HOW A R D,
nated. In the second autopsy a condition was found that, as far as I am
aware, has not been hitherto observed in this disease, viz., marked atro-
phy of the spleen and great reduction in size of the mesenteric and pre-
vertebral lymphatic glands. At first, I thought that this condition
might account for the oligaemia in that case, but the subject of haema-
topoiesis in the adult is so unsettled that I do not venture to express an
opinion as to the relationship existing between the anaemia and the state
of the organs in question, although they are generally supposed to be
concerned in the elaboration of the blood. A symptom observed in this
last case that interested me much during life was the high color and den-
sity of the urine. It did not resemble the urine of ordinary anaemia, but
rather that of rheumatic fever; and I am disposed to refer it to an exces-
sive destruction of the red globules, as neither fever nor rapid wasting
were present.
A fourth example of this disease came recently under my notice, in con-
sultation with Dr. Greene, of Granby, to whom I am indebted for a
report of the case.
CASE IV.-Mrs. W., aetat. 46, a highly respectable married woman, the
mother of four children, of whom two survive, and are robust and plethoric.
In early married life she had had a few slight attacks of epistaxis, but had
enjoyed tolerably good health till within about two years of the menopause,
during which period menorrhagia existed. Then her health began to fail, and she
became somewhat anaemic. No cause could be found in the condition of the organs
for the hemorrhagic tendency. When first visited by Dr. Greene, nearly two
years after (in March, 1875), she presented all the symptoms of intense anaemia,
including the blood-murmurs in the great vessels. The only evidence of local
disease discoverable was some fulness and tenderness of the liver, irritability
of the stomach, and a yellow tinge of the conjunctiva. Although the digestive
disturbance disappeared and she was able to enjoy carriage exercise during the
summer, and had a very good appetite, the anaemia increased, and she had two
or three slight attacks of epistaxis. In October the gastric symptoms returned
with increased severity, and an aphthous condition of the mouth and fauces,
which she had had more than once before, recurred, and was attended with slight
diarrhoea, with a daily augmentation of the temperature, which could not be
controlled by quinine or salicine. When seen by me last winter, in consultation
with Dr. G., she was unable to leave her bed, and exhibited all the symptoms
of advanced anaemia. A careful examination of all the organs, including the
uterus, rectum, external glands, spleen, liver, etc., failed to detect local disease,
and I expressed the opinion that it was a case of “progressive pernicious anae-
mia.” A drop of blood taken from the finger-point was thin and pale in color;
but was so spoiled by drying when I got back to Montreal that Dr. Osler could
not satisfactorily make out its characters. The patient died on January 17,
from exhaustion, preserving her mental faculties to the last. She had had two
or three very moderate losses of blood from the nose since she had been seen
by me. º
Although satisfied in my own mind that the case just related was one
of pernicious anaemia, yet as the diagnosis lacks the verification of an
examination of the blood during life, and of the body after death, I would
not have related it but that the family history appears to me important
as proving that a predisposition to anaemia may exhibit itself in families
and that it may perhaps be inherited.
This last patient’s youngest sister has been anaemic since childhood;
a married cousin has been anaemic since having an attack of typhoid
fever about two years ago; and a grand-uncle died at sixty-two, with
symptoms like those manifested by the niece, and was anaemic. Judging
P E R NIC I O U S P R O G. R. E S S I W E A N AF MIA . 437,
from the papers which have been of late written upon this subject, it is
not generally known that Dr. Wilks,' of Guy’s Hospital, in 1857, pub-
lished a series of cases of the disease we are considering under the cap-
tion, “Cases of Idiopathic Fatty Degeneration.” “This designation,” he
remarks, “is given to a class of cases in which an eaccessive anaemia and
debility are the peculiar phenomena observed during life, and a fatty
degeneration of all parts of the body, but especially of the heart, the most
remarkable appearance found after death.” And further on he says,
“The following seven cases will afford examples of this remarkably fatal
anaemia and fatty degeneration.” Two years” later, when describing
another case of “Idiopathic Anaemia,” he applies the latter title to his
former series of cases. What a notable anticipation of Gusserow’s
observations in 1871, and of Ponfick’s in 1873. It is due also to Prof.
Lebert to say that he was one of the first to call attention to our sub-
ject. In 1853 and 1854 he had met with six cases of what he called
“Puerperal Chlorosis,” only one of which, however, had terminated
fatally ; and in 1858, under the title “Essential Anaemia,” he published
the details of that fatal case and of another subsequently observed,
together with the appearances found after death. IIis third fatal case,
with autopsy, occurred in 1859.”
These series of cases of Dr. Wilks and Prof. Lebert are not mentioned
in Dr. Pepper's able paper on the subject, nor are the single cases of fatal
anaemia published by Dr. Combe" about 1823, by Sir Dominick Corrigan
in 1844, by Dr. Dickinson in 1863, and by Dr. King in 1871; nor Dr.
Barclay's two examples published in 1851.
I have met with ten alleged examples of pernicious anaemia recorded
since the appearance of Dr. Pepper's article: the first by Dr. F. Fede" in
October, 1875, however, appears to me to have been an example of so
called “Myelogenous Pseudo-leukaemia,” as the spleen was found after
death of threefold the normal size, and its firm pulp “consisted of some-
what larger cells than in the natural condition, and they appeared very
similar to the elements of the bone-marrow.” The bones of the skeleton
were thickened, the compact substance much reduced and replaced by a
wide meshed spongiosa, in which the microscope found similar structures
to the normal red marrow of bones; there were, however, numerous mul-
tinuclear (growing) cells and blood-corpuscle-containing elements. The
liver, also, was a little enlarged ; the blood contained no excess of white
corpuscles.
In December, 1875, Dr. Pye-Smith" published two cases of “Pernicious
Idiopathic Anaemia,” with autopsies. Both occurred in men; no cause
could be assigned for the disease in one; in the other, possibly, one or
two attacks of intermittent fever experienced seven years previously may
have stood in that relationship. The only morbid appearances discovered
at the examination of the cadavera were fatty degeneration of the heart
in both, of the liver in one, and thickening of the mucous membrane of
the stomach in one. The bones were not examined.
This year Dr. Scheby-Buch' has recorded two cases of “Essential Anae-
| Guy's Hospital Reports, 3d series, vol iii. pp. 203–213.
* Ib., vol. v. p. 108.
* Archives Générales de Médecine, Avril, 1876.
* Quoted by Dr. Dickinson, Trans. Path. Soc., xiv. p. 141.
* Quoted in Centralblatt f. d. Medic. Wissenschaften, Oct. 16, 1875.
° Virchow's Archiv, lxv. Dec. 27, 1875.
7 Deutsches Archiv für Klin. Med., xvii. Band. p. 467, 1876.
438 HO WAR D,
mia.” It is open to question whether either deserves the title of “Essen-
tial,” as the man, aged 48, had had “ulcers on his legs which discharged
from Easter to Christmas,” and the woman, aged 60, had been “sickly
for several years.” The spleen was found enlarged in both. In the
female there existed, in addition, dilated bronchi, fatty degeneration of
the viscera, and “numerous cells resembling white corpuscles, in groups,”
in the marrow of one radius. The marrow was pale-red, and contained
but “few fat cells,” and only a few red globules. (Perhaps these cases
ought to be regarded as examples of pseudo-leukaemia. I have retained
them however.)
In the number of the Centralblatt for June 24, 1876, there is a notice
of three cases of this disease recorded by Krieg," and an autopsy. Only
a very meagre report is given, and I have not been able to procure the
original paper. Two of the three patients were men, aged respectively
52 and 45 years, and in good circumstances. No other details of these
cases are given. The third case was that of a married peasant woman,
aged 48. How many children she may have had is not stated. It is
simply observed that she had been ordinarily stout till within a year.
During that time petechiae appeared upon the lower limbs, bleeding took
place from the gums, and pleurisy set in. The autopsy revealed visceral
hemorrhages, fatty degeneration of the heart’s fibre, and a fibro-sarcoma
at the base of the brain. Nothing is said about the condition of the
bones.
An instance of this disease is related by Dr. E. H. Bradford, in one of
the July numbers of the Boston Medical Journal for this year. The case
is interesting, as affecting a girl only eleven years old, the earliest age at
which the disease has been observed. No cause could be discovered.
The blood globules were reckoned during life, and both red and white
found to be numerically deficient. The red were paler than normal, and
had lost their biconcave contour. “There was not much variation in
size between the individual globules. All were smaller than usual.
There was not much detritus. The white globules seemed abnormally
granular, and were irregular in shape.”
Amongst the peculiar symptoms mentioned, are severe pains in the ear
and abdomen, and severe attacks of pain in different parts of the body ;
a daily expectoration of blood to the extent of about three ounces, and
upon one occasion equal to a pint. The temperature during the three
weeks before death, ranged from 101.9 F. to 994° F. Death was pre-
ceded for a day or two by loss of consciousness, a firmly contracted and
flexed condition of the right arm, and a motionless state of the right
leg. No disease of the spleen, lymphatic glands, lungs, or other organ
could be detected during life. No autopsy was made.
The latest reported case that has come under my notice, was brought
before the Société des Hôpitaux, on July 14, 1876,” by M. Lepine. The
anaemia began with the third pregnancy of a delicate woman, who,
however, had never been the subject of any serious disease, although she
had many times suffered from gastric troubles. A careful post-mortem
examination discovered only a circumscribed fatty degeneration of the
heart, and an insignificant unilateral broncho-pneumonia. No disease
of the spleen, glands, or bone-marrow, existed.
I have not tabulated Ponfick’s, Grofmer's, Quincke's, or Grenville's
1 In Würtemb. Corr. Bl., 1875, No. 39.
* Wide Bulletin Générale de Therapeutique, 30 Juillet, 1876, pp. 85–87.
P E R N ICI O U S P R O G. RESS I W E A N AE MIA. 439
cases, not having been able to procure their details. Zenker's case of
anaemia due to uterine hemorrhage, and Chadwick’s case arising appa-
rently from post-partum hemorrhage, I have also not tabulated, as they
are at least not typical cases. For a like reason, I have excluded a case
of extreme anaemia which occurred under my own care in a puerperal
patient without undue hemorrhage or other evident cause to account for
the profound anaemia; from which, however, she recovered after a long
struggle. Perhaps all cases of recovery from apparently pernicious anae-
mia, should, in the present state of our knowledge, be excluded, while
they should be very carefully studied in the hope that they may shed
light on this obscure department of pathology.
An analysis of these cases of pernicious anaemia suggests the propriety
of dividing them into distinct classes or groups, and even it may be of
refusing to some of these the title of “idiopathic”:—
GROUP I.—Thus all the cases which occurred during pregnancy ought
to stand by themselves, for while no sufficient reason can be assigned
why in such females the usual moderate impoverishment of the blood,
which obtains during gestation, should have attained such a development
as to have proved fatal, yet the existence of so well characterized a con-
stitutional state as that of gestation, as a condition common to so many
of the examples of so-called pernicious anaemia, cannot well be regarded
as accidental. To this class belong by far the largest proportion of
reported cases. All of Gusserow’s five cases were in pregnant females ;
several of Biermer's were ; one of Lebert’s fatal cases, and one of Wilks's
were ; Corazza's only case was that of a woman who had had four children
in five years, and died soon after delivery, and the latest reported case,
Lepine's, began with the third pregnancy of a middle-aged woman who
had only suffered from attacks of gastric disturbance.
GROUP II.-Some examples of the disease followed so closely upon
parturition, quite independently of undue losses of blood, that they should
perhaps be called puerperal cases. One of Marshall Hall’s cases, one of
Barclay's, and some of Biernner's, appear to have been in some way con-
nected with the puerperal condition. Indeed Lebert met with several
examples of severe anaemia under conditions which induced him to draw
special attention to an “acute puerperal chlorosis,” and many authors
have written upon the chlorosis of pregnancy (notably Beau, Andral
and Gavarret, Regnault, Cazeaux, and Sée).
As by far the largest proportion of the recorded examples of fatal per-
nicious anaemia have occurred during pregnancy and soon after delivery,
it would be important to be able to arrive at an explanation of the rela-
tionship between child-bearing and pernicious anaemia. This is perhaps
not possible. Even if it be urged that frequent child-bearing and more
or less prolonged lactation may be regarded as spoliative processes of no
mean power, and that amongst the poor, in whom these influences are
especially prevalent, there is very frequently an insufficient supply of
generous food and pure air to meet the spoliation, and hence the in-
poverished blood, it is difficult to comprehend why it is that pernicious
anaemia is after all so seldom met with, while the influences just
mentioned are so prevailing. Moreover, fatal anaemia occurred in one of
Gusserow’s cases during the first pregnancy, a circumstance which, in
the light of the preceding observations, renders it probable that the preg-
nant state per se predisposes to progressive blood deterioration, an idea
somewhat borne out by the rapid course of the disease in all Gusserow’s
440 HOW A R D,
cases, one of them lasting only five weeks, from first to last; two occupy-
ing but four to five months; a fourth even less time; and the last ending
in the eighth month of gestation.
GROUP III.-Closely allied to the pernicious anaemia of pregnancy
appears, on first thought, that common affection still styled chlorosis.
The latter, like the former, is most frequent in females; it is very generally
accompanied by disturbance of the uterine functions, and its causation
is unknown. On second thought, however, there is the striking differ-
ence that chlorosis very seldom proves fatal, while the anaemia of preg-
nancy appears to do so frequently; the former is amenable to treatment,
the latter rarely if ever is cured.
The only examples of fatal anaemia in young females independent of
pregnancy that I have tabulated are three cases recorded by Marshall
ITall; one by Wells in a married woman 31 years old; one by Immermann,
in a patient also married and of the same age ; one by King in a woman,
aged 27, who had had since puberty more or less menorrhagia and leu-
corrhoea; one by Pepper, in a woman aged 36, who had been exposed to
malaria and had had brouchitis for five months before the anaemia appear-
ed, and Bradford’s case of a girl only 11 years old. Of these eight cases,
only two, one of Marshall Hall’s, in a girl of 18, and Bradford’s ease, can
be fairly cited as typical examples of chlorosis proving fatal, and so
far resembling pernicious anaemia. Inasmuch, then, as the ordinary
chlorosis of young women is notoriously very seldom fatal, while that
less frequent form incident to pregnancy frequently is, we may not con-
clude without further light that both forms of anaemia acknowledge the
same causation, although we may grant that both may be called “idio-
pathic” or “essential,” until some satisfactory explanation of their origin
is forthcoming.
GROUP IV.-Another group comprises those cases which have been
preceded by chronic diarrhoea. Biermer states that pernicious anaemia
frequently follows that affection; but, with the imperfect history given
in very many of the published cases, his observation remains unproven.
It is true that diarrhoea is frequently mentioned among the symptoms of
the affection, but many authors fail to say whether the diarrhoea pre-
ceded the other evidences of the disease, or merely accompanied them.
Indeed, beside the cases given by Biermer, the only others in which
chronic diarrhoea is recorded amongst the antecedent conditions of the
anaemia are: Corrigan’s case, in which diarrhoea had existed “off and
on for years;” One of mine, in which a tendency to that affection had
been observed over eight years; and one of Pepper's, in which “chronic
follicular catarrh of the intestines had existed for many years;” this
patient had also “chronic suppuration of the gall-bladder,” and a former
history of psoriasis of twelve to fifteen years’ duration. These facts,
then, scarcely bear out Biermer's statement.
Diarrhoea formed a leading symptom in the following cases: two of
Lebert’s; three of Wilks's, in one of which there were cicatrices and
ulcers in the colon; one of Barclay's; one of Pye-Smith's, and Lepine's
case—in all eight. But it appears from the notes of all these cases
that an impoverished condition of the blood coexisted; and also some
one or more of the other conditions known to have preceded or accom-
panied pernicious anaemia in other cases, such as pregnancy, parturition,
hemorrhage, etc.
GROUP V.—Six more of the tabulated cases may be grouped together,
inasmuch as the antecedent conditions were such as to involve blood-
P E R N IC I O U S P R O G R E S S I W E A N AEM [A. 441
waste; they might have been included with the last group, which also
implies blood-waste, had not previous writers attached so much import-
ance to chronic diarrhoea per se in relation to pernicious anaemia. Such
are Wilks's case of an errand boy, aged sixteen, who had not been well
for three years, and had often suffered from epistaxis, and whose colon
contained cicatrices and ulcers; King's case, which had been preceded
during thirteen years by menorrhagia and leucorrhoea; my fourth case,
in which for two years before the cessation of menstruation, there had been
menorrhagia; one of Pepper's cases, preceded by chronic bronchitis for
five months; and Buch's two cases—one sickly for years, and the subject
of chronic bronchitis and an abnormal condition of the marrow of the
radius; the other, a case of pernicious anaemia, closely following upon
ulcers of the legs, which had discharged freely from Easter to Christmas.
Cases of fatal anaemia occurring in persons who have long suffered
from repeated attacks of loss of blood, or from protracted leucorrhoea, or
from chronic bronchitis, or from chronic ulcers, while they may be in
One sense included in the title “progressive pernicious anaemia,” cannot
strictly be regarded as examples of “idiopathic anaemia” as delineated
by Addison in his masterly description of the disease. He confined the
term to “cases in which there had been no previous loss of blood, no
exhausting diarrhoea, no chlorosis, no purpura, no renal, splenic, mias-
matic, glandular, strumous, or malignant disease.” This is a point which
has been so much overlooked of late that the terms “idiopathic anaemia”
and “pernicious progressive anaemia” are not now synonymous.
GROUP VI.-There is a group of six cases (one by each of the following
writers: Broadbent, Pye-Smith, and Lebert, two by the author, and
one quoted by Buch) occurring in patients from forty-one to fifty-seven
years of age, in which no antecedent condition is mentioned sufficient to
cause the anaemia except dyspepsia. In only three of these did the indi-
gestion last a considerable time, and in one of them (a case of my own)
it was not severe. In the other three cases the dyspepsia occurred
rather among the early symptoms than among the antecedent conditions.
It must be admitted that even severe and protracted dyspepsia very rarely
induces a fatal anaemia; and I incline to regard the relationship in these
cases as that of coincidence only.
GROUP VII.-E.ctreme poverty or poor diet were the conditions under
which pernicious anaemia was observed in four men (Lebert, Wilks,
Dickinson, and Cazenave, each a case), and if these were the real causes
of the blood disease, such cases require little discussion; the anaemia is
merely a consequence of inanition. But why this fatal form of anaemia
is comparatively so rare, while poverty and poor diet are so frequent, we
cannot say.
GROUP VIII.-A remarkable case is related by Pepper, in which a
man, after having had jaundice “about a month,” then exhibited well-
marked anaemia which proved fatal. In Corazza's case severe icterus
was also an antecedent condition, but the patient was also pregnant, and
had had four children in five years.
GROUP IX. —Finally, there remain nine cases in which no antecedent
condition is mentioned that can fairly be regarded as causative unless it
be a case of Pye-Smith's, in which there may have been two slight attacks
of intermittent fever, years before, “although on this point [the patient's]
account was somewhat uncertain,” and two of Wilks's, one, in which
| Addison's Works, Syd. Soc. Ed., p. 212.
442 HO WAR D,
“domestic trouble and recent marriage” coincided with the appearing
of the anaemia; the other, that of a woman aged fifty who had been
“ thirteen years in a lunatic ward.” Failing health and progressive
anaemia are a summary of the conditions mentioned in the whole nine
cases (Wilks three, Barclay, Combe, Pye-Smith, Lebert, Immermann, and
Howard, each one').
It results from this analysis that the conditions—as far as they are
known—under which these cases of pernicious anaemia originated, may
be thus grouped :—(1) pregnancy especially where oft repeated ; (2) par-
turition (and these two conditions appear to be especially frequent); (3)
chlorosis, which is rare; (4) chronic diarrhoea or intestinal catarrh,
which is by no means as often antecedent as some authors state; (5) blood-
waste, direct and indirect, from protracted menorrhagia and leucorrhoea,
from chronic ulcers, from chronic bronchitis, and from repeated epistaxis
combined with ulceration of the bowels, conditions present in six cases;
(6) dyspepsia, observed in three cases; (7) extreme poverty or poor diet,
mentioned in four cases only ; (8) jaundice, the only known antecedent
in one case, and associated with frequent child-bearing in another; and
last (9) no antecedent condition mentioned other than “failing health,”
which must exist when anaemia is developing.
Reflecting upon the frequency with which these several conditions
obtain, they cannot fairly be held to be frequently productive of, or
antecedent to, a progressive pernicious anaemia, and some of them seem
to be quite incapable of producing so grave a disease. The conclusion
is almost inevitable that either an inherited or an acquired predisposi-
tion to defective development or regeneration of the blood must exist in
these cases of pernicious anaemia, otherwise such conditions could not be
followed by such profound and unmanageable alterations of the blood.
Passing from the ante-mortem to the post-mortem conditions, it cannot be
said that Morbid Anatomy has thus far explained the occurrence or the
nature of the disease.
1. The fatty degeneration of the heart and other viscera first specially
insisted upon by Wilks in these cases of fatal anaemia, is a consequence,
not a cause, of the blood impoverishment, and is observed also after
severe hemorrhages, and in protracted fevers, in starvation, and other
analogous conditions.
2. The small size “hypoplasia” of the heart and of the large arteries,
pointed out by Virchow as existing in some severe cases of “chlorosis,”
and which may be regarded perhaps as congenital, even if it were
proved to be constant in chlorosis, could not be anticipated in the other
forms of anaeinia included under the term pernicious. It is true that we
have not many observations on this point, because the subject has not
been generally investigated. However, Pye-Smith found “ the aorta of
proper size and its coats healthy” in his second case ; its condition is not
given in his first ; in both the heart was over the average weight. Buch,
after comparative measurements, did not find the aorta smaller in his
two cases than in other anaemic and cachectic bodies, if not so wide as in
healthy persons.
3. In fifty-one autopsies of progressive anaemia that I have collected,
either the spleen is described as normal, or the “viscera” (and therefore
the spleen) are said to have been normal, thirty-six (36) times; as more
* Not having been able to get Krieg's original paper, I cannot say anything of his cases.
P E R N ICI O U S P R O G. RESS I W E A N AF MIA. 443
or less enlarged, usually but slightly, thirteen (13) times; once (1) as
small and shrivelled ; and once (1) its condition is not stated (Krieg's
case):—
Spleen normal . . . g º ſº º e -> © . 36
“ enlarged * e © o º e - º . 13
4 * small and shrivelled e e -> s o º ... 1
Condition not stated . tº º e º e e º . 1
51
Diermer appears to have found this organ free from lesions in his fifteen
cases; and Gusserow, although he mentions slight enlargement of the
spleen in his cases, says it presented no characteristic changes of its pulp.
In one of Pepper's cases, the spleen was enlarged by one-half; “its pulp
was dark and much softened,” without leukaemic lesions. In the other,
it was “slightly enlarged;” its pulp “softened and purplish, without any
leukaemic patches or enlarged Malpighian corpuscles.” “Under the micro-
scope, the field was crowded with small round cells (smaller than the
majority of the cells in the marrow), spindle-shaped cells, and very pale
red blood globules.” Much importance cannot be attached to the soft-
ness of the spleen in this case, as it had undergone sufficient decompo-
sition to crepitate when handled. In one of Buch's cases, the spleen
was moderately enlarged and of a pale red-brown color; in the other, it
was also somewhat enlarged (12; centimetres long, 6 broad. and 4 thick),
of a brown-red color and firm, and its glomeruli evident; in Immermann's
single autopsy, this organ was also slightly enlarged and hard. In the
only instance in which the spleen was found atrophied, it weighed but
thirteen drachms, felt tough and cut with resistance. Its cut surface
was pale, and the microscope proved an absence of pulp cells and blood
corpuscles and a preponderance of trabeculae and of nucleated fibre cells.
It cannot then be affirmed that this important blood gland, the spleen,
usually presents any abnormality, much less any special lesion in per-
nicious anaemia."
4. A similar remark may be made respecting the lymphatic ſlands. In
the fifty-one autopsies, their condition is not mentioned sixteen (16) times;
they presented no lesions thirty-three (33) times (including Biermer's and
Gusserow’s 20 cases), the mesenteric glands were “pretty generally en-
larged” in one case; and in the remaining one the same glands and the
lumbar were unusually small, as if atrophied. The last was the case in
which the spleen also was atrophied. In it also one gland only in the
body, an axillary gland, was found slightly enlarged.
Condition of lymphatic glands not stated in . - º . 16
No lesions in . e e º & º sº e e . 33
Mesenteric glands generally enlarged in . & tº e ... 1
Mesenteric and lumbar glands unusually small in . º . 1
51
5. One other lesion of great importance remains to be noticed. Prof.
Pepper, in 1875, on examining one radius of his last case of progressive
anaemia found the marrow “to be made up almost entirely of granular
cells,” which he considered as due to the hyperplasia of the marrow
with production of lymphoid cells—a change described by Ranvier in
| Disease of the spleen, no doubt, may be a cause of anaemia, just as disease of the other
blood-glauds and lungs may be.
444 - HO WAR D,
1867,' and by Neumann and others subsequently, as existing in some
cases of leucocythaemia. T)r. F. Fede, about the same time as Pepper,
described similar alterations of the marrow of the bone, in a case which
he published as one of progressive pernicious anaemia, but which, as
already stated, owing to the accompanying alterations in the spleen, is
rather an example of pseudo-leukaemia. This year Dr. Scheby-Buch
examined the radius in a case of pernicious anaemia, and found the mar-
row of a pale-red color, and containing a few fat cells, single drops of fat
here and there, and numerous cells in groups resembling white corpus-
cles, and only a few red corpuscles. On the other hand, in the latest
recorded case, M. Lepine found no affection of the bone-marrow. The
bones were not examined in the other forty-eight cases, so that the fre-
quency with which this little-known lesion may have existed in them
'annot be even surmised. -
The import and nature of the change itself are scarcely settled. It has
been observed in several cases of leucocythaemia, and in a few of pseudo-
leukaemia. Dr. Horatio C. Wood, Jr. (of Philadelphia).” examined the
long bones taken from patients dead of various chronic diseases, and only
in one instance found any abundance of leucocytes in the marrow, and
in that one there coexisted marked general enlargement of the lymphatics
and of the spleen. Circumstances prevented a complete examination of
the case, so that it may also have been one of leukaemia or pseudo-leuk-
aemia. He thinks it not improbable that the lesion occurs in scrofulosis
and in chronic or even acute pyaemia; and I am indebted to my friend,
T}r. Osler, Professor of the Institutes of Medicine in McGill University,
for the details of an autopsy which he recently made upon a man who
died of tuberculous peritonitis, in which the marrow of the femur, the
only bone examined, was found to have suffered these changes. Passing
over the notice of the case and of the condition of the periosteum ſound
after death, I will relate only his description of the bone-marrow.
“Medulla. Upper half of left thigh removed for examination. On section
of the bone, the medulla presented a uniform grayish-red color, nowhere having
the yellowish fat-like aspect of normal marrow. In the cells of the cancellated
portion the marrow was of a lighter red color.
“Red blood-corpuscles. A very evident difference in size existed in these
elements, very many of which measured rººm of an inch in diameter; a few
were even smaller. Curious irregular forms were numerous. due to the protru-
sion of portions of the stroma of the corpuscle. Nothing special was noticed
about their color or general characters.
“Colorless corpuscles. These elements outnumbered considerably the red
corpuscles in all the specimens examined. Three or four varieties were no-
ticed: (1) Corpuscles agreeing in general characters with those of the blood ;
protoplasm firmly granular, nucleus vesicular, variable in number, ranging
from one to three or four. Many of these were larger than ordinary white
blood-corpuscles, and the nuclei were evident without the addition of any re-
agents. (2) Somewhat smaller corpuscles with coarsely granular protoplasm
and one or two vesicular nuclei. They were not very abundant, and corre-
sponded closely with the coarsely granular corpuscles which are sometimes
met with in the blood. (3) Corpuscles with clear vesicular bodies and solid
nuclei, usually only one. These were not very numerous, three or four only
occurring in the field of the No. 9 (immersion). (4) Small bodies like free
nuclei, protoplasm finely granular. These correspond closely with the nuclei
| Wide Jaccoud, Nouveau Dict. de Méd. et de Chir., t. xx. p. 430.
* Am. Journ. Med. Sci., Oct. 1871, p. 376.
P E R N ICI O U S P R O G. R. E S S I W E A N AF M I A. 445
of the former variety, and are probably identical with them, having been freed
by the rupture of the cell. Of these varieties No. 1 was by far the most
abundant.
“Transitional forms. Nucleated, colored corpuscles were noticed in each
specimen examined, as many as three or four occurring in the field of the No. 9.
They ranged in size from gºod to 2 sºn of an inch ; the majority of them being
slightly larger than the ordinary red corpuscle. The nucleus in every instance
was single, and the protoplasm finely granular. Three corpuscles were seen
with the nuclei dividing. The coloration of the cell substance was in each
case very distinct, and only exceptionally was it less distinct than in the sur-
rounding colored elements.
“Cells containing red blood-corpuscles. Two or three only were observed;
in one case an ordinary white corpuscle contained a single red corpuscle and
two nuclei; in another a somewhat irregular protoplasmic Inass contained
three red corpuscles and one distinct nucleus. None of the ordinary myeloid
or giant cells were found.”
In this case of tuberculous peritonitis, then, there existed the changes
in the bone-marrow, which have been observed in so called myelogenous
leukaemia, and in Pepper's case of pernicious anaemia.
It is not logical, in the present state of knowledge, to conclude that a
condition of the marrow which has been found in so many different
affections, as leukaemia, Hodgkin’s disease, pernicious anaemia, and
tuberculous peritonitis, is a pathological state essential to those affec-
tions. Moreover, quite recently, Dr. Moxon," of Guy’s IIospital, and
more recently still, Dr. Schtschastny, of St. Petersburg,” have maintained
that the bodies resembling white corpuscles found in the bone-medulla
in leucocythaemia “were in reality leucocytes which had escaped from
the blood.” Even if it were true that the condition of the bone-marrow
in question was constantly present in permicious anaemia, the bearings of
the fact upon the nature and origin of the disease would remain to be
worked out, as physiologists have not altogether accepted the views of
Neumann and Bizzozero, that in the adult the medulla of bones is con-
cerned in the development of the white corpuscles of the blood (Flint,
Virchow, and others). It is worthy of notice that the two cases of perni-
cious anaemia in which the medulla was found in a morbid state were com-
plicated, and such as could scarcely be called by the original name of the
disease, “idiopathic anaemia.” Pepper’s patient, aged fifty, had suffered
from an obstinate form of psoriasis for twelve to fifteen years; from
follicular catarrh of the intestines for twenty-five years; and from the
want of nearly all his upper teeth for twelve years before his death, and
would not wear false ones. The autopsy revealed not only changes in
the medulla of the bones, but chronic suppuration of the gall-bladder,
enlargement of the solitary glands of the intestines, and enlargement of
the spleen. Scheby-Buch's patient had been sickly for several years,
and the autopsy discovered, in addition to disease of the marrow, chronic
inflammation and dilatation of the bronchi, and a somewhat enlarged
and firm spleen.
I will make only one observation upon the diagnosis of the disease.
Quite lately, Dr. H. Eichorst" has affirmed that the disease may be
certainly diagnosed in the early stages from the microscopic characters of
* Lancet, May 4, 1876.
* Petersburger Medicin. Wochenschrift, No. 20, 17 Juli., 1876.
* Centralblatt, Berlin, Juni 24, 1876.
446 HO WAR D,
the blood. He says some of the red globules are of normal size, but very
pale, and have lost their tendency to form rouleaux; others scarcely
attain one-fourth the diameter of a normal perfect corpuscle, so that they
look like drops of fat tinged red, and have lost their biconcave appear-
ance. As the disease advances, these “red drops” or foreign elements
increase in number ; so that before death he has found them as numerous
as the intact red corpuscles. The white corpuscles are always in small
number.
The diagnostic character here insisted on, viz., the presence in the
blood of red globules of much smaller size and paler color than natural,
has not always been found according to the few accurate reports made in
recent cases. The red globules were observed to be small and pale in
one of Buch's cases. In Bradford’s case, in which the blood was spe-
cially examined, while “there was not much variation in size between
the individual globules, all were rather smaller than usual; there was
not much detritus.” The “white corpuscles seemed to be abnormally
granular, and were irregular in shape.” In one of my cases (Mr. T )
Prof. Osler noticed “a somewhat unusual variation in size amongst the
red globules. Many of them scarcely measured stºrmth of an inch in
diameter; the white also presented slight variations in size, and were
more granular than normal, and Max Schultze’s granular masses were
abundant.”
On the other hand, Prof. Pepper carefully examined the blood in one
case, and makes no mention of this variation in size of the red globules,
which he describes as “pale, and less biconcave than normal,” and adds,
“no abnormal elements were seen.” And Pye-Smith reports in one case,
three weeks before death, that “the colored elements of the blood are
not evidently changed either in number or characteristics, but they form
no rouleaux.”
It should be borne in mind, too, that M. Laptschinsky, of St. Peters-
burg,' has described precisely similar alterations of the blood in various
diseases in which marked febrile symptoms obtain, with the addition,
however, of an increase in the number of white corpuscles.
It may be that the characters of the blood described by Eichorst are,
when present, highly suggestive of pernicious anaemia, but they do not
appear to be always present in that affection, and further investigation
of the subject is needed before accepting that author's confident state-
ment.
I must conclude this paper, already too long, without an examination
of the relations existing between pernicious anaemia and Addison’s dis-
ease, leukaemia, pseudo-leukaemia, and purpura haemorrhagica, or of the
part taken by the sympathetic system in the production of the blood-
changes. Time will not permit of such an undertaking.
The conclusions that I venture to draw on this subject are:—
I. That all the various forms of anaemia, i. e., forms as determined by
the conditions under which they occur, may occasionally take on pro-
gressive and pernicious characters.
II. That such is not unfrequently the case with the anaemia of preg-
nancy and parturition, while the converse is true of chlorosis.
III. That it has not been proved that there is a distinct variety of
| Lancet, Oct. 31, 1874, p. 157.
P E R NIC I O U S P R O G. R. ES SIVE AN AF M I A. 447
anaemia, having an etiology and pathogeny peculiar to itself, and de-
manding the name “progressive pernicious.”
IV. That neither the spleen nor the lymphatic glands usually present
any, much less any special, lesion in pernicious anaemia.
V. That it remains to be proved that hyperplasia or other change of
the bone-marrow, is a cause of anaemia.
VI. That if it be a cause, it has yet to be shown whether it is the
cause of a variety that should be especially styled pernicious and pro-
gressive, and that at present the weight of evidence appears to be op-
posed to that view.
VII. That it is premature to regard pernicious anaemia as a myelo
genous pseudo-leukaemia. .
VIII. That while pernicious anaemia is perhaps rather more frequent
in females than in males, the difference in the liability of the sexes is
not very great. Omitting Biermer's 15 cases, the majority of which
belonged to the female sex, there remain in my table 47, of which 20
were males, and 27 females.
IX. That with the view of obtaining information as to the nature
and causation of the defective haematosis in all cases of anaemia, and
especially fatal cases, it is necessary to obtain a careful history of the
patient’s previous health and that of his family, to investigate the pro-
gressive changes that take place in the blood and urine as the disease
pursues its course, and to examine post-mortem the condition of the bones
and their marrow, as well as of all the other organs of the body.
#
:
SHOWING some DETAILS OF SIXTY-Two CASES OF PERNICIOUS PROGRESSIVE ANAEMIA.
Author.
Dr. Combe, Trans.
Med.-Chir, Soc.
Edinb.
Marshall Hall, Dis.
Females, p. 84.
Sir l). Corrigan,
Dub. Med. Jour, p.
506.
Dr. Barclay, Med.
Times and Gaz. ii.
480.
Dr. Wilks, Guy's
Hospital Reports,
3d series, vols. iii.
and W.
1851
1857
1857
1857
1857
1857
1859
TABLE
SeX
cº | do
à M. F.;
1 || 1 | . . 47
4 . 4'18
1 || 1 | . . .21
ſ' 1 .. 34
2- 140
F'... 131
1|.. |52
1|50
1|.. 16
7-
1|31
1|30
1|46
S-
i
1
Wiscera. Spleen.
Healthy. Normal
Healthy. |. . . . . . . . . .
Healthy. - |. . . . . . . . . .
Chalky mass | Normal
in apex of
lung.
Healthy. Normal
Fatty. Normal
Fatty. Normal
Fatty. | . . . . . . . . . .
“Semilunar
ganglion
healthy.”
Cicatrices in Not mal
colon and
ulcers.
Ltings, Normal
stomach, and
intestines
all healthy.
Fatty. Large but
healthy.
Healthy. Normal
Marrow
Glands. Liver. Heart, Kid- Blood. of Previous condition of health. Remarks. Duration.
neys. bones.
-
s & gº tº e º s e Normal Pale— Normall........ Not Anaemic symptoms the first indication ; hydrothorax. 9 months.
like exam’d
flesh.
* * * * * * * * : * ~ * * * * * * I e g º e s s a e s is e s = * * * | * e s e s s s = Not The fatal case with autopsy occurred after confinement.
eX a m'd The other three patients never were pregnaut.
a * * * * * * * * * * * * * * * * Soft- . . . . . . . . . . . . . . . . . . Not Diarrhoea off and on for a year.
ened. eXam’d
Normal Normal; Pale, Cyst in . . . . . . . . Not Ill twelve months; pain across loins and scanty urine ;| 13 months.
healthy one. eXam’d l coma.
Normal | Normall Normal Fatty. |........ Not |Several children ; last, four months before death; sore| 4 months
exam’d mouth soon after confinement ; no other previous his- after
tory. Two months before death diarrhoea, which re- confinement.
curred ; continued to nurse for three months.
Normall Fatty. Fatty. Fatty. | No in- | Not No pregnancy; domestic trouble, and recent marriage. About 1 year.
crease exam’d One year of failing health ; no hemorrhage nor diar-
white rhoea ; a servant.
corpus.
Normal Fatty. | Fatty. | Fatty. Not Not 6 months poor diet; lupus in youth ; rheumatic pains. Not given.
stated. |exam’d and sometimes headache : tanner.
as tº & e º e º 'º Fatty. | Fatty. | Fatty. Not Not | 13 months in lunatic ward; no pregnancy : tolerable | Not given.
stated. |exam’d health till last few months of life : no hemorrhage or
diarrhoea.
Normal Fatty. | Fatty. | Fatty | No in- Not No ague; ill three years; frequent epistaxis; of late Ill 3 years.
crease exam’d diarrhoea and epistaxis both obstinate ; an errand boy.
White
corpus. g
& g g tº s = e tº Fatty. | Fatty. Fatty. Not Not No history, but that was very ill of bloody diarrhoea and Not stated
stated. |exam’d occasional haematemesis during last few weeks of accurately.
pregnancy, and violent epistaxis ; never had ague ;
occupation not stated ; died 7 weeks after delivery.
* & G e g º ſº º Fatty. | Fatty. | Fatty. | Not Not Good health previously ; no cause assignable ; gradual
stated. |exam’d weakness before admission for four months, and two
weeks before, blood per a num.
* * * * * * * * Fatty. | Fatty. Normall Not Not Single; health failing ; three years since catamenia 3 years and 7
| stated. 'exam’d ceased ; had been subject to diarrhoea. weeks ill.
P E R NIC I O U S P R O G. RESS IV E A N AE MIA.
449
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29
TABLE SHOWING SOME DETAILS OF SIXTY-Two CASES OF PERNICIOUS PROGRESSIVE ANAEMIA—Continued.
H-
Qºſt
| e C
. Sex. º
& | 3 | : 3. | Marrow
Author. * | 3 % = Viscera. Spleen. Glands. Liver. Heart. Kid- Blood Of Previous condition of health. Reniarks. Duration.
gº & M F - -: neys bones
-- — — — — — — – 2–~ --- -
l ...is No |. . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Healthy; shoemaker; no autopsy.
lm Inermann, . . . 131| 1 |........... ... [Slight en- Not Fatty. | Fatty. | Fatty. No in- |... . . . . . Healthy; married; number of children not mentioned.
Deutsches Arch. f. 1874; 2 largement stated. CI'08, S6
Klin. Med. 1874, *; | and white
Xiii. 209. hardness. Corpus.
Dr. Broadl:ent, 1875|| 1 ||...} 14:3; 1 || II ealthy all | Normal. | Normal' Normal Not Not | White | Not Good health till 4 months before admission. Indigestion
1°ractitioner, Jan. except pan- exam d exam’d corpus. |exam’d and severe vomiting for two months; no hemorrhage :
875. C l'éâ.S. defic:- jaundice. Pancreas larger, firmer, and more vascular
CIl [.. than usual ; blood globules rather larger and thinner.
ſ'. . ** No | ............ . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . No in- |. . . . . . . . A dressmaker; single; bronchitis 5 months; lived in 14 months
Cl’68 Se malarious region, and had doubtful symptoms of ague. from origin of
white Six or seven months after recovery from bronchitis bronchitis.
Corpus. great weakness and irregular fever in afternoon and
Dr. Pepper, Am. decided anaemia all present, Died comatose. No *I:
Jour. Med: Sci., |1877 33 1..57| 1 Fatt Enlarged Normall Fatty. | Fatty. | Fatty. |No i Not loºm in in 1871 : ia undice i O
lxx. pp. 313–347. • * atty n large OrłIl 8, auty. y. atty. No incr. * g. o: Good health ; slight sunstroke in 1871; jaundice in :
one-half. white |exam’d March, 1872, and when it disappeared a month later
& corpus. anaemia found present. 5-
l. 30. 1 ............ Slightly | Normal Fatty. | Fatty. | Fatty. No incr. Dis-, Psoriasis 12 years; no upper teeth 12 years : chronic ºd
t enlarged. White eased follicular intestinal catarrh and chronic suppuration t
l - corpus. |marrow of gall-bladder. º
ll. . [52]. 1 Healthy : Normal. Normall Normal Fatty. Not No in- Not . Porter; parents died at 78 and 98. Cough ; anorexia ;| 7 months.
ſ muc. melnb. fatty. crease exam’d transitory diarrhoea for four months, and then when
Dr. Pye-Smith, of stomach white first seen was intensely anaemic.
Virchow's Archiv, 1875|| 2 thickened. corpus.
lx V. 1|, |47| 1 | Solar plexus | Normal. | Normal Fatty. | Fatty. | Not No incr. Not |Doubtful attacks of ague; in last seven years has suf-| Could not be
normal. fatty. white exam’d | fered several times from dyspnoea, and his face paled determined.
* corpus. and strength failed gradually.
lſ . . i4S, I IIealthy. Mode- | Normall Normall Not Not | No in- Not |Carpenter ; no previous disease ; no unfavorable condi-| About 17
rately exam’d exam’d crease exam’d tions of life : ulcers on legs discharged freely from months from
Dr. Schelby-Buch, enlarged. * Fººtnº, 1871, and since then pale ; died ſº
Hºnºlº .*. 1876| 2- . . 1|60 l Dila tod Mode- Not Fatty. Fatty. | Fatty. | No in- Di - Nurse; sickly for several years; well-fed ; from Easter . Not to be
490. . Pp. bronchi. rately stated. crease eased 1873 grew worse and more anaemic ; died gradually determined,
e.g. * * * enlarged. white |mal row | collapsed and comatose. only 2 weeks
corpus. in hospital.
Dr. E. H. Bradford, 1876| 1 || || || || No ............ [..........|................ tº @ is a tº e º e ] e º e s e a s is About | Not |Health good : well-fed; other members of family healthy | About 71
Boston Med. and 1 white|exam’d looking : during March began to lose appetite, and days only.
Surg. Jour. July to 245 gradually lost strength and color. No disease found
1876. Y red. during life.
Krieg, quoted in ... 148] 1 Sarcoma in • * * * g e º s I e º s ºn e s a s \ = * * * * * * * Fatty. . . . . . . . . . Not Not Married peasant : not stated how many children ; was
Centralblatt, Ber- brain. given. |exam’d ordinarily healthy till a year before death ; during
lin, 24 June, from 1876. 3 | that year pet echiae ; bleeding gums and pleurisy.
Würtem b. Corr. || |* No | . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . * * * * g g g tº e º $ tº e I e g º e º s a e i e s is 8 tº s e s A provost ; no history given.
Bl. 1875, No. 30. Li ºl 49. No | . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . © º º • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A merchant; no history given.

i
5
Author.
Dr. R. P. IIoward,
Sept.
4 & April.
Notes given me by
Dr. (1 roome, of
Granby.
Dr. F. Fod', quoted
in Ceutral blatt f.d.
Medic. Wissen-
schafton, Oct. 16.
i
1871
:
ſ
4-
Sox.
M | F
#
. .33
46
... [30
l*-m-º.i
No
Marrow
Viscera. Spleen. Glands. Liver. IIeart. Kid- Blood. of Previous condition of health. Remarks. Duration.
neys. bones.
Healthy. Normal. Mesen- | Normal Normal Normal No in- Not |Forwarding merchant; healthy till two years before ; a About 2 years
teric en- crease |exam’d sister died of cousumption ; rest of family healthy. and 2 months.
larged. White For last two years at times uneasiness after meals,
corpus. sore mouth, and gradual loss of strength and color.
e e e º º is g º ºs e º e & s tº tº s tº s s a tº 1 g º g g g g g g | g g g g g g g s ........ . . . . . . . . . . . . . . . . . . . . . . . . . . |Merchant; ague sixteen years ago ; a tendency to diar-| Could not be
rhoea. Came to Montreal eight years ago, and since determined.
then complexion had gradually grown paler and ten-
dency to diarrhoea increased. Father died at 27 of
cardiac disease, and mother of bowel disease. No
autopsy, but no disease could be detected during life.
Calcareous |Atrophied. A tro- Normal Fatty. Normal No in- Not Bookkeeper; healthy, not robust; slight diarrhoea in About a year
masses in phied crease |exam’d 1872. April, 1874, indigestion, which continued in a from time he
lungs. IlleS (2 Il- White mild form all the year after, and pallor showed itself consulted me.
teric COrpus. in August.
and
lumbar
e e is tº e s s a s s ∈ n | * * * * * * *s w a º e = * s e e s s ........ [........] . . . . . . . . . . . . . . . . . . . . . . . . . Respectable married woman, four children ; years ago
had few slight epistaxes; menorrhagia for two years,
and then began to be anaemic ; seen by Dr. G. two
years later ; intense anaemia existed ; died exhausted.
Jan. 17, 1876. Famiily history indicated predisposition
to anaemia. No disease of organs detected during life.
& e º ºs º º $ tº & # * * 3 times | . . . . . . . . . Little Fatty. |. . . . . . . . . No in- Tumor Unmarried ; lived under unfavorable conditions ; had
normal enl’ged crease on ribs; heen always sickly, and was exhausted by repeated
size and White dis- hemorrhages; for a year had suffered rheumatic pains
cont’uing corpus. eased in joints; case of myelogenous pseudo-leukaemia (?).
larger Il) &l TI'0 W
cells than
matural,
and like
thoso
found in
IIlº, l'I’OW.
452
ALCOHOL IN ITS THERAPEUTIC RELATIONS AS A FOOD
AND AS A MEDICINE.
EY
EZR.A. M. HUNT, M.D.,
OF METUCHEN, N. J.
WE propose to consider the subject of this paper" by inquiring into—
I. The value of alcohol as a food ;
II. Its value as a medicine;
III. IIow far its value is modified by variability in the composition of
spirituous liquors.
I.—Any article, to rank as a food, must be convertible into tissue or
force, in such a way as to contribute to healthy vitality and aid the body
in the performance of its normal functions. This includes that energy
which the body needs in the execution of its own processes of nutrition
and repair, and that which must be generated to fit it for the expendi-
ture of proper force in its contact with the world about it. So definite
is the relation between the human system and the usual foods by which
it is sustained and propelled, that in respect to most of them we are not
left in doubt. If we take any one of the ordinary aliments, and subject
it to clemical analysis, and then apply the same process of examination
to human material, we are not slow to trace the correspondence of the
two. Since chemistry has come to be more perfect in its methods of
analysis, and physiological investigators have been careful to study rela-
tions, and test them by science and art combined, these adaptations are
seen to be systematic and definite.
[The ascertainable qualities which constitute a food are, in the original paper, illustrated
by a comparison of the various aliments with the organic constituents of the body. A
description is given of the ascertained processes of their conversion into tissue and force.
The testimony of Wanklyn, Fowne, Attfield, Bridges, Liebig, and Bernard is adduced as
to the accuracy of our knowledge of foods, with allusions to the experiments and testimony
of Voit, Bischoff, Wilson, Playfair, Lankester, Frankland, Haughton, Mapother, and others.
It is shown that alcohol, as subjected to such tests, fails to establish itself as a food.]
There has been such unanimity of consent among those of divergent
views in other regards, as to alcohol, that it is not a tissue-building
food, that it is by quite common consent excluded from this class. We
have never seen but a single suggestion that it could so act, and this a
mere guess. One writer (Hammond) thinks it possible that alcohol may
somehow enter into combination with the products of tissue decay, and
“under certain circumstances might yield their nitrogen to the construc-
tion of new tissue.” There is no parallel to this in Organic Chemistry,
nor can any evidence be found in Animal Chemistry to surround this
guess with the aureola of a possible hypothesis.
It has been conclusively proved, says Lionel Beale,” that alcohol is not
' [The entire paper being too voluminous for insertion, the author has furnished a synopsis
for the Transactions, reserving the right to publish the whole in a separate form.—EDITOR.]
* Med. Times, 1872.
A. L.C O HO I, A S A F O O D A N ID A S A. M. E. DIC IN E. 453
a food, and does not directly nourish the tissues. “There is nothing in
alcohol with which any part of the body can be nourished.” “It is not
demonstrable at present that alcohol undergoes conversion into tissue.”
Alcohol contains no nitrogen ; it has none of the qualities of the strue-
ture-building foods; it is incapable of being transformed into any of
them ; it is therefore not a food in the sense of its being a constructive
agent in the building up of the body.” The food tables of Letheby,
Frankland, E. Smith, etc., give no place to alcohol as a tissue-forming
food, and only allude to ale and porter as containing some nutritious
elements from the presence of other substances. The period of youth is
that in which it should be used to give muscular development and struc-
ture-building power, if possessing these properties, but authors and
experimenters with one accord exclude it from the diet of children.
In Comparative Histology we find the structure of animals, and the
laws of growth, repair, and tissue-secretion, quite similar to those in
man : yet none of the careful experiments as to foods, or the development
of the animal kingdom, have ever given alcohol a place for the construc-
tion of tissue. This undoubted exclusion of alcohol from nitrogenous
foods is all the more significant because recent investigations have shown
that this class of foods not only makes cells, but that it has very impor-
tant correlation in heat producing processes.
[Why alcohol cannot be placed amid carbonaceous, or heat or force producing foods. It
is now shown how uniform is the production of heat or force as the result of the union of
oxygen with the carbons; how accurately it can be tested, and how alcohol fails in this test.
The accuracyof experiments illustrated by those of Pettenkofer, Fowne, etc., with confirma-
tory quotations from Liebermeister, Edward Smith, Parkes, and H. C. Wood, Jr., showing
why alcohol fails as a producer of heat and force.]
The idea that alcohol is a heat-producing food, and so, like calorific
foods, is consumed in the system according to the usual law of disinte-
gration, has been so far accepted that Anstie, speaking of its anti-pyretic
effect, as now admitted, says, “Until within the last few years it was
never even suspected.” In his advocacy, while claiming that somehow
alcohol must be oxidized and converted into force, he then says “this
force cannot be heat.” In other words, the most remarkable exception
in all the laws of energy must be assumed to exist in order to make ten-
able the view that alcohol undergoes oxidation, so as somehow to elabo-
rate life force. Yet as H. C. Wood, Jr., in his recent work on Materia
Medica, expresses it: “No one has been able to detect in the blood any
of the ordinary products of its oxidation.”
[Examination as to whether alcohol increases the excretion of carbonic acid (carbon-
dioxide), which is a leading proof of the food value of the hydrocarbons, of oils, and of such
liquids as in their change impart vital force. It is shown that “the quantity of carbon-
dioxide and water produced” in vital processes is as accurately determined as in inorganic
analysis. Testimony of the leading experimenters examined and compared. The “weight
of evidence is that it diminishes the elimination of carbonic acid” (H. C. Wood, Jr.). So
far from combining in any way so as to form water, alcohol is the great parcher of tissue.
It is inquired next “Is not the formation of fat a result which proves a nutritive process,
and is it not secured by the use of alcohol 7” Whatever may have been the results from
malt liquors, or from sugary or other mixtures containing alcohol, it is shown that alcohol
neither contains any fat material, nor is any conversion of it into fat, such as takes place with
some foods, ascertainable. Explanation of cases of increase of fat while liquors are used.
Remarks as to how imperfect a test of healthy nutrition, is mere increase of fat. Examina-
tion of facts as to the reappearance of alcohol in the Secretions, and how far its quantitative
| Cameron, Manual of Hygiene, p. 282. * Hammond, Tribune Lecture, May, 1874.
* Richardson on Alcohol, p. 21. * Practitioner, vol. ii., 1873, p. 422.
* Op. cit., p. 107.
454 HUNT,
absence is a test of its appropriation as a food. The imperfection of the evidence as shown
by a survey of the experiments and views of Anstie, Ford, Parkes, Thudichum and Dupré,
Richardson, Duroy and Massing, Ringer, etc.]
Parkes says, in repiy to Amstie," “Even if complete destruction within
certain limits were quite clear, this fact alone would not guide us to the
dietetic use of alcohol. We have first to trace the effect of the destruc-
tion, and learn whether it is for good or for evil. You seem to think
that the destruction must give rise to useful force, but I cannot think
that this is necessarily so.” When an article appears to a considerable
extent in the excretions, it seems to indicate at least that it is not readily
assimilated. If under experiments absolutely complete, instead of very
defective, alcohol could not all be found, we would look for such results
of disintegration as the laws of animal chemistry would indicate, and see
how the changed products had been made available as food. Finding
none of those products which are derived from alcohol as consumed out
of the system, nor such as occur when foods are appropriated in the sys-
tem, we would be quite excusable for asking some evidence of food-value
beyond the fact that the exact quantity imbibed could not be recovered
from the excretions.
We can find no chemical law or practical excretory result which defines
alcohol as a food. “The mode of destruction is in fact unknown.” We
search in vain for products of oxidation, except a slight change perhaps
of a portion into acetic acid, in the stomach, and, in the case of the imbi-
bition of large quantities, the acidity of the urine which is found slightly
increased. “Yet in animals poisoned with alcohol, Buckheim and Mas-
sing could find no acetic acid in the blood.” No one has as yet been
able to show a method of consumption such as ought to be manifested if
this article acts as a food. If decomposed at all, it is, says Richardson,
probably “at the expense of the oxygen which ought to be applied for
the natural heating of the body.”
But if those who would defend alcohol as a food are unable to identify
it as such by any of those tests which indicate nutritive or energizing
foods, may we not assign it a place in what are called accessory or aux-
iliary foods?
[Accessory and auxiliary foods defined, and the terms shown not to be an indefinite escape-
ment for failures of evidence. How as a so-called accessory or auxiliary food alcohol fails
to find for itself such a place as is assigned to water, chloride of sodium, condiments, fruits,
etc. It is shown how modern chemistry has made even those which we once called accessory
foods to have a definable place.]
Alcohol not only does not merit a place as an accessory food, according
to any known laws of such foods, but it is very well known to induce
deterioration of tissue, and to disturb the relation between the nitroge-
nous foods and water. In appropriating the water so as to dry the tissue,
as already noted, it thickens membranes intended for that vital trans-
mission of fluids known as endosmose. Thus local “sclerosis or a harden-
ing of nerve tissues is one of its frequent manifestations.”
[Special examination of the attempt to define alcohol as an accessory food by saying
that it delays metamorphosis of tissue. The whole subject of progressive and retrogres-
sive metamorphosis of tissue examined. Their importance as physiological processes shown
to be such that delay of metamorphosis is in itself, as a rule, a disturbing and invaliding
process. It is so exceptionally beneficial that it must be directly shown, in the case of
any special medicament, that it is conservative of health, and how it is. Quotations from
Practitioner, p. 85. * Parkes, p. 272.
3 Ibid. * Hammond.
ALCO HOL AS A F O OD AND AS A ME DIC INE. 455
Pappenheim, Cameron, Beale, Hammond, and others, showing the inconclusiveness of this
kind of evidence. Full examination of this argument as attempted to be substantiated by
ºn or change in excretions, and by its impeding of corpuscle and other blood-
cnanges.
Examination of the claim that alcohol belongs to the catalytic substances, and modifies
metamorphosis by the “action of presence.”
Next, does alcohol show a food value by the tests of dietetic and sanitary experience 2
Examination of the cases of Anstie and Inman, and rebutting evidence. It is concluded
that alcohol is not shown to have a definite food value by any of the methods of chemical
analysis or physiological investigation.]
II.--We next propose to discuss the place of alcohol in the Materia
Medica, and its therapeutic action. “There is,” says Lionel Beale, “no
more important question in medicine to be determined than the action
of alcohol in disease.” As we come to inquire into the value of alcohol
as a medicine, after having found its reputation as a food unsustained,
it is well to remember that the terms food and medicine are often more
nearly allied than the mention of the words is apt to indicate. A medi-
cine is that which helps to heal or repair, for that is both the etymolo-
gical meaning of the word and the practical design of the article used.
The process of restoration or repair is often but an application of the
process of natural nutrition. Amid the progressive changes of food into
tissue, and the retrogressive disintegration which all life implies, we
must not deceive ourselves by terms. Much of the discussion, therefore,
as to the value of alcohol as a medicine, is in reality to be determined
by what it can do toward repairing the waste of tissue which occurs in
disease. What it can do in this regard depends largely upon the deter-
mination of its food value. This we have seen to be so small and inde-
terminate, that it will not do to push it forward as a valuable medicine
in those respects in which medicine chiefly concerns nutrition and the
production of animal heat.
When we find that alcohol has no nitrogen with which to nourish ;
that it does not respond to the laws by which animal heat is usually
evolved ; that it at best undergoes such imperfect change in the system
that much of it is found unchanged in the secretions, excretions, and tis-
sues; that the products of its primary or secondary change cannot be
identified ; that it is not settled whether it diminishes the carbonic acid,
or urea, or other excreta, or whether such diminution would be repara-
tive, we may well hesitate to assign this drug a place in the category
of medicinal agents. When it has eluded the ingenuities of science, the
persuasions of art, and the astute diligence of interest, to extemporize
it into a food, it must be remembered that it has made a signal failure
to vindicate its position as a medicine in any one of the particulars in
regard to which it is most frequently urged as of value.
|Next to the consideration of the place of alcohol as a medicine, we come to inquire how
far the variability in the composition of spirituous liquors and their unreliability modify
their therapeutic value.]
III.-If we are to consider any article therapeutically, we ought to be
able to know that it is the article which it professes to be. The clinician
who claims uniformity of result, and a declared therapeutic effect, from
a given article, has reason to question whether the effect was a result of
the conceived cause, when he finds that the alleged cause was necessarily
inoperative by reason of absence or admixture. If the article used was
not tested either as to quality or quantity, if the general rule in respect
456 HUNT,
to it is unreliability, we surely cannot trust general opinions as to its
dietetic or medicinal value. -
We have been used to hear criticism as to the composition of liquors
without much professional impression derived therefrom, supposing that
these criticisms were chiefly based upon general accusation, or the trial
of bar-room specimens, and that the bonded warehouse and the druggist’s
label were an assurance of purity. But in the medicinal examination of
liquors we find some facts which address themselves to us most directly
in their clinical bearings. In our inquiry in this line we shall pursue
the same course as when examining into food value, seeking our informa-
tion from chemists, from medical experts, and from the best accepted
authorities on the composition of alcoholic medicines.
There is much difference in different spirituous liquors, and in dif.
ferent specimens of the same kinds of liquor, as to the amount and kinds
of alcohol and other ingredients, independent of any question of adulte-
ration. A reference to the Proportion Tables of Brande, Fontenelle, Bence
Jones, Thudichum and Dupré, etc., will show at a glance such variations
as these: Wines, in general, contain from 8 to 26 per cent. of alcohol;
Madeira from 19 to 26 per cent. ; Port from 17 to 25 per cent; Sherry
from 19 to 25 per cent. ; and various other wines from 16 to 18 per cent.
Thudichum and Dupré state that a natural wine may contain from 9 to
16 per cent. of alcohol. Fowne says of them, “The quantity of alcohol
varies very much.” Sherry often has from 6 to 8 gallons, port wine
3 gallons, and the best port 13 to 15 gallons of brandy, added per cask.
This is not considered admixture, but original “fortification,” as it is
called. Native European wines, by the English law, must not have over
26 per cent. of alcohol. Champagne, Burgundy, and the Rhenish wines,
contain an amount varying from 8 to 14 per cent., by measure, of
alcohol.
Such statements are made still more significant from the authority of
Parkes, who says: “So various is the amount of alcohol in wines from
the same district, that a very general motion only can be obtained by
tables, and samples of the wine actually used must be analyzed.”
Brandy, whiskey, and gin contain from 50 to 60 per cent. of alcohol, and
rum from 60 to 80 per cent. ; apple brandy should have from 40 to 46
per cent. As we shall see hereafter, these are so varied in other regards,
in the various processes and methods of manufacture, that their more
restricted alcoholic variation is an inadequate measure of their thera-
peutical import.
If, as claimed by most, alcohol is the chief available medicinal ingre-
dient of alcoholic stimulants, it is clinically requisite to know just how
much we are administering in each dose prescribed. This all the more
when leading representatives of alcoholic treatment now claim that the
limit in health is within two ounces in twenty-four hours; and that the
limit in disease is far narrower than once believed. In face of the grave
facts which come to us from pathology and from practice as to the
effects of over-doses on the nervous and circulatory systems, and upon
secretion and excretion, it is not good practice to deal with an article
without some definite knowledge of the dose administered. While
effects are a proper measure of degree of use, when they are so watched
and classified, and so numerous, as to justify inferences, yet that must
* Op. cit. p. 265.
A L CO HO I, A S A. F O O D A N D A S A. M. E. DIC IN E . 457
ever be an imperfect clinical study of any medicine which is unable to
state the amount administered in any given case. #
But the time is already at hand when, in speaking of alcoholic liquors,
we must define what form of alcohol we mean, as well as how much of
it is present, since they are often mingled, and their physiological and
medicinal effects are totally different. Let us gather up briefly from
chemists and experimenters, such as Fowne, Attfield, Richardson, and
Prescott, a few significant facts, which are, we believe, not gainsaid,
and which present the question of the medicinal use of alcohol, so called,
in quite a new light.
Fowne gives a list of twelve alcohols, as belonging to what is known
as the monatomic series. Of these, five chiefly concern us in medicinal
and dietetic relations; these are the methylic, CH,0; the ethylic, C.H.O;
the propylic, C.II,0; the butylic, C.II,0; and the amylic, C.H.O. Fowne
says: “The term alcohol, originally limited to one substance, viz., spirit
of wine, is now applied to a large number of organic compounds, many
of which, in their external characters, exhibit but little resemblance to
ordinary alcohol.” Yet, as we shall see, no usual liquor is clear of some
one of them besides the ethylic, which is the one known as common
alcohol; and, secondly, their effects are medicinally quite different.
“The first of the series, methyl alcohol, naphtha, or wood spirit, is not
an original impurity in manufactures of an ethyl (or common) alcohol;
but in the form of methylated spirit has been added in the falsification
of liquors.” Pure methyl alcohol is a colorless, thin liquid, very similar
in smell and taste to ethyl alcohol, and, like it, is a mobile, watery
liquid.” “It has an aromatic Odor, free from empyreuma, and a sharp but
not acrid taste.” The methylated spirit has been used fraudulently in
the manufacture of the sweet spirit of nitre.” Richardson” has made
some important inquiries in respect to this substance. He names the
case of a well-known physician who himself used it in preference to
common alcohol, regarding it as less injurious. Richardson has long
used it in his practice as a substitute for the common alcohol. He says
“it is much more rapid in action, and much less prolonged in its effects,
than is common alcohol, so that it produces its effects promptly, and,
what is of most importance, it demands the least possible ultimate ex-
penditure of animal force for its elimination from the body. This latter
fact is of great moment, for, in the end, all these alcoholic fluids are de-
pressants, and although at first, by their calling vigorously into play the
natural forces, they seem to excite, and are therefore called stimulants—
they themselves supply no force.” He notices its special power of re-
ducing the temperature (p. 32), and calls it the lightest and least inju-
rious of the alcohols (p. 23). If we are giving an alcoholic medicine
made of this substance, we are using the spirit most allied to, and yet
very distinct from, ethylic alcohol, or the purported kind."
The propylic alcohol is not yet much understood in its medicinal
action. Chancel' obtained it from fusel or amylic alcohol by fractional
distillation. One of its isomeric modifications has a very close resem-
blance to ethyl alcohol. It is not unfrequently found with it in liquors,
and, of course, modifies its characteristics. Its medicinal action is not
| Prescott, Peninsular Journal of Medicine, Detroit. April, 1876.
2 Fowne, p. 510. * Prescott, loc. cit. 262.
, * Attfield, p. 384. * Cantor Lectures on Alcohol, p. 30.
* See also Monroe, “Is Alcohol Necessary 2” 7 Fowne, p. 31.
458 HUNT,
yet well enough understood to draw the contrast between it and the
genuine ethyl drink or medicine. It is, if possible, even more greedy of
water than the latter, and so still more robs the tissues.
Butylic alcohol is often contained in amylic alcohol, and so is present
in the usual fermentations. When valerianic acid is artificially prepared
from butylic alcohol, as is commonly done, the various valerianates are
often contaminated by butyrates." There is reason, therefore, to believe
that it is often present with the other alcohols. Richardson seems to
have shown that this heavier alcohol is much more apt than the ordi-
nary alcohol to cause tremors of the kind occurring in delirium tremens.
Its effect is certainly very different from that of the alcohol designed for
common medicinal use, and it must be studied by the physician in its
own distinct effects. -
The next in the series is known variously as amylic alcohol, potato
oil, grain oil or grain spirit, and fusel oil. In its relation to the ethylic
or assumed common alcohol of alcoholic liquors, it is of most interest to
the physician. “It constitutes,” says H. B. Prescott,” “the chief part
of fusel oil, which also contains the fourth alcohol (butylic), and traces
of the third (propylic), and these together appear quite invariably in
the alcoholic fermentation of sugar, their preparation being varied by
conditions.” “It is the great and naturally occurring inpurity of
liquors,” says Fowne (p. 535). In the manufacture of brandy from corn,
potatoes, or the must of grapes, the ethyl (common) alcohol is found to
be accompanied by an acrid oily liquid called fusel oil, which is very
difficult to separate completely from the ethyl alcohol.” Attfield” says,
“Amylic alcohol is a constant accompaniment of ethylie or common
alcohol, when the latter is prepared from sugar which has been derived
from starch.” This, of course, applies to all alcoholics prepared from
grains or vegetables, either by brewing or distillation.” Not only does
it thus occur naturally, but some of that found in wines and spirits is
probably added. Much of it is imported to England, it is believed, for
that purpose." No doubt much of it is thus returned to us as a direct
re-importation, marked pure from the bonded warehouse. As common
alcohol dissolves it readily,” as it has a pungent but not acrid taste by
dilution, and has a fruity taste and smell, it is much relished. It is the
heaviest and most injurious of the five alcohols thus far noticed. It has
a burning, acrid taste, its vapor producing oppression of the chest.”
When produced as so often in manufacture, or when added for profit
and improvement of flavor, it is “an extremely dangerous addition to
ordinary alcohol.” Its action is the same as that of butylic alcohol,
“except more prolonged by reason of its greater weight and insolu-
bility.”
In this country, where whiskey and other fermented products are so
largely used, the art of their concealment and modification so as to give
a relished flavor, is well understood. There is little doubt that certain
effects of alcoholic liquors of late years are due to the more profita-
ble utilization of the “contemporaneous” alcohols with the ethylic. It
is also true that the addition of such alcoholics as the methylic, or of
various substitutes for all the alcohols, has left what is called the expe-
rience of prescribers somewhat mythical.
* Attfield, Med. and Pharm. Chemistry, p. 322. * Loc. cit.
* Op. cit. p. 389. * Fowne, p. 520. ty
* Richardson, op. cit. p. 36. * Fowne, p. 535.
7 Ibid. p. 536. * Richardson, p. 37.
A L CO H. O L A S A F O O D A N D A S A. M. E. I.) I C IN E. 459
|Next it is shown how, in the various modes of preparation and manufacture, variations
occur not only from different vintages, distilleries, and breweries, but from difference in
method and the financial interests of makers—all within the limit of legitimate prepara-
tion.
Next it is shown, by the testimony of chemists, how different alcoholics are modified by
adulteration or imitation. Testimony of Thudichum and Dupré, Mülder, Parkes, Richard-
son, Battershall, Prescott, Cameron, etc.]
There is still another most important therapeutical view to be taken
of the various alcoholics.
The time has already come when prepared liquors which have never
seen a vintage or a distillery, dispute their right to be accounted genu-
ine, and not to be branded with the epithet “adulteration.” The ablest
and most candid French work and authority on the manufacture of
liquors (Duplais), discusses the question from the stand-point of business
integrity, and leaves it without adverse decision. Prof. A. B. Prescott,
the able chemist of Michigan University, in his work on the Chemical
Examination of Alcoholic Liquors, says: “The term brandy, as used
in commerce, without qualification, must be held by common consent to
include artificial brandy.” He makes three divisions, viz.: veritable
brandy, artificial brandy (or that made of the same ingredients according
to chemistry), and fictitious brandy ; i. e. a fraudulent imitation. There
are many preparations known as brandy essences, which are so combined
with spirit as to make artificial brandies difficult of distinction from the
veritable."
Griffen, who is an authority, and who has examined many specimens,
says that he found what he called Public House Brandy not to be a dis-
tilled spirit, and yet that it had the taste of a good cognac. He gives a
German recipe which he says, after long keeping, gives a brandy very
similar to real cognac in taste and odor. He adds that this sort of so-
phistication is evidently becoming an ordinary commercial practice.
The recipe, as given by him, contains much purified spirit, but only eight
quarts of wine to 150 quarts of mixture.
Duplais's most able and scientific work, of 700 pages octavo, translated
by McKennie, and published by Baird, Philadelphia, 1871, would be
incomplete without its pages on “Imitations.” Speaking of cognac, as
the most difficult of all brandies to prepare artificially, it says (p. 293):
“It is a fact worthy of note that the brandy obtained in consequence of
the addition of a spirit foreign to the wine, in limited proportions, cannot
be distinguished from the natural wine by itself, that is to say, without
the addition. Finally, brandy resulting from the new method, defies all
methods of investigation. We may suspect the mixture, and even know
of its existence, but we cannot furnish the proof; neither the most skil-
ful and practiced taste, nor the persevering researches of the most skilful
and learned chemists, have been able to detect it. M. Payen himself
acknowledged some time since that, in the actual state of the science,
the discovery of the mixture presented insurmountable obstacles.” Such
a book as that of Pierre Lacour, on “The Manufacture of Liquors, Wines,
and Cordials, without the aid of Distillation,” and others well-known to
makers, and but little to physicians and pharmacists, show to what
perfection the experts have attained. The chapter of Duplais on the
preparation of various liquors, of which alcohol, sugar, and water, are
the basis, also shows how artificial and successful are such compounds.
The author, after admitting that “the immoderate use of spirits, and
| Prescott, p. 23.
460 HUNT,
even liquors, is pernicious,” and after designating the drunkard as “a
wretch who is unworthy to live” (pp. 437–8), claims that the “aromatics
and sugar are good for digestion,” and the small quantity of alcohol not
injurious to persons in health.
We have had occasion to examine recent popular books of recipes for
the imitation of liquors, and it is wonderful to what perfection the art
has been elaborated. When we look into our recent chemistries and see
how many natural products are duplicated in art, and that fruit essences
and flavors are so well imitated that connoisseurs cannot distinguish
the artificial from the real, it is to be expected that the great profits
accruing would induce the production of liquors without the trouble of
vintage, wine press, or distillery. More Madeira wine is in the market
than could be made on the island of Madeira if each grape made a gallon.
Critical examinations have gone far enough to show that in all alcoholic
drinks, as consumed for thirst or medicine, the veritable article is largely
reduced or superseded by admixtures and imitations. The editor of the
London Lancet well says: “We suggest it were well worth our while
in the future for us to transfer our allegiance, when we would prescribe
alcohol, from the wine and spirit merchant to the chemist.” When
imitations are repudiating the reflection of being “spurious,” and
claiming legitimate place beside the “veritable” products, and when the
“fictitious” are difficult of distinguishment, is it not high time for the
therapeutist to take reckoning as to his professional position in reference
to alcoholics as at present prescribed : -
In face of facts, such as we have adduced, it is a burlesque on the pre-
cision of modern therapeutics to deliver ex cathedrá opinions as to the
medicinal value of alcohol, when we are using all sorts of remedies under
the name, are attributing to them results which are shown to be impos-
sible, and prescribing them with an unscientific laxity which would be
Scouted in the confines or even in the purlieus of any exact science or
any expert art. -
In the light of accumulating facts as to the whole alcohol series, as to
the manifold and variable combinations preseribed under the cognomen
of alcoholics, and with candid regard to the wide and contradictory
range of their composition, we must needs review the record of our materia
medica. We must recognize the unscientific and empirical data on which
we have rested, as insufficient to overcome the facts of histological and
pathological research, and feel that demand is made upon us to show the
conservative modus operandi of a medicine which so significantly asserts
itself as a toxic and depressant.
Such questions as these are presented for exact consideration, to a de-
gree that neither science nor practice would ignore.
(1) What is the effect of ethyl alcohol as a medicine :
(2) What trustworthy experiments have we as to its physiological
effects, and as to its therapeutic indications?
(3) What guide as to the quantity to be given :
(4) What testimonies of experience as to its clinical use?
(5) With present light as to the manifold variations of alcohol in
legitimate manufacture, and its change by admixture, are the usual tes-
timonies as to the advantage of ethyl alcohol as a medicine of any pro-
fessional value, unless composition has been determined :
| Lancet, Nov. 1, 1873, p. 639.
ALCO II O L AS A F O O D AND AS A ME DIC IN E. 461
(6) How far can methyl alcohol take the place of ethyl alcohol as a
medicine 21 .
(7) How much does any alcohol or fusel oil occur in various alcoholics,
either by virtue of manufacture or admixture ?
(8) How far are the effects of wines dependent upon their numerous
exhilarating ethers, their albuminous matters, their sugars, acids, and
salts, and how far are the effects of each kind due to the varying propor-
tions of these? The same inquiry may be made as to all alcoholics from
fruits.
(9) How far is the effect of whiskey due to its ethers, essential oils,
acids, sugars, malt, etc., and so as to all distilled liquors from grains :
(10) How far do the effects of malted ales, beers, etc., depend on sugar,
starch, etc. :
(11) How much are clinical experiments worth which speak of the
value of alcohol as a medicine, with utter disregard of such items ?
(12) Is it possible so to deprive wines, etc., of all alcohol, as to secure
their action independent of the spirit 7
[The rest of the paper reviews the changes in the use of alcohol in various diseases, and
shows how assumptions as to its value have been modified. It shows, also, how other ex-
hilarants can easily be substituted in a large majority of cases.]
The following are the conclusions submitted to the Section of Practical
Medicine:—
I. Alcohol is not shown to have a definite food value by any of the
methods of chemical analysis or physiological investigation.
II. Its use as a medicine is chiefly that of a cardiac stimulant, and
often admits of substitution.
III. As a medicine, it is not well-fitted for self-prescription by the laity,
and the medical profession is not accountable for such administration, or
for the enormous evils arising therefrom.
IV. The purity of alcoholic liquors is, in general, not as well assured
as that of articles used for medicine should be. The various mixtures,
when used as medicines, should have a definite and known composition,
and should not be interchanged promiscuously.
On motion of Dr. J. M. RIDGE, of Camden, N. J., seconded by Dr. N. S.
DAVIS, of Chicago, Ill., the conclusions of Dr. Hunt's paper were adopted as
expressing the opinion of the Section, and were ordered to be transmitted to
the National Temperance Society, the Women's National Christian Temperance
Union, and the Friend's Temperance Union of New York, in reply to commu-
nications addressed by those bodies to the International Medical Congress,
and by the Congress referred to the Section on Medicine.
| Richardson says that it is practicable to substitute it. A. B. Prescott expresses the
opinion that the views of Richardson are correct. The introduction of methylated spirit,
in place of the excise proof-spirit, has been a most important measure in Great Britain.
See Report of Professors Graham, Hoffman, and Redwood, Quarterly Journal of Chemical
Society, vol. viii., and Fowne's Chemistry, p. 518.
462
REPORT OF INVESTIGATIONS MADE UNDER THE DIRECTION
OF PROFESSOR, RUDNEW AT THE INSTITUTE OF PATHO-
LOGICAL ANATOMY OF ST PETERSBURG.
COMMUNICATED BY
PROFESSOR, RUDNEW.
I. SCLEROSIS OF THE WESSELS OF THE LUNGs.
By DR. BERESNEWITsch.
MANY eminent writers maintain that the vessels of the lungs are sub-
ject to a disease known as “Sclerosis,” or the “Atheromatous process.”
Dittrich, in his work entitled “Uber den Laenneckschen Lungeninfarct,”
especially describes this disease, and states that it affects the arterial
branches of the lungs, and causes the formation of a substance within
the inner and middle coatings of the vessels, which he further asserts
becomes, in time, either a fibrous tissue, or fatty or calcareous matter.
Dittrich further says that this affection occurs more frequently with
cardiac disease, especially of the right ventricle, or when the lungs are
themselves affected with atrophy and emphysema.
Far from agreeing with this authority, we are led to believe from
more recent observations, that instead of sclerosis resulting from emphy-
sema, emphysema is more probably due to sclerosis. Other writers and
anatomists seem to have given but little attention to this form of lung
disease, some being disposed to accept Dittrich's theory, while others
maintain the opinion that sclerosis of the lung vessels is extremely rare.
In consequence of the small number of careful observations made in
respect to this disease, and the diversity of opinion which appears to
exist, I have instructed Dr. Beresnewitsch, one of my pupils, to deter-
mine by the minutest microscopical observation, (1) what arteries are
directly affected (whether bronchial or pulmonary), and (2) under what
conditions this disease occurs, the latter question to be investigated before
the former.
Dr. Isaacson, one of my pupils, some years ago investigated, under
my direction, many cases of emphysematous degeneration of the lungs,
and found that this disease was always due to an affection of the lung
vessels. The development of emphysema begins when the blood vessels
become closed by coagula, around which the tissues disappear by reason
of want of nourishment. The occurrence of this coagulation is due to
the destruction of the inner coating of the artery, and now Dr. Beresne-
witsch has shown that this destruction is due to the presence of syphi-
litic infection, which in course of time manifests itself not only in the
capillaries but also in the larger vessels, sclerosis consisting in the de-
velopment of connective tissue between the layers which form the inner
eoating of the artery.
C O N TRIBUTIONS TO PATH O L O GIC A. L. A N A TO M. Y. 463
II. ON THE DEVELOPMENT OF CANCER IN THE LYMPHATIC GLANDS.
BY DR. AFANASIEFF.
Cornil, Thiersch, Waldeyer, Rudnew, and others, by their investiga-
tions, have already proved that the primary development of cancer
always originates from the morbid condition of true epithelium. The
greater part of the writers of the present day agree with this opinion,
while the number inclined to differ therefrom becomes gradually less
and less. The minute and careful investigations of later days tend to
confirm this view, as we hear of no cases at the present time, in which
cancer is reported as arising otherwise than in the epithelium.
This theory has been based upon the fact, only lately discovered, that
there are many new formations which have hitherto been considered as
cancerous, but which, although very similar, are not cancers at all, but
tumors which are called endotheliomatous, a term which perfectly sepa-
rates them from cancers which are epitheliomatous.
Upon the secondary knots of cancer, the opinions of different writers
do not accord—some affirming that the secondary formations actually
arise from the passing of cellular particles from the primary growth,
while others maintain that the cellular particles transferred, impregnate
those already existing, and thus together lead to the formation of the
secondary knots. Waldeyer, Lücke, and a few others, accept the former
view, but refuse to accept the latter. These authorities appear to base
their opinion upon the doctrine of Remak, who asserts that the cells of
the upper and lower layers of the embryo never mix with the elements
of the middle layer.
In conjunction with my colleagues, I have lately undertaken a careful
examination of the lymphatic glands affected with secondary cancer,
and we find that, whether the glands are sound or affected by previous
morbid processes, the condition of development of cancer knots remains
the same, and in either case is due solely to the cellular particles trans-
mitted from the primary cancer, and does not in any way result from
the already existing elements of the glands, which elements, far from
participating in the formation of the cancer knots, undergo a retrogres-
sive change.
III. PATHOLOGY OF SCLEROSIS OF THE ARTERIES.
BY DR. ENGELHARD.
The morbid changes to which the arteries are subject have been known
a long time. Crell, Haller, Morgagni, and other writers of past times,
described thickness and ossification of the arterial walls, but they did
not possess the means now brought to bear in investigation, and seem
to have considered the different stages of the disease, not as we now
understand them to be, various phases of the same affection, but as
totally distinct morbid conditions. The opinion of the authors referred
to, upon the causes of disease of the arteries, seems to have been vague
and contrary to fact, inasmuch as they attributed this form of disease
to the absorption of foreign matter previously infused into the blood.
Lebert and Stokes are, however, of opinion that sclerosis of the arteries
arises from local changes produced by the nutrition, while Rokitansky,
who formerly adhered to his own theory that the disease was due to the
464 R U DNEW,
deposit of a certain substance from the blood, now agrees with Dittrich
and Virchow in attributing its origin to abnormal extension of the
arteries.
With these three distinct forms of opinion, at variance with each
other, which is to be considered as the correct one 7 The recent investi-
gations made by myself and colleagues tend to convince us that not one
of the already stated views is according to fact.
We find that the first morbid appearance is due to a rupture of the
media which permits a passage from the adventitia to the intima. This
rupture causes irritation of the adventitia, and provokes inflammation,
the products of which pass through the seat of rupture and propagate
within the intima. This rupture, crevice, or cleft, as it may be termed,
although probably of minute dimensions at first, is greatly influenced
by the amount of the product of inflammation, so that, as that product
increases, so also does the crevice become increasingly large, until in due
course the media in certain parts are totally destroyed, and the regular
circulation of the blood is markedly obstructed, thus giving rise, after a
time, to the various forms of aneurism. This will explain the manner
in which sclerosis and aneurism of the arteries originate in certain cases.
Another form of the disease may be regarded as arising, not in conse-
Quence of an affection of the media, but of the intima itself. The internal
surface of the intima ceases to retain its natural smoothness and rotundity,
becoming undulating in appearance from an irregular thickening of its
tissues, which thickening gives rise to scores, the ulceration of which,
being permitted to increase, involves in destruction first the media and
afterwards the adventitia. When the destruction of the media is com-
plete, aneurism soon follows. -
Having thus classed the forms of this disease under two distinct heads,
permit me to specify the several causes by which they are produced.
The first and most frequent cause of the changes of the vessels may be
considered to be syphilitic infection of the body; the tissues of the media,
under a syphilitic influence, being extremely fragile and liable to be
ruptured from distension. Another very frequent cause is found in the
morbid effect produced by alcoholic drinks. I may mention in reference
to these two causes, that the first or syphilitic affection generally attacks
the media, while the influence of alcohol is found to affect chiefly the
intima. Among the many other causes of the production of sclerosis of
the arteries, is the absorption of certain poisonous substances, such as
mercury, phosphorus, etc., as well as of those poisonous matters the
chemical nature of which is but little known, as those of typhus and
intermittent fever, etc.
Now permit me to describe the anatomical changes, microscopical as
well as macroscopical, to which the coats of the blood vessels are liable.
The macroscopical changes consist in a local thickening of the intima,
having the appearance of yellowish spots dispersed over the inner surface.
of the arteries. The next stage or change is confined to the enlargement
of the artery until it reaches the condition of aneurism. In describing the
microscopical changes, I would distinguish very clearly the two different
changes in the coats of the vessels. In the first or syphilitic affection
the disease begins with a rupture in the media, which permits the
inflammatory product of the adventitia to pass to the intima. This
inflammation has generally the character of granulated inflammation.
The second form commences, on the contrary, in the intima, the first
C O N TRIBUTIONS TO PA. T H O L O GIC A. L. A. N. A.TO MY . 465
change consisting in the appearance of minute cellular particles collected
into nests of a size more or less large. These cellular particles arise
from two sources; sometimes they are formed by division of the tissue-
cells, but more generally their existence is due to the extravasation of
the white blood-corpuscles. These nests do not long retain their form,
but in consequence of the degeneration of the cells are transferred into
scores, giving rise to the Endarteritis ulcerosa.
30
467
SECTION ON BIOLOGY.
P. R. E S I D E N T OF T H E S E C T I O N .
JOHN C. DALTON, M.D.,
OF NEW YORK.
W I C E - P R E S I D E N T S .
AUSTIN FLINT, J.R., M.D., FRANCIS W. CAMPBELL, M.D.,
OF NEW YORK. OF MO N T R E.A.L.
S E C R. E. T. A. R. Y .
JAMES TYSON, M.D.,
OF PHILADELPHIA.
THE MICROSCOPY OF THE BLOOD.
tº BY
CHRISTOPHER JOHNSTON, M.D.,
OF BALTIMORE, MD.
A DISTINGUISHED writer, Dr. Thomas Williams," states that “in the cate-
gory of the nutritive fluids unmixed fluidity is not known; solids are
introduced. Fluids are not self-productive; they require either the direct
or the catalytic agency of solids. The fluids even of the vegetable organ-
ism bear floating corpuscles.” And again farther on he insists that “no
single real example occurs in the whole animal kingdom of a nutrient
fluid totally destitute of morphological elements. This rule (of the cor-
pusculation of the animal fluids) is ultimate and absolute.”
The blood proper, corpusculated therefore, the chiefest of nutrient fluids,
differs from any other, both in vertebrates and invertebrates, in that it is
contained in a closed system of vessels, and moves in a determinate circu-
latory orbit. It was “this circulation, the discovery of which does
not, and could hardly,” says Flourens, “belong to one man, or even to
a single epoch. Galen opposed Erasistratus; he opened the way which,
afterwards followed by Vesalius, by Servetus, by Colombo, by Caesal-
pinus, by Fabricius of Acquapendente, led us to Harvey.” Whilst
naming the great Servetus, however, we ought possibly to have cited
another Spanish claimant, Francisco de la Reyna, of whom Don Fran-
cisco Benito Jeronimo Feyjoo (a very eminent and learned man, who
“did more for the intellectual life of his country,” observes Tickmor.”
“than had been done for a century”), in the third edition of his “Cartas
Eruditas,” published in Madrid in 1774, makes the following mention.
In the twenty-eighth Carta he says: “The literary phenomenon which
you bring to my notice is rare, and curious as rare. Is it possible that
| British and Foreign Medico-Chirurgical Review, Oct. 1853, p. 301; Art. I., The Blood,
etc.
* Ticknor's History of Spanish Literature.
468 J O HNSTON,
a Spanish farrier can have been the first discoverer of the circulation of
the blood 7 You write me that a friend of yours has a Book of Farriery,
by the Farrier Francisco de la Reyna, printed in Burgos in the house of
Felipe de la Junta in the year 1564, and that he saw the fellow to it in
the Royal Library, probably the only copies in Spain. You send me the
transcript of a passage in Chapter 94 of the said volume, so clear, so
decisive, as to the circulation of the blood, that it establishes the fact
that the aforesaid Reyna was acquainted with it. This little sentence
banishes all doubt: “So that the blood goes round and circulates throughout
all the members (De manera que la sangre anda en torno, y en rueda por
todos los miembros).” Or, as Feyjoo, on page 318, quotes, “our Farrier,
who first, before Harvey, used the word circulation, and who left it dis-
tinctly written that the blood goes round and circulates through all the
members (la sangre anda en torno y rueda por todos los miembros).”
However this may be, the circulation of the blood, the passage of the
blood from the arteries into the veins, was proven as a fact by Harvey, but
the direct demonstration was wanting. It came at last, the microscope
afforded it; yet it was denied to the grand old age of Harvey, who died
without witnessing it. But in 1661 Malpighi saw the blood pass from
the arteries into the veins of the mesentery, the lung, and the urinary
bladder of frogs, and by that act crowned the work
“By the side of the Wolffian bodies, on the axial side, the general
epithelial lining of the great lymph sac, the pleuro-peritoneal cavity,”
thickens, its cells assume a columnar shape, they proliferate freely, and
then form a raised mass of “germ epithelium.” “From this layer the
ova are subsequently developed, whilst the vascular stroma of the ovary
is formed by an outgrowth from the side of the Wolffian body.” In these
few words a modern writer, while noticing the advanced genesial labors
of Dr. Foulis,” expresses upon certain points the common belief of embry-
ologists, and points out, in terms which they may or must accept, the
manner of a new departure of nucleated protoplasm in the production
of “primordial ova” from the germ-epithelial corpuscles. And again,
according to Schenck,” we assert that “originally the entire pleuro-peri-
toneal fissure is lined on its inner surface with cylindrical cells, which
originate from the subdivided lateral portions of what was at first the
middle germinal plate.” And this layer of cells serves exclusively to
form the subsequent peritoneal epithelium. But the cylinders soon dis-
appear, leaving as their descendants entirely flat, pale elements; the
median angle corresponding to Remak’s middle plate, and later the
Wolffian bodies, which grow out from this spot, alone retain their cover-
ing of cylindrical epithelium. Since then this peculiar cylindrical epi-
thelium, this germ-epithelium, gives rise out of its own elements to the
primordial ovum, it follows that all tissues whatsoever reckon these
extraordinary elements as their ancestors; and that, whatever be the
intermediate forms, the transition is neither sudden nor remote from
cylinders of germ epithelium to the corpuscles of the blood, that fluid
organ of which it is now our province to speak.
The microscopical study of the BLOOD, however fascinating, is beset
& a s s”.
with difficulties even if we confine ourselves to the human subject, and
| Error: “Huic sanguinis circulation; ex dextro cordis ventriculo per pulmones, etc.”
Andreas Caesalpini Quaestionum peripateticorum, lib. v. p. 125. Edition of the Giuntas,
Venice, 1593. -
* Lancet, March 14, 1876. * Stricker, p. 540, Beitrag, etc.
MIC ROSCOPY OF THE BLOO D. 469
these are greatly increased if our observations extend to other animals
which are spoken of as standing lower in the scale. Its state or condi-
tion as deprived of life, its constituent parts motionless and tending to
decomposition, must be regarded, or else it must be studied in the energy
of life as it hurries on in the performance of its errand, making its cir-
cuit, and coming again and again to the primum movemtem, as the sweet
bard of Avon spoke of “those ruddy drops which visit this sad heart.”
Nor is the blood simply alive, it is also the seat of life; it is life itself:
“Vita est in sanguine, vita est sanguis ipsa.” Again the blood may be
studied microscopically or otherwise, as an organ self-sustaining, replen-
ishing its substance, providing for its own nutrition and loss by wear;
as an organ, “mére de tous les tissus,” offering to every structure the
pabulum for its needs; as an organ, through or by its anatomical con-
stituents, brought into intimate association with the great acts of nutri-
tion ; and as an organ gathering up the molecules of somatic attrition
everywhere and conveying them to an emunctory. The blood also offers
for consideration various accidental, incidental, and temporarily abiding
matters, such as therapeutical remedies, introduced by the mouth or by
the hypodermic needle; poisons of every kind; bacteria, on the high
authority of Billroth and others; and Filaria sanguinis, as seen by many
in the blood of dogs, but studied in India, in the human blood, by T. R.
Lewis, M.B., and by him associated with that singular condition of
which chylous urine is a marked feature.
The elements of which this exceedingly composite fluid is made up, in
the vertebrata, may be arranged in several categories, one of which
would include all of the many components, whether tending centripe-
tally or centrifugally, whether these be a solvent, or be themselves held
in suspension or solution, and all regarded and scrutinized in the state.
in which they absolutely exist in the blood; another would segregate
the same elements, and present them isolated, each in its own distinct
and independent physical condition ; and finally a third would establish
a distinction between the elements having form and those having no
definite figure, or being formless in their actual mode of being in the
living, moving, sanguineous stream.
It is true that the microscope must be the handmaiden of science in
each of these fields, limitrophic but yet autonomic, whether the objects
be originally, primarily, or secondarily encountered in them ; but it is
with the elements of the third category that the microscope chiefly ex-
hibits and exerts its magical power, presenting to the eye, “and to the
intelligence by the eye,” life-histories of the forms which swarm in its
illuminated circle, whether the tendencies be intrinsic or extrinsic, nor-
mal or pathological. The elements which have a form, characteristic
and determined, and an approximative size, are the red corpuscles and
the leucocytes, white corpuscles, or white globules; and with these we
propose to deal exclusively, regarding them from two points of view,
viz., (I) that of anatomy and physiology, and (2) that of medical juris-
prudence.
It is with the origin and reproduction of the blood-disks, as with the
genesis of a new being; the most intense interest as well as curiosity is
excited, and all possible means of research are called into requisition to
push, plus ultra, the limits of knowledge, and to mark with tangible
definiteness the boundaries of legitimate speculation. And it so happens
* Dugès, Physiologie. Art. Sang. * Flourens, Leçons Orales. [C. J.]
470 JOHNSTON,
that an integer of the “germ-epithelium” becomes or is a primordial
ovum, and that from certain of its derivatives, even in the vascular sys-
tem itself, the ruddy corpuscles arise, oscillate, and hesitate with uncer-
tain aim, until the primum movems gives direction as it acquires power,
whereupon they speed away in ceaseless commotion. But the microscope
shows the forms of the “primordial blood-colored blood corpuscles,” and
recognizes these bodies in all their after career; and yet so differing are
judgments that they are asserted by Afanasieff to originate in the fowl
contemporaneously with the first vessels of the vascular area, or in the
vascular layer and area opaca, detaching themselves from the walls of
the vascular spaces, or originating, according to the views of His, in the
form of groups, from large masses of protoplasm in the walls of the ves-
sels, and at a later period bursting into their lumen.”
In mammals it is impossible to adduce other expression than Kölli-
ker's,” that at a very early period nucleated colored corpuscles in process
of fission are visible in the blood of the embryo.” In proportion, how-
ever, as the embryo and spleen especially undergo development, these
forms are less abundant ; and, after a certain time, leucocytes first make
their appearance in the blood of the liver. Or that of Schmidt,” in a
paper “ on the origin and development of the colored blood corpuscles in
man,” which is that “the facts already observed [by him], and being in
accord with each other, strongly indicate that the primary birth-place of
the colored blood corpuscles in the human embryo is to be sought in the
gland-like follicles of the umbilical vesicle.” We can, therefore, says
the same author, “look upon the blood corpuscle as a gland cell,” and
consider that in early embryonic and in later life the organs in which
the processes of generation and formation of the blood corpuscles in man
take place, represent nothing else but glands, and that the leucocytes, or
rather the nuclei of the leucocytes, are metamorphosed into colored cor-
puscles.
In January, 1875, the younger Flint,” in the first volume of his Physi-
ology, gives a summary of our knowledge, in the present state of which
the following seem to be the most rational views with regard to the de-
velopment and nutrition of the blood corpuscles:–
(1) “At their first appearance in the ovum they are formed by no
special organs, for no special organs exist at that time, but appear by
genesis in the sanguineous blastema.
(2) “When fully formed they are regularly organized anatomical ele-
ments, subject to the same laws of gradual waste and repair as any of
the anatomical elements of the tissues. &
(3) “They are generated de novo in the adult, when diminished in
quantity by hemorrhage or otherwise, and, under these circumstances,
they are formed in the liquor sanguinis by the same process by which
they take their origin in the ovum.”
From what has been advanced it appears that in all of the foetal life of
man, regarded as a representative of mammals, four conditions of the
blood manifest themselves, to wit: (1) the primordial, colored, flattened
corpuscles existing alone at a very early period; (2) the appearance of
leucocytes associated with the preceding; (3) the occurrence of circular,
! Remak; Rollett, in Stricker, p. 291. * Rollett, p. 291.
* Zeitschrift für Rat. Med., 1867. 4 Rollett.
5 H. D. Schmidt, M.D., Monthly Microscopical Journal, February 1, 1874.
* Flint, Physiology, vol. i., Blood, etc.
MIC R O S COPY OF THE BLOO D. 471
bi-concave disks mingled with the two other forms; and (4) the with-
drawal from the blood-mass of the first formed, the temporary embryonal
colored corpuscles, upon which the blood corpuscles, red and white, adopt
a relation which is only to be altered by disease or physical violence.
And here we are immediately struck with the difference between the
transient form as nucleated, and the permanent form as non-nucleated,
and we ask ourselves if it can be, as Flint has declared, that the red
disks are probably generated by the same process in the embryo and in
the adult. If, for a while, we wander from the domain of fact to the
regions of fancy, we may find in the works of Leeuwenhoek, that great
man largely in advance of his time, a wide generalization deduced from
observations made with indifferent lenses, or ill prepared objects. That
was about the end of the seventeenth century. In the fourth decade of
the eighteenth century (before 1745, the year of his “calling to a new
and holy office”), we find that learned visionary, Ennanuel Swedenborg,
in a tract “written in Latin before his illumination” on the Red Blood,
asserting that “the blood contains all organic forms from the primary
spiritual, to the ultimate angular, and in this respect is the compendium
and complex of all the forms of nature.” That “each blood globule
contains within it, and carries in its bosom, details more numerous than
the eye can ever discover, or the mind conceive.” And further he lays
down this postulate, that “the red globule admits of division into six
lesser and pellucid globules. For six lesser globules have been actually
seen in one large blood globule, and, indeed, the mode in which they are
united, and the relative position they occupy to each other, have been
described and drawn, and wax models representing the whole have been
constructed. Moreover, the several lesser globules have been seen in the
act of separating from the compound body; and furthermore, experience
has shewn that these prior or simpler globules are themselves divisible
into still lesser ones, and even into least, when [illogically enough he says]
sight can follow them no longer.” “All these particulars must be received
as true, because the observer, Leeuwenhoek, and the witnesses to his ob-
servations, are worthy of credit.” And finally, as far as we care to quote
this author, Chapter V. opens with the declaration that, besides the lesser
pellucid globules which constitute the large globules of the red blood, there
are also in the blood certain angular or saline and earthy parts. -
Rather more than a century later, in 1846, Dr. Carpenter” assures us
that the blood corpuscles “are to be regarded as nucleated cells, conform-
able in general character with the isolated cells which constitute the
whole of the simplest plants.” And of this there can be, says this emi-
nent author, no reasonable doubt. From this we should infer that they
have no power of reproducing themselves; and the recent observations
of Dr. Barry and other microscopists seem to confirm the statement
made long ago to that effect by Teeuwenhoek. The first change said to
take place is the appearance of delicate radiating lines between the
nucleus and the periphery, dividing the disk into several segments,
usually six in number. The margin is soon observed to be crenated by
indentations at corresponding points, and these indentations become
deeper until a complete separation takes place, setting free six young
cells or disks which seem to have been formed around the border of the
nucleus of the parent cell. And therefore should we expect to find, as
| Translated by John James Garth Wilkinson.
* Principles of Human Physiology, 3d ed., p. 107.
472 Jo HNSTON,
we do meet with, every size intermediate between the small newly gene-
rated disk and the full-sized corpuscle. To sum up, therefore, with regard
to the appearance in question of the red blood disk being constituted
of six parts (Leeuwenhoek") in the usual state, or divisible into seven
parts (Barry, Carpenter, and others), six around the assumed nucleus, it
may be fairly stated that now-a-days the crenation of the red disk is
regarded as the evidence of parting life, or of the earliest post-mortem
change.
If we now turn to form, we meet with two varieties of colored corpus-
cles in vertebrated animals, the elliptical and the circular, the former
occurring in fishes (with the exception of a few Cyclostomata, which
have circular disks), all amphibia, and birds, and, among mammals, in
the Camel and Auchenia;” and the latter characterizing the blood of
man and other mammals with the exceptions noted. The red blood disks
of all mammals are, according to Rollett, smooth, and give no indication
of any difference in the index of refraction of their several parts.” In
birds, amphibia, and fishes, however, the colored corpuscles do not appear
homogeneous, but offer a prominence on either side of the long edge
when viewed in profile, which corresponds to a central area somewhat
whitish or less deeply tinted when seen on its face. This prominence is
absent in Amphiuma.” It appears, then, continues Rollett, that we may
divide the blood corpuscles of animals into “two classes, the nucleated
and the non-nucleated, for the behavior of the central spot is so different
from the remaining substance of the corpuscle, but shows so great an
agreement with the structure termed the nucleus in other animal cells,
that we designate this structure as the nucleus of the blood corpuscle.”
On this point, as we shall see, Rindfleisch offers a conclusive observation.
And we may add our own experience as with Amphiuma, in the staining
with magenta and carmine of the large granular nuclei of the colored
blood corpuscles in even measure with the nuclei of the giant ciliated
epithelial elements of the mouth. Yet before proceeding further it is
necessary to recall attention to the fact that nucleated colored corpuscles
characterize the embryonal blood of man and other mammals.
Gulliver classifies all blood disks of vertebrates as the Pyrenaematous
and the Apyrenaematous, which divisions correspond to the oviparous
and non-oviparous groups, the corpuscles of all the latter being circular
in form and flattened, with the exception of the Camel's and Auchenia’s,
which are oval but still apyrenaematous, whereas the colored disks of all
oviparous vertebrates are nucleated. But Henle, even in 1843, while
claiming the human red blood disks among the nucleated in their early
condition, utters words which strongly remind us of the modern Beale
in reference to formed and germinal matter. Henle” says, “We have yet
to show, with regard to the higher vertebrates, as man, that when the
coloring matter accumulates in the blood corpuscles, and when their
envelope is flattened, their nuclei are dissolved or resorbed, and that con-
sequently the cellule of the blood, arrived at its perfection, is a simple
vesicle containing a fluid.”
The color, and especially the structure of the disks which we are con-
sidering, have greatly occupied the scientific world from the time when
Malpighi saw “globulos quasi subluteos in quibus non widi motum rota-
* Transactions Philosophiques, 1674; see Henle, Anat. Générale, p. 497.
* Rollett, p. 265. * Rollett, p. 266.
* Author. * Henle, Anat. Générale; Paris, 1843, p. 491.
MIC R O S COPY OF THE BLOO I). 473
tionis” until the present time." In man they have been declared to be of
a pale-yellow or a reddish-yellow color, quite in opposition to experience
elsewhere, which is that no mass of either yellow or reddish-yellow could
ever so behave with light as to assume the scarlet hue deep and glowing
of the human blood. For this reason we hold the yellow hue in doubt,
and because no observer can ever with unaided eye ascertain the true
color of a single colored disk. The microscope, in enlarging surface,
dims its brightness, and also dilutes or attenuates its color, so that while
it is altogether possible by apparatus below the stage of the microscope
to compensate for loss of light by the higher powers, no art can restore
color to a disk, probably crimson, when its image is amplified ten, a
hundred, or a thousand times in diameter. Now what holds good for
mammifers, obtains in all probability with the lower orders.” In evi-
dence of this statement it will be remembered that the eosenic red of a
single corpuscle intensifies if a number of corpuscles lie superposed in
the field. In the lower animals the color of the blood, or, what is the
same, of the colored corpuscles, varies to some extent, and were our ap-
preciation of the cachet of the tints of crimson sufficiently discriminating,
we might by recognizing them also identify, probably in this way alone
if dimensions failed to aid, the several possessors of the colored disks, as
Dugès asserts that the bloods of many creatures have been distinguished
from one another by their characteristic aura.
Leaving color we encounter structure, and here most probably begin
the real difficulties of our task. The corpuscles of the blood of mam-
malia, by reason of their size, do not afford facilities for the solution of
the first problem as to whether the disks have a limiting capsule. But
the larger blood cells of amphibians would seem to offer themselves as
easy solvents of the question, especially the frog’s ovate bodies and the
giant colored and largely nucleated corpuscles of Amphiuma tridactylum.
Unfortunately, however, microscopists are not in accord upon several
structural points, nor is disagreement confined to them alone. We have
already noticed the composite structure attributed to the “red globules”
(as they were called by Leeuwenhoek), referred to by Swedenborg, and
reproduced by Drs. Barry and Carpenter. But for more than a century,
from the time of Malpighi himself, who saw the circulation of the blood
and its corpuscles, the idea of an investing membrane and its contents
was debated in science, having been suggested most probably by Robert
Hooke's description of the cellular structure of plants in 1667. Indeed
we find it implied by writers of a later period, as Mandl in 1839, or dis-
tinctly expressed, as by Donné, who, in 1844, speaks of the blood disks
as being “flattened vesicles containing a more or less fluid substance.”
And he speaks of the substance of which the vesicle is composed as being
of an albuminous nature. -
Rölliker" entertained the same view, for in 1854 he says “that the
blood corpuscle is constituted of a very delicate but nevertheless tolera-
bly firm, and at the same time elastic, colorless cell membrane.” “The
corpuscle is consequently a vesicle, whence the name blood-cell is to be
preferred.” More recently Gulliver, in the Proceedings of the Zoologi-
cal Society, February 25, 1862, speaks of “the embryonic corpuscles as
* Malpighi, Opera Posthuma, p. 92.
* Quarterly Journal of Microscopical Science, 1855. [C. J.]
* Mandl, Traité pratique du Microscope; Paris, 1839, p. 113.
* Al. Donné, Cours de Microscopie; Paris, 1844, p. 66.
* Manual of Microscopical Anatomy; Philadelphia, 1854, p. 704.
474 JOHNSTON,
constituting a first or temporary set.” “These cells,” continues the dis-
tinguished author, “both in structure and size are the true analogues of
the red corpuscles of oviparous vertebrates.” And again “the corpus-
cles of the second set are those which replace the first, and, subject to
waste and supply, are the red corpuscles of the blood during the greater
part of utero-gestation and until death. The corpuscle is not homo-
geneous, but is composed of a colorless membranous part or basis, sepa-
rable by water, with a fluid viscid matter in which color resides.”
We cannot here enumerate the great authorities who have entertained
or who still entertain the view above quoted ; it suffices for us to present
it as one which still finds favor with many. The contrary opinion, more
bold in its enunciation, because at variance with accepted laws, finds its
able exponent in Beale, among others. He says in “How to Work with
the Microscope,” p. 134, that “by drawing a needle across the thin glass
under which the red corpuscles are placed, they may be divided into many
small globules. This proves that the red blood corpuscles consist of a
mass of soft viscid matter, the outer part of which is somewhat hard-
ened.” Or again, several red corpuscles may, under certain circum-
stances, coalesce, and even crystallize without exhibiting indications of
any cell wall whatever. Besides the subdivision into small spheres or
spheroids, the same author" adduces other reasons, as that the mass of the
germinal matter in the case of the nucleated blood corpuscle of the frog
and other vertebrates, or a portion of it, may pass right through the red
viscid material of which the outer part of the corpuscle is composed,
without the rupture of any membrane. Now Rollett” declares that,
“after the cautious addition of water,” it frequently happens in the
nucleated ellipsoids that the nucleus changes its position in the cor-
puscle with a jerk, and then lies eccentrically in the corpuscle. Finally
Beale remarks, “when water is added to blood corpuscles they swell up
just as a piece of jelly would swell up, but they do not burst as is gene-
rally stated.”
Whichever way we incline, we have fair grounds for our belief, as
also excellent authorities and companionship; but we are disposed to
favor the modern view, as being more consistent with observations upon
fresh blood and blood dried on slides, and as being entirely in accord
with what we know elsewhere of protoplasm, especially in the pyrenae-
matous colored corpuscles.
Of the leucocytes, what shall we say ? What are they : Whence
come they : Whither go 7 And do they appear pathologically under
the form of pus? Whatever interest may attach to the red disks, the
white equally claim our attention ; for, in the language of Rindfleisch,”
“the red blood corpuscles would form one pole, the amoeboid colorless
cells the other, and, between the two, formation and deformation go con-
tinually to and fro.”
The colorless morphological constituents of the blood, according to
Max Schultze, are of several kinds;* “first, round cells, less than the red
blood corpuscles, composed of a thin layer of cell substance investing one
or two nuclei. With these may be associated other forms, equalling in
size the ordinary red blood corpuscles, and like the former possessing
1 The Microscope in Practical Medicine, 1867, p. 170.
* Loc. cit., p. 277.
* Experiment. Stud. u. d. Histol. d. Blutes, v. Dr. Edward Rindfleisch; Leipzig, 1863,
p. 41.
* Rollett, p. 288.
MIC R O S COPY OF THE BL O O D. 475
nuclei. Lastly, finely and coarsely granulated amoeboid cells are met
with, and various intermediate forms between them.” “In freshly drawn
blood,” continues Rollett, “these last appear as more or less rounded or
irregularly shaped forms. At a temperature of from 95° to 104°F.,
lively movements resembling the creeping motions of an amoeba occur.”
“Such cells,” says Frey, “have been seen to pass out (after the manner
of an amoeba) through the walls of the capillaries (A. Waller, Cohnhein
[and Col J. J. Woodward, M.D., in his beautiful photograph of inflam-
mation of the mare's stomach]), towards or through the lining tissue, and
to take up into their contractile cell-like bodies small particles, such as
molecules of indigo, aniline, cinnabar, and carmine, the finest milk glo-
bules, and even extravasated colored blood corpuscles.”
These inclusions of red corpuscles by amoeboid leucocytes are not to
be confounded with “the so-called cells containing blood corpuscles,”
mentioned by Rindfleisch,” who declares that “the opinion only appears
to me admissible here that a secondary separation of fibrin has formed
about a group of blood corpuscles.” And Preyerº saw portions of the
red blood corpuscles of extravasated blood in amphibia, taken up by
white blood corpuscles, and thus explained the nature and mode of occur-
rence of the bodies that had been previously called blood corpuscle-
holding cells. But themselves or their analogues are to be found, ac-
cording to M. Cornil,” in the blood of the spleens of patients who have
died in the third week of typhoid fever, in the form of white globules in
large numbers, inclosing red globules to the number of five, six, or even
more in a single cell. Although, continues the reporter, the existence
in the blood of these large cells containing red globules is nothing new,
nevertheless Cornil is the first to insist upon their multiplication in
typhoid fever.
Besides the remarkable properties of the white corpuscles above men-
tioned, others equally surprising are most readily brought to the notice
of the observer. The migration of these bodies in a drop of the blood of
the newt or frog, placed in a moist cell, beyond the limits of a coagulum
to the circumvallating zone of serum, has been shown by Rollett” to
occur, and he points out the advantage of this method of isolating the
amoeboid cells, and suggests that “the migration of the individual cells
renders it clear that the individual movement is the chief if not the ex-
clusive cause of their emigration.” In confirmation of the alleged amoe-
boid inclusive movements of the white corpuscles, the famous experi-
ment of Cohnheim was done in the manner to be indicated: “A small
quantity of finely granulated coloring matter, suspended in water, is to
be injected by a Pravaz’s syringe on several consecutive days into one of
the large lymph spaces which lie under the skin of the frog. On exam-
ining a drop of blood, a considerable number of the colorless cells will
now be seen to be stuffed with the granules.”
Four chief matters of interest in connection with the white corpuscles
deserve at least passing notice in this place:–
(1) Their origin, which elicited from Rollett’ the following summary:
“Whether the colorless corpuscles always undergo multiplication within
1 The Microscope, etc., Dr. Heinrich Frey; New York, 1872, p. 102.
* A Text-book of Pathological Histology; Philadelphia, 1872, p. 65.
3 Rollett, p. 290.
* Monthly Microscopical Journal, May, 1876, p. 233.
* Rollett, loc. cit.
* Frey, The Microscope; New York, 1872, p. 231. 7 Rollett, loc. cit., p. 292.
476 & Jo HNSTON,
the blood itself, and by what mode of cell genesis they multiply, are still
open questions. It is certain,” says that author, “that a large number
of white corpuscles are added to the blood, not only during the period of
development and growth of the animal organism, but also throughout
life by the agency of the lymph current, the corpuscles of this current
originating in localized germ-producing organs situated external to the
blood (lymphatic glands).” Our own observation of the blood of a young
seventeen inch long Amphiuma tridactylum, goes to show that the leu-
cocytes had greatly multiplied in number after the head had become
much inflamed in consequence of repeated attempts of a larger Amphi-
uma to swallow that which was the subject of experiment. Again, the
pathological process of leukaemia,” so called, seems to be associated with
an increase in volume of the spleen, and often at the same time of the
lymphatic glands, although but seldom caused by the enlargement of the
latter organs alone.
(2) Their transformation into red or colored corpuscles, for which in
the frog we have the authority of Recklinghausen, Sclarewsky, and
Golubew, but which if it do occur in the human subject, happens very
slowly in convalescent leucocythaemic patients. The intermediate forms
met with in the blood of the frog were known, but not correctly referred,
by the earlier observers, as Wharton Jones and Hensen.” Besides we
have also the authority of Bizzozero and Neumann” for the statement
that the transformation of the lymphoid cells may be seen in the red
bone-marrow of mammalian animals; and this bone-marrow itself, is,
according to some authors, as Frey, one source of origin of the colorless
cells of the blood.
(3) Their relative proportion to the red corpuscles cannot be regarded
as fixed, for the averages of the best observers, as Welcker and Mole-
schott, differ sensibly. Thus, Welcker states his average as one white
corpuscle to three hundred and thirty-five (335) red, while Moleschott
finds one in three hundred and fifty-seven (357). The proportion also
varies with age, their number being greater in the young than in adults,
and, according to Hirt, they increase during full digestion, but diminish in
fasting. And lastly, Hirtº “found the number of white corpuscles seem-
ing greatly to differ in various parts of the vascular system ; thus in the
splenic vein they are as one to sixty (60) red ; in the splenic artery as one
to two thousand two hundred and sixty (2260); in the hepatic vein one
to one hundred and seventy (170); and in the portal vein as one to seven
hundred and forty (740).
(4) The migration of the lymphoid cells into the space of the connec-
tive tissue, and their relation to the pus cells. In this connection the
great name of Cohnheim immediately rises before us. His observations,
confirming the older views of A. Waller, possess, says Frey, “an extra-
ordinary range, and have rapidly called forth an entire literature.” In
connection, however, with this subject, interest may be awakened by
reference to the conviction of Mandl, expressed in 1839, that “we” demon-
strate the perfect identity of globules of pus and of the fibrinous globules
of the blood . . . as we understand it.” Henle” soon after declared
that he had “shown that the nuclei of the lymph corpuscles go through
the same metamorphoses as those of pus; they differ by their volume
| Frey, op. cit., p. 232. * Rollett, loc. cit., p. 291.
* Frey, op. cit., p. 307. - * Hirt, apud Rollett, p. 290.
* Mandl, op. cit., p. 120. * Henle, op. cit., p. 509.
MIC R O S COPY OF THE BLO O D. 477
only.” And in a note added by Prof. Stricker to the American edition
of his Histology, 1872, page 47, that eminent scientist assures us that
his “later investigations have shown that the process of division of
pus cells can be directly observed under the microscope.” But most
curious are the general conclusions arrived at by Mandl in his Memoir,
read before the Société Médicale d’Émulation, June 3, and found in the
Gazette Médicale de Paris, July, 1840. They are as follows: “1. The
fibrinous globules of the blood, the globules of mucus, and those of pus,
are identical. 2. All the globules are the product of the coagulation of
the fibrin in the serum, which has transuded through the walls of the
blood vessels. 3. The liquid in which the globules swim constitutes the
difference between pus and mucus. 4. If the fibrinous globules remain
fixed to the surface of the membrane where they are secreted, they
become the nuclei of epidermoid cells, which constitute the elements of
the epidermis. 5. If, on the contrary, the fibrinous globules remain free
on the surface of the membrane, they are expelled by the organism, and
form an element of pus and mucus. 6. These two elements are simply
filtered blood ; that is to say, they contain the elements of the blood,
except the globules, the serum at the same time undergoing chemical alter-
ation.” -
In opposition, in Virchow's Archiv, Bd. lxii. S. 47 (1876), we find that
Professor J. Arnold discovers “the white corpuscles themselves in the act
of escaping in an inflamed tissue, through the cement substance, that is
the stigmata, and that gelatine and vermilion also pass through the cell
wall at the position of the stigmata and cement substance.” How well
Mandl saw, but failed to interpret, may be understood by a comparison
of his conclusions, in 1840, with the beautiful researches of Waller, Cohn-
heim, Woodward, and J. Arnold, in later years.
As soon as the corpuscles of the blood were an assured acquisition to
science, they very naturally attracted and received great attention for
themselves as wonderful objects on account of the rôles which they were
supposed to play in physiology, and because of the very great importance
which their possibly positive recognition in the several classes or genera
of animals would necessarily assume in medico-legal investigations.
The interest in these elements has continued unabated until the present
hour, and all the resources of art have been put in requisition to insure
not only their detection under all and difficult circumstances, but also to
make certain their specific identification. To this end many devices
have been put in practice, such as bettering the modes of presenting the
corpuscle in every state for investigation; the use of high powers, and
improvement in the quality of the objeetives employed in their study;
their exact mensuration, relative and positive ; their enumeration ; the
establishment of the normal proportion existing between the colored
corpuscles and the leucocytes; and, finally, an appeal to the spectroscope,
which might discover in the minutest trace of cruorin the ghost of even
one departed red disk which had yielded up its form.
With regard to the first of these efforts, the best condition under which
these little bodies may be thoroughly investigated, we have nothing to
urge in behalf of the various preservative fluids which have had fortune
with microscopists, being satisfied that, as far as our own experience ex-
tends, the question is not as to how excellent a substitute may be pro-
1 Microscopical Journal, 1841, p. 80. * Monthly Microscopical Journal, June, 1876.
478 JOHNSTON,
vided for the liquor sanguinis, but rather how greatly superior is the
liquor sanguinis itself. Of course, this view involves the necessity for a
limited range of observation by each of the scattered students of compara-
tive haematology, for it is not given to each and several of these to push
inquiry with all the special bloods in their living or immediately recent
state. Amphiuma, proteus, and the musk deer, are not only strictly
local, but are very widely separated geographically; the standard bloods,
however, are almost everywhere accessible, for the frog, the horse, the
cat, and the dog, fishes and newts, are almost passim ; and thanks to
itinerant menageries and fixed zoological collections, many strange ani-
mals are assembled in unfamiliar districts. Besides, we can have, or
Ought to have, human blood at our own finger ends. -
For use as artificial standards, the corpuscles, mounted dry on the
under surface of the thinnest cover, are decidedly of the greatest service,
for as all mammiferous red disks, and perhaps a few of the other smaller
forms, confessedly shrink but little, and as in medico-legal investigations
the expert has usually to deal with dried hemorrhagic stains or clots,
like is directly compared with like, as could also easily be done if excep-
tionally immediate blood were obtainable as food for the microscope or
spectroscope. But let it be well understood that we greatly prefer the
recent, the living blood, if possible, on every account. Form is unal-
tered ; all physical qualities are unchanged; characteristic behavior
at the normal temperature, and in presence of such reagents as magenta,
acetic acid, water, or an alkali, is conspicuous; and heat, or life, or light,
or other modes of motion, start up in microcosmic play.
With regard to the methods of perfecting objectives, we propose to be
silent, leaving the problems which these create to our own Tolles and
Spencer, to Powell and Lealand, and the Becks, to Wales and Ross, to
Zeiss and Seibert, to Scheik and Plössel, and last, but not least, to Wood-
ward, and Wenham, and Keith. But we accept the superb work of the
great artist-scientists of the day, and we rejoice in the splendor of their
instruments.
More germane to our subject is an expression of opinion as to the
degree of amplification requisite for exhaustive and conclusive study of
the blood; and at once the microscopist is struck with the necessity for
the employment of high powers for all research excepting only what
might be called a general view of the field. For enumeration of the
corpuscles, a medium power suffices; for acquiring a collective idea of
blood, either in the vessels, or freshly drawn, placed on a slide, and sub-
jected to changes of temperature and the action of reagents, moderate
amplification offers the best hope; but for higher views, higher objectives
must be put to use, and an immersion' T's, sº, ºr, or even 7's inch objec-
tive, of the best maker, and of large angle, in the hands of a really good
manipulator, will afford a demonstration of all that is at present attaina-
ble. If size alone be in question, it is unscientific to hope to distinguish,
under low powers, human red corpuscles with an average diameter of
a gºatſ of an inch from those of the dog with an average measurement
of a sº a of an inch * and it is worse than unscientific to obtain large
images by forcing low objectives with short eye-pieces. We hold, there-
fore, that, with the results of mensuration of the blood-corpuscles, all the
conditions attending the measurements must be given, if their authors
| Woodward.
* Prof. Theo. G. Wormley, letter to author, May 16, 1876; New Measurements.
MIC R O S COPY OF T H E B L O O D. 479
expect to win and maintain the confidence of the world of science.
Thus Prof. Theo. G. Wormley regards the condition of his material as
attached to the under side of a thin cover; the thickness of that cover;
the temperature of the slide, by averaging measurements made at all
seasons of the year; the position of the collar of adjustment of the ob-
jective; and the identical disposition of the light in all observations;
and he employs a #3 inch objective. Besides, he has repeatedly tested
the assumed value of each of the divisions of his micrometer, and confined
himself to the employment of that or those only of which he has assured
himself as being absolutely true to the standard.
Before proceeding further with mammalian blood, let us not lose sight
of what is most probably quite as important as size, namely, the cachet,
or stamp of individuality possessed by each of the kinds of blood disks,
the determination of which is or will be a matter of necessity in micro-
scopy simple or applied. In support of this view, we would ask a serious
contemplation of two similar bloods on the same slide, of a feline, and
of an herbivore. Difference in diameter under a tenth objective may
not be a striking feature of the contrast; but a sentiment of something
beyond, for which we may not as yet account to ourselves, immediately
but stealthily takes possession of our senses.
It was with the intention of arraying in the opposition of contrast
human blood and the dog's, and human blood and the cat's, that that well-
known scientist, Dr. Joseph G. Richardson, flowed drops of blood from dif.
ferent animals so nearly in contact on a glass slide, that portions of the two
drops appeared in the same field, and could be photographed together."
Dr. C. Leo Mees, assistant to Prof. Wormley, in Columbus, Ohio, modified
this plan, spreading the bloods by the present writer's method, a half field
upon a slide, and another half field upon a cover, which is then turned
down and placed directly upon the slide. The method consists in catch-
ing a small drop of blood with the true edge of a well-ground slide, and
gently drawing it, that slide being inclined, over the face of another
slide or cover. Dr. Mees obtains half fields by scraping. “In this
manner,” says Prof. Wormley, “we obtain the bloods virtually upon the
same plane for powers under the # inch.” But after inspection, we fear
much for the assumption “virtually upon the same plane,” even for a
large angle, , inch ; nor are we prepared to admit the availability of
such slides for Prof. Wormley’s very fine sº inch objective. And besides
we are persuaded that the cachets of the two bloods, if they ever can be
recognized as distinctive, will hardly bear comparison when the disks of
one blood present their attached and flat surfaces towards the observer,
and the other disks their free, and, in the instance of circular mam-
malian disks, their excessively concave sides.
As measurement of the blood-corpuscles, colored and pallid, is nowa-
days scrutinized by the keen eyes of microscopical science and of the
law, we propose to offer in this paper some of the best modern and most
careful observations. But as a preparation for accepting the results of so
much patience and labor, and great skill, we beg to present a list of
measurements of the human blood in Hodgkin's and Lister's Micro-
scopical Observations, contained in the Philosophical Magazine, vol. xi.
p. 133, as given in the Microscopical Journal for 1841. It is as follows:—
| American Naturalist, May, 1876.
480 Jo HNSTON,
Hodgkin e e e * sn'so of an inch.
Jurine . - t e e • 52 + () { {
Jurine . w e º º Tºo “ (Second measurement.)
Bauer . º & e tº • Tºo { {
Wollaston . e o e 5 doo { {
Young . - º º - 50's 6 & &
Kater e º tº º º e idoo 4 &
Ditte . © tº o º 3 o'ow “
Prevost and Dumas º º . A 6'18 “
Nasse' . º & e - • 37%; “
A difference so remarkable as that between the rºotſ and the go'sm of
an inch, inspires little confidence in the means and the method, and such
series of observations must be now regarded as curiosities of microscopy.
Passing over the great hiatus separating the year 1840 from the time
in which we live, we would deal directly with four papers relating to
comparative measurements of the colored blood disks of vertebrates, two
of which are from the pen of Joseph G. Richardson, M.D., of Philadel-
phia, one by Col. J. J. Woodward, M.D., U. S. A., and the last and most
recent, by Prof. George Gulliver, F.R.S. In the first of these” “On the
value of high powers in the Diagnosis of Blood Stains,” an article of much
merit, the author “endeavored to work out a conclusive answer to the
question,” “whether practically we can or cannot discriminate the stains
of human blood from those made by the blood of oxen and sheep.” “In
conclusion,” he says, “I submit that the results of my experiments above
narrated, prove that since the red blood-globules of the pig (13'sſ of an
inch), the ox (4 º's 7"), the red deer (#334"), the cat (43'03"), the horse
(1 ºrg"), the sheep (sºon"), and the goat (gas s”), are all so much smaller
than even the ordinary medium size of the human red disk, as measured
in my investigations, we are now able, by the aid of high powers of the
microscope and under favorable circumstances, to positively distinguish
stains produced by human blood from those caused by the blood of any
of the animals just enumerated ; and this after the lapse of five years
from the date of their primary production.” “We may add to these,
the average measurements, those of recent blood disks procured from a
blood spot moistened with a one per cent. Solution of common salt, and
stained with a drop of [red 7) aniline solution. Thus the mean of ten cor-
puscles so treated was expressed by the fraction a 4'ss of an inch, the mini-
mum being 3 gºs of an inch, and the maximum s tº s of an inch.” Not-
withstanding the expression of belief" that the red corpuscles “rarely
contract,” the author gives the maximum a 3’s r of an inch, minimum
sºon of an inch, and mean sis'ss, of twenty recent red corpuscles of a
white male aged thirty. But again, and on the opposite side, “the
measurement of twenty corpuscles from part of the same specimen dried
in a thin film upon a slide gave a maximum of a sºrtſ, a minimum of a glºr,
and a mean diameter of st'ss of an inch.” And in the Oswego Green-
field trial, in June, 1876, Dr. Richardson testified that “drying dimin-
ishes all kinds of corpuscles.”
The second paper, by Col. J. J. Woodward, M.D., U. S. A., almost ex-
haustive in reference, and most ably presenting the author's research and
observations, appeared in the Monthly Microscopic Journal of February,
1875, five months after the valuable article just noted, and was suggested
by it as the first line distinctly assures us. The title is as follows: “On
! Valentin's Repertorium, 1840.
* Monthly Microscopical Journal, September 1, 1874.
* Loc. cit., p. 140. * Loc. cit., p. 137. * Loc. cit., p. 135.
MIC R O S COPY OF THE BL O O D. 481
the similarity between the red blood corpuscles of man and those of cer-
tain other mammals, especially the dog, considered in connection with
the diagnosis of blood stains in criminal cases.” The general tenor of
this paper is a dissent from the conclusions reached by Dr. Richardson.
Among the most striking points of stress of Col. Woodward, is the state-
ment: “For myself, after repeated measurements of the blood of the dog
and of human blood, I can only say that I find no constant difference
between them, whether the fresh blood or thin layers dried on glass be
selected for measurement. The mean of fifty corpuscles, taken at hazard,
is seldom twice the same, and sometimes that of human blood and some-
times that of the dog's blood is a trifle the larger.” In the same con-
nection, a little further on, the author gives two tabulated records of
measurements of red blood corpuscles, which very remarkably substan-
tiate the afore-mentioned doctrine, the one being measurements of red
corpuscles of human blood and the other of the same elements of the dog.
In both cases the blood was obtained from five individuals; fifty cor-
puscles formed the basis of each observation ; of the thirteen specimens
of human blood measured, four were moist ; of the nine of dog’s blood,
five were moist, and, singularly enough, “in each of the measurements”
of the two bloods “the great majority of the corpuscles ranged from 12
to 17 divisions of the eye-piece micrometer: that is, from .00024 to .00034
[ori Pº 6 to a girl of an inch.”
Before quitting this important field, Col. Woodward reminds the reader
that “the variations between the mean diameters assigned to human
blood by different observers are quite as great as the variations recorded
by any of them between the blood of man and of the dog, or even greater.”
Although there is admitted to be “no constant difference” between the
wet and the dry corpuscles, when fresh and used moist, or quickly dried
on thin glass, it is denied that a differential diagnosis can be possible in
the case of “blood dried en masse, when sprinkled on weapons, clothing,
wood, etc., for no one will pretend that it can be any easier to make the
diagnosis of such stains than it is in the case of moist blood or of thin
films dried on glass.”
In the same Journal, for May, 1875, Dr. Richardson replies to the
strictures of Col. Woodward, but states explicitly his “full corroboration”
of Col. Woodward’s assertions, and declares that “there is at present (1875)
no method known to science for discriminating, microscopically or other-
wise, the dried blood of a human being from that of a dog, monkey,
rabbit, musk-rat, elephant, lion, whale, seal, or in fact any animal whose
corpuscles measure more than athrm of an inch in diameter.” With this
admission we would fain conclude our notice of the article, but fairness
demands that the criticism of Col. Woodward, which we have reproduced,
should be followed with an explanatory statement from Dr. Richardson,
who says: “I wish to insist most emphatically that all my statements
in regard to the diagnosis of blood stains are applicable to stains only,
and not to masses of dried blood clot.” And we here would call attention
to the fact that in the case of State v. Lodicia and Albert Friedenburg,
for the murder of Orlo Davis, tried in Utica, in November, 1875, Dr.
Richardson testified" that he had examined certain spots on an axe helve
and “ had come to the conclusion that the corpuscles, or red blood disks,
or globules, were those belonging to human blood.” And again in the
Greenfield trial, held in Oswego, in June, 1876, Dr. Richardson, after
* Utica Morning Herald, Friday, November 19, 1875.
31
482 JOHNSTON,
examining dark spots on some chips belonging to the rail of a bedstead,
testified as follows: “If the question is narrowed down to whether this
is human blood or sheep's blood, I can say positively that this is man’s
blood. Because the corpuscles are such as could never circulate in the
veins of a sheep.”
In opposition to such testimony and teaching, we find in Dalton’s
Treatise on Human Physiology, sixth edition, 1875, an expression of
views which will meet with favor with the majority of advanced obser-
vers and thinkers. He says: “If a blood stain which in a watery solu-
tion gives the common spectrum of haemoglobuline, be found to contain
oval nucleated globules, this would show it to be the blood of a bird,
reptile, or fish ; and the oval form alone would show that it was not
human blood. The question, therefore, whether a particular specimen
be composed of human blood may often be decided with certainty in the
negative by microscopic examination. But if the specimen contain cir-
cular globules without nuclei, it will be impossible to say positively in
any instance that they belong to human blood, and not to that of some
animal, such as the ape or dog, whose red globules nearly approach the
human in size. In most of the domesticated quadrupeds the globules are
smaller than in human blood, but in both the sloth and the elephant they
are larger. If it were only required to decide whether a given specimen
of fresh blood belonged to man or to the musk deer, for example, or even
the goat, no doubt the difference in size of the globules would be suffi-
cient to determine the question. But within nearer limits of resemblance
it would be doubtful, because the size of the red globules varies to some
extent in each kind of blood ; and, in order to be certain that a particu-
lar specimen were human blood, it would be necessary to show that the
smallest of its globules were larger than the largest of those belonging
to the animal in question, or vice versä. The limits of this variation have
been tolerably well defined for human blood, but not sufficiently for
many of the lower animals to make an absolute distinction possible. In
the examination of stains or blood spots the difficulty is increased by the
fact that the drying and subsequent moistening of the globules intro-
duces another element of uncertainty as to their original size.”
The last paper we propose to notice, and the most remarkable of its
kind which science possesses, is entitled Observations on the Sizes and
Shapes of the Red Corpuscles of the Blood of Vertebrates, with draw-
ings of them to a uniform scale, and an extended and revised table
of measurements, by George Gulliver, F.R.S.; and appeared in the
Proceedings of the Zoological Society of London, for June 15, 1875.
The “present purpose” of this extremely sagacious and very laborious
production “is to give simply the averages, with brief explanatory com-
ments, of numberless measurements all made by me,” says Prof. Gul-
liver, “in the hope that they may be useful towards further researches of
the same kind.” “The measurements now recorded show the labors of
many years,” and consist of “many additions and revisions by new ob-
servations made since publication, upwards of a quarter of a century
ago,” of Prof. Gulliver's tables of measurements, which originally ap-
peared in the Proceedings of the Zoological Society, in 1845.
Simple as is the announcement, the variety and originality of the obser-
vations, inferences, comparisons, and deductions would be very surprising
were it not for a knowledge of the author, and of the fact that they are the
* Oswego Daily Times, Saturday evening, June 10, 1876.
MIC R O S COPY OF THE BI, O O D. 483
developed germs of more than thirty years of toil. It is foreign to our
purpose to follow this observer in all the paths that he has trod, but we
confine ourselves to the matter of measurements, and in this circle alone
we find abundant food for careful thought. Although the table of
averages “has been deduced from innumerable and generally correct ob-
servations,” the red corpuscles are found usually to differ among them-
selves in every field of vision, commonly to the extent of one-third larger
or smaller than the mean. And when we reflect upon “the real varia-
tions in size produced in the bird alternating between rest and excite-
ment; the probable diversities in some vertebrates at different times and
seasons; the possible ones influenced by climate, rest, and violent exer-
tion, periodical rise of temperature—as in python, sex, the system—
whether arterial or venous, the ever-varying state of the liquor san-
guinis,' pathological or septic changes,” it need not surprise us that the
author advances the proposition “ or fact that in a single healthy species
the corpuscles are so prone to minute variations of size that no two ob-
servers, nor even one observer, can be certain of obtaining precisely the
same average measurements.” Nevertheless “the relative value of the
measurements, though probably not unexceptionable, may be entitled to
more confidence as fair approximations to the truth.”
. The applications of what has preceded are extremely numerous, and if
it had been possible to extend the scope of this paper their number
would have been measurably increased. But we will here refer to but
two, as perhaps the chief among them, the physiological and the medico-
legal. In the former connection we encounter bodies doubtless of the
same significance and function, but which differ strikingly in size, cachet,
and form, and what is more remarkable the almost perfect correspond-
ence established between a majority of” mammalian vertebrate and
apyrenaematous red blood corpuscles, having a discoid biconcave form,
and between oviparous vertebrate and oval pyrenaematous blood disks.
But while the oval blood disks of the exceptional camel conform in small-
ness of size to the circular corpuscles of other mammalia, they are non-
conformable to the oval pyrenaematous type of oviparous vertebrates.
In general, with regard to size in apyrenaemata, we are called upon to
admit as “a rule that the largest corpuscles occur in the large species,
and the smallest corpuscles in the small species of a single order or
family. It extends to the whole class of birds, but neither to reptiles,
batrachians, nor fishes, except in some partial instances which seem to
be rather indeterminate or accidental than regular.”
After form and size, we naturally encounter number, which conspicu-
ously has importance in relation to physiologičal or pathological action.
If with Schmidt" we assume the blood mass in a human subject to weigh
10 kilogrammes (26 pounds 9 ounces, troy), then the sum of the blood
cells would amount to 56 billions 570,000 millions. But this vast figure
gives us no advantageous information, and its consequence fades out be-
fore the more practical efforts of Vierordt (1852) and Welcker (1853),
the former of whom counted all the red disks in a known cubic measure
of blood, by successive instalments poured and dried upon a slide, and
reducing his calculation to one millimetre, obtained at first 5,171,400,
and at a later period 5,055,000. Welcker, both by counting the red
corpuscles in blood diluted with albumen, with the aid of a crossbar
* Also Kölliker, op. cit., p. 605. * Gulliver, loc. cit., p. 482.
* Kölliker, op. cit., p. 569.
484 JOHNSTON,
Ocular micrometer, and by comparing diluted blood with an established
color scale, fixed his estimate at 4,600,000 corpuscles in a cubic milli-
metre for a healthful person, 3,800,000 in an hysterical person, and
2,400,000 in a patient far advanced in consumption."
We next refer to the advance made by Potain” in estimating the num-
ber of red corpuscles contained in a cubic millimetre, by counting a small
portion of diluted blood, and to the labors of Mélassezë in blood count-
ing. The haematimètre of Hayem and Nachet, recently described by
Mélassez," in the hands of Drs. E. L. Keyes and L. A. Stimson, gave as
an average of 33 counts the number of red corpuscles in one cubic milli-
metre as 4,990,550, a table derived from exceptionally good sources.
“The above estimate,” says Dr. Keyes, “ of nearly 5,000,000 blood cor-
puscles for the cubic millimetre, I believe to be a high average for
Americans in the neighborhood of New York, during the summer and
autumn.”
“To compare the above results with those obtained by other investi-
gators, we find that Hayem" places the mean at about 5,000,000 more or
less, for the blood of the finger of the healthy adult male; Vierordt"
established as a mean for his own blood something over 5,000,000;
Welcker" estimated it at 4,600,000; Cramer at 4,726,000. Mélassez
gives the lowest average, placing the number at something less than
4,500,000, but he is not very definite upon the subject of healthy average,
being more interested in his writings in a description of the instrument
and in considerations of diseased blood.” “In the most extreme cases of
anaemia (excepting only two cases), Hayem never counted less than
3,000,000.” In this respect my own experience, concludes Dr. Keyes,
“has been similar to his.”
In this last connection it deserves to be noted that Dr. Ordenstein, of
Paris, suggests the possibility of a connection between leukaemia and
hereditary syphilis, and in a case of his own exhibited Van Swieten’s
solution of bichloride of mercury for several months with surprising
benefit.” And finally we feel constrained to mention the conclusions
arrived at by Liègeois and Wilbouchewitch, as quoted by Keyes, and
those of Dr. Keyes himself: (1) that syphilis diminishes the number of
red corpuscles below the healthful standard ; (2) that mercury in small
doses, continued for a short or for a long period in syphilis, alone or with
iodide of potassium, increases the number of red corpuscles in the blood,
and maintains a high standard of the same ; and (3) that mercury de-
creases the number of red cells when given in excess, especially in hos-
pitals.”
Not less interesting, and certainly not less important, than the physi-
ological, is the medico-legal application of what the microscope may
teach. The law calls upon the expert to be thoroughly au fait in all that
modern science has established with regard to the blood in its living and
in its dead state, in its youth and adult periods, in its pathology, in its
different and indifferent conditions of preservation, in dryness and in
moisture, in heat and in cold ; and the character, size, form, and num-
ber of the corpuscular elements in all attainable classes, orders, species,
and families of the zoological series. Nor will his attainments be re-
1 Kölliker, op. cit., p. 704. Note by Da Costa.
2 E. L. Keyes, Am. Journ. Med. Sciences, January, 1876, p. 21.
3 Ibid. 4 Ibid. -
5 Gazette Hebdomadaire, Mai, 1875, p. 295. * Kölliker, op. cit. 7 Id. op.
8 Medical Times and Gazette, November 13, 1875. * Keyes, loc. cit.
MIC R O S COPY OF THE BL O O D. 485
garded as determinative, unless he be also master of micro-chemistry
and familiar with absorption bands, and the expression of their wave
length, awakened in ghostly shapes in the spectroscope made an ally
to the microscope. In short, accusing justice, and defensive crime or
innocence, claim not only an absolute recognition of blood, as distin-
guished from all other matters or elements whatsoever, but the specific
determination of the kind of blood, as well as a positive acquaintance
with all the disturbing agencies of time, heat, dryness, and moisture, as
affecting the cruor offered in condemnation or exculpation.
That microscopical science is so assured in her varied knowledge, even
if its application be restricted within very narrow limits, cannot be as-
serted. From what has preceded it must appear that even for human
red blood disks there is no fixed and established standard. The obser-
vations of Gulliver upon the variations in size of the red corpuscles in
birds, under the different circumstances of excitement and repose, and
the positive statement of Col. Woodward that “the blood disks of dif-
ferent persons, and even of the same persons at different times, vary
more in size than the ordinary difference between human and dog's
blood,” are germane to this issue. But we would consider our task as
glaringly incomplete if we failed to give becoming prominence to the
averages of the most perfectly conducted work of our distinguished
friend, Prof. Theo. G. Wormley, M.D., of Columbus, Ohio, and to state
the expression of his variance with Col. Woodward’s record, that “this
is certainly contrary to all our own experience.” With Dr. Wormley's
permission we offer a few of his measurements, which were furnished in
the course of a recent correspondence:—
Human blood, average of all averages, including over 2000
measurementS . º º e e e º e . 52's 6 inch.
Dog, average of averages . e & e © - 53' 5 “
Cat, § { § { e e e e e e # 8, 2 & &
Rat, & 4 { * º e ſº e e - a 5's g “
Horse, { { * { * & e o e . A 2's 2 “
Jack, & 4 { { e º e c e o 53's T { {
Mule, € $ * { & g e & © & 3:66 ( &
Ox, * { { { -> e t * g • Å 'rg ( &
Opossum, “ * * e º s e e • 3r'âg “
Muskrat, 4 * { % g dº & º , * º 52'sz ( &
To these measurements the following is added as a note: “You are
aware, I believe, that in getting our standard for micrometry every pos-
sible care was taken to have it correct. The ordinary scales are subject
to considerable variation.” In acknowledging the favor of the above, we
beg to add that we have seen the whole record of the admirable aver-
ages of Prof. Wormley, the work of many years, which evidences the
industry, the patience, the intelligence, and the scrupulous fidelity of the
author.
It had been our purpose here to close this essay, but we pause to notice
a paper by Col. Woodward, read at the Centennial meeting of the Ame-
rican Medical Association, which has for its title “The Application of
Photography to Micrometry, with special reference to the Micrometry of
|Blood in Criminal Cases.” By the plan proposed, which may be destined
to supersede all others, and to abate the value of all former more labori-
ous and less exact procedures, “the blood is placed on a glass stage
* Sorby, Monthly Microscopical Journal, May 1, 1875.
* Letter to Author, March 28, 1876.
486 JOHNSTON,
micrometer, and photographed with any convenient power;” and in the
elegant photographs offered in illustration “both blood and micrometer
appear sharply defined. The measurements are then made on the nega-
tive.” “For the purpose of soaking out blood stains” the able author
prefers to “use a strong solution of caustic potash, as described by Vir-
chow in 1857.” The development of this mode of fixing the averages is
insisted upon by the distinguished microscopist, who now regards the
eye-piece micrometer as a “snare and a delusion,” and claims that the
negative on glass possesses an exactness which may be expressed in mil-
lionths of an inch, and may be tested at leisure by any number of per-
sons. And another point of interest attaches to these light pictures, i.e.,
the equal delineation, under high powers, of all corpuscles, whether large
or small, of normal shape or deformed.
Remotely related to the subject are the “micro-photographs of the
blood in disease,” recently issued by Dr. E. Cutter, of Cambridge, and
Dr. G. B. Harriman, of Boston.
In conclusion we beg to remark that the copious literature of this ex-
tensive subject, the Microscopy of the Blood, is nowhere complete in this
country outside of its Capital; and that, in spite of the distinguished
courtesy of the eminent scientist in charge of the Army Medical Mu-
seum, this treasury of knowledge cannot always be made available by
the busy professional men who reside at a distance.
DISCUSSION ON DR. JoHNSTON's PAPER.
After the reading of the preceding paper, Dr. J. G. RICHARDSON, of Phila-
delphia, said:—I should like to offer an explanation in reference to my testi-
mony at the trial in Herkimer County, New York. I did not state absolutely
that the corpuscles were those of human blood, but that they corresponded
to those of human blood. Microscopy has long been employed as an aid to
the administration of justice; and serves easily, for example, to distinguish
human blood from that of a fish, because the corpuscles in the former are
round, while in the blood of the fish they are oval. At first the legal authori-
ties demanded no more than this, but when the facilities for microscopic
examination became more complete, we began to draw a still sharper line
of distinction—that is, one between human blood and that of the musk-deer
or goat. Now, with improved immersion lenses, we are, I contend, able to
distinguish between the blood of a human being and that of an ox, horse,
or other animal having corpuscles of similar size; but when circumstances
do not thus narrow down the demands of justice in a trial, I would never
attempt to discriminate the kind of blood with certainty. Our power to aid
justice in this matter is due to the fact that when a man is arrested with
blood-stains on him, and tries to explain how they got there, he generally
alleges that he has been in a position to be stained by the blood of some ani-
mal; and then, by microscopic examination, we can distinguish between human
blood and that of the Ox, pig, or sheep, to which the suspicious stains are
usually attributed. -
Dr. Johnston said:—That would not be a positive recognition of human
blood-disks, which is what the courts desire; for the blood might be that of a
dog or guinea-pig, and not of a human being.
Dr. HENRY D. DIDAMA, of Syracuse, N. Y., said:—I know of a case in which
the question presented was, whether the blood was that of an ox or human
being; and though, in such a case, an expert might not be able to say that the
blood was human, yet he could prove that the statement made by the criminal
MI C R O S CO PY OF T H E B L O O I). 487
was untrue. I wish to ask Dr. Johnston whether, if he should find a blood-
disk sºon of an inch in diameter, he would be willing to swear that it was not
the blood of an ox or pig 7 because, as I understand the matter, the blood-
globules of the ox and pig never reach that size.
Dr. Johnston said:—Where the variations were not exceedingly great, I
would be unwilling to give an opinion.
Dr. RICHARDSON said:—I understand Prof. Johnston to say that, on exam-
ining some unlabelled slides of man's, dog's, and guinea-pig's blood, offered
him by Dr. J. J. Woodward, he found himself unable to discriminate between
them. This is what I should expect; but I would like to ask Prof. Johnston
whether, if a person of unproved veracity should bring him a specimen of
blood, covering the name, and telling him that it was from a sheep, and he
should find, on measurement, that the corpuscles averaged 3 gºt of an inch in
diameter, he would not feel justified in contradicting the statement 7
Dr. DIDAMA said:—Would not Prof. Johnston, if he found blood-disks of
sºon of an inch, be certain that they could not have circulated in the capilla-
ries of a sheep 7
Dr. John STON said:—It is a very difficult question to answer, as both vessels
and corpuscles are extremely elastic, and capillaries constantly allow corpus-
cles to pass through them, which are larger in diameter than the capillaries
themselves. -
Dr. JAMES Tyson, of Philadelphia, said:—It seems to me that this is an
ambiguous mode of putting the question, because, as Dr. Johnston says, even
if we could assert that a particular blood was not that of a sheep, we could not
say that the corpuscles could not have circulated in the capillaries of a sheep,
on account of the property of elasticity correctly attributed by Dr. Johnston
to both corpuscles and capillaries, to say nothing of the varying size of the
latter. But the fact is that the peculiar organization of the human mind
has something to do with the drawing of conclusions. Some persons would
feel at liberty to draw the same conclusions from the premises named by Drs.
Didama and Richardson as they, while others would not. I, for example,
would be willing to say that such blood was more likely to be that of an ox
or sheep than that of a man, while I might not be willing to say absolutely
“this is the blood of an ox or sheep,” and not that of a man.
Dr. S. E. CHAILLE, of New Orleans, said:—I desire to ask two questions:
I think we all agree with Prof. Johnston that human blood corpuscles cannot
be positively distinguished from all others; but frequently, in court, some
witnesses assert that a particular stain is human blood, while others say, no,
it is the blood of an ox. The Court asks the microscopist, “Can you decide
whether this is human blood or that of an ox—or, let us say, of a sheep?” Is
it Prof. Johnston's opinion that such a decision could be made, and would he,
under such restricted circumstances, feel justified in saying whether the blood
was that of a sheep or of a man 7
Dr. JoHNSTON said:—I could answer negatively, that the blood was not
human.
Dr. CHAILLé said:—My second question is this: I have been told that cer-
tain specimens of blood have been offered to Dr. Richardson, and that he has
been able to discriminate between them. I would ask of Dr. Richardson if such
is the fact?
Dr. RICHARDSON said:—Such was the case, not in one series of specimens
only, but in two.' The number of samples in each series was three; one being
the blood of an ox, one that of a sheep, and the other human blood. I was
able to distinguish between them by microscopical examination alone.
Dr. Joh NSTON said:—There is more than the mere diameter of the corpuscles
to be considered; we must consider the cachet, or the stamp of individuality
of the blood.
! See American Journal of the Medical Sciences, July, 1874; also, London Monthly
Microscopical Journal, Sept. 1874.
488 JOHNSTON, MICROSCOPY OF THE BLOOD.
Dr. L. S. JoyNEs, of Richmond, Va., said:—I would like to ask Dr. Richard-
son as to the relative ease of distinguishing between different bloods when dry
and wet. Can we restore dried corpuscles so certainly as to distinguish
whether they are human or otherwise ? It is difficult to know how far blood
corpuscles on the clothing are altered from their original condition.
Dr. RICHARDSON said:—My experience has been that in dry blood-stains there
is a shrinkage of from five to ten per cent. That is, that the fresh blood
corpuscles of man average sºon of an inch, while in stains they measure from
saloo to 37'o'o. The blood corpuscle of an Ox, which averages 43'37 of an inch,
when fresh, would measure rºot, or rºo after re-moistening.
TJpon the conclusion of the discussion, Dr. RICHARDSON said:—As strong
evidence of the presence of a true cell-wall in red blood corpuscles, upon the
existence of which the value of my method for the diagnosis of blood-stains
largely depends, I invite the members of the Section to inspect, beneath a
Holmes's class microscope, a red disk of the Amphiuma tridactylum, in which
the imperfectly crystallized cell-contents occupy the upper end, while the Oval
granular nucleus fills the inferior extremity, leaving the membranous capsule
relaxed and wrinkled longitudinally, hanging like part of a half-flaccid balloon
between them. (Fig. 1.) I also show, as corroborative testimony, a slide
Fig. 1 (X 400). Fig. 2 (X 400).
bearing a blood corpuscle of the Menobranchus, which displays, within what I
deem to be its limiting membrane, a single crystal made up of all the cell-con-
tents except the nucleus." (Fig. 2.)
* See Trans. Am. Med. Association, vol. xxi., 1870, p. 271.

489
THE EXCRETORY FUNCTION OF THE LIVER,
BY
AUSTIN FLINT, JR., M.D.,
PROFESSOR OF PHYSIOLOGY AND PHYSIOI,OGICAI, AN ATOMY IN THE BELLEVUE IHOSPITAL MEDICAI,
- COLLEGE, NEW YORK.
I HAVE selected as the subject which I shall have the honor to present
to the Section on Biology, the Excretory Function of the Liver, for the
reason that it seemed to me better to discuss a question concerning which
I had made personal and original investigations, than to recite the obser-
vations of others, however interesting and important the latter might be.
I have ventured to assume that the views which I have to offer are not
without importance; and they are certainly not so familiar as many other
topics which I might with propriety have selected. I shall, therefore,
endeavor to bring to your notice, in the simplest manner possible, what
I have myself learned with regard to the liver as an organ of excretion.
It is now well known that the liver has a variety of important func-
tions with which physiologists are more or less completely acquainted.
It produces a substance which is converted into sugar and is carried
away in the torrent of the circulation. It secretes bile, which performs
an important office in digestion. In addition to the digestive function
of the bile, I think I have shown that this fluid serves as the vehicle for
the elimination of at least one excrementitious principle, which is dis-
charged in a modified form in the feces. If the liver serve as an organ
of excretion, it is evidently of great importance, from a pathological as
well as a physiological point of view, that we should have an accurate
knowledge of the mechanism of this function. For a long time, many
pathological conditions have been attributed to defective or perverted
action of the liver; still, the terms, “liver complaint,” “biliousness,” etc.,
have failed to convey any definite pathological notion, and it is probably
true that the liver has been accused of numerous sins of omission and
commission without any positive scientific reason. Many medical writers
have assumed, in an indefinite way, that the liver possesses an excretory
function ; but, so far as I know, no physiologist had ever described any
definite excrementitious substance eliminated by this organ prior to my
observations in 1862. -
There are certain general laws applicable to secretions and to excre-
tions, which it is important to consider in discussing the probable func-
tions of the bile:—
I. Secretions have some useful purpose to serve in the economy, and,
as a rule, they are not discharged from the body in health. Excretions
have no function in the economy and are discharged from the body.
II. The flow of secretions from the glands is usually intermittent, oc-
curring when their function is called into action. The flow of excretions
is usually either constant or remittent.
III. The production of excretions depends upon the general process of
disassimilation, which is constant. The production of secretions has no
490 FLINT, J.R.,
relation to disassimilation, but is connected with processes which
usually take place at intervals.
IV. The elements of secretion, which give to secreted fluids their cha-
racteristic physiological properties, are formed de novo in the glands them-
selves out of materials furnished by the blood, and they do not pre-exist
ready-formed in the circulating fluid. The elements of excretion pre-
exist in the blood, being taken up by the lymph or by the blood from
the tissues, and they are separated from the blood by organs which have
no part in their actual production; except that excrementitious sub-
stances may be changed one into another, as creatine into creatinine, or
uric acid into urea. -
V. When secreting organs are removed or destroyed, there is no vica-
rious production of the peculiar elements of the secretions; these ele-
ments do not accumulate in the blood ; and the system suffers simply
from the absence of the function of the special secretion. When excret-
ing organs are removed or destroyed, there may be a vicarious elimina-
tion of the excrementitious principles by other organs, or the system
may suffer toxic effects from the accumulation of excrementitious matters
in the circulating fluid.
VI. The characteristic elements of true secretions are generally reab-
sorbed by the blood ; but they are taken up in a modified form, so that
they are not to be recognized in the circulating fluid. Elements of excre-
tion are with difficulty reabsorbed by the blood after they have once
been separated by the proper organs.
The applications of the foregoing general laws may be readily made to
the pancreatic juice as contrasted with the urine, which two fluids we
may take as types respectively of secretions and of excretions. Before
we make an application of these laws to the bile, we may consider the
simple question as to whether it can be shown that this fluid has a use-
ful function to perform as a secretion. If the bile have no such function,
an animal would live and maintain its normal condition if the bile were
diverted from the intestine and discharged from the body. This question
has been made the subject of experimental observation by simply cutting
off the bile-duct, and making a fistula into the gall-bladder, by which the
bile is discharged. The operative procedure involved is not difficult, but
is very apt to be followed by fatal peritonitis, so that few experiments
of this kind have succeeded. In the experiments which have succeeded,
in the hands of Schwann, Bidder and Schmidt, Nasse, Bernard, and
myself, the dogs have lived for thirty or forty days, dying with all the
symptoms of inanition. In one remarkably successful experiment per-
formed by myself, the dog lived for thirty-eight days, had a voracious
appetite, and died at the end of that period after having lost about four-
tenths of his weight. In this experiment, the bile-duct was ligatured in
two places, and the intermediate portion was exsected. A fistula was then
made into the fundus of the gall-bladder, which was kept open. The
animal ate well the very day of the operation, and there was very little
peritonitis. The only observation in which contrary results were obtained
is one made by Blondlot." In this case, a fistula was made into the gall-
bladder after the bile-duct had been divided. The animal lived for five
years, and, after fifteen days following the operation, was in good flesh
and apparently suffered no inconvenience from the discharge of the bile
| Blomdlot, Essai sur les fonctions du foie et de ses annexes, Paris, 1846, page 55, et seq. ;
and Inutilité de la bile dans la digestion, Paris, 1851.
E X C R ETO R Y FUNCTION OF T H E L I V E R. 491
from the fistula. During the first fifteen days the animal licked the bile
from the fistula, but this was afterward prevented by a muzzle. After
a time he made no attempt to lick the bile. Blondlot attributed the
emaciation which occurred during the first fifteen days to this licking
of the bile. When the animal died, more than five years after the Opera-
tion, an examination of the parts was made in the presence of several
physicians and students of medicine, and no communication could be
found between the bile-duct and the intestine. From this observation,
Blondlot concluded that the bile had no function in digestion, and that
it was a purely excrementitious fluid ; and he assumed that the cause of
death in other experiments of a similar kind was the licking of the bile
as it flowed from the fistula. In my own case of biliary fistula, in which
the dog died after thirty-eight days, the animal was prevented by a muz-
zle from licking the bile.
The only point to consider, as it seems to me, in this single experiment
of Blondlot, is whether or not a communication had been re-established
between the bile-duct and the intestine. If such a communication
existed, it would be easy to explain the survival of the animal. The fol-
lowing experiment, which I undertook for a different purpose, satisfied
me upon this point:-
I attempted to estimate, in a dog, the entire quantity of bile dis-
charged in the twenty-four hours. With this object in view, I cut down
upon the bile-duct, emptied the gall-bladder, secured a canula in the duct,
and attached a rubber-bag to the canula, for the purpose of collecting the
bile. Twenty-three hours after the operation, the bag was in place and
nearly full of bile. Just before the end of the twenty-four hours, how-
ever, the animal ruptured the bag, and the experiment, as far as its
original object was concerned, was a failure. I then simply pulled the
canula from the wound and set the animal at liberty. In about four
weeks, after the wound had closed and the feces had become of normal
color, the animal, being in a perfectly normal condition, was killed, and
the parts were carefully examined in the presence of several assistants.
It is well known that, in dogs, ducts that have been divided have a
remarkable tendency to become re-established. In this case, inasmuch
as no bile was discharged externally, and the feces were of normal color,
it was certain that the bile was discharged into the intestine. Neverthe-
less, I searched for more than an hour for the communication before it
was discovered. The only reasonable way, as it appears to me, to recon-
cile the single experiment of Blondlot with those of other observers, is to
suppose that, in his observation, a communication between the bile-duct
and the intestine had become established, which he failed to find. The
difficulty which I experienced in finding the communication in my own
observation led me to conclude that a communication existed in the
case reported by Blondlot, which he did not discover.
It is in accordance with my own observations, as well as with those of
other physiologists, to conclude that the bile is a secretion, and that it
has a function to perform in connection with the digestive process, which
function is essential to life.
Assuming that the bile has an important and an essential office in
digestion, is it not possible that it may also serve the purpose of elimina-
tion, and contain elements of excretion ? This is a view which has not
been advanced by physiologists, who have regarded the bile either as a
secretion or an excretion, and have not imagined that it could serve both
functions. Before I take up the experimental facts bearing upon this
492 FI,INT, J.R.,
question, I propose to consider the arguments to be drawn from a study
of the composition of the bile, and its discharge into the intestine. It
was this idea which first led me to investigate the physiological rela-
tions of cholesterine.
The bile certainly has an important function as a secretion; and its
flow, although not intermittent, is more abundant during the process of
intestinal digestion. The peculiar biliary salts (the glycocholate and the
taurocholate of soda) are formed in the liver and do not pre-exist in the
blood. When the structure of the liver is invaded by disease so as to
interfere with the production of bile, the biliary salts do not accumulate
in the blood. The biliary salts are reabsorbed in a modified form in the
intestine; for the quantity of one of their elements (sulphur) found in
the feces is very much less than the amount discharged into the intes-
time.
On the other hand, with regard to one constant constituent of the
bile (cholesterine), we do not know that it has any function in connec-
tion with digestion. The secretion of bile is continuous, although its
flow is increased during digestion. Cholesterine, while it is an invariable
constituent of the bile, exists in the blood and in certain of the tissues
of the body.
The questions to determine experimentally with regard to cholesterine
are the following:—
Is cholesterine produced in any of the tissues of the body ?
Is cholesterine separated from the blood by the liver?
When the liver undergoes structural change in disease, does choleste-
rine accumulate in the blood 7
Is cholesterine reabsorbed in the intestine or is it discharged, either
unchanged or in a modified form, in the feces :
These are the questions which I endeavored to answer by a series of
experimental investigations, made in the spring of 1862, and published
in October of the same year, in the American Journal of the Medical
Sciences.
Process for the Estimation of Cholesterine in the Blood.—The following is
the process which I fixed upon, after a number of trials, for the quanti-
tative analysis of the blood for cholesterine: The entire blood, serum
and clot, is evaporated to dryness. The dry residue is then pulverized
in an agate mortar, and treated for from twelve to twenty-four hours
with ether, in the proportion of about one fluidounce of ether to one
hundred grains of the original weight of blood. This is filtered, and
the ethereal extract, which contains cholesterine and fats, is evapo-
rated. The residue of this evaporation is then extracted with boiling
alcohol, in the proportion of one fluidrachm for one hundred grains of
the original weight of blood. This extract is filtered while hot, and the
filtrate is evaporated, leaving the cholesterine and a certain quantity of
saponifiable fats. To remove the saponifiable fats, add to the residue a
weak solution of potash, and allow it to remain for about two hours; then
dilute with water, filter, and wash the filter with water until the liquid
which passes through becomes neutral. Dry the filter; wash it with
ether; evaporate the ether; extract the residue with hot alcohol as be-
fore; evaporate the alcoholic extract, and the residue will consist of
cholesterine, perfectly pure, as can be determined by means of the micro-
scope. Using this process for the determination of cholesterine, a number
E X C R E TO R Y F UN CTION OF T H E L IV. E. R. 493
of observations were made upon dogs, from which I select the following
as typical, the results having been repeatedly confirmed.
OBS. I. Eacperiment showing an Increase in Cholesterime in the Blood passing
through the Brain. (The dog was not etherized.)
Blood from the carotid, 140.847 grains, contained 0.108 grain of choleste-
rine, or 0.768 part of cholesterine per 1000.
Blood from the internal jugular, 97.81.1 grains, contained 0.092 grain of
cholesterine, or 0.947 part of cholesterine per 1000.
The increase in the proportion of cholesterine in the blood in passing through
the brain was 23.309 per cent.
This observation, which was frequently repeated with the same gene-
ral result, seems to show that the blood gains cholesterine in its passage
through the brain. It is well known that cholesterine is always present
in nervous substance—not in a crystalline form, but in a state of mole-
cular union with nitrogenized and other matters. In order to verify
this fact, I examined the brains of two subjects who had been killed
instantly by accident while in perfect health, in one case finding a pro-
portion of cholesterine of 7.729 parts per 1000, and, in the other, 11.456
parts per 1000.
The experiment just detailed was made with a view of determining
whether or not the brain gives up cholesterine to the blood as it circu-
lates through this organ ; and the following experiment was made to
determine whether the venous blood of other parts contains an excess of
cholesterine. Theoretically, the blood of the femoral vein should contain
a little more cholesterine than arterial blood, this excess being derived
from the nerves of the extremity, although the increase would probably
be not so great as in the blood of the internal jugular, which comes
almost exclusively from the great nervous centre.
OBS. II. Eacperiment showing an Ea:cess of Cholesterine in the Blood of the
Internal Jugular and Femoral Veins over the Arterial Blood. (The dog was
not etherized.)
Blood from the carotid, 143.625 grains, contained 0.679 grain of cholesterine,
or 0.967 part of cholesterine per 1000. -
Blood from the internal jugular, 29.956 grains, contained 0.046 grain of
cholesterine, or 1.545 part per 1000.
Blood from the femoral vein, 45.035 grains, contained 0.046 grain of choles-
terine, or 1.028 part per 1000.
The increase in the proportion of cholesterine in the blood in passing through
the brain was 59.772 per cent.
The increase in the proportion of cholesterine in the blood in passing
through the lower extremity was 6.308 per cent.
This experiment confirms the previous observation upon the increase
of cholesterine in the blood in passing through the brain, and it shows,
in addition, that the blood gains cholesterine in other parts. Inasmuch
as the nervous tissue is the only tissue in the extremities which contains
cholesterine, it is probable that the excess contained in the blood of the
femoral vein over the arterial blood was derived from the nerves.
It occurred to me that cases of old hemiplegia would present favorable
conditions for verifying in the human subject the observations made on
the lower animals. It has been ascertained that, when the function of
nerves is permanently abolished, they soon become degenerated and their
nutrition modified; and it seems probable that, if cholesterine be one
494 FI,INT, J.R.,
of their important products of disassimilation, the amount of cholesterine
in the blood from paralyzed parts should be very small. Taking the
blood, for example, from the paralyzed arm of a hemiplegic, this blood,
coming from paralyzed parts, should contain less cholesterine than the
blood from the sound arm. Of course, the blood from the arm contains
no blood which has passed through the brain, which is assumed to be
sound upon the paralyzed side. I examined, therefore, the blood from
both arms in three cases of hemiplegia in the Charity Hospital on Black-
well's Island:— Q
CASE I. Sarah Rumsby, aet. 47, is affected with hemiplegia of the left side.
Two years ago she was taken with apoplexy and was insensible for three days.
When she recovered consciousness she found herself paralyzed on the left side.
She says she had epilepsy four or five years before the attack of apoplexy.
She has now complete paralysis of motion on the affected side, with the excep-
tion of some slight power over the fingers. Sensation is not affected. The
speech is perfect and her general health is good.
CASE II. Anna Wilson, aet. 23, is affected with hemiplegia of the right side.
Four months ago she became unconscious, and recovered in one day, with loss
of motion and sensation on the right side. She is now improving and can
use the right arm slightly. The leg is not so much improved because she will
make no effort to use it.
CASE III. Honora Sullivan, aet. 40, is affected with hemiplegia of the right
side. About six months ago she became unconscious, recovering the next day
with paralysis. The leg was less affected than the arm from the first. Her
condition is about stationary as regards the arm, but the leg has somewhat
improved.
A small quantity of blood was drawn from either arm in these three
cases. In each instance it was drawn from the paralyzed side with diffi-
culty, and but a small quantity could be obtained.
The specimens were all examined for cholesterine, with the following
results:—
OBS. III. Quantities of Cholesterime in the Blood of the Paralyzed and the
Sound Sides in three cases of Hemiplegia.
CAs Es. Blood. Cholesterine. Cholesterine per 1000 parts.
Grains. Grains. ſº
Case I. Paralyzed side . . . 55.458 ............... The watch-glass contained 0.031
grain of substance, but the
most careful examination with
the microscope failed to show
crystals of cholesterine.
Sound side . . . . . 128.407 0.062 0.481.
Case II. Paralyzed side . . . 18.381 ............... Same as Case I.
Sound side . . . . 66.396 0.062 0.808.
Case III. Paralyzed side . . . 21.842 ............... Same as Case I.
Sound side . . . 52.261 0.031 0.579. *
The conclusion from the experiments upon dogs and the three observa-
tions upon the human subject is inevitable, that cholesterine is produced
in the substance of the brain and in the nervous tissue generally, as this
substance is not contained in the muscular tissue or in any other parts
except the crystalline lens, the liver, and the spleen. The question now
to determine is the relation of cholesterine to the nervous system. Is it
E X C R. ETO R Y F U N C TI O N OF THE LIVE R. 495
one of the products of disassimilation of its tissue 2 If this be the fact,
cholesterine is an excrementitious product, and it must be separated from
the blood by some organ or organs and discharged from the body. Inas-
much as the bile always contains cholesterine, we naturally look to the
liver as the organ for its elimination; for it is not found in the product
of any other gland. -
I employed essentially the same method in studying the question of
the elimination of cholesterine as that used in determining the seat of
its production, analyzing the blood going to and coming from the liver.
Upon this point I made a number of observations, the general results of
which were invariable. The following experiment is a type of these
observations:—
OBS. IV. Eacperiment showing that Cholesterine is separated from the Blood
Žn its Passage through the Liver. (The dog was etherized.)
Arterial blood, 159.537 grains, contained 0.200 grain of cholesterine, or
1.257 part of cholesterine per 1000.
Blood of portal vein, 168.257 grains, contained 0.170 grain of cholesterine,
or 1.009 part of cholesterine per 1000.
Blood of hepatic vein, 79.848 grains, contained 0.077 grain of cholesterine,
or 0.964 part of cholesterine per 1000.
The loss in the proportion of cholesterine in arterial blood in passing through
the liver was 23.309 per cent. º
The loss in the proportion of cholesterine in the portal blood in passing
through the liver was 4.460 per cent.
The bile always contains a certain proportion of cholesterine, which I
found, in a specimen taken from the gall-bladder of a subject who had
been killed instantly while in perfect health, to be 0.618 part per 1000.
As I have demonstrated that the blood gains cholesterine in its passage
through the brain and probably also from the general nervous tissue, that
cholesterine is separated from the blood in its passage through the liver,
and that cholesterine is invariably found in the bile and is discharged
into the intestine, it seems to be proven that one of the functions of the
liver is to eliminate this principle. If it can be shown that the choles-
terine thus separated from the blood by the liver is discharged from the
body, the fact that it is apparently produced in the nervous tissue and is
taken up by the blood would point strongly to the conclusion that cho-
lesterine is an excrementitious principle and is one of the products of
disassimilation of the nervous matter.
Stercorine.—I made repeated examinations of the normal feces, with a
view of determining the presence of cholesterine and its quantity. Al-
though it is often stated by authors that cholesterine exists in the feces,
I was unable to find it after the most careful examination, and I subse-
quently failed to discover any writer who had actually extracted it from
the normal dejections. The process which I employed was essentially
the same as that used in examinations of the blood, except that the
extracts were decolorized by filtering through animal charcoal, and the
alcoholic extract was treated with potash for one or two hours at nearly
the boiling point. Treated in this way, the feces gave an extract which
was non-Saponifiable, but which did not crystallize for several days. It
fused at a temperature of about 97° Fahr., while cholesterine fuses at
293°. After a few days, delicate, needle-shaped crystals began to appear,
gradually increasing in number and breadth, and, as they became
496 FLINT, J.R.,
broader, becoming split at the points and edges. These crystals pre-
sented all the characters of the crystals of a substance extracted from the
serum of the blood by Boudet, in 1833 (Annales de Chimie et de Physique),
which he called séroline. In some of my earlier observations upon the
blood, I obtained these crystals; but I came to the conclusion that the so-
called séroline was not a normal constituent of the blood, but was formed
during the process used for the extraction of cholesterine. With this
view, finding the so-called séroline a constant constituent of the normal
feces, I called the substance stercorine, regarding it as one of the ex-
crementitious principles of fecal matter. Crystals of stercorine are
shown in the accompanying figure (Fig. 1). The rounded drops are
probably composed of the same substance, as they disappear when the
crystallization is complete. The idea that these crystals obtained from
blood result from the transformation of cholesterine, is strengthened by
the fact that the cholesterine of the bile is changed into stercorine in its
passage through the alimentary canal. Stercorine, like cholesterine,
is soluble in ether, very soluble in hot alcohol, and strikes a red color
Stercorine from normal human feces (tº inch objective).
with strong sulphuric acid. The points of distinction are the low
fusing point and the form of the crystals. -
I obtained from the feces of the twenty-four hours of a perfectly
healthy man 10.417 grains of stercorine. It is estimated by Dalton that
the total quantity of bile in twenty-four hours is 16,940.00 grains, and
the total quantity of cholesterine, according to my estimate of 0.618
parts per 1000, is 10.469 grains, giving a difference between the esti-
mated quantity of cholesterine and the actual quantity of stercorine ex-
tracted from the feces of only 0.052 of a grain. This sustains the idea
of the change of the cholesterine of the bile into the stercorine of the
feces.
Observations made by myself and others seem to show that the change
of cholesterine into stercorine is incidental to the process of digestion.
Cholesterine is found in quantity in the feces of hibernating animals
and in the meconium, when, of course, there is no intestinal digestion,
but when the bile is none the less discharged into the alimentary canal.
I made an examination of human meconium and found cholesterine in
the proportion of 6.245 parts per 1000, and no stercorine. I examined

ExcFETo RY FUNCTION OF THE LIVE R. 497
the human feces in a case of simple jaundice from obstruction of the
bile-duct, the feces being clay-colored, and found neither cholesterine
nor stercorine. Nineteen days after, when the jaundice had disappeared
and the color of the feces was normal, I found stercorine and no choles-
terine. In the feces of a dog which had been deprived of food for forty-
eight hours, I found stercorine and a small quantity of cholesterine. As
far as can be learned from these facts and observations, then, it seems
that the cholesterine of the bile is discharged in the feces unchanged
when no digestion takes place, but that it is discharged in the form of
stercorine under the ordinary and normal conditions of the digestive
process.
JPathological Relations of Cholesterine ; Cholesteraemia.--A knowledge
of the relations of urea to nutrition bears so directly upon the pathology
of renal diseases, that the pathological relations of any newly-discovered
excrementitious principle assumes at once the greatest importance. If
it be true that cholesterine, like urea, is a product of disassimilation,
and that it is eliminated by the liver as urea is eliminated by the kid-
neys, we should expect to find, in cases of serious structural disease of
the liver, an accumulation of cholesterine in the blood, or cholesteraemia,
as we have uraemia in certain stages of extensive organic disease of the
kidneys. It has long been observed, indeed, that, although simple jaun-
dice due to resorption of the coloring matter of the bile is usually a
trivial affection, there are cases of extensive change in the structure of
the liver in which there is apparently a toxic condition dependent upon
the presence of some excrementitious or poisonous substance in the
blood. Pathologists have examined the blood in such cases with a view
of ascertaining the nature of the supposed poisonous matter. Frerichs
and others repeatedly examined the blood in cases of grave jaundice,
expecting to discover the biliary salts or acids, but they never detected
any substance which would react with Pettenkofer's test." Becquerel
and Rodier examined the blood in a case of jaundice and found “choles-
terine excessively abundant,” but they did not recognize the significance
of this fact.” In such cases pathologists have looked for the biliary
acids and their derivatives, and not for cholesterine. In order to throw
some light upon the pathology of grave jaundice, Müller,” Kunde,” Leh-
mann,” and Moleschott" have extirpated the liver in frogs and kept the
animals alive for several days, or even two or three weeks. On examin-
ing the blood, these physiologists failed to discover the biliary salts.
They made no analyses of the blood for cholesterine. I hope to be able
to show conclusively, by observations upon cases of disease of the liver
in the human subject, that there may be an accumulation of cholesterine
in the blood, or cholesteraemia, and that this occurs in certain eases of
serious structural disease of the liver.
In cases of simple jaundice, there is resorption of the coloring matter
of the bile from the excretory passages.
In cases of grave jaundice, which almost invariably terminate fatally,
there is cholesteraemia, or accumulation of cholesterine in the blood.
Frerichs, Diseases of the Liver; New Sydenham Society, London, 1860, vol. i. p. 95.
Becquerel et Rodier, Traité de chimie pathologique; Paris, 1854, p. 210.
Müller, Manuel de Physiologie; Paris, 1851, tome i. p. 122.
Kunde, De Hepatis Extirpatione; Berolini, 1850.
* Lehmann, Physiological Chemistry; Philadelphia, 1855, vol. i. p. 476.
* Moleschott, Comptes Rendus; Paris, 1855, tome xl. p. 1040.
:
32
498 FLINT, J.R.,
There are cases of structural disease of the liver, in which there is no
jaundice, but nevertheless there is cholesteraemia.
In the following cases, having first determined the proportion of cho-
lesterine in normal blood, I examined the blood for cholesterine with
reference to the points just stated:—
OBS. W. Proportion of Cholesterine in Normal Blood.
Male, aet. 35 tº sº 0.445 part of cholesterine per 1000.
$6 6% 22 © 4. 0.658 § { 6 4. $6
$6 {{ 24 º © 0.751 66 { % { %
OBS. VI. Case of Jaundice dependent probably upon Duodenitis.-This case
presented the symptoms of simple jaundice from temporary obstruction of the
bile-duct. June 21, 1862, 212.428 grains of blood were taken from the arm.
The proportion of cholesterine per 1000 was 0.508, which was within the limits
of health, according to the results obtained in my examinations of normal
blood. The feces, which were clay-colored, were examined, and I found neither
cholesterine nor stercorine. July 11, the patient had entirely recovered; there
was no jaundice; and the feces had become normal.
OBs, VII. Case of Grave Jaundice with Cirrhosis.—This case presented
intense jaundice, ascites, great general prostration, and, toward the close of
life, symptoms of blood-poisoning. The patient was admitted to the Charity
Hospital on Blackwell's Island, June 16, 1862. On June 21, 50.776 grains of
blood were taken from the arm. This blood contained a proportion of 1.850
part of cholesterine per 1000, an increase of 146.338 per cent. over the maxi-
mum quantity obtained from normal blood. The patient died June 27, 1862.
There was double vision six days before death, and stupor for the last three
or four days. The liver, examined after death, was in a condition of cirrhosis.
The gall-bladder was contracted and contained but about two drachms of
bile. The fibrous substance of the liver was increased in quantity, and the
liver-cells were shrunken. The feces were taken a few days before death. The
amount was small, only 27.2.1 grains in twenty-four hours, and contained 0.077
of a grain of stercorine. I found 10.417 grains of stercorine in the feces of the
twenty-four hours in a healthy male.
OBS. VIII. Case of Cirrhosis with Ascites and considerable affection of the
General Health.-In this case there was general prostration, confining the
patient to the bed. After a tapping, the liver was explored and found to be
considerably diminished in size. 117.193 grains of blood were taken from the
arm, containing a proportion of 0.922 of a part of cholesterine per 1000, an
increase of 22.769 per cent. Over the maximum proportion obtained in my
examinations of normal blood. In this case there were no nervous symptoms.
OBs. IX. Case of Cirrhosis with Ascites and slight Constitutional Dis-
turbance.—This patient had suffered from ascites for eighteen months and had
been tapped about thirty times. He is immediately relieved by tapping and
goes out the next day. July 1, 1862, 251.567 grains of blood were taken from
the arm, which gave a proportion of cholesterine of 0.246 of a part per 1000,
or 44.719 per cent. less than the minimum obtained in my examinations of mor-
mal blood.
The cases just detailed, taken in connection with my observations
upon animals, are certainly very striking. In the case of simple jaun-
dice, which recovered, the proportion of cholesterine in the blood was
within the limits of health. In the case of ascites, the patient not suf-
fering much disturbance, the proportion of cholesterine in the blood was
considerably below the normal standard. In the case of grave jaundice,
which terminated fatally with symptoms of serious disturbance of the
nervous system, the proportion of cholesterine in the blood was enor-
E X C R ETO R Y F UN CTION OF T H E LIVE R. 499
mously increased, being nearly three times greater than the maximum
obtained in my examinations of normal blood. In the case of cirrhosis
with considerable affection of the general health, the proportion of cho-
lesterine in the blood was considerably above the maximum obtained in
my examinations of normal blood. -
Literature bearing upon the “New Eaccretory Function of the Liver,” since
the Publication of my Observations in 1862.
October, 1862.—My researches were published in the “American Journal of
the Medical Sciences.”
1868.-A translation of my memoir into French was published in Paris and
presented to the Academy of Sciences for the Monthyon prize.
1869.— The commission from the French Academy of Sciences reported
upon my observations and awarded an “honorable mention” with a “recom-
pense” of fifteen hundred francs. t
1869.—Grollemund (Thèse de Strasbourg) made observations upon the injec-
tion of the biliary salts into the blood in large quantity in dogs, and noted
certain disturbances of the nervous system.
1869.-Tincelin (Thèse de Strasbourg) made observations in which he failed
to obtain any marked nervous disturbances following the injection of the biliary
salts into the blood in dogs.
1869.-Pagès (Thèse de Strasbourg) injected the bile-duct in dogs with a
solution of sulphate of iron, which he thought destroyed the epithelium of the
liver and interfered with its eliminative function, producing accumulation of
cholesterine in the blood.
1870.—Feltz and Ritter (Journal de l’Anatomie, Paris, 1870) confirmed the
results obtained by Pagès with the sulphate of iron. They found no marked
effects following the injection of the biliary salts, taurine, or glycochol into the
veins. They also injected cholesterine in soap and water. The cholesterine
was not dissolved, and masses of cholesterine were found in the small pulmo-
nary vessels, producing death by embolism.
1872.—Picot (Journal de l’Anatomie, Paris, 1872) noted an accumulation
of cholesterine in the blood in a case of acute, yellow atrophy of the liver, which
terminated fatally. He found a proportion of cholesterine in the blood in this
case of 1.804 part per 1000, more than double the maximum which I obtained
in examinations of normal blood.
1873.-Koloman Müller (Archiv für experimentelle Pathologie und Pharma-
kologie, Leipzig) made an elaborate series of experiments upon dogs. No
serious or marked results followed the injection of the biliary salts or taurine
into the blood. He rubbed cholesterine with glycerine and made a solution in
soap and water. He injected 2.16 fluidounces of this solution, containing about
69 grains of cholesterine into the veins. In five experiments he produced
“a complete picture of the symptoms of grave jaundice.”
Conclusions of Koloman Müller.—“It appears to me to be certain that those
cerebral symptoms which accompany severe jaundice and many diseases of the
liver, the general manifestations of which have been called ‘cholamic intoxi-
cation,’ are produced by an abnormal accumulation of cholesterine in the blood.
This accumulation of cholesterine is contingent upon that alteration of the tissue
of the liver, which, in such cases, it suffers more or less.”
1875 and 1876.—Feltz and Ritter (Journal de l’Anatomie, Paris, 1875 and
1876) in opposition to their former experiments, conclude that the biliary salts
injected into the blood produce grave changes, mainly in the blood corpuscles.
The corpuscles become diffluent, change their form, the haemaglobine transudes
and crystallizes, and the power of absorption of oxygen progressively di-
minishes.
The general results of observations bearing upon the physiological re-
lations of cholesterine, made since 1862, are confirmatory of my observa-
500 FLINT, J R.,
tions. As regards cholesteraemia, the experiments of Müller are the most
important. Indeed, they supply the only missing link in my chain of
experimental evidence; and they show conclusively that the symptoms of
“grave jaundice,” which I connected with cholesteraemia, may be pro-
duced by the artificial introduction of cholesterine into the circulation.
As an inevitable result of my observations, confirmed by others and
extended by Koloman Müller, I can now confidently repeat the conclu-
sions which I published in 1862.
Conclusions.—I. Cholesterine exists in the bile, the blood, the nervous
matter, the crystalline lens, and the meconium, but does not exist in the
feces in ordinary conditions. The quantity of cholesterine in the blood
of the arm is from five to eight times more than the ordinary estimate.
II. Cholesterine is formed, in great part if not entirely, in the sub-
stance of the nervous matter, where it exists in great abundance, from
which it is taken up by the blood, and constitutes one of the most im-
portant of the effete, or excrementitous products of the body. Its forma-
tion is constant, it always existing in the nervous matter and the circu-
lating fluid.
III. Cholesterine is separated from the blood by the liver, appears as a
constant element of the bile, and is discharged into the alimentary canal.
The history of this substance, in the circulating fluid and in the bile,
marks it as a product destined to be gotten rid of by the system, or an
excretion. It pre-exists in the blood, subserves no useful purpose in the
economy, is separated by the liver and not manufactured there, and, if
this separation be interfered with, accumulates in the system, producing
blood-poisoning.
IV. The bile has two separate and distinct functions dependent on the
presence of two elements of an entirely different character. It has a
function connected with nutrition. This is dependent on the presence
of the glycocholate and taurocholate of soda, which do not pre-exist in the
blood, subserve a useful purpose in the economy and are not discharged
from it, are manufactured in the liver and peculiar to the bile, do not
accumulate in the blood when the function of the liver is interfered with,
and are, in short, products of secretion. But it has another function
connected with depuration, which is dependent on the presence of cho-
lesterine, which is an excretion. The flow of bile is remittent, being much
increased during the digestive act, but produced during the intervals of
digestion for the purpose of separating the cholesterine from the blood
which is constantly receiving it.
V. The ordinary, normal feces do not contain cholesterine but contain
stercorine (formerly called séroline from its being supposed to exist only
in the serum of the blood), produced by a transformation of the choleste-
rine of the bile during the digestive act.
VI. The change of cholesterine into stercorine does not take place when
digestion is arrested, or before this process commences; consequently,
stercorine is not found in the meconium or in the feces of hibernating
animals during their torpid condition. These matters contain cholesterine
in large abundance, which also sometimes appears in the feces of animals
after a prolonged fast. Stercorine is the form in which cholesterine is
discharged from the body.
VII. The difference between the two forms of jaundice with which we
are familiar, the one characterized only by yellowness of the skin and
comparatively innocuous, while the other is attended with very grave
symptoms and is almost invariably fatal, is dependent upon the obstruction
E X C R E TO R Y F U N C TI O N OF THE LIVE R. 501
of the bile in the one case, and its suppression in the other. In the first
instance, the bile is confined in the excretory passages and its coloring
matter is absorbed, while, in the other, the cholesterine is retained in the
blood and acts as a poison. a
VIII. There is a condition of the blood dependent upon the accumu-
lation of cholesterine, which I have called cholesteraemia. This occurs
only when there is structural change in the liver, which incapacitates it
from performing its excretory functions. It is characterized by symptoms
of a grave character referable to the brain and dependent upon the poi-
sonous effects of the retained cholesterine on this organ. It occurs with
or without jaundice.
IX. Cholesteraemia does not occur in every instance of structural dis-
ease of the liver. Enough of the liver must be destroyed to prevent the
due elimination of cholesterine. In cases in which the organ is but mode-
rately affected, the sound portion is capable of performing the eliminative
function of the whole.
|X. In cases of simple jaundice, when the feces are decolorized and the
bile is entirely shut off from the intestine, stercorine is not found in the
evacuations; but in cases of jaundice with cholesteraemia, stercorine may
be found, though always very much diminished in quantity, showing
that there is an insufficiency in the separation of cholesterine from the
blood, though its excretion is not entirely suspended. After death, but
a small quantity of bile is found in the gall-bladder.
DISCUSSION ON DR. FLINT’s PAPER.
After the reading of the preceding paper, the President, Dr. John C. DAL-
To N, of New York, said:—We have all listened with the greatest pleasure to the
paper which has just been read. Though the subject is not entirely new, yet
we are almost exclusively indebted to Dr. Flint for the latest light we have upon
it. Those of us who are devoted to physiology are forced to select some par-
ticular department, and are therefore apt to be more interested in the develop-
ment of that department than of others; but I am certain that if we make any
distinction between the departments of physiology, physiological chemistry
must be given the lead, for the study of the ingredients of animal forms lies at
the foundation of all physiological study. We cannot claim that we are thor-
oughly familiar with physiology until we know the component substances of
bodies—what they are, how they get into them, and what they do after getting
there; what changes they undergo; and under what forms they disappear.
The changes and operations of these substances constitute nutrition. Choles-
terine, if I recollect aright, was discovered nearly a hundred years ago in gall-
stones, was found to be extractible by hot alcohol, and was supposed to be an
accidental deposit in an accidental, morbid form. But slow progress was
made, and further discovery, until investigation proved that cholesterine ex-
isted in the liver. It was afterwards found in fresh bile, and then, after a con-
siderable lapse of time, was shown to be an ingredient of the blood. Some
years subsequently a curious discussion arose as to whether the nuclei of the
red blood globules were not formed of cholesterine, and it was afterwards dis-
covered that both the blood globules and the liquor sanguinis contained this
substance, which was ultimately found in morbid exudations in all regions.
Then came Dr. Flint's investigations in regard to the comparative amounts of
cholesterine going to, and coming from, the organs. In this way the investiga-
tion has gone on for nearly a hundred years, and I suppose that Dr. Flint him-
self would not consider that the entire history of cholesterine has been yet
exhausted. There is a great deal of work still to be done in this field to ascer-
502 FI,INT, J.R., Exc RETo RY FUNCTION OF THE LIVE R.
tain the amount of cholesterine in the blood, and the different conditions and
circumstances which determine its precipitation in morbid products. As we
now know, it also forms an ingredient in some common articles of food. The
study of cholesterine seems to me of the greatest importance in regard to
excrementitious matters. I think we sometimes misrepresent to ourselves the
character of the excrementitious process, in describing it as a process of destruc-
tion. But excrementation and disassimilation are not destruction ; when food
is taken into the stomach it undergoes a change there, and a further change in
the blood, and so on, until it finally appears as carbonic acid or as choles-
terine. Then comes the process of excrementation. The food has accom-
plished its duty in the nourishment of the body, and is wanted no longer. We
could illustrate the process very well by all the steps upwards from the sowing
of a cotton-seed to the manufacture of the cotton into cloth, and the final use
of the rags in the manufacture of paper, and then the return of all the products
back again to the soil. There are difficulties in the way of these investigations,
and therefore we ought to feel ourselves very much indebted to those who help
them on. - -
Dr. J. G. RICHARDSON, of Philadelphia, said:—Dr. Flint's experiments estab-
lish three important facts in science, and complete a physiological chain in
regard to the formation of cholesterine in the brain, its entering the circulation
and being abstracted from the blood by the liver, and its being carried thence
by the bile into the intestines where it is converted into stercorine. I would
ask Dr. Flint whether he has made any experiments in regard to the formation
of cholesterine in ovarian fluid 7
Dr. FLINT said:—I have not done so, but cholesterine is liable to be found
in almost all the pathological formations of the body.
On motion, the conclusions of Dr. Flint's paper were adopted as expressing
the opinion of the Section.
503
REPORT OF INVESTIGATIONS MADE UNDER THE DIRECTION
OF PROFESSOR ZAVARIKINI, AT THE INSTITUTE OF
NORMAL HISTOLOGY OF ST. PETERSBURG.
COMMUNICATED BY
DROFESSOR, RUDNEW.
I. THE STRUCTURE OF THE SWEAT GLANDS IN MAN, IN THE HORSE, AND IN
THE SHEEP.
By DR. GALANI.
THE epithelium of the sweat glands in man consists of very minute,
oval cells, which are polygonal, and which are disposed in two layers,
immediately under which lies the membrane consisting of fusiform ele-
ments with oval nuclei. By means of reagents we discover that these
cells are simply muscular fibres. In the sweat glands of the scalp we
find that these muscular fibre cells are intermixed with cells having the
characters of connective tissue.
The epithelium of the sweat glands in the horse and sheep forms only
one layer, while in all other animals there are two layers. The cells of
this epithelium, viewed from the surface, have an hexagonal appearance,
while from the side they appear of cylindrical form. Beneath the epi-
thelium of the horse lie only the cells of connective tissue character, and
these cells are so disposed one to another as to resemble in form a house
tile. Beneath the epithelium of the sheep is found a membrane which
consists of muscular fibres. -
For the investigation of sweat glands we have employed the lens
under which we have been able to separate the particles of the glands,
and for the recognition of the muscular tissue we have used the follow-
ing reagents, viz., a 36 per cent. solution of caustic potassa, chloride of
palladium, Carmine, and pieric acid.
II. UPON THE TERMINATION OF NERVES IN THE PLEURA OF THE
RABBIT, DOG, AND CAT.
By DR. LEBEDEFF.
The nerves, after separating into different arms and branches, termi-
nate in a network in which it is sometimes possible to discover nervous
cells of various sizes. Beneath the endothelium the network is com-
posed of regular rhomboidal nooses, within which are found sometimes
the cells of the endothelium, in numbers from one to five. Between the
cells of the endothelium are disposed the fibres, which sometimes envelop
the cell, and sometimes enter the cell and surround the nucleus. The
greater part of the nerves possess nerve cells between their fibres, in
number from two to fourteen, and this is especially observed in the
rabbit. Some nerves do not terminate in the network, but in pear-
shaped cells.
504 ZAVA RIKINI,
III. UPON THE MICROSCOPIC ANATOMY OF THE NERVoUs APPARATUS OF
THE BRONCHI AND LUNGS IN THE FROG, THE RABBIT, THE DOG, THE CAT,
THE HORSE, AND THE MOUSE.
By DR. SANTCHICH.
There are within the pleura many nerves which permeate the paren-
chyma of the lungs. The nerves form a double network, one being ante-
rior and the other posterior. In each network are disposed from one to
seventy cells, and the distributions are to the walls of the bronchi, the
walls of the vessels, and the pulmonic pleurae. The greater number of
these cells are bipolar, and some few of them are even multipolar. All
the nervous fibres emerging from the cells ramify to different parts of
the lungs, and form networks. The nervous fibres found in the bronchi
form two networks, one of these serving for two layers of the bronchi,
and the other forming a surrounding network. The nervous fibres
which go to the epithelium of the bronchi form a network exactly under
the epithelium, and some of them at the same time penetrate the epithe-
lium itself. If we isolate the epithelium cells, we observe that the
nerve fibres are in intimate connection with the protoplasm of these
cells. In the cartilage of the bronchi, viz., in the perichondrium, we
find the minute fibres of the nerve, which sometimes penetrate into the
upper part of the cartilage, but are more generally confined to the peri-
chondrium. The glands of the bronchi are surrounded with a network
of nerve fibres, which sometimes enter into the epithelium of the glands.
In the bronchi and in the tissue of the lungs we meet with the termina-
tions or ends of the nerve, in the form of either round or pear-shaped
cells, and sometimes we find nerves which terminate in rhombic bodies,
the nature of which is not at present known. The nervous fibres and
networks are surrounded with the periaxial space, which space is covered
with the epithelium cells. For examination the lung is stained with a
solution of chloride of gold, one-half to twelve per cent., and sometimes
with nitrate of silver and osmic acid.
IV. UPON THE TERMINATION OF NERVES IN THE HUMAN SKIN.
By DR. SANTCHICH.
In the fibrous layer which lies immediately under the epithelium ex-
ists a nervous network of an extremely close and fine construction, the
rhomboid meshes being very minute. This network does not contain
nerve cells, except in very few cases, but within the fibrous meshes are
to be found epithelium cells, in numbers from one to seven. The nerves,
after permeating the Malpighian layer, terminate under the horny layer.
If the epithelium cell with its nervous fibre be examined under the
microscope in an isolated form, the fibre will be found in intimate con-
nection with the protoplasm or body of the cell. Besides the network
of nerves interlaced between the cells of the epithelium, there are seen
minute fibres which do not take any part in the formation of the net-
work, but which are also connected with the epithelium cells.
Within the outer sac of the root of a human hair is found a network
of nervous fibres, some of which possess a pulp while some have none.
Some of these fibres permeate the inner sac, and terminate in a minute
network around the capillary vessels, while others pass through to the
C O N TRIBUTIONS TO NO R M A. L HISTOL O G Y . 505
epithelium, and here end between the epithelium cells. The papilla of
the hair is supplied by the same network of nerves as the other parts of
the hair follicle.
I may at this point describe the nerves appertaining to the fat glands
and sweat glands of the skin. Around both, the nerves form a network.
With the fat glands some of the nerve fibres lie either immediately
beneath the epithelium or between the epithelium cells, and we have
occasionally been able to distinguish how the nerve fibre, after passing
into the fat gland, terminates in a body similar to a mulberry, with two
or four nuclei. The networks of nerves which are disposed between the
epithelium cells anastomose with each other, so that we can observe how
the network of the papilla is combined with the nerves of the hair
follicle.
We have worked under the microscope with chloride of gold solution,
#—# per cent., and for the isolation of epithelium cells we have used a 10
per cent. Solution of common salt.
ON FUNGOUS GROWTHS IN SOLUTIONS FOR HYPODERMIC
MEDICATION, AND THEIR PREVENTION BY
SALICYLIC ACID.
BY
JOS. G. RICHARDSON, M.D.,
ATTENDING PHYSICIAN TO THE PRESBYTERIAN Hospit AL, PHILADELPHIA.
AMONG the minor inconveniences of medical practice, few are more
annoying to the careful physician than a failure to afford the hoped or
prayed-for relief from pain, by the subcutaneous injection of morphia. I
therefore venture to occupy a few minutes of the time of the Section with
a brief account of a new method for preventing diminution in the strength
of morphia solutions, in so far as it is due to the common cause of such
deterioration, namely, the formation in the fluid of fungous growths,
which necessarily develop at the expense of the contained solid ingre-
dients.
If we examine under a microscope of high power one of the white floc-
culent masses which appear after a week or two of warm weather in our
ordinary Magendie's solution of morphia, we will commonly find it made
up of an immense number of branching threads, on an average about
sºon of an inch in diameter, often distinctly septate, and probably recog-
nizable as the mycelial condition of one of the genera of the Mucorini or
siphonaceous plants.
Complete identification of the exact species is only possible, even for
the professed mycologist, by investigation of its aerial fructification.
We, however, often find, as it develops entirely beneath the fluid, an evi-
dent attempt towards the formation of some sort of reproductive body,
and in many cases are to be seen in active motion, near the filaments, spore-
like bodies, analogous to the antherozoids of the unmistakable algae and
fungi, which have doubtless escaped from broken fragments of the aquatic
mycelial threads.
The atoxic quality of Salicylic acid, as demonstrated by the moderate
and even large doses administered in thousands of cases of acute rheu-
matism, etc., suggests at once its employment for the purpose of prevent-
ing the growth of these fungi ; and I think it quite probable that it has
already been so used by others of my fellow-practitioners as well as by
myself. No exact observations upon this subject have, however, l believe,
as yet been published, at least in our own country.
In order to determine the precise amount of this antiphytic agent
required to produce the desired effect, I prepared on the first of August
last, now five weeks since, one dozen two drachm vials, each containing
one fluidrachm of a solution of acetate of morphia (gr. xv.j to faj), such as
is usually employed for hypodermic medication. These samples were num-
bered from 1 to 12, and after the acetate, except impurities, had been dis-
solved by the aid of a small quantity of acetic acid, I added to Nos. 2 and
4 each one-sixteenth of a grain of salicylic acid, to Nos. 6 and 8 each one-
eighth of a grain of the same substance, and to Nos. 10 and 12 each one-
PR E W E N TION OF F U N G O U S G R O W T H S. 507
quarter of a grain of the like material. Nos. 1, 3, 5, 7, 9, and 11 were left
unmixed with other ingredients, and all were corked tightly and equally
exposed to the light, and to the unusually elevated temperature of our
Centennial summer. At the end of one week, small whitish flocculi, evi-
dently composed of filamentous tufts, were visible in the bottles the con-
tents of which were unmixed with salicylic acid, and similar minute
Specks, in much less quantity, had made their appearance in Nos. 2 and
4, which contained each one-sixteenth of a grain of salicylic acid.
Under the microscope, specimens of these tufts were seen to be made up
of mycelial threads, probably of some species of physomycetous fungi,
such as I have already described. At the present time, after five weeks
have elapsed, those vials which were not protected by salicylic acid pre-
sent every one large masses of fungous growth, as each member of the
Section may see for himself by inspecting them upon the table. Nos. 2
and 4, in each of which it will be remembered that one-sixteenth of a
grain of the acid was dissolved, display small tufts of mycelial threads.
No. 8 shows a mere trace of fungous growth, whilst Nos. 6, 10, and 12
exhibit to the naked eye (as they do also under a one-fifth objective) no
indication of living fungi in the slight deposit of brownish impurities let
fall at the bottom of the glass.
In specimens of similar morphia solution, containing one-eighth of a
grain of salicylic acid to the fluidrachm, carried in the hypodermic syringe
case, and used from time to time in my daily practice during three months
of cooler spring weather, no flocculi of living fungi were discoverable with
the naked eye or under the microscope. Further, no unusual effects of
any kind were observable in patients, some of whom received as much as
m, viij at a dose. Injections made into my own arms for the purpose of
testing the fluids in Nos. 10 and 12, produced but little smarting sensa-
tion, and afforded the ordinary anodyne, with no uncommon nauseating,
depressing, or disagreeable effects of the drug.
I therefore recommend the preparation of a fluid for hypodermic injec-
tions according to the following formula: Morphiae acet. vel sulph. gr.
xvj; acid. acetici (No. 8), gtt. ij; acid. Salicylic. gr. iss; aq. destillat. fšj.
If a sediment is left undissolved, this liquid should be filtered, or, after
standing a few days in a vial, or preferably a conical glass, the clear fluid
may be drawn off by means of the hypodermic syringe itself, and pre-
served for use. By employing such a preparation, the practitioner is
almost certain to avoid the disappointment in the relief of pain liable to
arise from injecting a solution, the strength of which has deteriorated,
and he will also escape that danger of producing abscess by the insertion
of fungous elements beneath the integument, against which we have
been cautioned by some authorities, although perhaps without sufficient
cause for the warning.
In conclusion, I would suggest that a similar application of salicylic
acid to the preservation of watery preparations of quinia, atropia, etc., to
solutions of bromide of potassium, eitrate of potassium, etc., and to vege-
table infusions, when it is desirable to avoid the employment of even
small quantities of alcohol, may prove of great value to the pharmaceutist
as well as to the physician.
508 RICHARDS ON,
DISCUSSION ON DR. RICHARDSON's PAPER.
After the reading of the preceding paper, the President, Dr. JoHN C. DAL-
TON, of New York, said:—Dr. Richardson has referred to two disadvantages
that might result in the hypodermic use of solutions of morphia without this
precaution, but in language which leads us to suspect that perhaps he does not
think much of the danger of producing an abscess. I would like to inquire
whether there is any definite information in regard to the danger, or whether
in his opinion the danger exists at all 7
Dr. RICHARDSON said:—Theoretically I have felt inclined to suppose that
danger would exist, but in order to test the theory I have tried several experi-
ments, injecting my own arm with a solution containing fungi, and in no case
has an abscess been produced.
Dr. DALTON said:—Of course it would be more agreeable to inject a fluid not
containing fungous growths; at the same time ought we to anticipate that
these growths would continue their development in a subcutaneous tissue 2
My attention was once very directly called to the difficulty that might arise
from such development. I made a series of observations in order to determine
how many definite kinds of microscopic fungi might be derived from ordinary
atmosphere. Taking fresh slices of boiled potato, I placed them on a plate
that had been immersed in boiling water, and covered them with a bell-glass,
under which also a moist sponge was placed. A considerable variety of these
microscopic growths showed themselves from time to time, of various colors;
and notwithstanding their minute size and apparent want of specific character,
they had differences in form and size and structure. A few weeks after finish-
ing the experiment, I found one day on the back of my hand a spot which was
irritable and itching ; this spread, two or three other spots appearing, until
finally I was compelled to give attention to the matter, and on examination I
found that my hand was the seat of a tricophyton, which was finally removed
after treatment for four or five weeks. It then occurred to me that perhaps I
had inoculated myself while engaged in the experiments. I had been raising
microscopic fungi, and I had unknown to myself been infected with them. Fur-
ther, upon the same subject, Dr. Vandoren told me that in a series of experi-
ments he had demonstrated that the ovum of the mosquito is not deposited
directly in the water, but floats in the atmosphere, and is brought down by the
rain. So it would seem that in reality there are a larger number of germs,
both vegetable and animal, that may arrive at their destinations through the
elements. My impression is that this fact in regard to the ovum of the mos-
quito is new.
Dr. RICHARDSON said:—My recollection is that our natural histories gave
us pictures of the mosquito in the act of laying eggs in the form of a boat which
floated upon the surface of the water for some days or weeks before hatching.
I think the experiments mentioned are entirely novel.
Dr. DALTON said:—In regard to the boat in which the eggs are contained, is
it barely possible that Dr. Richardson may be thinking of the mosquito itself
coming out from the integument of the larva Ż
Dr. RICHARDSON said :—No, sir; that is a subsequent performance. But I
wish to ask Prof. Dalton in respect to the infection of which he spoke, whether
his health had been deteriorated in any way ? I make this inquiry because one
of the most difficult questions in regard to the development of these ento-
phytic and epiphytic diseases is whether the health is first deteriorated, so that
a suitable midws for the fungi to grow in is afforded, or whether, on the con-
‘trary, the fungi are the primarily active agents which deteriorate the health.
Dr. DALTON said:—I can testify, with the greatest confidence, that I was in
perfect health.
Dr. RICHARDSON said:—Some years ago I had an interesting case bearing
upon this point in my own family. On the chin of my little daughter appeared
PR E W E N TI O N OF F U N G O U S G R O W T H S. 509
a small pimple, which became inflamed, and seemed to have a yellow head upon
it. In examining it I was struck with its remarkably dry appearance, and its
sulphur-yellow rather than brownish hue. I placed a portion of it under the
microscope, recognized the presence of the fungus of Favus, and soon cured the
disease with corrosive sublimate solution. The child was in perfect health,
and I could only account for the attack by supposing that she had leaned her
chin on the sill of a car-window, where some person infected with achorion
Schonleinii had accidentally left a few spores of the disease. I would like to ask
another question, whether there has been any corroboration or disproof of the
experiments described by Simon in regard to the dependence of ocular diphthe-
ria upon micrococci developing in the cornea of rabbits; where two punctures
were made, in the one side with a diptherized needle, and in the other side with
a clean needle, in every case the result having been that the cornea infected
was marked with brownish streaks, which under the microscope displayed
minute fungus spores. I look upon it as exceedingly important to know whether
the fungi can develop in an internal portion of the system, secluded from the
air, and that in a previously healthy part of the organism.
Dr. DALTON said:—I am not familiar with any corroboration of those experi-
ments. I tried some experiments of a similar kind, two or three years ago, with
results which convinced me that it did not require for such parasitic growths
the previous existence of a morbid condition of the recipient. The experi-
ments were with regard to the ordinary decomposition or rotting of fruit. It
can no longer be maintained that rotting is a continuation of the ripening pro-
cess. An external wound is absolutely necessary to the rotting of any fruit
with a hard integument, such as the apple and the pear, though it is not
absolutely necessary with other fruit, like the orange. I tried the experi-
ments with apples, and proved that they could be kept for any length of time,
if uninjured, and also that rotting was contagious. The rot could plainly be
seen to spread away from the point of contamination. I have exposed a dozen
apples, half sound and half broken, to the ordinary atmosphere, and the rot
always began at the point of injury. The spores came in from the atmosphere.
Indeed, an injured apple can be kept from rotting by being protected from the
atmosphere. I have taken a sound apple, and made a little cut in it, and then
put it under a bell-glass, and kept it an indefinite time. The experiments can
be easily tried, and are most convincing.
Dr. RICHARDSON said:—You speak about the rot starting from the wound
in the integuments of the apple in a way that resembled the spread of erysipelas
from the edges of a wound in the human body. Did it ever occur to you to
cover the wound in the apple with carbolized putty before exposing it to the
infection of the fungi which cause decay, and thus throw a ray of light upon
one of the great surgical problems of the day ?
Dr. DALTON said:—I never did so, but I think that it might be an interesting
experiment.
Dr. RICHARDSON said:—I would ask Prof. Rudnew whether these experi-
ments of Oertel and Nassiloff (the latter, I believe, a Russian observer), nar-
rated in Prof. Simon's report, have been confirmed or disproved by others of
his countrymen 7
Prof. RUDNEw, of St. Petersburg, said:—I have studied these investigations,
but have made no similar researches myself, and believe that the views of those
gentlemen are still considered sub judice.
510
THE MECHANISM OF JOINTS.
BY
HARRISON ALLEN, M.D.,
PROFESSOR OF COMPARATIVE ANATOMY AND zoologY IN THE UNIVERSITY OF PENNSYLVANIA,
SURGEON TO THE PHILADELPHIA HOSPITAL, SURGEON TO ST. Jose.P.H.’s HOSPITAL, ETC.
THE' limb being subservient to both support and motion, it is reasonable
to expect that in certain joints the former function should be observed,
and in others the latter. When the apparatus for support is conspicuous,
the joint may be said to be of static value. But when this purpose is
subordinate to flexion (i. e. deviation from the axial line of the limb), the
joint may be said to be of dynamic value.
The most striking distinctions between the static and dynamic articu-
lations lie in the relations of the opposed surfaces. To explain this por-
tion of my remarks a few words of a general character are necessary. I
premise that the typical “ball and socket” joints consist of well-defined
balls embraced by perfect sockets. No such joints are found outside
of the vertebral column. The articulations between the bodies of the
vertebrae, although spoken of as amphiarthroses, are in truth “balls
and sockets.” The central intervertebral mass is the “ball;” the op-
posed vertebral surfaces and the peripheral interlacing fibrous bands
of the disk make up the “socket.” I also premise that the simplest
forms, or at least the first forms, of joints appear in the vertebral
column, since this structure answers to the axial line of the body.
The movable union between any pair of segments or bodies of this
axis may be taken as typical of what is possible under more complex
conditions elsewhere. If it is remembered that a rod or axis cannot
be projected far without segmenting, the best basis is secured upon
which to rest any consideration of arthrosis. Obviously motion between
a pair of bony segments is the main fact to consider in every problem.
The questions which I believe can be asked with reference to further
development of this theme are, in what way is support secured through
a series of such mobile joints, and how can the apparatuses of motion be
varied ?
The limb is a special structure appended to the body. It moves chiefly
at the joint between its first and second bones. This joint, in both the
anterior and posterior extremities, is a ball and socket, as usually de-
scribed. But it evidently in each instance is a portion of a ball opposed
to a partial socket; since only small portions relatively of the head of
the humerus or femur can be brought in relation to the socket at one
time. So generally throughout the limbs (although in less marked de-
gree), it is found that segments of spheroids play within concave sur-
faces. I propose to call all such surfaces modified balls and sockets (the
type of which is exhibited only in the vertebral column), and proceed to
define the two main varieties, named above, to wit: (1) Where the rela-
' [This paper is an abstract of a more elaborate study which the author reserves the
right of publishing hereafter in a separate form.—EDITOR.]
M E C H A N IS M OF JOIN T S. 511
tions between the two surfaces are such that the ball lies in its socket,
and suggests rest. (2) Where the ball is suspended from the socket, and
suggests motion. The occipito-atloid articulation is an example of the
first, and the temporo-maxillary of the second variety.
The dynamic joints are apt to be crossed by powerful muscles, if in-
deed it may not be said of them that the muscles aid to a great degree
in maintaining the efficacy of the articulations. Thus if the muscles
about the shoulder-joint are divided, the humerus breaks contact with
the scapula, and the joint is destroyed. This is also true of some other
articulations, as the temporo-maxillary, in part. In some other instances
of the same variety, the relation while not maintained by muscular action
is strengthened by the presence of muscles crossing the joint, as at the
ankle and wrist-joints.
As in all other studies in biological science, typical forms are united
by intermediate ones. Some joints, as the knee and elbow, do not
naturally fall within either static or dynamic kinds. The elbow-
joint is especially difficult to study, it being varied from its type to a
remarkable degree. The knee-joint, although exceedingly intricate, is
resolvable in its several portions to static and dynamic functions, the
structural modifications from typical points being pronounced. In the
same way the first or swinging joints in the respective limbs, while of the
same variety, since the ball is suspended from the socket in both, differ
from each other in that the hip-joint is more fixed than the shoulder-joint.
In a word the hip-joint is a dynamic joint, modified or specialized to do
static work. In order that the work can be done effectively, stout bands
cross its capsule, and the head of the femur is received within the aceta-
bulum in such wise that the weight of the body is borne, not upon the
centre of the head of the bone, but upon its upper surface.
If these general statements be remembered in studying the etiology of
fracture and dislocation, more especially in examples of indirect violence,
it will be recognized that a static joint will not be apt to be dislocated
as long as the weight of the superincumbent mass presses directly within
the socket. Thus a dislocation at the occipito-atloid articulation is rare,
as is dislocation of the astragalus. But if the force be obliquely directed,
causing the weight to be received violently against the side of the socket,
then the joint may easily be luxated.
In the many positions assumed by the body, it often happens that an
injury may be sustained from a reversal of the normal or typical rela-
tion. Thus while the extremities are described from the shoulder down,
with the hands free (the main idea of the entire limb being motion), it
becomes a different subject when studied with the limb suddenly assum-
ing a supporting use—as for example when the body falls forward, and
the hand strikes the ground while the limb is extended. Here the head
of the humerus is driven up against its socket by the downward weight
of the body, and the idea of swinging is lost. In a word, a dynamic
joint is abruptly called upon to be a static one. A natural result is
luxation of the shoulder, or, if the muscles about the joint be particu-
larly rigid, fracture of the clavicle. In less degrees of violence, the force
being expended nearer the hand, the wrist is either luxated or the radius
broken. In medium degrees of violence, particularly seen in young
subjects, the outer condyle of the humerus will break by the weight of
the body being thrown through the convex radial head of the humerus
downward upon the fixed concavity of the head of the radius, provided
that the arm be forcibly extended. If the arm be partially flexed, the
512 AL LEN,
weight of the body being transmitted to the forearm at an angle, the
humerus will be apt to break transversely a little above the elbow-joint.
I do not speak here of the frequency of such fractures induced by in-
direct violence, but only of the way in which the articular surfaces as
described would in my judgment behave under the circumstances de-
tailed. - -
The lower limb, however, is always prepared for the conduction of
lines of force so exceptional in the upper. The whole limb, while ex-
pressing motion, is also designed to sustain the weight of the body.
Hence the greater strength of the joint surfaces, as well as the more
prop-like appearance of the limb. In walking, the weight of the body
is sustained for one moment at the astragalo-scaphoid joint in a nearly
straight line, embracing, in the limb, the femur, tibia, and astragalus.
The scaphoid bone and the inferior calcaneo-scaphoid ligament constitute
a socket which receives and sustains this enormous weight. In falls from
a height, which terminate by the foot striking, the weight not being
received directly within the centre of the socket may be deflected, and
luxation of the astragalus may occur. But from the rarity of this acci-
dent I infer that the mere exaggerations of the lines of force acting in
its accustomed directions, are less injurious than the same kind of force
acting upon the superior limb which is taken at a disadvantage.
The remainder of my remarks will be in application of the above data
to the study of joints, including new observations of some special forms
of articulation.
In the knee-joint, for example, I think that it can be shown, from the
shapes of the articular surfaces, that the outer femoral condyle is the
static or axial half, and the inner is the dynamic or swinging half. This
study involves many details which would occupy too much time to elabo-
rate." Suffice it to say, however, that when a person stands erect, the
femur rests upon the tibia as a ball in its socket, chiefly through its
outer condyle. In flexion, this condyle is “switched off” (for the most
part through the action of the popliteus muscle upon the outer semilunar
cartilage), while the swinging of the inner condyle of the tibia upon
the inner femoral condyle is initiated—not, it is true, by a ball suspended
from its socket, as much as by a gliding of a shallow concave tibial sur-
face upon a slightly convex femoral surface.
The term “switching off,” as applied to the outer femoral condyle in
passing from extension to flexion, needs explanation. The outer tibial
condyle is observed to be convex toward the tibial spine. It is evident
that, if any portion of the convex surface of the femoral condyle comes
in contact with this convexity, no support is possible. This is what
takes place when the knee is flexed. But when it is extended, the femoral
condyle is placed firmly in a tibial concavity, the inner boundary of
which is now formed by this eminence. As above stated, the outer semi-
lunar cartilage is the factor producing the change. The Outer tibial con-
dyle is a true saddle surface, modified by the presence of the semilunar
cartilage. The best example of a pure saddle surface is seen on the
proximal surface of the trapezium. Here the convexity increases also
toward the inner border. The first metacarpal bone of the thumb may
be described as lodged upon this convexity in flexion of the thumb, and
'The details embrace the study of the cancelli of both femur and tibia, the shapes of the
femoral, tibial, and patellar facets, the shapes and motions of the semilunar cartilages, as
well as a refreshened account of the so-called crucial ligaments.
M E C H A NISM OF J O IN T S. 513
as relaxed or “switched off” in extension. It is evident that this lodg-
ment and relaxation must be limited by appropriate ligaments. Inordi-
nate or uncorrelated motions determine dislocation.
In the limbs of some lower animals, special adaptations in joints are
recognized, which result in fixing or locking some of the facets. The
immediate result of such locking is to conserve muscular power. Ap-
plications of this principle to some joints in the human frame may
prove useful. Thus the knee-joint is nearly immobile at forced flexion
or forced extension, but is freely movable at points between. It is
probable that a careful study of other joint-surfaces will show similar
peculiarities.
The facets upon the ends of bones are arranged in the order of the
succession of the bones themselves in a given limb. The most evident
arrangement is to have a facet upon the proximal and distal surfaces of
each bone, in such wise as to allow the longitudinal axis to answer to
the centre of each facet. These may be termed primary facets, since
they are the most constant in any series of studies, and are least subject
to change in special apparatuses. Assuming that the generalization of
Goodsir is correct, that a process sent from the main shaft of a bone, as
from the ribs of fishes and birds, may be termed a rayed process or actino-
pophysis, I will suggest that the same term may be given to the analogous
process in a forked rib. If this be conceded, I think it not improbable
that, in the event of the shaft of a bone and its actinopophysis becoming
facet-bearing, such ray-borne articular surface should receive the name
of actinic, or secondary surface. I believe that the inner femoral con-
dyle is an instance of such a surface. I also believe that the surfaces
upon the sides of certain bones, as those between tarsal and metatarsal
bones, and between the tibia and fibula, or between the radius and ulna,
are of subordinate value to the primary facets, since they appear to be
caused by mutual compression of the bones themselves, and hence may
be termed lateral or tertiary facets.
A joint may be said to be at rest when the least pressure exists be-
tween its opposed facets. The supine position will tend to rest static
joints, since it diminishes the pressure of the weight. It will not, neces-
sarily, so rest completely dynamic joints, since the muscles may be more
or less active in the supine position. The lower jaw, for example, is not
so rested. It is evident that to place in absolute rest a joint of this
kind, its muscles must be kept from contracting. Any apparatus, there-
fore, to keep a joint at rest, must include all the muscles influencing
the joint. When it is recalled that in the lower extremity the muscles
are so disposed that the contraction of those arising from the hip effects
changes in portions beyond the knee, and even down to the foot, it may
be concluded that to make quiet any one, or part of one, of these surfaces,
the entire limb should be kept quiet."
It is at the same time true that, in a joint in which the articular sur-
face on one side is larger than that on the other, those portions at any
time not in use; may be said to be at rest. Thus, in the knee, some por-
tions of the condyles are at rest in extension, while others are at rest in
flexion. It follows from this that, in diseased action, products of patho-
genesis will be absent from surfaces removed from pressure or friction.
| Rest is perhaps best secured at semi-flexion, i.e., at the point at which extension ceases,
and flexion has but just begun. All parts are then relaxed. This, while a theoretical
point in some joints, has fixed value at the knee.
514 AL LEN,
Now pressure long continued will destroy tissue, while friction will in-
duce hypernutrition. It can be seen when a diseased joint is examined,
with this fact in mind, at which points the pressure, and at which the
friction has been. Thus in a knee-joint long the seat of chronic rheumatic
arthritis, the outer condyle of the tibia will be found reduced in size,
while the inner will be exaggerated. Also knee-joints flexed in diseased
conditions will have points of pain localized at the inner side, while knee-
joints extended in similar conditions will have like points developed upon
the outer side.
If the outer condyle is axial, it will so remain, no matter what por-
tion of the axis is reserved for articulation. So that in motion, after
excision of the knee-joint, the line of axial support is preserved, and a
good limb for standing is secured. Dut in consequence of the special
apparatus for flexion having been removed, the limb below the knee is a
mere wabbling appendage during attempts at bending.
DISCUSSION ON DR. ALLEN’s PAPER.
After the reading of the preceding paper, the President, Dr. John C.
DALTON, of New York, said:—The paper contains much that is new to me,
while many things previously unexplained are now made clear. It has, how-
ever, occurred to me, as it undoubtedly has to the author, that he might have
extended his principle also to the ligaments. I recall that while dissecting
joints, as a student of medicine, after removing the external ligaments and
retaining the capsule only, on bending the members making up the joint, it
was impossible to say when certain parts were on the stretch and when not.
It appears to me that this could also be explained by supposing the internal
concave surface of the capsular ligament to be made up of a large number of
facets operating in succession.
Dr. ALLEN said:—The occasion demanded that a single topic only should be
discussed. Had time permitted, much could have been said upon the relation
that articular surfaces bear to ligaments, both intrinsic and extrinsic. The
fasciae and muscles of every limb are also interested in every joint motion,
and of the latter more particularly those that cross more than one joint. One
series of these problems blends so easily into others that the line drawn between
any two of them must necessarily be arbitrary. As Emerson has said, the
answer to one riddle is another riddle. All Our conclusions are relative, and
invite renewed investigation. With reference to the ligaments of the knee-
joint, it may be remarked that the great variety of function assigned to them
by different writers is proof that their actions are not thoroughly understood.
Dr. BURT G. WILDER, of Ithaca, N. Y., having asked permission, as a visitor,
to comment upon Dr. Allen's paper, said:—I understood Dr. Allen to say that
the primary or fundamental movement of the limbs, among mammals, was
forward and backward as with most quadrupeds, but that man had the power
of raising the arms away from the trunk by means of the deltoid muscle, and
that the head of the humerus presented a peculiar and characteristic facet,
indicative of this movement of the limb. I would remind Dr. Allen of certain
facts in embryology and comparative anatomy, well known to him of course,
but apparently not present in his mind at the time of preparing his paper.
At a certain period of development, the forearm of man is in a state of pro-
nation, as it is permanently in most quadrupeds, and afterwards acquires the
power of complete supination, which seems to be correlated with the peculiar
action of the entire limb alluded to by Dr. Allen. But, at a still earlier
period, when the limbs have first appeared as little buds from the sides of the
body, their narrow borders are forward and backward, while their flat surfaces
M E C H A N IS M OF JOIN T S. 515
look outward and inward. Were any movement possible at this period, it is
evident that to be effective it would have to be not forward and backward, but
upward and downward, that is, dorso-ventral, and thus similar to that of which
the human arm is capable in its greatest perfection in man’s adult condition.
In like manner, as far as we know, are developed the limbs of all Vertebrates;
and the dorso-ventral or primitive motion is retained with most fishes and
with the marine turtles. It is likewise persistent throughout life with the
aquatic mammals, as the whales and porpoises, the manatee and dugong, the
seal and beaver, and the curious duck-bill, or Ornithorhynch ws, of Australia.
It may be worth while to examine the shoulder-joint of these forms for the
peculiar facet which distinguishes man from the ordinary quadrupeds.
At any rate, it seems somewhat significant that the dorso-ventral movement
which, as Dr. Allen has stated, distinguishes the upper and nobler arm from
the leg, and is likewise peculiar to man in his adult and perfect condition, in
contrast with the monkeys and ordinary quadrupeds, should be also the
primordial movement of both the arms and legs of all mammals, as indicated
by the earliest condition of the limbs, and that it should likewise be retained
in the case of certain low forms. In other words, the highest estate of man
recalls his earliest condition, and suggests his relationship to the lowest
members of his class. *
Dr. A LLEN said:—While the act of walking expresses the swing of the
anterior extremity, a yet better example of the characteristic motion of this
part is swimming. This act, as performed by a man, is essentially different
from the same act as essayed by a quadruped. In man, the arm is at one
time forcibly abducted by a powerful deltoid. This muscle, in its distinctive
shape, is not developed in the lower forms of animals, and in consequence the
spinal play of facets between the scapula and humerus is, with them, absent.
SECTION ON SURGERY.
P R E S I D E N T o F T H E s ECT I o N.
JOSEPH LISTER, F.R.S.,
OF ED 1 NBURGH.
v 1 c E-P REs I D E N T s.
J. A. GRANT, M.D., JOHN ASHHURST, Jr., M.D.,
OF OTT AWA. OF PHILADELPHIA.
8 E C R. E. T. A. R. Y.
JOHN H. PACKARD, M.D.,
OF PH I I, A DELPHIA.
On taking the chair, Professor LISTER said:—
GENTLEMEN:—
Although I am well aware that the time of this Section is exceedingly
precious, I cannot refrain from expressing my deep sense of the honor I have
received, an honor as great as it was entirely unexpected, in being called upon
to preside over the Surgical Department of this great International Congress,
sitting as it does in the chief centre of medical instruction on this vast conti-
nent. A merican surgeons are renowned throughout the world for their inven-
tive genius, and boldness and skill in execution. It is to America that we
owe anaesthesia, the greatest boon ever conferred upon suffering humanity by
human means; from America came the ligature of the common iliac artery for
aneurism; the ligature of the internal iliac for the same disease; the “exten-
sion treatment” by the weight and pulley for fractures of the thigh, and other
injuries and diseases; the reduction of dislocation of the hip-joint by manipu-
lation ; and that model of ingenuity, which I cannot mention without alluding
to the name of its inventor, Sayre's splint for morbus coxarius. These are
but samples of what surgery owes to this country, and it might, therefore, well
have been that some American surgeon should have been called upon to pre-
side over this Section of the Congress. Yet I assure you, gentlemen, that
highly as I esteem this honor, it is the more gratifying to me, because I am
persuaded that it has not been conferred on account of any special merit of
my own, but in consequence of the interest felt by the profession in Antiseptic
Surgery, with which my name happens to be connected. It was the circum-
stance of my observing in the programme of the business of the Congress that
the subject of Antiseptic Surgery was to coine on first for discussion, that led
me to cross the Atlantic ; and I should be pleased, indeed, if the discussion
which is about to take place should have the effect of strengthening the belief
of the profession in the truth, the value, and the practical application of the
principles of Antiseptic Surgery.
518
ANTISEPTIC SURGERY.
BY
JOHN T. HODGEN, M.D.,
PROFESSOR OF SURGICAL ANATOMY AND OF FRACTURES AND DISLOCATIONS IN THE ST. LOUIS
MEDICAI, COLLEGE, ST. LOUIS, MO.
PUTREFACTION is a decomposition experienced by animal substances
when deprived of life and placed under special circumstances. The pro-
ducts of pntrefaction are the results of the retrograde metamorphosis of
nitrogenized substances. The process bears a striking resemblance to
similar retrograde changes that occur in vegetable matters, resulting in
the production of carbonic acid, alcohol, acetic and butyric acids, etc.,
while the products of the decomposition of animal substances are repre-
sented by carbonic acid, ammonia, butyric acid, leucine, sulphuretted
hydrogen," and many other matters whose chemical characters are not
well established, and yet which cannot but be recognized as active agents
in the production of septicaemia. Pasteur has shown that neither in
vegetable nor in animal substances can putrefaction occur rapidly with-
out the presence of living germs.”
Tyndall has, by the aid of electric light, and by almost innumerable
experiments in reference to the development of living organisms, shown
that the germs, without which putrefaction cannot be induced, and with-
out which living organisms cannot be made to appear in vegetable and
animal infusions, are found in unnumbered multitudes in the atmos-
phere.” The observations of Rindfleisch make it appear that these putre-
factive and infusorial germs are abundant in water (terrestrial water),
and less abundant,” and perhaps not even present, under ordinary circum-
stances, a few hundred feet above the earth's surface.” Tyndall has,
* The Antiseptic System, by A. E. Sansom, p. 31. Nitrogen, hydrogen, ammonia; sul-
phuretted, carburetted, and phosphuretted hydrogen; carbonic acid; carbonic oxide; acetic,
butyric, and valerianic acids, and various other phosphorus and nitrogen bases
* Quarterly German Magazine, 1872; Mildew and Fermentation, by A. De Bary. Liv-
ing yeast cells capable of growing and budding are absolutely necessary to the introduction
of fermentation. . . . In dead substances in which we find bacteria, they are undoubtedly
the vital promoters of decomposition.
* British Medical Journal; abstract of paper read before the Royal Society, January 18,
1876, by Prof. Tyndall.
* Virchow's Archiv, 1872, Bd. liv. S. 402. Examination of Lower Organisms, by Prof.
Rindfleisch, of Bonn. Inaugural Thesis by Lothar Jasper, of Berlin, 1873. Treatment of
Wounds by the Open Method and by Antiseptics. . . . . Atmospheric air carries the
organisms which produce suppuration. . . . The air does not contain the organisms which
produce decomposition, these are contained in terrestrial water and on all objects moistened
by it.
W. See The Antiseptic System, by A. E. Sansom, in which Schroeder and Dusch (in 1854
and 1859) testify that air passed through cotton-wool, which acted as a filter, was free from
organisms. (p. 36.) “In 1860 M. Pasteur . . . filtering the air through a quantity of gun-
cotton, dissolved the latter in ether, and thus obtained in a small space a number of bodies
whose appearance announced them to be organized.” (p. 35.) . . . He sowed the germs and
produced organisms. “In some places the air was more fruitful than in others; especially its
fertility diminished in proportion to the altitude from which it was obtained.” (p. 36.) “In
the air of sick rooms, hospitals, crowded halls, etc., many fungoid organisms have been
noted by Trautman, Brittan, and Swayne, Dundas Thomson, Rainey, Lund, Lemaire, and
A N TIS E PTIC S U R G E R Y . 519
moreover, shown that, in the absence of currents of air, the germs do not
reach infusions contained in vessels terminating in bent tubes, the ends of
which are directed downwards, showing that germs must fall, or be carried
by currents of air, into infusions, if they reach them at all, and establish-
ing beyond a doubt that the specific gravity of the germs" is greater than
that of the atmosphere.
Pasteur has determined that the ferments present different physical
peculiarities,” so that the one may be distinguished from the other, and
that they feed upon albuminoid substances.” Prof. Tyndall filled 100
tubes with infusions, and from the irregular manner in which the con-
tents of the individual tubes were smitten, concludes that the germinal
matter of bacterial life is not uniformly distributed in the air," and thus
accounts for the difference in the behavior of different wounds similarly
circumstanced.”
The atmosphere of hospitals seems to be pervaded by living germs, and
the walls and ceilings seem to be encrusted with them. Chalvet" found
put rescible matters in the atmosphere and on the curtains, the windows,
the walls and the ceilings of the Hospital Saint Louis. He also states
that the vapor of water condensed near a suppurating wound is charged
with irregular corpuscles resembling dried pus. “The experiments of
Chauveau and Burdon Sanderson demonstrate that if a septic fluid capable
of producing toxaemia when injected into the veins of a living animal
be strained through a porcelain filter, the liquor so filtered may be in-
jected with impunity, whereas the solid residue remaining on the filter
retains in full force all the septic properties of the original fluid matter.”
Mr. Lund found bacteria in the air of the Manchester Royal Infirmary.”
Septicæmia, in the surgical sense, expresses that condition of the blood
which is induced by the presence of the products of putrefaction, a con-
dition of the circulating fluid that unfits it for the proper performance of
its function. Putrid matters may enter the circulation through any of
the mucous, serous, or cutaneous surfaces, or from any part of the body
in which they may be present.”
In surgery, the meaning is limited to the presence of putrid matters
Ransome. More recently Dr. Maddox has carefully examined the particles derived from
the atmosphere,” . . . and “ found pollen grains, minute germs of fungi or protophytes,
and excessively minute bodies, ‘molecules,’ ‘globules,' etc.” (p. 59.) “Dr. Percy found the
dust of the British Museum to contain 50 per cent. of inorganic [Qu. organic *] matter.
The latest investigations of this subject have been made by Mr. Tichborne, F.C.S. The
following were the results of analyses: Street dust in Dublin contained organic matter 31
per cent. Dust from places of Public Concourse contained organic matter 32 to 53 per cent.
Dust from Nelson's Pillar, 134 feet in height, contained organic matter 29 per cent.” (p. 60.)
* See The Antiseptic System, by A. E. Sansom, p. 58. Pasteur and Lister find that
putrefactive germs are arrested in bent tubes.
* See Sansom, p. 36. “By further researches Pasteur concluded that the different kinds
of organisms met with in putrefying solutions differed widely in the conditions of their
nutrition and their vitality. Some absorb oxygen and excrete carbonic acid; others the
converse.”
* Pasteur, Annales de Chimie et de Physique. Burdon Sanderson. Transactions of the
Pathological Society of London, vol. xxiii., 1872. Cohn, Quarterly Journal of Microsco-
pical Science, 1873, p. 156.
* Sansom, p. 36; Pasteur's experiments.
* Prof. Tyndall's recent researches; Abstract of paper read before the Royal Society,
January 18, 1876. From the British Medical Journal.
* Chalvet, Mémoires de l'Académie Impériale de Médecine; Paris, 1863, tome xxvi.
7 See A. Clinical Lecture on Septicaemia, delivered January 26, 1876, by S. Messenger
Bradley, F.R.C.S., Surgeon to the Manchester Royal Infirmary.
8 Ibid.
* Pathology and Morbid Anatomy, by T. Henry Green, London, 1876.
520 HIO DG EN,
derived from the decomposition of the solids and liquids of the body
itself; and these putrid matters may be formed either in parts in direct
contact with the air, or in those with which the air does not come directly
in contact." Common observation indicates that absorption of these noxious
matters takes place more rapidly in recent wounds, and in the early stages of
inflammations, while the experiments of Billroth attest that after healthy
granulation is fairly established, absorption of putrid matters goes on
so slowly (if at all) that the phenomena of septicæmia are not presented.
Pſe says,” “Certain circumstances are necessary for putrid matters to be
taken into the blood of man. Such substances are taken through the
healthy skin and mucous membranes when the putrid substances have a
destructive or cauterant action, or an active power of penetrating, like
fungi and infusoria.” “Diseased skin or wound-surfaces take up such
putrid matters more readily, but even they only do so under certain cir-
cumstances; for instance, germs do not readily pass through well organ-
ized, uninjured granulations.” “If we dress a micely granulating wound
on a dog with charpie dipped in the filthiest putrid matter, if the latter
contains no cauterant substance that may destroy the granulating surface,
the animal will not sicken ; nothing will be absorbed. . . . If the
septic poison be introduced into fresh tissue, it not only excites severe
local inflammation, but quickly induces general fever.”
Putrid pus is found in abscesses in many parts of the body; near the
alimentary canal or respiratory passages, and in the Soft tissues of the
extremities, as well as in and about the bones, and, indeed, in every part
of the body. A destructive inflammation may be set up about these col-
lections, and the protecting walls may melt away and furnish more mat-
ter to undergo putrefaction, while the conditions left by their destruc-
tion will favor the absorption of septic matter. And it is probable that
the septicaemia that so frequently follows the discharge of large collec-
tions of putrid pus is due, not so much to the admission of air and fresh
agents active in the production of putrefaction, as to the rekindling of a
destructive inflammation in the walls of such abscesses. This renewing
of inflammatory changes may be due to the increased flow of blood to
their walls, permitted by suddenly removing the pressure that may have,
for an indefinite period, acted as a barrier to its entrance. The renewal
of inflammatory processes from any cause in tissues surrounding collec-
tions of putrid matters is apt to be followed by septicæmia.
Certain conditions of the solids and liquids of the body are essential to
the ready action of septic substances. In the physiological processes of
the body, disintegrations and retrograde metamorphoses are constantly
occurring as a consequence of vital actions, and the elements of the tis-
sues assume a condition of fitness for putrefaction; all of the excretions
are examples of these products. Febrile states, inanition, over-exercise,
all induce changes in the organism that favor putrefaction in the solids
and liquids of the body. -
The impregnation of the tissues with certain substances tends to pre-
vent putrefaction. Prof. Polli, of Milan, found that the bodies of animals
that had been fed on the sulphites resisted putrefaction longer than those
of similar animals not so fed, and that urine passed after taking sulphites
remained “fresh, acid, and clear, and did not undergo ammoniacal fer-
mentation for eight days during the hottest Italian summer.” According
Joseph Bel), M.D., Edinburgh Medical Journal, 1869, p. 982, et seq.
* Billroth, Surgical Pathology, American Edition, 1871, p. 334.
A N TISE PTIC SU R G E R Y . 521
to Polli, these salts do not destroy the ferments, do not directly kill living
germs, but modify the tissues so that they are incapable of being acted
upon by catalytic germs, and thus putrefaction does not occur." Prof.
Gamgee's process of preserving meat consists in impregnating it with
carbonic oxide and sulphurous acid.”
Any condition or any substance that opposes putrefaction is antiseptic,
and, in its widest sense, this term includes many methods of action. In
the surgical sense any agent which prevents those changes in the blood
which ordinarily result from the rapid absorption of large quantities of
putrid matters, must be regarded as antiseptic. Filters, used to prevent
the contact of living germs with the putrescible discharges from wounds
and the tissues, furnish a most admirable method of preventing septi-
camia. A. Guérin, in 1870, used, at St. Martin’s Hospital, cotton-wool
as a dressing after amputations.” The great practical difficulty in the
successful use of cotton lies in the fact that we cannot be sure that the
cotton-wool itself does not contain germs which may become active in
the production of putrefaction.” Attempts have been made to correct
this possible condition by exposing the cotton-wool to air of an elevated
temperature, and also by impregnating it with various substances, with
the hope that germs already existing in the cotton may be destroyed.
Prof. Lister, in 1871, prepared cotton-wool by diffusing through it chlo-
rine gas, sulphurous acid gas, carbolic acid vapor, and vapor of benzine.”
This end is attained by Prof. Lister in the use of his antiseptic gauze,
with the advantage that it is a material which may be much more neatly
and easily applied, and more readily rendered antiseptic, being in thin
sheets, the fibres of which are all easily reached by the germ destroyer.
Charcoal, animal and vegetable, is one of the best of protective dress-
ings, acting (if a sufficiently thick layer be used) as a filter, and also as
an absorbent by which the discharges are held until they may be removed;
and, if putrefaction has actually taken place, the fetid emanations are
held, and do not contaminate the surrounding air. Chalk, plaster of
Paris, and clay, serve the same purpose as charcoal, but less efficiently.
I’owdered madder root" and Peruvian bark not only act as filters and
condensers of fetid gases, but actually prevent putrefaction by destroying
the activity of living germs, and, perhaps, by altering the escaping liquids
so that they do not readily putrefy. Among the most valuable anti-
septics are the metallic salts, as those of iron, copper, lead, zinc, mercury,
and silver." All of these used in a sufficiently concentrated state act as
caustics, and less concentrated they simply condense the tissues, and alter
the solids and liquids so that they do not readily putrefy ; in addition to
this action they destroy the vitality of the living organisms upon which
rapid putrefaction depends, and also destroy noxious products.”
As a first application to a recent wound, perhaps, no substance of this
* Observations on the treatment of zymotic diseases by the administration of sulphites.
Read in the medical section before the annual meeting of the British Medical Association,
August, 1867, by Prof. John Polli, M.D., of Milan.
* Scientific American.
* Extracts from Thesis of R. Hervey; Paris, 1873.
* Prof. Tyndall, paper read before the Royal Society, January, 1876.
* British and Foreign Medico-Chirurgical Review, October, 1875.
° London Medical Record, May 15, 1876; Antiseptic Properties of Madder Root, by M.
de Restaing.
7 Experimental investigations of the Action of Medicines, by T. Lauder Brunton, 1875.
* Therapeutics, Materia Medica, and Toxicology, by H. C. Wood, M.D.; Philadelphia,
1874.
522 H ODG EN,
class is better than chloride of zinc, which coagulates at once the super-
ficial layer of the albuminoid substances with which it comes in contact,
and, coagulating the blood and lymph while yet within the mouths of
the minute vessels, seems not only to prevent putrefaction, but also to
render rapid absorption improbable.
Since the prevention of absorption is as efficient as the prevention of
putrefaction' in avoiding septicaemia, this and a similar class of sub-
stances are among the very best antiseptics. Chlorine,” bromine,” iodine,”
and the alkaline sulphites are active destroyers of germs and preservers
of flesh, while the permanganates and manganates are chiefly valuable
as scavengers,” as they hasten oxidation, and thus rapidly alter organic
compounds to a degree that renders them incapable of putrefaction.
Quinine,” salicylic acid,” salicine, benzoic acid, and boracic acid,” all
destroy the vitality of bacteria," and prevent and check putrefaction.
Carbolic acid, creasote, and thymic acid, not only devitalize the germs,
but alter the tissues so that they do not so readily undergo putrefactive
changes, and alter recently wounded tissues so that absorption does not
readily occur, but they do not destroy the products of decomposition."
Drainage tubes" cannot be neglected in enumerating the valuable
methods of getting rid of putrescible matters;” so, also, the water-bath,
in which the water is continually changed, dilutes and carries away the
putrid matters, and so prevents their absorption;" so, also, the contact of
currents of dry air rapidly desiccating the putrid discharges, prevents
both putrefaction and absorption. Alcohol and alcoholic tinctures” have
attained considerable eminence as antiseptics, and no doubt owe their
efficiency to the power possessed by alcohol of coagulating the albumi-
noid products of wounded surfaces, as well as of the tissues with which
it comes in contact,” and also to the fact that in the manner in which
they are employed, they seem by repeated changes to remove the putres-
cible matters before putrefaction can occur; they are, no doubt, farther
beneficial in preventing absorption, since the change they effect in the
tissues would render these less liable to the entrance of matters from
without.
| The Action and Use of Antiseptics in Surgical Practice, by Charles Roberts, F.R.C.S.,
Assist. Surg. for the Victoria Hospital for Children; Lancet, vol. i., 1872.
* H. C. Wood, op. cit. * Brunton, op. cit.
* New York Medical Journal, January, 1876; Gangrene, by Dr. N. G. McMasters.
Polytechnisches Journal, July, 1876; Antiseptic Properties of Salicylic Acid, by Prof.
Kolbe, of Leipsic.
* Lancet, May 20, 1876; Boracic Acid as an ordinary Dressing for Wounds, by Dr.
Leonard Cane.
* Brunton, op. cit.
7 Sansom, op. cit.; Mould and Mildew are rapidly destroyed by carbolic acid. . . . It
prevents the germination of the spores of the yeast plant. . . . Albumen precipitated by
carbolic acid does not putrefy. (p. 24.) An infinitesimal quantity of carbolic acid instantly
kills bacteria, vibriones, etc. (p. 25.) When carbolic acid is added to a putreſying solution,
it is observed that all infusoria present in that solution instantly die, and the cessation of
putrefactive change is coincident with their death. And when carbolic acid is added to a
solution susceptible of putrefaction, but before the commencement of any putrefactive
decomposition, no organisms are developed. (p. 29.)
* British and Foreign Medico-Chirurgical Review, vol. liv., 1874, p. 1; Review by Mr.
Callender.
* Half-Yearly Abstract; Isolation and Treatment of Wounds, by G.W. Callender, F.R.S.
19 Memoir read before the French Academy of Medicine, 1870, by Dr. Leon de Fort.
* Pansement des plaies Chirurgicales; par le Dr. Benjamin Anger, Paris, 1872.
* Alcohol and Alcoholic Preparations in Surgery, etc.; by F. J. Batailhé and Ad. Guil-
let, Paris, 1860. See Amputations of the Thigh, by John Green, M.D., Boston Medical
and Surgical Journal, June, 1863.
A N TIS E PTI C S U R G E R Y . 523
The value of the antiseptic treatment of surgical diseases is attested by
many of the most eminent surgeons of Europe.' The practice is infinite
in variety, extending from the simple protection of wounds from contact
of catalytic germs, to the purification of hospital wards, water-closets,
and grounds. So general is the practice of antiseptic surgery, and so
thorough the faith of the profession in the value of its observance, that
we find none so bold as to deny its value, or so reckless of the lives of
his patients as to dare neglect its teachings. -
One practises isolation as the surest method of preventing septicaemia,
another has unlimited faith in ventilation and personal cleanliness;”
One moves with deadly intent on the hosts of bacteria that infest his
wards, another keeps watch over his wounds with a fidelity that chal-
lenges admiration ; one places a barrier to the contact of the dreadful
cause of putrefaction, another seals the absorbent surfaces and denies
admission to the products of putrefaction ; one leaves the wound open
for the escape of the deadly enemy, another bars the paths of entrance
so that none but the pure shall enter; one washes and scrubs, another
plasters and daubs—all seek the same goal but by a variety of paths.
When we consider the fierce contest that for years has been waged in
reference to the theory of the spontaneous generation of infusoria, and
learn how difficult it is to prevent the entrance of germs into infusions;
when we remember how difficult it is to prepare an infusion, and protect
it, so that living matter shall not enter it from without, we cannot but
realize the utter impossibility of protecting wounds from the contact of
catalytic germs. Accepting as true the doctrine now so thoroughly
established by Pasteur and others that fermentation and putrefaction do
not occur except in the presence of living germs, and recognizing the
presence of these germs in the blood of living human beings,” and their
action as attested by the presence of collections of putrid matter in every
part of the human body, we can readily see the utter hopelessness of a
struggle to prevent by filters, plasters, or powders, their contact with
open wounds.” Dr. E. Fischer found bacteria septica under Lister's dress-
ings in every case, notwithstanding that all the cases, except one, had
a favorable course.” Ranke and Von Birch-Hirschfeld found the same.
It should not be forgotten that through the various channels of excre-
tion, septic matter may be eliminated from the body, and that if absorp-
tion is not more rapid than elimination, no poisoning occurs. If, there-
fore, we can keep the absorption of septic matters within bounds, we
virtually prevent septicaemia. The practice of washing out the cavity
of the uterus after the removal of fibroids affords a good illustration of
the value of preventing a too abundant absorption of putrid matter,” as
" Volkmann, Thiersch, Sigmund, Holmes, Syme, Lister, Nankivell, Kolbe, Bennett,
Rivington, Cane, Polli, Green, Hervey, Cadge, Bradley, Guérin, Jasper, Esmarch, Bell,
Dougall, Macnamara, Leisrink, Koenig, Holderness, Manson, Ross, Sansom, Hamilton,
McCormac, Bickersteth, Hulke, Baker, Bartlett, Goodall, Sydney Jones, Saxtorph, Lund,
Walton, Wells, Bastleto, Jessup, etc.
* British Medical Journal, April 25, 1876; Prevention of Pyaamia in Hospital Practice,
by Wm. Cadge, Surgeon to the Norfolk and Norwich Hospital.
* Clinical Results of Lister's Antiseptic Treatment, and the Substitution of Salicylic for
Carbolic Acid ; Prof. C. Thiersch, Leipsic.
* Medical Times and Gazette, vol. ii., 1875; The Antiseptic System in Surgery, by
George Thomson, M.D., Surgeon to Oldham Infirmary.
* Deutsche Zeitschrift für Chirurgie, Feb. 1876, Bd. vi., No. 4, S. 319; Lister's Dressing
and the Organisms found beneath it, by Dr. E. Fischer, Strasbourg.
* On Intra-Uterine Fibroids; by J. Marion Sims, Surgeon to the Woman's Hospital of
the State of New York, 1874. Remarks upon the Enucleation of Uterine Fibroids, with
illustrative cases; by T. Gaillard Thomas, M.D.
524 HO DG EN,
does also the washing out of the uterus after giving vent to accumula-
tions of old menstrual fluid (Emmett).
Some of the eminent German surgeons affirm that, during the Franco-
Prussian war, a large percentage of the fatal results in gunshot wounds
of the peritoneum was due to septicaemia, and that good results were ob-
tained by repeatedly washing out the cavity.
Hervieux' urges the value of washing out the uterus in cases of puer-
peral metritis, and Fordyce Barker recommends the injection of carbolic
acid solution four, five, or six times a day in the same disease. The
washing out of the cavity of the chest after evacuation of pus, in empy-
ema, the cleansing of putrid matters from abscesses and sinuses, all afford
examples of the benefit of preventing the too rapid absorption of septic
matter.
Good results are said to be obtained also by favoring the elimination
of septic matters through the various emunctories of the body. Sulphite
of magnesia has been used not only with the intent of protecting the
tissues and destroying the septic germs, but also as an aid to the elimina-
tion of septic matters through the kidneys and intestines.
In connection with antiseptic surgery, the antiseptic ligature” cannot
be ignored; most favorable results have been reported after its use. The
advantages claimed are: (1) That it does not cause suppuration; (2)
That it becomes absorbed ;” and (3) That the ligature becomes organized,
1 The Puerperal Diseases, by Fordyce Barker, 1874, p. 322.
* On the Employment of Carbolized Catgut as a Ligature in Amputations and other
Major Operations; by A. W. Nankivell, Resident Surgeon to Saint Bartholomew's Hos.
pital, Chatham ; Lancet, Feb. 19, 1876.
* I. On Ligatures made with Catgut ; by D. Murinoff. Inaugural Discourse, St. Peters-
burg, 1875; from Centralbl. f. Chirurgie, 1875, No. 43.
II. On the different kinds of Ligatures employed in the treatment of deep-seated Cuts;
by Eliaschewitsch, Russian Military Medical Journal, June, 1875; Centralb. f. Chir., 1875,
No. 43.
I. The experiments, the conclusions of which we report here, have been made upon dogs
and rabbits. Simple threads of catgut, soaked in chloral, and “catgut phenique” were
employed in making the ligatures. All the ligatures on two or three dogs were soaked
with juices; on the seventh day they were swollen, soft, and covered with a thin transparent
layer of connective tissue; the knots were adherent to the surrounding tissue. The finest
threads were re-sorbed in ten days, the catgut No. 4, of Lister, in from twenty to thirty
days. This disappearance is effected by the division of the thread into fibrils which grad-
ually disappear upon the contact of granulations. It requires the same time to be accom-
plished, whatever thread may be employed, provided that it is of the same dimensions. The
simple thread of gut does not irritate in the least the neighboring parts; the thread soaked
in chloral irritates them a little; the catgut a little more. As to consecutive hemorrhages
after section of a large arterial vessel between two ligatures, Murinoff gives the following
statistics: catgut, 10 per cent. ; thread of gut soaked in chloral, 25 per cent. ; simple
thread of gut, 87 per cent.
II. Eliaschewitsch has sought to establish by experiments upon animals the different
influence exercised by the threads of the suture according to their nature. Relating to
inflammation, as to the influence which they exert upon the point of suture itself, he ar-
ranges them in the following decreasing order: Cotton, linen, silk (waxed silk being less
irritating than raw silk), metal (whatever it may be), Florence thread, crin végétal, catgut
phénique. The thread in a cord of non-carbolized gut irritates less than that covered with
phenic acid, but it is less resistant. The presence of Florence thread or catgut in the
depth of a wound does not hinder its reunion by first intention. The greater or less
rapidity with which sutures cut, depends upon the irritation produced by the thread itself,
and its degree of tension, and finally upon the condition of the lips of the wound. In the
second series of experiments, Eliaschewitsch has endeavored to ascertain what becomes of
catgut threads left in the wound. He has discovered that as soon as they come in contact
with granulations they split up over their whole surface, and fibrils are detached which in
their turn are divided into bits finally constituting only a granular detritus. The pro-
cess began upon the fifth day in threads which had been used for ligatures of large arteries
on a dog; at the end of a month no trace of a ligature was found.
A N TISE PTIC S U R G E R Y. 525
and becomes a ring of living tissue surrounding and occluding the ves-
sel."
| Lancet, April 3, 1869. On Ligature of Arteries on the Antiseptic System ; by Joseph
Lister, Esq., F.R.S., Professor of Surgery in the University of Glasgow. & © tº e
. . . . . . . In order to put the antiseptic animal ligature fairly to the test, I made
the following experiment: Ligature of the carotid artery in the calf on the antiseptic
system with threads composed of animal tissues.—On the 31st of Dec. 1868, I tied the
right carotid about the middle of the neck in a healthy calf a few days old; the animal
being under chloroform. Ligatures of two different kinds were employed at an interval of
about an inch and a half, the sheath of the vessel being left undisturbed in the intervening
part. The cardiac ligature was of home manufacture, composed of three strips of peritoneum
from the small intestine of an ox, firmly twisted together into a threefold cord. The distal
thread was of fine catgut, called “minikin-gut” by the London makers. Both had been
soaked for four hours in a saturated watery solution of carbolic acid, which swelled and
softened them so that the thread of my own making was too large to enter the eye of the
aneurism needle, except near the ends, where it was thinner than elsewhere. This sub-
stantial ligature bore the strain of tying well, but the fine catgut broke as I tightened the
noose; I did not, however, remove it, but, having a second piece at my disposal, passed it
round at the same place, and with gentle traction completed the knot. There were thus
two ligatures of the gut at the distal side. All were cut short except one end of the catgut,
which I purposely left about three-quarters of an inch long to give a better opportunity
of ascertaining what would become of the foreign material. . . . . . . . A month
(thirty days) after the operation, the animal, which had continued in perfect health, was
killed, and the soft parts of the neck, below to the spine, were removed for examination.
On dissection, I was struck with the entire absence of inflammatory thickening in the
vicinity of the vessel, the cellular tissue being of perfectly normal softness and laxity. On
exposing the artery itself, however, I was at first much disappointed to see the ligatures
still there, to all appearance as large as ever. But had I borne in mind what I had
observed in some of my earlier cases of compound fracture treated antiseptically, I should
have been prepared to find these threads present in appearance, though absent in reality.
It may be well for me to quote from the account I have before given of one of these cases.
It was a compound fracture of the leg produced by direct violence, with a wound of con-
siderable size, and a great deal of extravasation of blood into the limb. In accordance
with the practice which I then followed, a piece of lint soaked with undiluted carbolic acid
had been placed over the wound, and had formed with the blood a firm crust. Nearly
three weeks after the accident, I was detaching a portion of the adherent crust from the
surface of the vascular structure into which the extravasated blood beneath had been con-
verted by the process of organization, when I exposed a little spherical cavity, about as
big as a pea, containing brown serum, forming a sort of pocket in the living tissues which,
when scraped with the edge of a knife, bied even at the very margin of the cavity. This
appearance showed that the deeper portions of the crust itself had been converted into
living tissue. For cavities formed during the process of aggregation, like those with clear
liquid contents in a Gruyère cheese, occur in the grumous mass which results from the
action of carbolic acid upon blood; and that which I had exposed had evidently been one
of these, though its walls were now alive and vascular. Thus the dead but nutritious mass
had served as a mould for the formation of new tissue, the growing elements of which had
replaced the materials absorbed, so as to constitute a living solid of the same form. Hence
it might have been anticipated that the ligatures of peritoneum and catgut placed on the
calf's carotid would, after the expiration of a month, be found transformed into bands of
living tissue. Such was, in truth, the case, as was apparent on closer examination. They
had, indeed, a deceptive resemblance to their former condition from the persistence in their
substance of the impurities of the original materials, the dark adventitious particles being
of mineral nature incapable of absorption, so that they had remained as a sort of tatooing
of the new structure. Nevertheless a marked alteration in color had taken place, espe-
cially in the distal ligature, where the dirty gray of the softened catgut had changed to a
dirty pink tint.
The two pieces of catgut which had been tied round the vessel at that part had become,
as it were, fused together into a single fleshy band, inseparably blended with the external
coat of the artery. The knots were nowhere discoverable, and the only indication of the
end which had been left long at the time of the operation was a black speck here and there
upon a delicate thread of cellular tissue in connection with the vessel. The cardiac ligature
was in like manner continuous in structure with the arterial wall. The short ends had
disappeared; but the massive knot was represented by a soft, smooth lump, which appeared
first entirely homogeneous, except that it was speckled with dark particles, as before
referred to. On Section, however, I discovered in the interior of the mass, and lying close
526 H O DG EN,
Prof. Lister says:—“Ample as was the evidence afforded to the naked
eye of the organization of these ligatures, it was satisfactory to find it
to the wall of the artery, a small residual portion of the original knot, of comparatively
firm consistence, and with the threefold twisted character of the cord plainly visible. It
was quite distinct from the living tissues that surrounded it, so that it could be readily
picked out from its bed with a pair of needles. A slender and irregular remnant of the
noose was also found lying in a sort of tubular cavity, extending about half way round the
vessel. Thus the process of organization had not yet quite invaded the entire thickness of
the foreign solid, and it was a happy circumstance that the cord had been so constructed
that the distinction between the old structure and the new could be plainly recognized.
Ample as was the evidence afforded to the naked eye of the organization of these ligatures,
it was satisfactory to find it confirmed in the clearest manner by the microscope. A bit of
the knot having been teased out with the needles in a drop of water, presented, like a fresh
piece of peritoneum, the wavy bundles of parallel fibres, characteristic of perfectly developed
fibrous tissue. Adhering to the surface of the remnant of the ligature was some soft,
opaque material, readily washed off with water, consisting of corpuscles of different forms,
most of them caudate or fibroplastic, but some spherical, though not resembling pus; and
here and there fragments of the original peritoneal tissue, affected more or less with inter-
stitial cell development. At a short distance from the remains of the old thread, the
fleshy material which had been formed at its expense proved to be a most beautiful
example of fibroplastic structure, the coarse fibres which mainly constituted it being com-
posed of very large elongated cells, often containing several nuclei, and presenting in their
course branchings and thickenings of various forms. Here and there were some fibres
more perfectly formed, and also cells of a more rudimentary character. Again, the band
which had resulted from the organization of the two fine threads of catgut, which from the
smallness of their bulk had no doubt vanished early, having had longer time to perfect its
structure, was a comparatively well-developed form of fibrous tissue, consisting of coarse
fibres rather than elongated cells, being thus intermediate between the merely fibroplastic
condition of more recent growth and the completed texture of the original thread. For it
is to be remarked that a piece of catgut exhibits, under the microscope, abundance of
perfect fibrous tissue.
A more favorable period for the investigation, with a view to establishing the nature of
the change which ligatures of animal tissue experience under antiseptic management, could
hardly have been selected. Between the parts tied, the calibre of the artery was occupied
by adherent coagulum, which was for the most part decolorized, and exhibited, under the
microscope, fibroplastic cells of irregular forms. A similar clot was present between the
distal ligature and a small branch that arose about a quarter of an inch beyond it. But
between the proximal ligature and the heart the formation of a coagulum had been entirely
prevented by a large vessel taking origin immediately above the part tied, which had thus
borne for a month the full brunt of the cardiac impulses. Yet the vessel, so far from
showing any sign of giving way, as it would inevitably have done had it been tied in such
a situation without antiseptic precautions, appeared to have derived additional strength
from the operation. The encircling ring of new tissue incorporated with the arterial wall
must have had a corroborative effect, and within its grasp the inner coats which seemed to
have been but imperfectly ruptured by the soft and substantial ligature were considerably
thickened and had coalesced, so as to form a strong cul-de-sac, the irregularities of which
had been smoothed over by a little fibrinous deposit, which had assumed the characters of
a firm fibrous tissue, and presented a free surface, undistinguishable from that of the lining
membrane of the artery. At the situation of the distal ligature, the structure of the vessel
seemed entirely unaffected. The middle coat was seen in longitudinal section as a pink
streak between two white lines, representing the external and internal tunics, neither thicker
nor thinner than in the neighboring parts. The catgut threads had been tied too gently
to produce rupture of the internal and middle layers, and their presence, and the constric-
tion which they occasioned, whatever may have been their effect in the first instance, had
left no permanent marks of the disturbance; while the fleshy band which had replaced
them, though in time it would doubtless have dwindled to an insignificant filament, was at
least a temporary addition to the strength of the artery. These appearances at the distal
ligature are calculated to revive under a new aspect the old question whether it would not
be better always to avoid rupture of the internal and middle coats, which could easily be
done by using a pretty thick piece of catgut, softened by steeping it in a watery solution
of carbolic acid. In this way the wall of the vessel would be left from first to last entirely
intact. This, however, is probably a matter of indifference. Indeed, judging from the
condition of the artery at the cardiac ligature, the injury done to the vessel at the outset
by tight tying seems to lead to changes which increase its power of resistance, which was
certainly severely tested in the present instance. It appears, then, that by applying a
A N TISE PTIC S U R G E R Y. 527
5
confirmed in the elearest manner by the microscope;” and he adds, “It
appears, then, that by applying a ligature of animal tissue antiseptically
upon an artery, whether tightly or gently, we virtually surround it with
a ring of living tissue and strengthen the vessel where we obstruct it.”
Mr. Fleming, who made a series of experiments to determine the
changes accomplished in antiseptic ligatures, says:– “The results" of
these experiments show that a gradual softening takes place from with-
out in, the catgut breaking down and becoming infiltrated with cells,
probably leucocytes; . . . next, the pultaceous mass into which it
has been converted begins to metamorphose, and is soon permeated with
blood-channels and ultimately may be described as a cast of the catgut
in a kind of granulation tissue freely supplied with blood vessels which,
in many of my sections, were freely injected.” It is a well-established
fact that epithelial cells, far removed from the circulation and actually
dead, placed in contact with a granulating surface, live again and multi-
ply ; and there seems no reason why the cells of the fibrous tissue of the
sheep should not also. Ivory pegs driven into bone become absorbed ;
metals, glass, wood, and silk ligatures may remain in the tissues for an
unlimited time without exciting irritation, inflammation, or suppuration.
The question as to the special value of carbolized catgut remains open
since the facts above stated of wood, metal, silk, glass, etc., are well
established. Prof. Paul F. Eve, of Nashville, Tenn., informs me that for
ligature of animal tissue antiseptically upon an artery, whether tightly or gently, we virtually
surround it with a ring of living tissue, and strengthen the vessel where we obstruct it. The
surgeon, therefore, may now tie an arterial trunk in its continuity close to a large branch,
secure alike against secondary hemorrhage and deep-seated suppuration, provided always
that he has so studied the principles of the antiseptic system, and so carefully considered
the details of the mode of dressing best adapted to the particular case in hand, that he can
feel certain of avoiding putrefaction in the wound. For my own part, I should now,
without hesitation, undertake ligature of the innominate, believing that it would prove a
safe procedure.
| Prof. Lister, in the Discussion which followed the reading of this paper, objected to
the position in which he had been placed in reference to the organization of the ligature
antiseptically applied, and the following explanation was subsequently made by the author:
“It is due to Prof. Lister, due to the Surgical Section, and due to myself that I should
correct a misstatement of the position of Prof. Lister in regard to ligatures antiseptically
applied. In the Report on Antiseptic Surgery, in the part relating to the use of the
antiseptic ligature, the following passage occurs: Prof. Lister says, “Ample as was the
evidence afforded to the naked eye of the organization of these ligatures, it was satis-
factory to find it confirmed in the clearest manner by the microscope,' . . . and again,
* It appears, then, that by applying a ligature of animal tissue antiseptically upon an
artery, whether tightly or gently, we virtually surround it with a ring of living tissue and
strengthen the vessel where we obstruct it.' These are the precise words of the report,
and the precise words of an article On Ligature of Arteries on the Antiseptic System,
by Joseph Lister, Esq., F.R.S., Professor of Surgery in the University of Glasgow, as
published in the London Lancet for April 3, 1869, page 451, and copied into Braith-
waite's Retrospect, vol. lviii., 1869, pp. 139, 140. So far, it would appear that in the
Report on Antiseptic Surgery I was entirely correct in my quotation of Prof. Lister's lan-
guage, as it appeared in print; but Prof. Lister having stated in the Surgical Section that
he had not advocated the theory of the revitalization of the antiseptic ligature, I must
accept his statement as correct, and modify my report accordingly. The quotation
embraces but two sentences of an elaborate article, a careful reading of which, prompted
by Prof. Lister's disclaimer, permits me to conclude that the expression, the organization
of these ligatures,’ is not intended to convey the thought that the tissues of the ligature
are revitalized, but that a living tissue takes the place of the absorbed ligature; and that
the expression, “a ring of living tissue,” does not refer to a revitalization of the tissues of
the ligature, but to a new tissue occupying the former site of the catgut, as if cast in its
bed.”
* The Behavior of Carbolized Catgut inserted among Living Tissues; by Wm. J.
Fleming; Lancet, May, 1876.
528 H ODG EN,
forty years he has been in the habit of using the sinews of the deer for
ligating vessels. He says: “I have never used carbolized spray or liga-
tures. The tendons of the deer, dried and torn into shreds and rolled
into ligatures, are what I employ. They are absorbed, and I have never
seen a knot made in tying a vessel. I have occasionally used them as
sutures, but generally apply silk for this purpose.” Dr. Eve's experience
with the tendons of the deer leaves us free to conclude that the carbolized
oil and water with which Prof. Lister's catgut is prepared has no special
value in preventing suppuration or hastening absorption.
The following propositions are sustained by our present knowledge of
the subject of Antiseptic Surgery :-
T. Putrefaction may and does occur in the solids and liquids of the
body both with and without the direct contact of germs borne in the air
or water. In sustaining this proposition, I need only call attention to
the innumerable abscesses containing fetid pus that may occupy any site
within the human body, sites so remote from all the mucous and cuta-
neous surfaces that neither air nor water as such can reach them.
II. Putrefaction of the solids and liquids of an open wound may in
many cases be prevented by not permitting the contact of living germs
with the surface, or by destroying their vitality after contact with it.
The experiments made by Prof. Tyndall are so conclusive that to deny
their force and completeness seems irrational. If they were negative, or
if they were few, a question might arise, but being positive and almost
in numerable, there seems no reasonable doubt of the correctness of his
conclusions. In his admirable series of experiments he allowed the float-
ing particles to settle from the air until it was optically pure, and found
that infusions placed in this pure air did not undergo putrefaction, and
that living organisms were not produced. There are many agents by
which the vitality of septic germs may be destroyed; and their contact
with the cut surfaces is sufficient to destroy the vitality of such germs as
may be present at the moment. While it is exceedingly difficult in the
case of an open wound to prevent the contact of septie germs that per-
\ a de the atmosphere, it may generally be accomplished for a brief period.
And while there are many substances that efficiently destroy the vitality
of septic germs, the profusion in which they exist renders it necessary
that the applications for their destruction shall be so precisely made, and
so frequently renewed, that it will in practice rarely be accomplished.
III. It is possible that the living solids and liquids of the body may be
so altered that they shall not furnish the conditions necessary to putre-
faction. Polli’s experiments with the sulphites afford evidence of the
truth of this proposition. For he found that the bodies of dogs fed with
the sulphites did not decompose, and that urine passed during the admin-
ist ration of sulphites did not putrefy.
IV. Practically, the conditions to be met in preventing putrefaction
are so difficult, that in many cases it is impossible to comply with them ;
yet even partial success is eminently worthy of our best efforts. In
the experiments made by Prof. Tyndall, in which he determined the pres-
ence of germinal protoplasm in the air, it appears that several days of
absolute quiet are necessary for the complete settling of the germs so
that the air becomes free from them. These particles of living matter
are so infinitely minute' that they are utterly beyond the reach of the
! Spontaneous Generation Controversy, by Rev. W. H. Dallinger; Monthly Microscopical
Journal, vols. x. and xiii. See Popular Science Monthly.
A NTIS E PTIC S U R G E H Y. 529
microscope, and can only be made visible by a condensed beam of light.
Dallinger and Drysdale have shown that, while the life of the monad
will not resist a temperature of 140°, the germs that Prof. Tyndall recog-
nized by his electric beam are capable of germinating after having been
subjected to a temperature of 300°. In view, then, of these facts, and the
one established by Pasteur, that putrefaction occurs only in the presence
of living germs, and that Prof. Fischer has uniformly found bacteria
under antiseptic dressings so ingeniously devised as those of Prof. Lister,
we must conclude that germs cannot be prevented from coming in con-
tact with wounds. While this is true, the rapidity of putrefactive
changes may be diminished, the absorption of septic matters limited, and
the eliminative functions stimulated so that septicaemia may not occur.
In conclusion: Putrefaction does not occur in the absence of living
organisms; this fact was established by Pasteur and is supported by
Tyndall.
The germinal matter active in putrefactive changes is found abundantly
in air and water; most conclusive evidence of this fact is furnished by
the experiments of Tyndall and Rindfleisch.
The germinal matter resists exposure to a temperature of 300°, while
monads cease to manifest vital phenomena after exposure to 140°; the
experiments of Dallinger and Drysdale are presented to sustain this
position.
Septicaemia is induced by the presence of the products of putrefaction
in the blood ; the precise element which causes by its presence septicaemia
is not determined.
Professional experience teaches, and the experience of Billroth demon-
strates, that absorption of putrefactive products does not occur with suf-
ficient rapidity from a granulating surface to produce blood-poisoning.
Hence, in the early stages of the healing of injuries, septicæmia is more
to be feared than after granulations have been formed ; and the danger
in this period is heightened by the presence of dead and decomposing
fragments of original tissue.
Antiseptics may simply strain out the catalytic germs, as cotton-wool;
or destroy the germs, as carbolic acid, salicylic acid, the salts of copper,
zinc, mercury, etc.
Antiseptics may destroy the products of putrefaction, as iodine, bro-
mine, chlorine, and permanganate of potassium, etc.
Antiseptics may alter the putrescible matters so that putrefaction can.
not occur, as sulphurous acid, etc.; or antiseptics may alter the tissues of
a wounded surface so that, though septic matters are present, they may
not be absorbed, as perchloride of iron, etc.
The rapid removal of septic matter from contact with an absorbing sur-
face will prevent absorption, as is done by the water-bath. -
The difficulty encountered by experimenters in preventing the develop-
ment of infusoria in vegetable and animal infusions, teaches, and the
experience of surgeons confirms, the impossibility of invariably prevent-
ing the admission of germs to putrescible substances, either in the most
carefully constructed reservoirs or on the free surface of the human
body."
! I am indebted to Drs. Evers and Boutwell for translations from the German, and to
Drs. Boisliniere and Lebeau for translations from the French. I must also acknowledge
my obligations for the use of the Army Medical Library, at Washington, and of the valu-
able collection of the College of Physicians of Philadelphia.
530 H ODG EN .
Discuss[ON ON DR. HodgEN’s PAPER.
After the reading of the preceding paper, Dr. ADDINELI, HEwson, of Philadel-
phia, said:—I have been for many years interested in the subject of Antiseptic
Surgery, and have tried almost every substance which has been introduced for
the purpose of destroying germs. I have relied principally of late upon earth,
as I am satisfied that dryness is the most essential element in any dressing.
As Prof. Hodgen has said, water produces germs rapidly, and it is impossible to
prevent this even with powerful antiseptic agents. I have therefore, during the
past year, at the Pennsylvania Hospital, absolutely prohibited the washing of
any wound during its entire treatment. In addition to dry dressings, it is impor-
tant to remember that there are other necessary conditions for rapid healing,
and I have not used a ligature in the Pennsylvania Hospital for ten years,
employing always either acupressure or torsion, and thereby avoiding foreign
bodies in the wound. I also enjoin quietude of the parts, with infrequent
changes of dressings; I have also tried the effect of color, by covering wounds
with blue paper, to exclude all but the actinic rays. For six months I have
tried salicylic acid, sprinkling it freely upon the wound, and covering the latter
with cotton-wool and then with blue paper. I never wash wounds nor disturb
the dressing save to remove the outer layers when they are soiled. The sali-
cylic acid produces no pain, but acts as a sedative, so much so that at first I
thought it was narcotic, but I subsequently found this to be an error. I am
seldom obliged to give morphia, but, to satisfy the patient, have tried hypo-
dermic injections of a fluidrachm of cold water, a remedy which I have also
found successful in relieving sciatica. I have partially superseded earth by
salicylic acid, but have not abandoned the former, save when the prejudices
of patients or nurses have thrown obstacles in the way of its successful em-
ployment.
Dr. J. H. POOLEY, of Columbus, Ohio, said:—I have come to consider car-
bolic acid as important in surgery as instruments themselves. I have known
large ragged wounds to heal under its application without one drop of pus. I
have found the most efficacious form to be one part of carbolic acid to seven of
olive oil, which is less offensive than linseed oil. I always make the applica-
tion with a brush, carrying the oil well down into every portion of the wound,
then applying lint saturated with the same mixture, and retaining all with a
bandage. This should be repeated every twenty-four hours, brushing the oil
in thoroughly, and removing all sloughs. I have recently seen an extensive
crush of the soft tissues of the foot heal, without discharge, in three weeks
under this dressing, while under ordinary circumstances the cure would have
occupied two or three months. It must be added that, while carbolic acid for
a time assists the healing process, yet after a certain period it seems positively
to retard cicatrization, pointing to the possibility that this acid has the same
repressing power upon granulations that it has upon germs. I have had but
little experience with salicylic acid, but in one case in which I used it upon an
immense mass of granulations situated over the region of the liver, and from
which had been discharged a large number of gall stones, the dusting of the
surface occasioned severe pain, an opposite effect to that described by Dr.
Hewson, who has stated that the application is painless.
Dr. HEWSON said :–In amputations, when I close the wound with a covering
of powdered salicylic acid and cotton-wool, there is no pain; but the same
dressing in open wounds does give pain. I should add that I always close
the wound, not with adhesive plaster, but with strips of gauze and collodion,
which is less irritating and favors primary union, besides giving the advantage
of a visible wound, and preventing the direct contact of the salicylic acid or
earth.
Dr. WILLIAM CANNIFF, of Toronto, Canada, said:—It is, I believe, very gene-
rally acknowledged that the air is inhabited by various forms of germs—
ANTISEPTIC SU R G E R Y. 531
organisms possessing different degrees of vitality; but it remains a question
whether putrefaction is due to the operation of these microscopic organisms.
Dr. Hodgen’s first proposition states that “Putrefaction may and does occur
in the solids and liquids of the body, both with and without the direct contact
of germs found in the air or water.” Well, if that is the case, I submit that
the doctrine urged by Prof. Lister is undermined.
Dr. HoDGEN said:—I did not intend to convey the meaning that germs are
not present in all cases of putrefaction. The organisms may be introduced to
the part through the blood.
Dr. CANNIFF said:—Then what is the use of applying to a wound or open
abscess means to form a barrier to the ingress of germs ? If organisms can
enter the system through the lungs, or any other mucous surface, and find
their way to a certain part to work mischief, it is entirely futile to adopt any
procedure to prevent their action. I should like to ask the advocates of the
germ theory if they hold that organic matter can never putrefy without the
operation of air germs ? Because if it ever does, it would be difficult in any
given case of putrefaction to show that this was not a simple chemical change
in the elements composing the dead animal matter. It is a received doctrine
that the body is made up of an infinite number of cells, or molecules, each of
which possesses a distinct individual life. They have a moment of birth, and a
period of growth and development, of maturity, of decline, and of death ; and
during their period of life they, like the whole body, are subject to disease, and
to degeneration ; they may be feeble, or possessed of vigorous vitality. They
are also individually and in number liable to injury. Take a contused wound;
in it may be found a number of cells crushed to death ; others are injured in
various degrees, some of which will or may under favorable circumstances
recover and be completely or partially restored to their normal vitality. Which
must perish and which shall be restored, has to be determined by nature.
The line of demarcation has to be established ; and the cells deprived of life
sequestrated. This is a work of time, and is accomplished by natural laws. I
am unable to see in what way the presence of germs can affect this procedure.
If a portion of tissue is crushed to death, beneath it is carried out the work of
sequestration ; and this is attended with chemical changes in the dead organic
matter. It is asking a good deal to expect us to believe that this is due to air
germs.
My own experience is such that I find it impossible to entertain the doc-
trine of germ putrefaction. I will mention three cases in my own practice :
A man of over sixty had his leg crushed by a wagon heavily laden. There
was a compound dislocation of the knee-joint, with fracture of the upper extre-
mity of the tibia. The limb was placed in a proper position, the parts adjusted,
and cold water dressing alone applied. The wound was freely and constantly
exposed to the air; and, although the weather was hot, the wound healed, and
the man recovered with perfect use of the joint and with no suppuration
whatever. Two men, injured at the same time by a railway accident, were
brought into the Toronto General Hospital. One had contused wounds of the
leg. Cold water dressing was employed; and he made a rapid recovery. The
other man, in a bed beside the first, had severe contusions of the leg, but no
wound. The skin was unbroken. In a number of days it was found that sup-
puration had taken place. The abscess was opened, and forth came put refying
pus. Now here the putrefaction must have taken place without the presence of
germs, or else they had been exceedingly active in finding their way through
a mucous surface and by the blood to the part. I may say that the practice
recommended by Prof. Lister has not been adopted in the Toronto Hospital; his
doctrine is not as yet acted upon ; and I feel safe in saying that the success
attending the treatment of wounds in that Institution is not exceeded by
that in any other. Of course, in hospitals and other places, the organisms
which exist in the air are often depraved; they take a low form of degraded
life, and the result is an impure air which will more or less affect open tissue ;
532 HO DG EN,
but I am referring to ordinary air. I have in hundreds of cases seen incised
wounds, many in connection with plastic operations, in which healing by primary
adhesion has taken place, and yet in which no care has been taken to keep
away supposed germs. Often the wound is allowed to remain open for some
time, until all oozing of blood has ceased. Now how are we to account for
these results, if the air is every where peopled by organisms bent on working
destruction whenever a solution of continuity takes place on the surface of the
body ?
In speaking of the treatment pursued in the Toronto Hospital, I do not
intend to convey the impression that the agents called antiseptics are not used.
They are constantly employed for purifying tissue, not with the view of
destroying or preventing the action of air germs, but to arrest or prevent putre-
fying decomposition due to chemical changes. In conclusion, I would say that
I believe that everything, almost, depends upon cleanliness in the management
of wounds; and I believe that the success which has been obtained by those who
practise according to Prof. Lister’s theory, is greatly due to the cleanliness
which that practice secures. Next to cleanliness, I think that the maintenance
of rest is valuable; physical and physiological rest. Rest after the evacuation
of an abscess will often secure an early adhesion of the walls of the collapsed
sac. Pressure again is an important element in the treatment of wounds so
as to press away fluid in the part, and to prevent feeble circulation or stagna-
tion of blood in the tissues which have to supply the reparative material. And
lastly, attention must be given to the constitution and to the surroundings of
the patient. Is it not to be feared that the particular treatment advised by
Prof. Lister tends to divert the attention of the surgeon from these essential
points 7
Dr. F. H. HAMILTON, of New York, said:—In common with all the other
members of the surgical section, I feel a great interest in what you, Mr. Presi-
dent, will have to say on the subject of antiseptics in surgery. The medical
men of this country are familiar with your labors in this direction. They
know with how much zeal and intelligence you have prosecuted your inquiries,
and I may add for myself, personally, that I have never seen a medical gentle-
man who had enjoyed the privilege of witnessing your practice in your own
wards, who was not delighted with the results. Nevertheless, a large propor-
tion of American surgeons seem not to have adopted the practice; whether
from a lack of confidence or for other reasons, I cannot say. We are happy,
therefore, that you have this opportunity to address us at this time, and we
hope sincerely that you will be able to remove such doubts and practical diffi-
culties as remain in our way. Indeed we would be glad to have you convince
us that your method is the best.
It seems necessary to remind the Section, however, that there are in this
country and abroad other methods of treating open wounds, for which their
advocates claim exceptional and extraordinary results. Recently our atten-
tion has been called by a paper read before the American Medical Association,
I think at St. Louis, to what is called the “open-air treatment,” in which no
dressings whatever are employed, but the wound is left open to the air, the
discharges being permitted to drop into proper receptacles, or to dry upon
the surface. My friend, Prof. Moore, of Rochester, called my attention to a
case of amputation at the shoulder-joint treated in this manner in one of his
šurgical wards, which was closing rapidly and with very little suppuration.
At the Bellevue Hospital this method has been employed recently, in quite a
1, umber of major amputations, and with remarkable success. It must be noticed
that the open-air treatment is the exact opposite of Prof. Lister's antiseptic
method, yet there are not a few who claim for it equally good results with
those obtained by Prof. Lister. A few years since I was appointed operating
surgeon to the St. Francis's Hospital, a hospital of several hundred beds, in
the city of New York, where I found Dr. Rose and the other gentlemen (all
of whom were German, and thoroughly educated) employing warm water in
ANTISEPTIC sur GERY. 533
the treatment of nearly all surgical accidents. The same plan was pursued
by these gentlemen, under my observation, after I became connected with the
Hospital, and, I must say, with most extraordinary results. No ointments nor
antiseptic washes were used to my knowledge, unless as a rare exception, but
the warm water dressings were applied to all open sores, whether simply
traumatic or specific, in the form of either baths or fomentations. Under this
treatment, pyaemia, septicaemia, erysipelas and gangrene were almost unknown,
except as these originated outside of the hospital and before admission to the
wards. That is to say, under the warm-water treatment the origin or develop-
ment of these conditions was almost unknown.
The same plan has been adopted to a certain extent by myself and some of
my colleagues in the Bellevue Hospital, and several of the gentlemen, including
Prof. Gouley, who I believe is present, have attested its excellence, if not its
superiority. My largest and most satisfactory experience, however, has been
obtained while occupying the position of Surgeon-in-Chief of the New York
Reception Hospitals. The results have been given to the profession in a couple
of papers, one of which was published in the Richmond and Louisville Medical
Journal, in 1874, and the other in the Medical Record of New York, during
the same year; but the most complete essay upon the subject was published,
in 1875, by my former pupil, Dr. Frederick E. Hyde, of New York, in the
Buffalo Medical Journal, and subsequently in pamphlet form.
There are yet other plans for the treatment of wounds and other surgical
accidents, for which their advocates have made special claims, all of which
may be considered as contending with the method advocated by Prof. Lister,
for respectful consideration, if not for preference.
It may not be possible for this body to decide now between the merits of
these several methods, but we shall listen with great interest to what the
distinguished gentleman from Edinburgh shall say upon this subject.
Dr. J. A. GRANT, of Ottawa, said:—For many years we used cold-water
dressings at the Ottawa Hospital, with great success, yet failed to obtain
results equal to those secured by Prof. Lister. I therefore made a visit to
Edinburgh, and was fully convinced of the superiority of the antiseptic method.
I was particularly attracted by the extreme care and cleanliness which charac-
terized all of Prof. Lister’s operations.
Dr. R. A. KINLoch, of Charleston, said:—While I am willing to accord to
the antiseptic system, carried out in the various ways which have been sug-
gested, all or much that has been claimed for it, I think that rest is an important
factor in the treatment of wounds, which is too much overlooked, and to which
may perhaps be attributed much of the good claimed for certain kinds of
dressing. The value of immobility is recognized in the treatment of fractures
and joint diseases, but it is equally important in dealing with lesions of the
soft parts. The benefits said to have been derived from the use of warm
water, may be in part due to the quietude of the limb within the box in which
it is placed during the course of treatment. The cotton dressing serves ad-
mirably the purpose of securing apposition and immobility of the wounded
tissue, and many of the forms of antiseptic dressing are similarly effective,
because the dressing is but seldom disturbed. The dirt dressing of Dr. Hew-
son may do good in the same way; it moderately compresses, supports, and
keeps at rest the injured structures. Even the plan now carried out at Belle-
vue Hospital, of exposing wounds to the air, may act in the same manner.
The parts are secured in their proper situation, and not handled ; a crust forms
on the surface, and serves still further to protect and insure rest to the parts.
Dr. JOHN T. CARPENTER, of Pottsville, said:—I enjoyed the opportunity of
practising antiseptic surgery on a somewhat extended scale, many years before
the origination of the germ theory or of the use of carbolic acid. It was my
fortune, in 1862, as Medical Director of the U. S. Army Hospitals in and
around Cincinnati, to supervise the treatment of a large number of cases of
Hospital Gangrene. Recognizing the extraordinary virulence of this septic
534 H ODG EN, ANTISE PTIC SURGERY.
disease, and yet believing its constitutional symptoms to be exclusively the
result of local infection, I directed the employment of an antiseptic local treat-
ment, which met with most gratifying success. The hospital surgeons were
directed to remove, as thoroughly as possible, the whole of the diseased tissues
with the knife; to bathe the wound with freshly generated chlorine gas (used
as chlorine water); to pack the then purified raw surfaces with lint saturated
in creasote ; and to trust to free ventilation, good food, and tonic treatment,
for the rest. Of more than a hundred cases of hospital gangrene thus faith-
fully treated, I recall now but two which proved fatal, one from erosion of a
large branch of the femoral artery, the other from thrombosis with enormous
heart-clot. Here then was made a decided attempt, in treating a putrefactive
disease : (1) to remove the poisoned tissues; (2) to disinfect those which
could not be removed, and (3) to occupy the wound with a protective dressing
as a means of preventing any re-inoculation by a poison which we all recog-
nized as existing in the atmosphere of the wards. Here were recognized at
that early date the principles of causation and of treatment, which have only
recently been thoroughly expanded and perfectly carried out. I may add
that creasote was the only chemical agent known at that time which could
substitute or replace our present carbolic acid, and which would produce results
at all similar.
Dr. FREDERIC HYDE, of Cortland Willage, N. Y., said:—In according value
to any form of topical treatment, whether antiseptic or not, the true condition
of the part, both at the time of and often anterior to the occurrence of the
injury, should be taken into account. Whether the conditions existing
before the wound or injury was received were strictly physiological, or more
or less pathological, will materially influence the results of any and all forms
of local treatment, and whatever importance and value may belong to one
mode or another, we shall observe in the results that the rapidity or tardiness
of repair, and the degree of recovery, will depend much upon the state of the
patient at the time the injury was received.
Dr. R. F. WEIR, of New York, said:—Perfect cleanliness is important in the
treatment of wounds. By using cotton waste instead of sponges, by the em-
ployment of the douche for washing wounds, and by paying great attention to
the cleansing of bedding, etc., we have been able to almost banish septicaemic
diseases from the Roosevelt Hospital. We use both carbolic and salicylic acid,
but not for the purpose of excluding germs from wounds.
On motion, the discussion of Dr. Hodgen’s paper was adjourned, and the
President, Professor LISTER, was requested to address the Section the next
day upon the subject of Antiseptic Surgery.
ANTISEPTIC SURGERY.
REPORT OF REMARKS MADE BEFORE THE SURGICAL SECTION, DUIRING
THE ADJOURNED DISCUSSION ON DR. HOI) (; EN'S PAPER.
By
JOSEPH LISTER, F.R.S.,
PROFESSOR OF CI,INICAL SURGERY IN THE UNIVERSITY OF EDINBURGH.
(PRESIDENT of THE SECTION.)
HAVING been requested to address the Section on the subject of Anti-
septic Surgery, I will reply to some of the objections which have from
time to time been raised against this plan of treatment.
The first objection is, that it is “too much trouble.” I grant that it
is somewhat troublesome, and yet I believe that the trouble is more
imaginary than real, and is one of the necessary results of a want of
the proper apparatus and appliances, together with inexperience as to
their use. There is always trouble with any operation until one has
learned the minutiae of the various steps. But even supposing that it
does require a little more attention at the time of the operation, I think
that when the infrequency of dressing, and the shortening of the period
of cure, are taken into consideration, it will be seen that the labor per-
formed is far less than when ordinary means are employed. Again, it
is worth some trouble to be able to seal up an amputation, an exsection,
or a large wound, with the absolute certainty that no evil effects will
follow.
The second objection is, that “other modes of treatment give good
results.” I grant that they give good results, but not the best attain-
able. Without strict antiseptic treatment, it is impossible to freely lay
open a knee-joint, with the certainty that no danger will follow ; or to
take out a wedge-shaped piece from either femur, as I have recently
done, and yet to feel that such a produced compound fracture is per-
fectly safe, and without risk. And then we must consider the progress
of the wound. The blood becomes organized under the dressings, and
cicatrization occurs without one drop of pus, and almost without granu-
lations, so that, when we take away the superficial blood-crust, a clean
surface is found beneath. This I venture to say never could be done
without antiseptic treatment. Again, to be able to open a chronic ab-
scess of the spine, without fear of irritative fever, or pyaemia, requires
the strictly antiseptic plan. And in acute abscess, it is pleasant to feel
that after the procedure of opening and pressing out the accumulated
material, not one drop more will form. Again, in the ligature of a large
artery near a great branch, it is a great relief to know that rapid healing
will occur, and that the danger of hemorrhage will be avoided. None of
these things can be done without risk, unless putrefactive changes are
strictly prevented.
I must object to the definition of Antiseptic Surgery, given by Prof.
Hodgen, as that includes the disinfection of water-closets, etc. I pre-
536 LISTER,
fer to use the term “antiseptic system,” and construe this as meaning
“the dealing with surgical cases in such a way as to prevent the intro-
duction of putrefactive influences into wounds.”
Another objection which has been made, is that “putrefaction may be
due to germs introduced from within ;” but this is an objection easily
met. Every simple fracture disproves it, for in every fracture we have
a most serious wound, even although it is not visible to the eye—bones
and soft tissues are all mutilated to a greater or less degree—and if par-
tial destruction and mere feebleness of tissue would cause putrefaction,
then we should have it occurring in every injury of this kind.
Another point raised by Dr. Hodgen, is that, when serious results
occur after the opening of an abscess, they are caused not so much by
putrefactive changes as by injury to the pyogenic membrane and conse-
quent absorption. With all due deference, I would say that a pyogenic
membrane is a much better absorbing surface than a mass of granula-
tions. It is well known that large granulating surfaces, which are dis-
charging so profusely as to taint with their horrible odor a whole
hospital, yet are not sufficiently absorbent to injure the system to any
perceptible degree.
Opening of such abscesses antiseptically, will certainly prevent putre-
factive changes and a relaxed condition of the pyogenic membrane, and
thus prevent constitutional disturbance. As to the cause of this dis-
turbance, when the antiseptic system is not used, I would only say that
in a chronic abscess the pyogenic membrane is not in the condition of a
granulating surface. In acute abscesses it may be, but in chronic cavi-
ties we sometimes have no secretion of pus until after the abscess is
opened. This is sometimes seen in cases of diseased bone, in which
clear liquid is all that can be drawn off, and pus is not secreted until
subsequently. In proportion to the chronicity of an abscess does its
pyogenic membrane partake of the characteristics, not of a granulating
surface, but of cicatricial tissue with the epidermis stripped off, and in
this latter state it is vastly more likely to absorb. The bad symptoms
usually appear within the first few days, while the membrane is in this
condition, and patients sometimes die within twenty-four hours after the
opening of the abscess, in which time the membrane certainly cannot
have assumed the condition of a granulating surface. Pus may not form
until the third day, while the irritative fever is usually observed earlier
than this. The danger at first is from this irritative fever; afterwards,
when the pyogenic membrane is in the condition of an open sore, from
hectic.
[Prof. Lister then gave a practical demonstration of the application of the antiseptic
system upon the person of a patient, and spoke of the different forms of carbolic acid.]
At first I used the German creasote, which is very offensive from the
krealic acid which it contains. I now used the purest acid I can procure,
which is absolute phenol, and I have found that its solubility and want
of offensiveness are in direct proportion to its purity. Calvert’s carbolic
acid requires twenty parts of water to dissolve it, this only sixteen. An-
other advantage is that a solution in which there are no undissolved
particles is far less irritating than one in which the little portions of pure
acid are brought into direct contact either with the wound or the sur-
geon’s hand. Pure carbolic acid is used most satisfactorily in water, and
for detergent purposes it has no equal. It is exceedingly penetrating, as
evidenced by its action on India-rubber, and when used in the proportion of
A NTIS E PTIC S U R G E R Y. 537
1 to 20, will most effectually purify every portion of the epidermis, while
instruments soaked in the same solution are rendered thoroughly antisep-
tic. For the purposes of atomization, its volatility is an advantage, and
although I most heartily wish that I could dispense with the spray, yet
I do not see how it can be accomplished. Thiersch, of Leipsic, substituted
salicylic acid for a time, but he has now returned to carbolic acid.
[Prof. Lister then showed a Spray Producer, manufactured by J. Gardner, of Edinburgh,
which, by a modification of the French plan of having one tube and wick within another,
was so arranged that alcohol was volatilized, and then this vapor burned, thus securing a
very large flame and insuring a rapid stream from the boiler.]
When the pressure is sufficiently great, the atomization will be so fine
that there will be scarcely any perceptible wetting of the surgeon’s linen,
and when thus minutely divided the carbolic acid is much less irritating
to the wound. The large size of the stream is also of great advantage in
giving a larger area for work. The surgeon should always see the
spray, and then he will be certain that it is in the right place. When
assistants are scarce, the atomizer can be placed upon a table and made
to play upon the part.
The skin being throughly cleansed, the instruments soaked, the hands
washed, finger-nails brushed, and sponges prepared, the incision is com-
menced; and from this time until the completion of the dressing, if the
surgeon's hands or an instrument are passed beyond the area of spray,
they must not be again brought near the wound until they have been
dipped in the antiseptic solution. It is the close attention to these minute
details that renders this system so absolutely certain and safe in its results.
Carbolized catgut ligatures are always used, both ends being cut-off.
Before closing the wound, a purified Chassaignac's drainage-tube is intro-
duced, if needed, when the dressing can be applied with the perfect
assurance that, every organism having been thus far excluded, none can
enter the wound, and healing without suppuration will occur.
The gauze employed is simply loose, open, cheap, cotton-cloth, impreg-
nated with carbolic acid, one part; paraffine, five parts; and common resin,
seven parts, thoroughly spread over the surface when hot, and put under
heavy pressure in a stout wooden box. The paraffine prevents stickiness,
and the resin makes an excellent vehicle. In dressing a fresh wound it
is best to protect the raw edges by a small piece of thin oiled silk,
covered with copal varnish, in order to prevent any injurious effect from
the direct contact of the carbolic acid, and to allow the blood clot more
easily to organize. If this is done, a wound need not be opened for a week,
but it will otherwise require earlier dressing. The next substance to be
applied is a layer of gauze, soaked in fresh carbolic solution, since the
dry gauze might contain organisms from accumulated dust, and in its
dry state not be able to destroy them. Over this is placed half a dozen
thicknesses of the same material, loosely wrapped around, the spray
meanwhile playing continuously upon the part. Then is applied a layer
of Mackintosh cloth, and over all is wrapped a loose bandage made of the
same carbolized gauze torn into strips. The wound may now be left with
a feeling of absolute security, and without any anxiety, for a week, or
until the discharge begins to soak through, when the outer dressings
may be raised under the spray, and fresh ones applied. The deep dress-
ings need not be disturbed for weeks, if necessary. For changing the
dressings, in private practice, I carry a small atomizer which can be packed
in a box in the pocket. In wounds too large to be covered by the spray
538 LISTER,
from this instrument, one side can be dressed at a time. One or two dress-
ings are all that are usually required.
I have found resin a most excellent vehicle for the carbolic acid, as it
holds the latter with extreme tenacity, while at the same time it has no
affinity for the discharges, allowing them to pass through for a long time
without extracting the virtues of the acid. I have found also that the
energy of a drug depends not alone upon its quantity, but upon the
affinity of its vehicle, so that 1 to 5 of resin is no more pungent than 1 to
20 of oil, or 1 to 100 of water.
It may be thought that all this caution in dressing is unnecessary and
troublesome, and it would be so if one had to do all this and then failed
to secure a good result, but when these minutiae are heeded bad results
will not occur; wounds will heal so rapidly and kindly that one will
Soon come to find that it is not the most but the least troublesome mode
of dressing, when he takes the course of the case into account. Many
doubtless fall short of these good results simply because they neglect the
precautions mentioned, and then they blame the system for their failure.
I have been making strenuous efforts to improve the catgut ligature,
and believe that I have at last obtained the desired result. Old ligature
is far preferable to new, and yet the knots will sometimes loosen. I have
seen a case of Caesarean section progress admirably until the stitches in
the uterus gave way, and then death speedily followed. The old liga-
ture is harder and does not absorb as readily as the new, but I have
found that gut which is reliable when tested with warm water, will yet
loosen under the action of the liquor sanguinis. The ligature must not
be made too hard, or it will be too stiff for tying, and will even act as a
foreign body as much as silk does, and yet it must be so hard that after
soaking in serum for weeks it will still hold firmly. I have tried many
substances; chromic acid will harden the gut, but when the latter is
soaked in serum it is as unsatisfactory as before. Glycerine gives a
ligature which will knot well, but is still too hard. I have at last made
a mixture of carbolic acid, glycerine, chromic acid, spirit of wine, and
water, which I think will prove the very thing required. The ligature
which I show has been soaked a month in serum, and yet the knots
are perfectly firm.
The germ theory of putrefaction is the foundation of the whole system
of antiseptic surgery, and, if this theory is a fact, it is a fact of facts that
the antiseptic system means the exclusion of all putrefactive organisms.
Burdon Sanderson a few years ago established a fact when he showed
that water developed bacteria. When Pasteur's solution, with sugar
and ammoniacal solutions, was boiled and exposed to the air, various
forms of fungi were found, but no bacteria; but if one drop of undis-
tilled water was added then these latter appeared. Again, when a
wineglass was filled with cooled Pasteur's solution, bacteria were found
in the contents; but these were attributed not to air dust but to adhering
water upon the glass. If it were true that water alone was the carrier
of these germs, it would be of no use to employ the spray; it would
only be necessary to cleanse the hands and instruments. Formerly,
when I used the carbolized putty, I have seen a joint which had been
laid open do admirably until the blood clot at the wound was pulled
away, when upon the next day the whole articulation would be in a
state of putrefaction. I should like to know how this could occur Save
from air dust.
A NT IS E PTI C S U R G E R Y . 539
[Prof. Lister then showed a glass stand, cup, and cover, which he had used for his ex-
periments. The cast-iron box in which they were heated to 300° F., in order to destroy
all living organisms, was fitted with a cover, in the groove in the lid of which was placed
cotton, in order to filter the air which would otherwise pass uninterrupted through the
crevice during the cooling process.] f
If a liquid free from organisms is introduced into such a prepared
glass, it will remain without fermentation until it dries up. This proves
that if a liquid be freed from living organisms, putrefaction will not
occur. The lid may be raised for a moment, and some of the liquid Se-
cured for experimentation, yet no dust will enter during the short space of
time required for this manoeuvre. If instead of Pasteur's solution we use
boiled milk, and remove the cover for fifteen minutes, then bacteria will
appear. Milk is more favorable for the development of different kinds
of bacteria than Pasteur's solution. We may have these organisms
without putrefactive changes, and I have found them in milk treated
as above described for days without any smell or putrefaction; but if we
let in air or water, at once the liquid will put refy. This would indicate
that there are bacteria of several kinds, just as there are great numbers
of torulae which cause alcoholic fermentation. Boiled milk is not prone
to sour, but if we introduce one drop of sweet milk, we almost immedi-
ately find bacteria.
Again, suppose that we try how such organisms behave in boiled urine.
It may be objected that the boiling will prevent decomposition of the
urine, but it is possible to obtain pure urine which has never been exposed
to the influences of the air, and in which there is therefore no need of
boiling to destroy any germs, unless those germs existed in the bladder.
It may be set down as a rule that living tissues prevent the development
of bacteria in their immediate vicinity. This is instanced in the puncture
of an oedematous limb, where the liquor sanguinis which does not ooze
away never putrefies, while if it were situated in meshes of cotton in-
stead of connective tissue it would certainly do so, showing that the
living structures prevent this process. Again, take the instance of heal-
ing under a scab ; here is an underlying layer of liquor sanguinis, yet
fermentation never occurs. Hence we might infer that the mucous
membrane of the urethra would also exercise a forbidding effect upon
the development of these germs, since, although the acts of micturition
are infrequent, no organisms are ever found beyond the meatus, even
when the glans and prepuce are abundantly supplied with them.
For experimentation, let the penis be thoroughly washed with a solu-
tion of carbolic acid, 1 to 40, which will produce no irritation; then,
taking a flask which has been removed from the “heating box” before
described, gently lift the cover, and let the patient micturate into the
flask. One will then have pure, uncontaminated, unboiled urine, which
will keep for a year, even although it contains vesical mucus. When it
is wished to obtain some of the contents of this flask, it is only necessary
to remove the cap, slip over the mouth one-half of a rubber ball, which
has been steeped in carbolic acid, and through a hole in this any amount
can be poured, the little drop remaining at the orifice acting as a valve.
Into one of these glasses of unboiled, pure urine, put one drop of boiled
milk. The first day, nothing ; the second, a dimness and milkiness;
and now, if we look, we will find long, spiral forms of bacteria. Inocu-
late a second glass of urine with one drop of this liquid; and now the
bacteria, having become accustomed to the liquid, will cause it to become
filled with germs within a few hours. Transfer a drop from the second
540 LISTER,
glass into Pasteur's solution; again we have bacteria, but of different
forms. The former were motionless; these are quite active. Now inocu-
late a glass of boiled milk, and large, moving germs are soon seen. One
drop of this last will produce lactic acid fermentation almost imme-
diately. If we believe that torulae are the cause of alcoholic fermenta-
tion, d fortiori we must believe that the bacteria lactis are the cause of
lactic acid fermentation.
In regard to the inferences to be drawn from these experiments in
regard to the healing of wounds, I would ask why the effused lymph, in
the operation for harelip, does not putrefy 7 I believe that the explana-
tion is to be found in the fact that this lymph lies between two healthy
living surfaces, which prevent the development of organisms just as does
the urethral mucous membrane. I believe that we should even go fur-
ther, and say that blood-clot should also be regarded as tissue. I made
an experiment several years ago, which consisted in laying bare the jugu-
lar vein of an ox, just struck down, applying two ligatures, and cutting
away the vein beyond each, thus obtaining a receptacle of living tissue
containing blood. This vein could be kept for hours without any change
taking place in its contents. I then drew out the blood into a flask,
and covered it with gutta-percha to prevent evaporation and dust; for
twenty-four hours the blood still remained fluid, save where it was in
contact with the glass, but the instant that the glass was stirred, coagu-
lation took place.
The formation of clots in aneurismal sacs may be explained by this
experiment; as long as the wall remains smooth and uninjured, clotting
does not occur; but when the sac is injured, or free circulation inter-
fered with, then coagulation takes place. If the blood-clot in wounds
does not receive injury, it will organize, and should be accounted as
tissue. In this blood-clot are many consituents—fibrin, white corpuscles,
etc. These leucocytes act just as the connective-tissue corpuscles, and
prevent fermentation, and the explanation of the organization of blood-
clots, when not disturbed, can thus be explained. Putrefactive changes
may be introduced into the clot, and yet putrefaction not occur—a cir-
cumstance which can be best accounted for by the fact that the clot acts
as a living tissue, and thus prevents putrefaction, just as does the urethral
mucous membrane before mentioned. There are undoubtedly often deep
blood-clots in the tissues when acupressure is used after amputations;
and yet these fail to putrefy, but become organized. This may occur
under any form of treatment, but by employing the antiseptic system
such a result is rendered exceedingly probable.
As regards the question of constitutional treatment which has been
raised, I would say that, with strict antiseptic precautions, the wound is
placed in a condition similar to that of a simple fracture, in which the
injured parts are free from the dangers of atmospheric exposure, and the
surgeon has far less need to attend so closely to the patient’s constitu-
tional condition, as the cases will almost always progress favorably.
The statement that cell-forms have been found beneath antiseptic
dressings, must be received with caution. I have recently met a gentle-
man who was with Rancke, in Halle, when he found, as he supposed,
these organisms beneath antiseptic coverings; and when this gentleman
pointed out to me the bacteria which he called putrefactive, I at once
recognized them as of the non-putrefactive variety; and the gentleman
was forced to admit that they differed from those found in decomposing
Ill a SSGS.
A N TIS E PTI C S U R G E R Y . 541
As regards bacteria found in abscesses when the skin is not broken,
and in which Dr. Hodgen stated that the forms came from within, I
think the instances are very rare, although I acknowledge that such
cases do occur. Again, it does not follow that every foul-smelling ab-
scess is putrefactive. In ischio-rectal abscesses there is usually a stinking
odor, even although no communication has been established with the
bowel. My treatment for this class of cases has been not to poultice
them, for that would surely make a true fistula, but, after thoroughly
disinfecting the skin, to lay them freely open under the spray. I then
cover them with lint soaked in carbolized oil, and over the mass place a
T-bandage, which can be drawn aside at each act of defecation. I never
inject them, nor use a drainage tube. Under this treatment they soon
heal without either suppuration or odor; and I have never failed to
secure this result save in one case, in which the house-surgeon, on the
first day, failed to change the dressings under the spray.
In regard to salicylic acid, I think its action is chemical, and that it is
especially useful in destroying those odors which are not the result of
putrefactive change. That it has this chemical property is proved by
the fact that, when mixed with amygdaline and emulsine, it prevents the
formation of hydrocyanic acid. Mixed with mustard, also, it prevents
the evolution of the volatile oil. I have thought that the action of sali-
cylic acid is very similar upon living tissues. Other classes of cases for
which this agent is especially suitable, are compound fractures, which do
better if kept closed for weeks, and yet are liable to become offensive
before the expiration of that time, and chronic abscesses connected with
diseased vertebrae, when the skin is excoriated and ulcerated. In such
cases I simply smear the under surface of the carbolized gauze with the
powder of salicylic acid, and then have allowed a single covering to
remain for six weeks without either odor or irritation.
DISCUSSION ON MR. LISTER’s ADDRESS.
Upon the conclusion of Prof. Lister's remarks, Dr. W. H. WAN BUREN, of
New York, said:—I would ask how far the antiseptic treatment is applicable
to a certain class of operations, as, for instance, those for the relief of stran-
gulated hernia; and how far it is safe to throw the carbolized spray upon the
peritoneum in ovariotomy and laparotomy 2 Absorption has occurred in such
cases, as evidenced by the production of haematuria, and other symptoms of
carbolic acid poisoning.
Mr. LISTER said:—Upon this point I can speak from experience, as I have
repeatedly operated for strangulated hernia under the spray, and, in one case
of abdominal wound, a cloth soaked in the carbolic solution lay upon the
exposed intestines for several hours without producing any irritation. As for
ovariotomy, I am informed that Mr. Keith now uses the spray in all his ope-
rations, and also that Nüssbaum attributes his great success in this class of
cases to the use of the antiseptic system. I myself think that the danger to
be apprehended is not so much from peritonitis as from the toxic effects of
the acid. In one case, in which a large ovarian tumor had been removed and
hemorrhage occurred, I did not open the wound, but simply applied a large
carbolized sponge, with pressure, and although a large amount of clotted
blood remained in the peritoneal cavity, yet no inflammation resulted. I have
seen a few cases of danger from the toxic effects of carbolic acid, the symptoms
being weakness, failure of appetite, sometimes vomiting, and the urine very
much darkened. These effects have seldom occurred since I have ceased the
542 LISTER,
use of the antiseptic putty, and I believe that they will only be found where
there is a peculiar idiosyncrasy.
Salicylic acid I consider inferior to carbolic acid as a detergent, yet, in those
cases in which a deep dressing is to be left on for weeks, and in which the
odor is apt to become very offensive, I have used it with great advantage.
This odor is particularly disagreeable in dressings applied to the feet, axilla,
or perineum, and is not due to putrefaction or to the presence of organisms.
Dr. T. E. SATTERTHWAITE, of New York, said:—The vegetable germ theory
seems to be regarded by some as an essential foundation for the antiseptic
system of surgery.
The hour being late, I merely desire to point out a few facts which, in my
Opinion, militate against the theory, as far as it claims that a certain class of
minute living organisms of a vegetable character is essential to disease-pro-
cesses. Pasteur has, of late, considerably modified his ideas, so far as to
acknowledge that alcoholic fermentation may be initiated without the presence
of certain minute living vegetable organisms, in other words, torulae or allied
forms, whatever their name. A statement to this effect was made at the
recent discussion on the Germ. Theory in London. Le Chartier and Bellamy
have observed that, in some modified forms of alcoholic fermentation, such
minute organisms may at first be absent, though later they make their appear-
ance. Again, Hiller has inoculated eggs with bacteria, and no putrefaction
has ensued. Some French observers also have found no organisms present in
putrefaction.
These facts are stated to show merely that it is questionable whether alco-
holic fermentation and putrefaction are due solely to certain minute living
vegetable organisms, to the growth and multiplication of which these processes
are due.
The early views of Pasteur have met with opposition, notably from Liebig,
Stahl, and others of the German school, and views of a somewhat similar
nature are still maintained now by those who oppose the “germ theory.” As
for the changes which it has been stated take place in one and the same bac-
terial body, under differing circumstances, I think that this is an important
and interesting fact, and one that has not as yet received sufficient recognition.
But it is an argument that is exceedingly valuable to those who do not
believe in the vegetable germ theory. It helps to explain a fact that has led
to a great deal of confusion, viz., that the different organisms alleged to be
found in different diseases may owe their differing form not to the disease,
necessarily, but rather to the peculiar menstruum in which they happen to be.
With regard to the experiment recited by Mr. Lister, in which urine was
passed into a glass vessel that contained air, but no floating particles, where
the fluid continued to resist ammoniacal decomposition until, the air being
admitted, it was seen to contain particles, I would say that the presence of
these particles does not necessarily indicate that they are bacteria; in fact, the
experiments of Blackley, in England, and of Wyman and others, have shown
that the air contains numerous particles beside bacteria, such as the pollen of
grasses, epithelial scales, and what is known as granular matter, whatever that
may happen to be in any given case; and we have a right, in view of certain
other experiments, such as the production of putrefaction without bacteria, to
believe that some of these particles—not bacteria—may have occasioned the
change.
The same statement applies to Prof. Tyndall's experiments, in which he
passed the beam of the electric light through a box fitted with windows, where
the box contained matter easily susceptible of putrefactive change. When the
electric beam showed that the inclosed air contained floating motes, then the
fluids soon commenced to putrefy, but when the beam showed that the par-
ticles were no longer in the air, the tubes might be introduced and exposed to
the air, and yet would remain unchanged indefinitely. Now it is implied by
Prof. Tyndall that the presence of particles is synonymous with the presence
A NT IS E PTIC S U R G E R Y . 543
of bacteria, which is certainly an assumption, as the electric beam does not
show that these particles are bacteria in distinction from other particles.
Experiments with vacuum tubes in relation to putrid matters, if performed
with delicacy, tend to show that the fluid of such infusions, although virulent
in so far as inoculation is concerned, may still remain clear or transparent for
an indefinite time, without the formation of bacteria.
In some experiments made with salicylic acid and putrid matter intimately
mixed, infection took place in animals I inoculated, when the quantity of sali-
cylic acid was sufficient to prevent the development of bacteria in organic
infusions. These are simply a few of the points maintained by those who
oppose the vegetable germ theory as generally accepted. In my paper read
in the Section on Sanitary Science, these and other facts are stated at more
length.
Mr. LISTER said:—I am of the opinion that Pasteur has not materially
modified his views. The penicilium glaucum, without air, produces a degree
of alcoholic fermentation; there are also certain forms, which when grown
under water have thick filaments, with loose joints, and which closely resemble
torulae; but, if in oxygen, the growth is much more rapid, and the similitude
is less marked. Pasteur made an experiment with grapes kept in an atmos-
phere of carbonic acid, and although they showed evident signs of fermenta-
tion, yet Pasteur attributed this process to the natural change in the vegetable
cells of the fruit itself, and not to organisms.
I have made numerous experiments to determine the question as to whether
the cause of fermentation is a chemical or a vital one ; also whether this is in
solution in water, or in suspension. I can hardly believe that living things are
soluble, and yet if they are only in suspension, by taking minute enough drops,
we ought to avoid them. I have tried as small a quantity as gº of a drop of
putrefying liquid, introduced by means of a syringe into different solutions,
and have found that no matter how small the quantity used, yet under favor-
ing circumstances, bacteria are developed. I would mention as a point worthy
of note, that I have discovered that bacteria are killed by the reduction of
temperature to a degree still considerably above the freezing point.
Dr. SATTERTHWAITE said :–In regard to the modification of Pasteur's views
which I stated had taken place, the instances referred to by Prof. Lister illus-
trate the point which I am desirous of making.
In certain of these instances, as in the well-known experiment where grapes
were suspended in an atmosphere of carbonic acid, Pasteur admits' that fer-
mentation took place without the intervention of certain minute organisms, by
which is doubtless meant the yeast plant or other allied organisms. The for-
ment was, in this case, Pasteur said, the tissue elements of the fruit, the vege-
table cells, rather than the minute organisms known as fungi, torulae, etc. I
am aware that Pasteur claims that this admission does not necessarily affect
his doctrine, but I must still maintain that Pasteur's view, as generally under-
stood, is considerably modified, to use no stronger expression. The ferment is
in this case stated to be the substance of the fruit, rather than a minute
microscopic organism ranked among the cryptogams. This is the only point
I am desirous of making in this matter, and the object of introducing it is
not so much because fermentation and putrefaction have to do with the discus-
sion, as because the connection between minute living organisms and these
processes is brought forward as good & priori evidence of a similar relation
existing between other minute organisms, such as bacteria and disease-processes.
In reference to Liebig and others of the German school who have opposed
Pasteur, I did not allude to them as expressing distinct statements as to the
nature of the fermentative agent, for these views varied as the discussion on
| Bull. de l'Acad. de Médecine, Mar. 2, 1875, No. 9, p. 255; Lancet, April 10, 1875, p.
508.
544 LISTER, ANTISEPTIC su RGERY.
these topics went on, but rather as showing that there have been and still are
those who believe that these changes are not dependent on the growth and
multiplication of such living organisms as have been described.
In reference to the nature of disease-poisons, it does not necessarily follow
that because they may not be bacteria, they may not be molecular; indeed, it
is my present conviction that this is the case in a certain number of instances,
as filtration experiments appear to show. The most virulent fluids with which
I have experimented have never produced lesions when they have been passed
through porous clay.
Mr. LISTER said:—Pasteur has shown that if the grape is bruised, and then
placed in the atmosphere of carbolic acid, fermentation no longer takes place;
implying that only living tissues undergo this change. I have tried the experi-
ment of passing solutions through pores so fine as to arrest bacteria, but I
have found that albumen is also stopped, and it may be that chemical substances
in solution are also prevented from passing; consequently the experiment proves
nothing save that the cause of fermentation has been prevented from passing.
Handworterb, d. r. und a. Chimie, 1848, S. 232; Annalen der Chim. u. Pharm., 153, S.
l, 6, 146. Bastian, Researches illustrative of the Physico-Chemical Theory of Fermenta-
tion; Proceedings of the Royal Society, No. 172, 1876.
THE TREATMENT OF ANEURISM.
BY
W. H. WAN BUREN, A.M., M.D.,
PROFESSOR OF THE PRINCIPLES AND PRACTICE OF SURGERY IN THE BELLEVUE HOSPITAL
MEDICAL COLLEGE, NEW YORK.
IN seeking for information concerning the medical and surgical treat-
ment of aneurism, we find by far the most ample experience in the records
of English surgery. Breschet, in his well-known memoir on aneurism,
published in Paris in 1832, frankly admits that the pathology of this dis-
ease had received more attention in England than in France, because of
its greater frequency in that country." The greater frequency of aneu-
rism in the British Islands than elsewhere still exists; and, unless we
accept the suggestion that it is the result of the more general use of beer
and spirits in those countries, I must follow Breschet in ignoring its
cause. Although our own country has been singularly prominent in the
boldness and success of operations upon the great arteries for aneurism,
yet the disease is not so frequent here as in England, and at the same
time spirit-drinking is very common. On the continent of Europe, where
the consumption of spirits is less general, aneurism is comparatively rare.
In connection with the etiology of the disease it is to be remarked that
the weight of opinion in favor of syphilis as a cause of aneurism is notice-
ably less than formerly.
In the very able lectures on the treatment of aneurism delivered in
1872, 1873, and 1874, by Mr. Timothy Holmes, as Professor of Surgical
Pathology in the Royal College of Surgeons of London, he states that, in
collecting his materials, he addressed letters to more than thirty hospital
surgeons throughout Great Britain and Ireland, and that he received notes
of no less than three hundred and thirty-seven cases of aneurism, in reply,
covering ten years of practice. Mr. Holmes complains, moreover, that
the pathological museums of London alone are so overstocked with mate-
rial that it is difficult to master their contents, whilst the bulk of pub-
lished matter outruns the best efforts of any one inquirer to keep up with
it. Such recent and ample supply of material bearing on our subject
leaves little scope for further research, and the evident ability shown in
its collation and digestion gives these lectures great value. Since Guth-
rie lectured on this subject from the same chair more than forty years
ago, we have had nothing more judicial and authoritative. I shall, of
necessity, draw largely from them in this report.”
The purely medical treatment of aneurism, more especially of internal
aneurism, has risen into greater importance within the past ten years.
Mr. Jolliffe Tufnell, of Dublin, has fairly and ably demonstrated the posi-
! Mémoires de l'Académie de Médecine de Paris, t. iii.
* It is to be regretted that Mr. Holmes's eighteen lectures “on the medical and surgical
treatment of aneurism in its various forins” are only accessible in the pages of the journals
in which they were reported at the time, without any copies of the drawings, or tables, or
pathological preparations by which they were illustrated. They are too valuable to the
profession not to be reproduced in a more permanent form.
35
546 VAN BUREN,
tive value of absolute repose in the horizontal position, conjoined with a
greatly restricted diet, omitting entirely the frequent bleedings which
had brought the so-called treatment of Walsalva into disfavor. Mr. Tuf-
nell’s successful results certainly justify the systematic enforcement of
his method, especially in cases of thoracic and abdominal aneurism, which
we are too much in the habit of regarding as incurable. “The method
I advocate,” says Mr. Tufnell, “is the imitation of nature's cure; the pro-
duction artificially of that consolidation which in isolated cases has from
time to time occurred spontaneously.” The recumbent position is the
secret of cure, but it must be steadily maintained. It places the same check
upon the circulation in internal aneurism which in external cases is pro-
duced by mechanical appliances. Three months of horizontal position,
with eight ounces of solid food and six ounces of fluid as daily allowance,
were the measures with which he cured Doyle, a hackney coachman of
thirty-five, with an abdominal aneurism as large as an orange." Tufnell’s
method is legitimately derived from the principle so ably illustrated by
the Irish surgeons when they established the value of compression as a
remedy, the principle originally demonstrated by Hunter, that to pro-
duce coagulation in an aneurismal sac it is only necessary to slow its cur-
rent of blood, not to arrest it entirely; and, in the judgment of the
writer it is destined hereafter to play a prominent part in the therapeu-
tics of aneurism.
The aid of drugs has been also invoked in the medical treatment of
aneurism for the purpose of slowing the action of the heart and favoring
coagulation; digitaline and ergotine have been used by Albertini; and
Langenbeck has made trial of ergot in subcutaneous injection. Acetate
of lead has also been used internally. I have met with little evidence
in their favor. A case of orbital aneurism is reported by Dr. Holmes, of
Chicago, which got well after six weeks’ use of tincture of veratrum
viride in doses of five minims, with a fluidrachm of extract of ergot, sug-
gested by the late Professor Brainard.”
In a recently published work Dr. Balfour brings forward further evi-
dences of the value of potassium iodide in causing solidification of inter-
nal aneurism.” This remedy has been tested by the profession, and there
are favorable reports of it.” In many instances, however, the recumbent
position and restricted diet have been employed at the same time with
the iodide. In aneurism in a syphilitic subject its use would be indi-
cated. Pretty certainly the iodide in such a case would increase the
number of the red globules of the blood, as Keyes has observed to be the
case under the use of small doses of mercury, and, possibly, also, its fibri-
nating power." Until we gain more accurate knowledge of the causes
| The Successful Treatment of Internal Aneurism by Consolidation of the Contents of
the Sac. By Jolliffe Tufnell, F.R.C.S.I., etc., President of the Royal College of Surgeons
of Ireland, etc.; 2d edition, London, 1875.
2 Amer. Journ. of Med. Sciences, July, 1864.
* Clinical Lectures on Diseases of Heart and Aorta ; London, 1876.
* See case of cure of aortic aneurism in a woman of thirty-five, attributed to doses of the
iodide of twelve to fifteen grains three times a day for several months, by Dr. T. M. Matthews,
of Texas, in Amer. Journ. Med. Sci. for January, 1875, and others. Mr. Annandale, of
Edinburgh, from “repeated observation,” bears testimony “to the value of the iodide in
relieving the symptoms and promoting coagulation in this disease.” Brit. Med. Journ., Oct.
.30, 1875, p. 550. -
5 On the Effect of Small Doses of Mercury in modifying the number of the Red Blood
Corpuscles in Syphilis, a study of Blood-counting with the Hématimetre; by E. L. Keyes,
M.D., etc.; New York, 1876.
T R E A T M. ENT OF A N E U R IS M. 547
which modify the quality or quantity of its fibrin, the mode of action of
drugs in favoring coagulation of the blood must remain obscure.
The ligature, as applied by Hunter, maintains its character in a general
way as the most prompt and certain of the surgical remedies for aneu-
rism, and, when not employed in the first instance, it is always held in
reserve as a final resort in all cases to which it is applicable; but safer
methods of cure are constantly being sought for in order to escape the
dangers which are still inseparable from the use of the ligature, viz.,
hemorrhage, gangrene, and inflammation of the aneurismal sac.
The ligature of carbolized catgut prepared by Professor Lister's method
offers the best promise, at this time, as a preventive of secondary hemor-
rhage. Bickersteth, of Liverpool, Pemberton, of Birmingham, Heath,
Maunder and Holmes, of London, besides Professor Lister himself, cer-
tain of his colleagues of the Royal Infirmary of Edinburgh, and others,
have recorded evidence that the carbolized catgut ligature is competent
to constrict an artery for a sufficient time to bring about the consolida-
tion of an aneurism without causing ulceration of its coats. After this
duty has been accomplished the substance of the ligature then softens
into a mass which is, as it seems, capable of serving as a nidus for cell-
growth, and, having excited no suppuration whatever, the catgut becomes
finally identified with the surrounding tissues.” Thus, after such a liga-
ture has been applied, both of its ends may be cut off and the wound
closed as for quick union. This latter result is more likely to be
attained, according to Professor Lister, when the operation is done under
carbolized spray, and the wound dressed according to the antiseptic
method. The Edinburgh surgeon expresses his readiness to ligate the
innominate artery by this method, believing confidently that the vessel
will be obliterated with greatly diminished risk of suppuration and
ulceration, and with increased chances of rapid consolidation of the
wound.” A double surety would be thus obtained against secondary
hemorrhage. -
It is proper to state, however, that some instances have been recorded
"An Introductory Address on Recent Progress in Surgery, delivered at the Liverpool
Medical Institution, Liverpool, 1871, p. 20.
* Observations on the Ligature of Arteries on the Antiseptic System, by Joseph Lister,
F.R.S., etc., Lancet, April 3, 1869, p. 451. More recently, Professor Lister's statements
have been confirmed by Mr. Fleming, Lecturer on Physiology in the Glasgow School of
Medicine, in a very conclusive series of experiments on dogs and rabbits, reported in the
London Lancet, May 27, 1876, p. 771. Mr. F. says: “The results of these experiments show
that a gradual softening takes place from without in, the catgut breaking down and becom-
ing infiltrated with cells, probably leucocytes. This part of the process takes from five days
to about twenty, varying with the specimen of catgut, the tissue amongst which it is situ-
ated, and the age and vitality of the animal. Next the pultaceous mass into which it has
been converted, begins to metamorphose, and is soon permeated with blood channels, and
ultimately may be described as a cast of the catgut, in a kind of granulation tissue freely
supplied with bloodvessels, which in many of my sections are very fully injected.
“If, then, we admit these conclusions, we can easily account for the different results ob-
tained by the use of catgut in different hands. We see that it is in reality merely a tem-
porary ligature, because when in the softened stage we cannot consider it to have any con-
stricting effect.
“Whether, then, this temporary condition lasts long enough to produce embolic occlu-
sion of the vessels, depends upon the sample of catgut and the vitality of the patient.
“In conclusion, my experiments seem to demonstrate that an aseptic, dead, foreign, ani-
mal body may under appropriate conditions become, by a process of softening, absorption,
and re-deposition, changed into or replaced by a living, vascular, and comparatively highly
organized, animal structure.”
* Holmes's Lectures on the Treatment of Aneurism, ut supra, Lancet, June, 1872.
548 VAN BUREN,
in which the catgut ligature has become prematurely soft, and pulsation
has returned in the aneurism ; and in which, when the wound has not
united, secondary hemorrhage has occurred." The answer has been made
that in these cases of failure the catgut may not have been well prepared,
and that the necessary details of the antiseptic method were possibly
neglected.”
Meanwhile, those who, like Mr. Maunder, lack confidence in the cat-
gut ligature, have reverted to the use of carbolized silk, which was em-
ployed by Professor Lister before he adopted the catgut; and it has been
found in several reported cases to answer the same purpose. There is
no danger that the carbolized silk ligature will give way, but Lister had
reason to suspect that it might provoke suppuration, and therefore pre-
ferred the catgut.”
The problem is to discover a mode of preparing catgut ligatures so that
they shall possess first the right amount of strength and durability when
exposed to soakage in the tissues, and at the same time that their very
desirable quality of disappearing by blending with the tissues shall not
be impaired. Professor Lister has just announced to us that he has rea-
son to believe that he has succeeded in solving this problem, which has
cost him so much labor. By this event surgery will have secured a great
triumph over the danger of secondary hemorrhage after ligature of the
great arteries for aneurism.
The employment of pressure upon an artery previous to its ligature has
been heretofore regarded as a means of averting the danger of gangrene,
which, according to Norris, causes 12.2 per cent. of all the deaths after
ligature of large arteries for aneurism.” As early as 1820, Todd, of
Dublin, had practised compression as a preparatory course prior to ope-
ration “in order that mortification of the limb might be prevented by
allowing some progress to be made in establishing the collateral circu-
! My late colleague, Dr. Krackowizer, used a carbolized catgut ligature upon the primi-
tive iliac artery for aneurism at the German Hospital, New York, and pulsation returned
in the tumor within twenty-four hours, rendering it necessary to reopen the wound and apply
another ligature. Similar cases are recorded by Dr. E. Watson, of Glasgow, in the Glas-
gow Med. Journ., May, 1870, p. 340; by Professor Spence, of Edinburgh, in the Lancet, June
5, 1869; by Mr. Holden, in St. Bartholomew's Hosp. Reports, vol. viii. p. 187; by Mr. H. L.
Browne, Lancet, May 6, 1876; and by Mr. Maunder, in Surgery of the Arteries, London,
1875, p. 147, where the results of ten cases of “antiseptic” ligature are detailed, some of
which are favorable, and others the reverse.
* It is only fair and just to Professor Lister that when the remedy he has proposed is
under judgment, the conditions under which he employs it, and on the strength of which he
recommends it, should be strictly complied with.
* Careful microscopic examination of the tissues around a loop of prepared silk which had
successfully obliterated an artery, after rapid healing of the wound, in one of the lower ani-
mals, has shown as a rule the persistent presence of portions of the substance of the silk,
which have been found in several instances surrounded by granulation tissue in process of
organization along with some pus corpuscles, proving that silk does not become entirely
blended with the tissues, and does not so readily lose its identity as the properly prepared
catgut. Ilister, ut Supra.
In a recently published clinical lecture at the Royal Infirmary, Glasgow, Dr. Eben Wat-
son describes a patient in whom he had tied both external iliacs for inguinal aneurism at an
interval of nine months. Both operations were done under carbolic spray, carbolized silk
ligatures applied, and then cut off. The wounds healed well, and the ligatures were never
heard of. Dr. W. gives evidence for his belief that they became encapsulated. He prefers
them to catgut, which, for reasons derived from his own experience, he considers less safe
than silk. Lancet, Aug. 12, 1876, p. 213.
* Contributions to Practical Surgery, Philadelphia, 1873. In one hundred and eighty-
eight cases of ligature of large arteries for aneurism, gangrene occurred in thirty-one, and
was the cause of death in twenty-three.
TRE AT MENT OF A N E U R IS M. 549
lation.” This idea has been effectively disputed recently, by Mr. IIolmes,
who, controverting certain conclusions arrived at by Mr. Jonathan Hut-
chinson, asserts that the larger experience contained in his (Holmes's)
collected table of hospital cases leads to precisely the opposite conclusion,
viz., that the mortality from ligature, after compression has failed, is 10 per
cent. greater than when the Hunterian operation has been performed at once.”
Mr. Clement Walter tied the external iliac, at St. George's Hospital,
for inguinal aneurism, after six weeks’ trial of pressure, both distal and
proximal, as well as flexion, without avail, and the patient died in four
days with incipient gangrene.” It is well known, also, that pressure, espe-
cially if intermittent, or irregularly applied, is liable to provoke inflam-
mation of the sac ; and that it is possible, in rare instances, for pressure
itself, alone, to occasion gangrene, as in a case recently reported by Dr.
Oscar H. Allis, of Philadelphia.” These facts should teach us, when it
is decided to try compression, to use all possible means to command
prompt success, and, these failing, not to prolong unavailing efforts. -
The prestige acquired for the Hunterian operation by the brilliant
successes of Astley Cooper, Abernethy, Travers, Mott, and others, caused
the ligature to be regarded, during the first half of this century, as the
remedy above all others for all forms of aneurism, wherever its applica-
tion was possible; and it continued to be so regarded, in spite of its really
high mortality, until the feasibility of a safer cure by compression was
established by the Dublin surgeons. After it became an established fact
that the disease was safely curable by compression, numerous other
devices were proposed to attain the same end to the exclusion of the
ligature, and of compression also ; some of greater, others of less promise,
but mainly of a bloodless and safer character. These methods, after a
few remarks on compression, I propose to enumerate.
Meanwhile, it seems to me profitable to ask ourselves how far English
and American surgeons may have carried a partiality for Hunter's ope-
ration to excess, and tied arteries for aneurism in cases in which other
methods might have offered a better chance for life : That this has been
the case in some degree we have the authority of Syme, of Edinburgh,
undoubtedly one of the greatest operators of his day. Towards the
close of his life, this surgeon formally raised the question as to the
applicability of Hunter's operation to axillary and iliac aneurisms, after
having advocated it, as he states, for thirty years. After a series of
operations upon the greater arteries, unequalled in brilliancy and success,
he felt himself justified in asserting that “aneurisms of the popliteal,
femoral, and carotid arteries alone are proper subjects for ligature by the
Hunterian method,” and that all other aneurisms are more safely treated
! Practical Remarks on the Treatment of Aneurism by Compression, with plates of
instruments, etc., by Jolliffe Tufnell, M.R.I.A., etc. etc., Dublin, 1851, p. 24. Tufnell here
quotes Todd, who adds, “at the same time not altogether without hope that by diminishing
the current of blood in the trunk of the artery so as to favor coagulation of the blood in
the sac, a cure without operation might be effected.” This is interesting as showing that
the idea of cure by compression was still fairly in view at this early period.
* Lecture iv., part i., 3d series, Lancet, July, 1874. The probability of this conclusion
had been already demonstrated by Dr. J. Ashhurst, Jr., in his System of Surgery, Phila.,
1871, p. 543.
* St. George's Hospital Reports, vol. vi., 1871–72.
* In a robust colored man of 50, with a recent popliteal aneurism, a cure was effected on
a second attempt at compression in thirteen hours. Gangrene appeared in the foot and
leg on the next day, and the patient died in eight days. Dr. Allis states that he has found
one other case of gangrene after pressure. Trans. Path. Soc., Phila., 1874, vol. iv. p. 117.
550 VAN BUREN,
by the old operation of laying open the sac." After careful study of his
very interesting cases, it is difficult to refuse a large share of assent to
Syme’s conclusions. Even if we cannot admit his premises, which have
been shown to be untenable by Holmes and Henry Lee, and refuse to
return formally to the “old operation,” preferring to trust to the medical
treatment of Tufnell, or to the promises held out by galvano-puncture,
coagulating injections, the manipulation of Fergusson, distal ligature in
one of its new applications, or even to some form of compression—which
Syme, through what Holmes calls a “strange prejudice,” so singularly
undervalued—nevertheless, the terrible mortality of the Hunterian ope-
ration in subclavian, axillary, and iliac aneurisms demonstrates clearly
that the Edinburgh surgeon was right in raising the question of its
applicability to these cases. “The Hunterian operation on the inominata,”
says Holmes, “and upon the first part of the subclavian, gives twenty-
eight cases, in only one of which did the patient survive, and then after
repeated attacks of hemorrhage—a ghastly record of death and blood.”
The ligature of the second and third parts of the subclavian for aneurism
is also very unpromising; Mr. Poland gives us twenty-one cases, of
which only nine recovered.” In consequence of the pushing up of the
clavicle by the growing tumor, ligature of the subclavian in its third
portion for aneurism is often difficult, sometimes impossible, and always
dangerous. Dupuytren abandoned it on one occasion, after persevering
for an hour and a half, asserting that it was the most difficult operation
he had ever undertaken ; and Liston punctured the aneurismal sac in
carrying his ligature around the vessel, and lost his patient.” On the
other hand, in two cases of rapidly advancing axillary aneurism, Syme
limited himself to dividing the tissues at the root of the neck so as to
permit a finger to be introduced to compress the artery against the first
rib, and then he laid open the tumor in the axilla and tied the vessel as
it entered and again as it left the sac, and in both instances saved his
patient. In two cases of axillary aneurism of a still more desperate cha-
racter, he succeeded in saving the patients by amputation at the shoulder-
joint after the ligature had failed ; and Mr. Spence adopted the same
mode of procedure, at least with temporary advantage, in a case of sub-
clavian aneurism.” -
Now, granting that Syme has demonstrated that laying open an
aneurism is a safer and more certain mode of cure than the Hunterian
ligature in these localites and others similarly situated, where pressure can
be momentarily effected between the tumor and the heart, does not this
success also prove that it is feasible to attempt a cure, perhaps at an
earlier period, by galvano-puncture, or coagulating injections?—for it is
in cases in which the circulation can be thus suspended that these novel
and ingenious remedies offer the best prospect of successful application.
* On the Treatment of Axillary Aneurism, Med.-Chir. Trans., vol. xliii. p. 142. See also
another paper in vol. xlv. of the same Transactions.
* This includes thirteen cases of ligation of the innominata, and fifteen of the subclavian.
Holmes, ut supra, Lect. iv., part ii., 1st series, 1872.
* Statistics of Subclavian Aneurism, by Alfred Poland, Guy's Hospital Reports, vols.
xv., xvi., xvii.
* Surgeon Otis, of the U. S. Army (in Medical and Surgical History of the Rebellion),
gives 76 per cent. of deaths for ligature of the subclavian outside of the scaleni, mainly
for hemorrhage or traumatic aneurisms after gunshot wounds, however. In my table of
eighty-six cases of the same operation for all causes, the deaths were nearly 40 per cent.
Contributions to Practical Surgery, Phila. 1865, p. 194.
* See Mr. Poland's paper in Med.-Chir. Trans., vol, lii. p. 277.
TREAT MENT OF A N E U RIS M. 551
In thirty-two cases of ligature of the primitive iliac, tabulated by Dr.
Stephen Smith, of New York, the operation was done for aneurism in
fifteen, in which ten died, and one only, Mott's patient," was permanently
cured.”
Whatever value, therefore, may be ultimately assigned to the ope-
ration of Hunter elsewhere in the arterial system, it seems clear that,
in these localities at least, it has proved neither safe nor reliable, and
cannot be so regarded in future.
For gluteal aneurism, the Hunterian operation is equally unpromising.
Holmes, who studied this subject thoroughly two years ago, succeeded
in collecting but twelve cases in which the disease was considered spon-
taneous, and for which the internal or common iliac had been ligated ;
of these five, or nearly half, died.” On the other hand, there were twenty-
one cases in which the affection was pretty certainly traumatic ; in two
of these the Hunterian operation was done—one of them the case of Dr.
Bigelow, of Doston—and both ended fatally. To these I can add an
unpublished case I witnessed in the Bellevue Hospital, New York, some
years ago, in which ligature of the internal iliac was undertaken, but
the patient died within a few days, as was supposed, from wound of the
iliac vein. There are several other cases on record in which the same
cause of death is noted, showing the difficulties which attend the ligature
of this vessel.
In summing up his conclusions concerning gluteal aneurism, Holmes
hardly shows his usual surgical acumen. He says: “The old operation
by laying open the sac and tying the vessel, is a desperate business, and in
spite of the really considerable amount of success which has attended it,
no prudent surgeon could contemplate it without repugnance.” Now, if
the success of the old operation in gluteal aneurism has been “really
considerable,” as could be readily shown if time permitted, is not this
conclusion rather sentimental than surgical ? The affection is undoubt-
edly, in the great majority of cases, traumatic in its origin, and the
treatment demanded is that of a wounded artery, whenever practicable.
Syme succeeded by laying open the sac, following the lead of John Bell
in his famous case of the leech catcher. Mr. Bickersteth, of Liverpool,
and others, have been also successful in a similar mode of procedure.
The source of fatal delay in quite a number of cases has been the fear of
uncontrollable hemorrhage, and lack of power to command it. This
risk, in the hands of a less confident and skilful operator than Syme, is
a great drawback, and it is certainly very desirable to find some safe
mode of commanding the circulation in this locality. Lister's adrtic
clamp, as used by Syme in the case in which he successfully attacked an
iliac aneurism by the old operation, is not free from danger of crushing
the intestines and causing congestion of the kidneys, as proved by Mr.
Bryant's fatal case at St. Bartholomew’s.”
I have a suggestion to offer which seems to me feasible and effective,
| Phila. Journ. Med. and Phys. Sciences, vol. xiv. p. 176.
* Amer. Journ. Med. Sciences, July, 1860.
* Lectures, ut supra, June, 1874.
* This was an attempt to cure an aneurism of the aorta very near the diaphragm by
means of distal pressure. Holmes's Lectures, ut supra.
Mr. Geo. Pollock, in trying the rapid pressure treatment with Lister's compressor upon
the aorta with chloroform for two hours and ten minutes, and again with ether for an hour
and a quarter, was obliged to desist on account of faintness on each occasion. The attempt
was also followed by hapmaturia which lasted for several days. He did not succeed.
Trans. Clin. Soc. London, vol. vii. 1874.
552 V AN BU R EN,
and which I shall put in practice if I encounter one of these rare cases.
In explorations of the rectum, after stretching the sphincter ani, where
several fingers or the whole hand, after the suggestion of Simon, of Hei-
delberg, have been introduced into the bowel, I have been struck with
the facility with which the great arteries of the pelvic cavity could be
felt by the fingers, and compressed against its bony walls; and I am
confident that either the external or internal iliac or their common trunk
could be thus easily commanded long enough to render it a safe opera-
tion to lay open a gluteal aneurism and secure the artery involved, if
external to the pelvis. All that is necessary is a reliable assistant with
a small hand, who is somewhat familiar with the manoeuvre."
If, possibly, a gluteal aneurism should take its origin within the pel-
vis, emerging through the sciatic opening, this fact might be also ascer-
tained by rectal examination, as already advised by Holmes; and at the
same time, carrying the exploration a little further, the feasibility of
commanding the circulation through the tumor by digital pressure from
the rectum could be determined. In this latter event, to attempt a cure
by distal ligature would involve less risk to life than the operation of
tying the internal or primitive iliac.
I would therefore venture the conclusion, in view of the uncertainty
of diagnosis of gluteal aneurism and its generally slow progress, together
with the great probability of its traumatic origin and the ascertained
difficulty and risk to life of the Hunterian operation, that its employ-
ment, in this variety of aneurism, is of doubtful propriety.
Ligature of the external iliac for inguinal and femoral aneurism, in
ninety-seven cases collected by Norris, gave twenty-six deaths, or a mor-
tality of about twenty-seven per cent., a comparatively good result, and
equal to that attained by compression ; so that judging from mortality
alone, there is little choice in these localities between the two methods.
According to Holmes’s table of cases, the same general conclusion will
apply to popliteal aneurism.
Owing to the number and size of the branches given off by the com-
mon femoral artery, relapse of aneurism has occurred quite frequently at
the groin after obliteration of the external iliac artery, whether by liga-
ture or compression, and this is an argument in favor of the old operation.
in this locality. It is certainly to be preferred in cases of relapse, and
after the failure of flexion, to ligature of the primitive iliac, as Mr.
Annandale, of Edinburgh, decided in a case which he has treated suc-
cessfully within the year by laying open the sac.”
The distal application of the ligature for the cure of aneurism, as pro-
posed originally by Brasdor, and executed successfully half a century
later by Wardrop, after having been for a long period regarded with
distrust, is again finding favor. In the well known case of Lambert, it
produced a cure of an aneurism confined to the root of the primitive
carotid." At the suggestion of Dr. Cockle, of London, Mr. Christopher
Heath, in a case of aneurism of the arch of the aorta involving the origin
of the left carotid, recently ligated the latter vessel, and the operation
* I have since learned that this idea had already been conceived and placed on record by
Dr. Frank Woodbury, Resident Physician at the Pennsylvania Hospital. Am. Journ.
Med. Sciences, Jan. 1874, p. 131.
* Double femoral aneurism treated with success by rapid compression; return of one
aneurism; ligature of external iliac, unsuccessful; cure by laying open the sac. Lancet,
April 22, 1876, p. 297.
* Wardrop, on Aneurism, London, 1825, p. 36.
TREAT MENT OF A N E U R IS M. 553
was followed by shrinking of the aneurismal tumor and decided benefit
in relief of symptoms." Mr. Annandale, of Edinburgh, tied the right
carotid in a case of aortic aneurism, in March, 1875, and, as I recently
learned from him, his patient is still living, and the disease is apparently
arrested.”
After having failed in four cases of subclavian aneurism, the distal
ligature has at last been crowned with success in the hands of Prof.
Toland, of San Francisco, California. In January, 1874, a miner pre-
sented himself with an aneurism as large as his fist, extending from the
inner border of the left sterno-mastoid to the anterior border of the tra-
pezius. Two ligatures were applied to the third portion of the subcla-
vian ; they came away on the twentieth day. Pulsation in the tumor
was perceptibly lessened immediately after the ligature, and gradually
decreased up to the sixth week from the date of the operation, after
which no pulsation or bruit could be discovered.”
Of innominate aneurism there are instances enough on record in which
benefit has followed the obliteration of one or both of the branches of
this great trunk to warrant Holmes’s conclusion that “there are some
cases of this disease in which the distal operation is not only allowable,
but imperative.” Although there are only three cures reputed certain
(the cases of Fearn, Evans, and Morrison), of the forty-three he has col-
lected of distal ligature for supposed in nominate aneurism, yet the
favorable consequences of the operation recognized in studying the indi-
vidual cases leave a far more favorable impression on the mind than
this bare statement would convey. In several of the unsuccessful cases,
for example, decided relief to dyspnoea, and to other symptoms, followed
ligature of the carotid.
In fact, in a case in which operative interference is decided on, our
present experience points to ligature of the right carotid in the first
place, as the most judicious course; and to the subsequent consideration
of the question of tying the subclavian, and at what part of its course.
Any tendency to spontaneous obstruction of either branch of the in-
nominata should be most carefully sought for, as this “would be a first
and grand step towards a cure of the disease.” Since Holmes wrote,
the double simultaneous ligature, which has never yet succeeded, has
been done on a Hottentot in South Africa by Mr. Frederic Ensor; the
patient survived more than two months, and died from bursting of the
sac.” And in another case by my colleague Dr. R. F. Weir, of New York,
whose patient did not survive so long."
Dr. Cockle, “Med. Soc. Proceedings,” vol. i. p. 5, and Heath, “On the Treatment of
Intrathoracic Aneurism by Distal Ligature.”
* British Med. Journ., Oct. 30, 1875. The patient was a man of sixty-two.
* Western Lancet, July, 1874. Abstract in Amer. Journ. Med. Sci., Oct. 1874.
* Surgery of the Arteries. Lettsomian Lectures of the Medical Society of London, 1875,
by C. F. Maunder, Surgeon to the London Hospital, p. 25. He refers in this connection
to the striking case of Dr. Herbert Davies, in the London Hospital Reports, 1864, vol. i.
p. 50, in which the subclavian and its branches were already occluded, so that ligature
on the carotid would have completed the cure.
* Lancet, Feb. 6, 1875.
° In a most interesting case, published within a few days, of an aneurism of the aorta
projecting at the root of the neck on the right side and simulating innominate aneurism,
Dr. S. Fleet Speir, of the Brooklyn City Hospital, Brooklyn, New York, obliterated the
right carotid by his invaginating “constrictor,” and forty-eight hours later applied a silk
ligature upon the third portion of the right subclavian. Immediate shrinking of the aneur-
ismal tumor and relief to symptoms followed each of the operations; but inflamination of
the sac, taking its origin at the subclavian ligature, with subsequent hemorrhage from this
554 VAN BUREN,
If the promise offered by the carbolized catgut ligature of Lister, or
by the methods of Howard or Speir, be fulfilled, we shall be justified in
applying these to the subclavian in the first part of its course. When
this can be accomplished successfully, the distal treatment of aneurism
of the innominata and also of the aortic arch—in certain cases—will be
established as a more hopeful resource to which the sufferer from these
forminable affections will be entitled, hereafter, when milder means
have failed.
It will be more profitable, perhaps, in connection with the distal treat-
ment of subclavian aneurism, to refer to the recent case in which Prof.
Warren Stone, of New Orleans, succeeded in curing a traumatic aneur-
ism involving the second division of that artery by distal pressure applied
by the fingers upon its third portion where it crosses the first rib. Its
interest will justify a glance at the details of this unique case, for it not
only illustrates further the value of the distal treatment of aneurism by
ligature, but also that of compression. A healthy man of twenty-five
was wounded, in April, 1874, by a pistol ball which entered immediately
above the left clavicle, near its inner extremity, and passed downwards
and backwards, lodging under the skin at the posterior margin of the
scapula. There was great pain, and partial paralysis of the arms, show-
ing lesion of the brachial plexus of nerves, but only a trifling amount of
hemorrhage. At the end of six weeks an aneurismal tumor the size of
an egg had formed at the cicatrix of the wound, and was steadily in-
creasing. It was attributed to a bruise of the artery at the summit of
its convexity. Digital compression by a relay of competent assistants
was begun on the 15th of June, 1874, and continued for thirty-nine
hours, when the skin began to suffer, and the patient was exhausted.
The tumor was reduced to one half its original size, was much harder,
and feebler in its pulsations. It continued to diminish and to grow
harder from month to month. About the middle of March, 1875, all
pulsation had disappeared, and up to the present date it has not returned.
The tumor is now as hard as a marble, and quite as small."
This is the only recorded case I have been able to find in which a
subclavian aneurism has been cured by distal pressure.
Since the Dublin surgeons re-introduced compression as a remedy for
aneurism, and established its value on a permanent basis, it has steadily
point, produced a fatal result in the fifth week. At the post-mortem examination the
aneurismal tumor, which sprang from the aortic arch by a narrow opening, was found filled
entirely by a “solid mass of coagulated fibrin.” The “constrictor” had obliterated the
carotid successfully, and the wound had closed perfectly by quick union. See Archives of
Clinical Surgery, New York, Sept. 1876, p. 96.
' A case of traumatic aneurism of the left subclavian artery treated successfully by distal
compression, by Warren Stone, M.D., Professor of Surgical Anatomy, Charity Hospital
Med. Coll., New Orleans, from the New Orleans Medical and Surgical Journal, July, 1875.
In a private note, under date of May, 1876, Dr. Stone kindly adds the following details to
the published case : “I examined the patient a few weeks ago in company with my friend
Dr. Choppin. We found a mere remnant of the tumor, with not a particle of pulsation in
it. But there was evidence that blood had found its way through the main trunk of the
artery (probably by way of the subscapularis), for, by pressing it against the first rib,
radial pulsation was arrested, as on the other side of the body.” Dr. Stone also adds this
interesting fact, since published by Dr. S.: “In Dr. Smyth's successful case of ligature of
the innominata—which was also traumatic in its origin—notwithstanding all direct current
was cut off, as well as the distal flow through the carotid and vertebral, the sac eventually
filled again (taking ten years it is true), suppurated, bled, and caused the patient's death.
Post-mortem examination showed that it was principally supplied by the subscapular
branch of the axillary.”
TREAT M B N T OF A N E U R IS M. 555
advanced in the favor of the profession, and has attained new methods and
a wider range of application. At first the process was slow, intermittent,
painful, accomplished only by mechanical contrivances, and uncertain in
its results. Now, thanks to our countryman, Knight, of New Haven,
and to the Italian surgeon, Vanzetti, who have taught us the advantage of
accurate compression by the fingers, and thanks also to the American
discovery of anaesthetics, we are often able to cure aneurism by compres-
sion in a few hours. The method has been extended from the femoral,
to which it was at first confined, to the largest arteries; where the liga-
ture has failed, it has succeeded ; an aneurism of the abdominal aorta has
been cured in five hours by compression applied to that vessel; another
in ten and a half hours; and an iliac aneurism in five hours of aortic
compression—all under anaesthetic influence." The fatal case of Mr.
Bryant, of St. Bartholomew’s, of rapid aortic compression, in which the
patient died of peritonitis,” and a similar case of Mr. Maunder, at the
London Hospital, in which death occurred suddenly at the fourth hour,
apparently from the effects of chloroform,” warn us as to the direction
in which danger lies. Nevertheless, Mr. Holt has cured an abdominal
aneurism at the Westminster Hospital, London, after fifty-two hours’
pressure under chloroform.”
At first employed only indirectly upon the artery between the aneurism
and the heart, compression has also been applied with advantage directly
to the aneurismal tumor, as in a successful case of subclavian aneurism,
recorded by Mr. Poland,” and another of femoral aneurism, cured by Dr.
Buckminster Brown, of Boston.” In a solitary instance a subclavian
aneurism has been cured by digital compression applied to the artery on
the distal aspect of the tumor—the case of Prof. Stone, already cited ;
and, in not a few instances, both indirect and direct pressure have been
used conjointly in the same case.
Perhaps the most remarkable cure of subclavian aneurism by pressure,
is the case published last year by Dr. Tiffin Sinks, of Leavenworth, Kansas.
A pistol ball at close range perforated and comminuted the clavicle,
and, according to the best judgment of the surgeon, entirely divided the
subclavian artery at the commencement of its third portion. The pro-
fuse discharge of arterial blood which the surgeon, who was present, saw
welling up in a column of three-eighths of an inch in diameter to the
perpendicular height of an inch, caused profound and death-like syn-
cope; but the patient, a robust man of forty-six, unexpectedly rallied,
and had no return of bleeding. The cylindrical opening through the
bone, with its projecting spiculae, seemed to have fixed the clot which
formed during the syncope so firmly that it acted like a stopper, and the
result was the formation of a circumscribed aneurism at the seat of
injury. Although the pleural cavity slowly filled afterwards in conse-
quence of internal leakage, showing that it also had been opened by the
bullet, this ceased after a few days, and the pleural effusion was slowly
* An account of a case of aneurism of the abdominal aorta, which was cured by com-
pression of that artery immediately above the tumor; by Wm. Murray, M.D., etc., Phys. to
the Dispensary, Newcastle-on-Tyne, and Lecturer on Physiology, etc., Med. Chir. Trans.,
vol. xlvii. Mr. Moxon cured a case in ten and a half hours, using Lister's acrtic compres-
sor under chloroform. Med. Chir. Trans., vol. lv., 1872. Mr. Claudius G. Wheelhouse
cured an aneurism of the external iliac by Lister's instrument applied to the aorta, in five
hours, under ether. Trans. Clin. Soc., vol. vii., 1874.
* Holmes's Lectures, ut supra. * Surgery of the Arteries, ut supra, p. 11.
* Trans. Clin. Soc., vol. vii. p. 56. * Med. Chir. Trans., vol. lii. p. 277.
* Boston Med. and Surg. Journ., Oct. 21, 1875.
556 VAN BUREN,
absorbed. The compound fracture went on to consolidate, and, strangely
enough, the external wound closed entirely without any suppuration,
which is ascribed to the fact that no compresses or plugs were at any
time applied to it. Eventually a time came when diminution of the
general swelling allowed pressure to be applied to the artery just at the
outer border of the scalenus, by which the pulsation of the aneurism
could be controlled. By the judicious use, at first of intermittent and
later of permanent pressure at this point, conjoined with temporary
pressure by a mass of lead modelled from a plaster cast of the parts, ap-
plied to the tumor itself, all swelling and bruit finally disappeared, so
that at the end of three months the patient was able to take a trip to
New York on business."
In the form of acupressure—by needles, or by metallic wire, what Dr.
Pirrie, of Aberdeen, styles “metallic pressure, removable at pleasure”—
this remedy of systematic pressure has been subjected to various modifi-
cations for the purpose of curing aneurism. In one form it has been ap-
plied successfully as a wire compress to the carotid, and again, to the
femoral, by Mr. Dix, of Hull, England.” Mr. George H. Porter, of Dublin,
laid bare the innominata, and compressed it by an instrument of wire
resembling a miniature lithotrite, hoping to obliterate the calibre of the
artery without dividing its coats; but they ulcerated under the chafing
and pressure, and the patient bled to death. I have seen the preparation
from this case, and also the instrument. With the latter in a modified
form, Mr. Robert Perssé White, of the Meath Hospital, has since cured
an inguinal aneurism by compressing the external iliac.” Mr. W. Stokes,
of the Richmond Hospital, has also applied Mr. Porter's instrument, as
perfected by himself, to the abdominal aorta so effectually as to stop ac-
curately the current of blood through that great vessel without injury
to its coats, but the patient perished from shock and incipient peritomitis.”
Mr. Bickersteth, of Liverpool, has also failed in an attempt to obliterate
the innominata by means of an apparatus of lead wire and caoutchouc.”
The so-styled “constricting ligature” of our countryman, Dr. B. Howard,
in which a loop of silver wire is applied around an artery so loosely as
not to cut through its coats, may also be regarded as a variety of “me-
tallic compression.” It is not removable at will, for the wound is closed
over it as for quick union, with the belief—founded on experiment—that
the little loop will be tolerated by the tissues, and become encysted, and
that the inclosed vessel, which is not so tightly constricted as to cause ul-
ceration of its coats, will nevertheless become permanently obliterated."
* Medical Herald, Leavenworth, Kansas, Aug. 1875, p. 15.
* Two cases of aneurism, one of the carotid, and one of the femoral artery, treated by
the wire compress, by J. Dix, M.R.C.S., etc. etc., in Brit. Med. Journ., August 28, 1875.
Mr. Dix cuts down upon the artery, and introduces a strand of flexible iron wire beneath
it in the usual way by the aneurism needles. Each end of the wire is then threaded to an
ordinary needle, and brought out through the tissues by the side of, but clear of, the wound,
which is then closed entirely as for healing by first intention. A piece of cork is then
placed between the two points of emergence of the wire, and pressed down firmly upon the
artery, and over this cork the wire is tightly twisted until the circulation is stopped. At
the end of six or seven days the wire is withdrawn.
* Dublin Medical Press, November 24, 1875, p. 428. In this case, the artery is stated to
have been compressed one hundred and sixty-two hours, and yet there was no ulceration nor
hemorrhage.
* Dublin Quarterly Journ. Med. Sci., August, 1869.
* Holmes's Lectures, ut supra.
* An Essay on the treatment of Aneurism by a new method, with experiments upon the
closure of arteries. By Benj. Howard, M.D., late Prof. of Clinical Surgery, etc., from
Transactions of Amer. Med. Association, 1870.
TRE ATM E N T OF A N E U R IS M . 557
Dr. S. Fleet Speir, of New York, has also devised an ingenious artery
compressor which can be applied upon the continuity of an artery, so as
to divide the middle and inner coats, and then to invaginate the external
coat of the artery within the tube of the constricting instrument to a
sufficient extent to roll up the two inner arterial tunics into an impass-
able barrier equally efficient with that produced by the method of tor-
sion. After this, the instrument is withdrawn, and the wound closed.
This ingenious device has been successfully applied to the carotid three
times, to the femoral and the brachial, each, once; in each instance it has
caused obliteration of the artery, and, as Dr. Speir informs me, has in
four cases caused a cure of aneurism."
On the whole, the results of compression by metallic wire have not
been very satisfactory in any of its modes of application, so that, at the
time he wrote, Mr. Holmes felt justified in asserting that, for his part,
whether Mr. Lister be right or no in saying that, with the carbolized
catgut ligature properly applied, the ligature of the innominata will be
found a safe proceeding, he, Holmes, would much prefer tying that vessel
on this method to making any attempt at acupressure.” But, although
he alludes to a case in which he used a wire ligature successfully, Mr.
Holmes does not mention B. Howard’s method.” In my judgment, we
cannot afford to ignore this method of employing silver wire, for, in
case the carbolized catgut ligature should in the end prove unreliable, it
seems to me that Howard's suggestion, and the invaginating constrictor
of Speir, hold out the best remaining promise of occluding an artery
without dividing its coats.
But the most interesting case of metallic compression has occurred
since the date of Holmes’s lecture : it is that in which Mr. Arthur Fer-
guson McGill, of Leeds, succeeded in consolidating an aneurism of the
left subclavian artery by means of a pair of ordinary artery forceps
applied to its first division for ten hours. Unfortunately, in consequence
of the anomalous position of the vessel, the pleura was wounded, and
through this accident he lost his patient." In this case the efficacy of
* See Arch. Clin. Surg., ut supra, pp. 96, 106, and 115; also New York Med. Journ.,
vol. xv., 1872, p. 175, “Successful application of Dr. Speir's artery-constrictor,” by Dr.
Chas. A. Hart; New York Med. Record, March 1, 1873, p. 102, and March 15, 1873,
“The artery-constrictor, with cases, by Dr. Speir.”
* Holmes's Lectures, etc., ut supra.
* Holmes says of this case, in which he tied the femoral artery for popliteal aneurism
with silver wire, that it was “thoroughly satisfactory,” the wound healing, though not
without suppuration, in less than a fortnight. Nothing was seen of the ligature; and he
believes that it “buried itself in the tissues of the vessel, and in all probability without
having divided the continuity of the latter;” Lect. iii., Part i., 1st series, June, 1872.
He also speaks of an experiment upon an ass, in which the carotid was obliterated and not
divided, and adds a caution about not tying the wire too lightly, lest it cause ulceration.
* A case of left subclavian aneurism, treated by temporary compression applied directly
to the artery in the first part of its course, with remarks; by Arthur Fergusson McGill,
F.R.C.S., surgeon to the Leeds Public Dispensary, Med.-Chir. Trans., vol. lviii. p. 338,
London, 1876. A woman of 35, with a left subclavian aneurism, had already been very
decidedly benefited by four applications of galvanic needles, but she had resumed a laborious
occupation and the tumor began to grow again, and the pain of the shoulder and arm
which had been relieved by the galvano-puncture returned. The tumor had extended above
the clavicle into the neck, and was approaching the surface. She was too poor to spare
the time to try Tufnell's medical treatment, and refused amputation of the shoulder, which
had been proposed in consequence of its partial success in Mr. Spence's case. Mr. McGill
had no confidence in the distal ligature without amputation, and makes no mention of distal
compression. He, therefore, proceeded to cut down upon the artery in the usual way, failed
to find it in its usual place on following down the inner border of the scalenus anticus, but
discovered it after a tedious search at the depth of his finger, “apparently through a layer
558 VAN BUREN,
rapid pressure by a metallic substance applied directly upon an artery is
indisputable, for the subclavian, in its first portion, was certainly oblite-
rated without division of its coats, and, therefore, without danger of
subsequent hemorrhage; and it may be fairly assumed that the aneurism
would have been permanently cured, but for the fatal wound of the
leura.
p This brings us to consider the propriety of attempting the ligature of
the left subclavian in the first part of its course. Holmes briefly passes
it over as an operation not likely to be again undertaken on account of
its great difficulty, the danger of wounding the pleura, and, perhaps,
because Sir Astley Cooper once relinquished an attempt to tie this artery
through fear of wounding the thoracic duct. But Rodgers accomplished
the ligature of the artery at the New York Hospital safely, without
wounding either thoracic duct or pleura. Unfortunately, his ligature of
silk cut through the walls of the artery, and his patient died in the third
week from secondary hemorrhage. McGill, hoping to obliterate the
artery by employing metallic compression in place of the silken thread,
and thus to surmount this danger, felt justified in repeating the opera-
tion ; and he succeeded in his object of safely obliterating the artery and
avoiding the danger of hemorrhage; but, less fortunate than Rodgers, the
anomalous position of the vessel led to the perforation of the pleura, and
this accident caused the death of his patient.
Now, is the danger of wounding the pleura in this operation so unsur-
mountable as to forbid its repetition ? This question must be answered,
for if, in the future, it becomes certain that we may trust the carbolized
catgut ligature (or even Howard’s constricting loop of silver wire) to
safely obliterate an artery without dividing its coats, then the risk
incurred in laying bare the left subclavian would be the only remaining
obstacle to its successful ligature. I feel confident that others will under-
take this operation, under the lead of Rodgers, as McGill has done; and
as neither of these excellent surgeons had any trouble from the thoracic
duct, we have only the danger of wounding the pleura to provide against,
and the other intrinsic difficulties of the operation.
My late valued friend, Dr. Charles E. Isaacs, after Dr. Rodgers's opera-
tion in 1845, “in order to improve our knowledge as to the relations of
the pleura to the parts at the root of the neck,” examined in a series of
years no less than one hundred dead bodies most carefully in reference
to this point of anatomy. He found that the pleura rises higher above
the clavicle than is usually recognized by anatomists, averaging in his
100 cases nearly an inch and a half at its highest point, whilst in 23 out
of the 100 it rose to two inches and upwards; and that both subclavians
within the scaleni muscles are in contact throughout their whole length
with the pleurae. The reason why the pleura has not been more fre-
of pleura” which, in passing the needle around the vessel, was perforated. He then effected
compression of the artery by means of a pair of ordinary torsion forceps, stopping effectu-
ally all pulsation in the tumor, and closed the wound. Three hours later the pulse was
130; respiration 44; and the air was rushing in and out through the wound as she breathed;
but the artery was effectually compressed, and when, ten hours after its application, the
compressing forceps was withdrawn in consequence of the patient's feeble condition, so that
the wound could be entirely closed, the tumor was solid and pulseless. She died on the
sixth day from intra-thoracic inflammation, just as death occurs from a perforating chest
wound. The pleura contained a pint of bloody serum. The aneurism was filled with a
hard firm clot; in fact it was cured. “The artery had been compressed just before the
origin of the vertebral; it was patent, and in a perfectly healthy condition.” (p. 341.)
T R E A T M E N T OF A N E U R IS M . 559
quently wounded in tying the right subclavian in its first division is, he
thinks, because the vessel is nearer the surface, and can usually be
seen."
Now, the surgeon, as he approaches the first division of the left sub-
clavian from above and in front, as it rises almost perpendicularly from
the aorta to arch over the dome of the pleura, unless he fully recognizes
the facts brought out by Isaacs, and systematically pushes the serous
membrane out of his way, just as we are compelled to raise the peritoneum
in approaching the primitive iliac, must incur great risk of perforating
it ; but an accurate anatomist, keeping these relations of the pleura
always in view, may, as Rodgers did, accomplish the operation safely.
In cases where an aneurism is seated near a joint, so that its pulsation
can be arrested by maintaining the limb in a flexed position, this simple
device continues to be successfully employed, as another variety of com-
pression, under the designation of “the method by flexion,” or “posi-
tion.” It has been used most frequently at the knee-joint for popliteal
aneurism, but Dr. Gurdon Buck, at the New York Hospital, extended
its application to a case of inguinal aneurism which he cured by flexing
the thigh upon the pelvis. This was a case of relapse, such as is liable
to occur in this region, the aneurism having returned sixteen months
after a cure by compression. Pressure upon the external iliac did not
arrest the returned pulsation; the vessel in fact had been obliterated.
Its ligature, therefore, was out of the question, and the old operation
seemed to be the only alternative, as in the similar case of Mr. Annan-
dale already mentioned. Buck had observed, however, that extreme
flexion of the thigh arrested the pulsation in the tumor, and he decided
to employ this method. In about a fortnight solidification was nearly
complete, and an entire cure shortly followed.” In a case of femoral
aneurism treated first by compression, without result, and finally by liga-
ture of the external iliac, Dr. Gay, amongst other devices to arrest the
circulation, tried flexion of the thigh upon the abdomen, which controlled
it completely ; but it was abandoned in six hours on account of the pain.
The parts had become tender under the previous digital and instrumental
* Isaacs, “on the extent of the pleura above the clavicle,” in Transactions of the New
York Academy of Medicine, vol. ii., part i., New York, 1857. Isaacs ascertained that in
100 subjects the pleura averaged 1.42 inches above the upper margin of the clavicle on the
right side, and 1.23 on the left. It averaged higher in the male than in the female—1.53 to
1.40. In 23 cases it rose to two inches and upwards above the clavicle, and there were only
5 out of the 100 in which the pleura did not project above its superior margin. The sternal
or internal aspect of the pleura of the right side extended across, even to the left of the
median line, in 11 cases, from half an inch to an inch and a quarter. A similar disposition
of the parts was never observed on the left side. The pleura rises higher in long-necked
people; in bull-necked subjects the reverse is the case. In the 23 cases in which the pleura
rose two inches above the clavicle, 14 were on the right, 5 on the left, and 4 only on both
sides. In these cases the subclavian was high in the neck, and in many of them this
artery in the third part of its course rested upon the pleura for a very considerable extent.
He asks if the symptoms of wound of pleura and collapse of lung in operations at the root
of the neck have not been falsely attributed, in some cases, to entrance of air into the
veins? Erichsen states that thoracic inflammation was the cause of death in 9 out of 22
cases of extra-scalene ligature of the subsclavian arteries, and that it was not the pneu-
monia which so often follows great operations, but inflammation attacking the pleura and
pericardium in preference to the substance of the lungs, looking as though the complication
arose from causes essentially connected with the disease or operation. Isaacs thinks that
one of these causes is probably the unrecognized proximity of the pleura, which he shows
exists in one case out of every four. He also speaks of “ the curious fact that the top of
the pleural sac is not always dome-shaped, but sometimes forms cul-de-sacs extending
upwards, and sometimes laterally into the recesses at the root of the neck.” (p. 18.)
* Amer. Journ. Med. Sciences, January, 1870, p. 69.
560 VAN BUREN,
pressure." In the case of a Japanese of 40, who was too fat for compres-
sion of the external iliac, and unwilling to submit to ligature, Dr. Stuart
Eldridge, of Yokohama, succeeded in curing an inguinal aneurism by
this method. He devised an apparatus consisting of a jacket and thigh-
sheath connected by copper wire, in which the thigh was kept flexed on
the pelvis for twenty days, at the end of which time pulsation had per-
manently ceased. The patient was seen six months later, and there was
no return of the disease.” Dr. Edward T. Caswell, of Providence, R. I.,
reports a case of double popliteal aneurism in which genuflexion short
of completely arresting the circulation cured both tumors. At the end
of six weeks, during which time the man had resumed work, one of the
tumors suddenly returned (evidently by rupture), and, after failing with
ordinary compression, it was necessary to tie the femoral. There was
subsequent suppuration, and discharge of clots.” In April of the same
year Dr. Montgomery cured a traumatic aneurism at the bend of the arm
by simple forced flexion of the forearm upon the arm for twenty-four
hours.”
From these facts we may infer that this method is still in favor, and
certainly gaining in extent of application, for heretofore it has been con-
fined to aneurisms at the knee and elbow; and also that, when tried, it
should precede compression by ordinary means, which are liable to leave
the parts tender. It is well to remember, also, that Theodore Maunoir,
of Geneva, who reported the first case of cure by the method of flexion,
in 1858, demonstrated that the position need not be forced or painful,
but that, as in ordinary compression, a very moderate obstruction to the
circulation may effect a cure.”
To conclude the subject of pressure, it is evident that digital compres-
sion is steadily gaining ground and taking the place, wherever it is
applicable, of pressure by means of mechanical appliances; and also that
the process known as “rapid compression,” under anaesthetics and ano-
dynes, is increasing in favor.
Still, we must not forget that the old method by moderate and inter-
mittent pressure has also from time to time effected striking cures, and
these in localities—as, for example, upon the primitive carotid—where
it cannot be safely replaced by more permanent or rapid pressure. The
following cases of orbital aneurism are in point: that of Galezowsky,
who cured a traumatic case in an adult female by digital compression
applied to the carotid, for an hour or so every day at first, and afterwards
at longer intervals, for several months." In Scaramuzza's case of idio-
pathic orbital aneurism a cure followed digital compression, employed
very cautiously on account of aortic disease, for not more than five
minutes at a time, and afterwards for eighteen days, twenty or thirty
minutes every day in five or six turns—the total period of compression
being only seven hours and twenty minutes.”
I have noticed amongst hospital surgeons of experience a tendency to
allow intelligent patients to manage pressure for themselves, by means
of bags of shot, or of sand, or by a mass of lead modelled to the part, and
gradually increased in weight. At St. Thomas's Hospital, in London, I
saw a man in Mr. McCormac's ward with a subclavio-axillary aneurism,
who was successfully controlling its pulsations by a buckskin bag of shot,
| Amer. Journ. Med. Sciences, January, 1875. 2 Ibid.
* Ilid., October, 1875, p. 444. * Ibid., April, 1875.
* L'Echo Médicale, Neufchatel, Switzerland, September, 1858.
* Gazette des Hôpitaux, 1871, p. 237. 7 Archives Générales, 1858, t. xii. p. 731.
TRE ATM E N T OF A N E U RIS M. 561
to which he had given a peculiar shape; and Prof. Tilanus, at the princi-
pal hospital of Amsterdam, showed me a weight of three kilogrammes,
by which, he said, several cases had been treated in this way.
If time permitted, the subject of orbital aneurism might occupy us pro-
fitably. Mr. Rivington, of the London Hospital, has lately made a very
thorough study of this curious and obscure affection in connection with
a case which he finally cured by ligature of the carotid." Dr. Morton,
of the Pennsylvania Hospital, by his unusually rich experience, has also
added to our knowledge of this subject. His last published case illus-
trates the great difficulty that often attends its diagnosis—already shown
in the cases recorded by Bowman,” and by Aubrey, of Rennes,” in both of
which, with unmistakable symptoms of aneurism—such as pulsation,
bruit, and protrusion of the eyeball——no arterial lesion whatever was
found after death. In Dr. Morton’s case, with all the characteristic
symptoms of orbital aneurism, except pulsation in the protruded globe,
symptoms sufficient to warrant the diagnosis of aneurism of the internal
carotid in the cavernous sinus, and ligature of the carotid, no trace of
aneurismal disease was found after death on the day following the opera-
tion." It is to be noted that in each of these cases ligature of the carotid
produced immediate relief of the symptoms.
Mr. Holmes, as usual, discusses this subject ably in his lectures." In
view of the great uncertainty of diagnosis, and the possibility also of a
spontaneous cure—such as took place in the cases recorded by France,”
Collard, of Berne," Erichsen,” and I may add also a more recently reported
case of Mr. Jonathan Hutchinson,” together with the admitted dangers
of the operation, he urges delay in resorting to ligature of the carotid.
At the same time, whilst reasoning against it, Holmes speaks of the ope-
ration in this affection, in his Surgery, as “a most successful one ;” and
it is noteworthy that the delay which he advised in Rivington's case led
to more loss of vision, and that the ligature was resorted to, of necessity,
in the end.
In a still more recent case of Dr. Greuning, of New York, diagnosti-
cated as aneurism of the internal carotid in the cavernous sinus, the
operation was promptly and entirely successful."
Mr. Rivington arrives at the conclusion, derived from his very com-
plete collection of cases, that “ligature of the carotid is, beyond question,
' A Case of Pulsating Tumour of the Left Orbit consequent upon a fracture of the base of
the skull, cured by ligature of the left common carotid subsequently to injection of perchlo-
ride of iron, after digital compression and other means of treatment had failed; with
remarks, and an appendix containing a chronological résumé of recorded cases of intra-
orbital aneurism. By Walter Rivington, etc. etc., Surgeon to the London Hospital. Read
March 3, 1875, published in Med. Chirurg. Trans., vol. lviii. p. 183.
* Ophthalmic Hospital Reports, April, 1859. * Gazette des Hôpitaux, 1864.
* Amer. Journ. Med. Sci., April, 1876, p. 339.
* Op. cit., June, 1873, 3d Lect., 2d series.
* Guy's Hospital Reports, 3d Series, vol. i., 1853, p. 58.
7 Gazette Médicale, 1866, p. 631.
* Science and Art of Surgery. Phila., 1873, vol. ii. p. 108.
* A pouched aneurism of the internal carotid as large as a bantam's egg was found at
the post-mortem examination of a woman of forty, who had died of aneurism of the ab–
dominal aorta. Ten years before, Mr. Hutchinson had seen her with ptosis of the eyelid.
of this side, dim vision, paralysis of the ocular muscles, except the superior oblique, intra-
cranial bruit, throbbing, and bad headaches. He had diagnosticated intra-cranial aneurism,
and advised ligature of the carotid, but had been overruled, and spontaneous cure followed.
British Med. Journ., April 17, 1875.
1° Archives of Ophthalmology and Otology, vol. v. No. 1, p. 40.
36
562 VAN BUREN,
the means most generally applicable to cases of intra-orbital aneurism
dependent on morbid states of the arteries.” His cases give forty-six
instances of ligature of the carotid in forty-four cases (two being double),
and six deaths." With such experience, ligature of the carotid in orbital
aneurism will continue to be employed, even though in some degree
empirically.
I may record the fact that our countryman, Dr. McGill, of Maryland,
was the first to tie both carotids in this disease.” Erichsen places his
name second on his list of double ligatures of the carotid, for all causes.
Dr. Foote, of Cincinnati, also tied both carotids at the same interval of a
month, arresting a traumatic orbital aneurism at the second ligature.”
It is proper to observe, in concluding my remarks under this head, that
ligature of the primitive carotid for aneurism other than orbital, has proved
a very fatal operation, mainly through embolism and interference with
the blood-supply of the brain, probably less than half the cases on record
having been successful.” The evidences, therefore, in favor of compression
of this vessel, collected by Mr. Holmes, carry great weight. Of his seven
cases, five were cured; and in the two in which compression did not suc-
ceed, the ligature also failed.”
Galvano-puncture, as a method of treatment for aneurism, can hardly
be said to be gaining rapidly in the confidence of the profession, perhaps
mainly on account of the intrinsic difficulties which attend the process;
but, as has been truly said, it occupies at the present time a more pro-
mising position than did compression in the days of Guthrie, who did
not hesitate to speak almost contemptuously of the pretensions of the
latter. The promise held out by the relief of pain and the arrest of pul-
sation, which so often follow an electrolytic operation, is not fulfilled
with certainty; for after a short interval the pulsation almost always
returns. This disappointing result seems to be due to the softness and
friability of the resultant clot, which is broken and wasted away by the
arterial current. We have learned, however, that this soft clot possesses
| Of these 44 cases, 25 were cured—one after subsequent injections (case of Brainard of
Chicago; Lancet, 1853, p. 162, vol. ii.), 7 received partial benefit, 5 were unsuccessful,
and 6 died. Two of these deaths were in patients over sixty years of age, and two others
(cases of Critchett and Pétrequin), in patients who survived several weeks, and died event-
ually from other causes, are not chargeable to the operation.
* In a letter to the late Dr. J. Kearney Rodgers, of New York, from Dr. Joshua J. Cohen,
of Baltimore (in the N. Y. Med. and Phys. Journ., Sept. 1825, p. 576), it is stated that in
this case “an ugly, confused mass protruded beyond the sockets of both eyes,” and was
increasing every day. The operations were done at an interval of about a month. Dr.
McG. found the effect of tying one carotid to be limited to one tumor, and ventured upon
the bold attempt (in which he had but one precedent, and probably was not aware of that)
of arresting the progress of the other by tying the remaining carotid. Several months after
the last operation the patient was doing well, and the tumors subsiding. At this early
date there were no recorded examples of successful ligature of the carotid for tumors about
the head except the cases of Travers (1809), and Dalrymple (1812), in both of which the
disease was supposed to be “aneurism by anastomosis.” Doubtless Dr. McGill regarded
his case as of the same nature. Cases of soft cancer protruding from both eyes, and doing
well some months after ligature of both carotids, are not of probable occurrence, whilst
double aneurism has existed in several instances.
Since the above was written, I have seen a note from Dr. Charles McGill, of Richmond,
Va., dated June 9, 1876, in which he writes as follows: “ In 1823 my brother ligated both
common carotids of a woman in Williamsport, Md., for vascular tumors of the orbits. The
interval between the tying was about four weeks. The operation was successful, and the
woman was still living and in good health in 1861, when I left the State of Maryland.”
8 Reported by Dr. E. Williams, in New York Med. Record, April, 1868, p. 75.
* Maunder, ut supra, p. 44, and Le Fort, Gazette Hebdomadaire, 1868, Nos. 28, 30, 35.
5. Op. cit., Lect. ii., second series, June, 1873.
TRE AT MENT OF A N E U RIS M. 563
neither noxious nor irritating qualities, so that the operation, which is
better done under an anaesthetic, may be repeated indefinitely.
We owe to Dr. John Duncan, of Edinburgh, the knowledge that in-
flammation of the sac, the principal danger that attends the process, is
not to be feared if there is no cauterizing effect produced by the needles,
and that this can be certainly avoided if they are effectually insulated
by a coating of vulcanite—a device introduced and perfected by Dr.
Fraser and himself. “I have never met with the slightest reaction,” says
Duncan, “when using insulated needles; and in one case I continued
the operation for two hours and ten minutes.”
This being the case, the eschars and fatal hemorrhages, and inflamma-
tion and suppuration of the sac, which complicated some of the earlier
cases of galvano-puncture, can be now surely escaped, and we have only
the uncertainty of the result to contend against.”
The plan of operating which experience seems to point out as the best,
is to insert both the positive and negative needles, thoroughly insulated
by means of vulcanite, into the sac; to employ a battery of large electro-
motor force; to prolong the operation so that the sac may be occupied as
fully as possible by clot; and, finally, to repeat the application as soon as
improvement shall have distinctly ceased.
Perhaps the best idea of the value of the electrolytic treatment can be
got from Holmes's abstract of the cases of Ciniselli, of Cremona, who has
employed it more largely than any other surgeon. In these, twelve in
number, there were two relapses after many months of good health, one
of which was permantly cured by repetition of the operation, and three
other cases in which a cure had been maintained for still longer periods
at the time of the report. Of the eight cases which were not benefited, in
only one was death caused by the direct action of the electricity, and no
harm seems to have followed its use in the others.” Abeille cured a case
of subclavian aneurism in a woman, having kept a weight of one
kilogramme upon the tumor for ten hours after the application of the
needles.”
The great point in favor of this method is that it may be applied to
thoracic and abdominal aneurisms where other surgical remedies are
powerless, in combination, for example, with Tufnell’s medical treatment.
In thoracic aneurism, both Ciniselli and Duncan have certainly succeeded
in averting imminent death from hemorrhage where the tumor was
already projecting beyond the ribs.” In abdominal aneurism no success
has been as yet attained. In Keyes's case the manoeuvre was accomplished
safely, but without apparent result beyond relief of pain." In Dell’
* Lectures on Electrolysis, by John Duncan, M.D., etc., Assistant Surgeon to the Royal
Infirmary, Edinburgh, Lecturer on Surgery, etc.; British Medical Journal, June 28, 1876,
. 621.
P., See the case of Pétrequin (Journal de Chirurgie de Malgaigne, t. iv. p. 246, 1840),
and another case in Broca (sur les Anévrysmes, etc., Paris, 1856, p. 342), in which the
needles, uninsulated, were applied seven times in one week for an aneurism under the
jaw; there was no consolidation, but inflammation and suppuration followed, with secondary
hemorrhage, necessitating ligature of the carotid, and free opening of the sac, and other
measures to stop the bleeding.
* It is proper to note that Ciniselli's mode of operating is probably more liable to irritate
and inflame the sac than when insulation by vulcanite is employed.
* Archives Générales, t. xx. p. 49, 1849.
* Lectures, etc., ut supra.
* New York Med. Journ., December, 1871, p. 569. Keyes demonstrated, however, that
eleven needles could be passed through several layers of peritoneum and convey the current
from thirty-two cells (of a Stohrer's battery) without causing inflammation. His needles
were insulated by vulcanite.
564 v AN BUREN,
Acqua's case the aneurism burst during the struggles of the patient
under chloroform, and he died on the table." McGill reported a case of
subclavian aneurism as greatly benefited after four operations, manipu-
lation having been also employed conjointly with electrolysis after the
last application. Dut relapse took place, and nine months later the
woman was subjected to the operation on the left subclavian already
reported.”
As to galvano-puncture in external aneurisms, Ciniselli cured a popli-
teal case in 1846—the second recorded example of success by electrolytic
treatment, Pétrequin, of Lyons, having cured a small aneurism of the
temporal artery the year before.
|Broca, in external aneurisms, recommends direct moderate pressure to
be applied immediately after the withdrawal of the needles, with the
view of its effect upon the tumor in the way of malaxation, or manipula-
tion, as it was employed, in fact, in Abeille's successful case of subclavian
aneurism ; and this seems to me an excellent practical suggestion. An
Esmarch's bandage for example would really offer the best means of
effecting distal pressure (which in the leg and forearm is not easy to ac-
complish) during the operation, and, if it were afterwards carried up-
wards over the whole limb including the tumor, it might materially
assist in preventing the liability to washing away of the clot.
Dr. Duncan says, in his summary of conclusions, that “in external
aneurisms electrolysis should be tried, if compression be not available, or
have failed ; and it is to be preferred to the ligature—at least of the in-
nominate and iliac arteries.” -
In his address on Surgery before the British Medical Association, in
August, 1875, Prof. Spence, of the University of Edinburgh, stated that
his colleague Dr. Duncan had had successful results in treating large
cirsoid aneurisms by electrolysis. There is additional evidence on this
point in Dr. Duncan’s lecture since published.” It is also very generally
conceded that for most forms of aneurism by anastomosis, and erectile
tumors, electrolytic treatment offers, at the present time, greater advan-
tages than any method of treatment in use.
Manipulation, one of the bloodless methods of treating aneurism, with
which the name of Sir William Fergusson is principally connected,”
has not yet achieved credit for the success which it seems to promise
and to deserve. According to Holmes, this method has been practised
in five cases of subclavian aneurism, and in two of aneurism of the
lower extremity, “with clear evidence of cure in two, and a good
advance towards cure in another,” and no certain proof of injury to the
sac, which is the great danger of the proceeding, in any case.” This
surgeon has proved by carefully studied preparations and cases that
| Gazetta Medica Italiana, Lombardia, No. 28, 1870, p. 217.
* My colleague Dr. Sands, with the aid of Dr. Guleke, attempted to arrest the progress
of a traumatic subclavian aneurism in a young man of nineteen, at the N. Y. Hospital, in
March, 1869. He made four electrolytic operations of fifteen minutes each, following
Ciniselli's method mainly. The tumor became momentarily firmer, but it continued to
enlarge, and finally burst. (Thesis of Dr. Allan McLane Hamilton, New York, 1870.)
* British Med. Journ., August, 1875, p. 189. In the same Journal, June 10, 1876, p.
715, Dr. D. says: “There are four recorded cases in which electrolysis has been used in
cirsoid aneurism, and in three the disease has been cured. In a case in which Syme de-
clined to operate, six applications of the battery effected a cure.”
* Med.-Chir. Trans., vol. xl.
* Op. cit. Lect. v. Part i., 1st series, 1872. I do not think that Dr. Lidell's successful case
is among these.
T RE A T M E N T OF A N E U R IS M . 565
impaction of clot in the distal end of the artery as it leaves an aneu-
rismal sac is naturally (not always necessarily) followed by obliteration,
more or less complete, of the sac. The curative effect of the distal liga-
ture is thus explained, and also that of the method we call manipula-
tion. By the latter proceeding a portion of clot is intentionally and by
violence detached from the internal wall of the aneurismal sac, and
pushed by the fingers, or carried by the current, into its distal outlet, so
as to plug it like an embolus. A large proportion of the cases in which
aneurism is said to undergo spontaneous cure are doubtless brought
about in this manner, and Sir William Fergusson has wisely recognized
Nature's lead in proposing it as a remedy.
I think that many cases reach their final cure in this manner after the
interference of art, in which the real methodus medemdi is not recognized,
or is referred to some other cause. Take, for example, the cases collected
by Mr. Tufnell, at page 89 et seq. of his excellent “Practical Remarks
on the Treatment of Aneurism by Compression,” published in 1851, in
which, after a certain amount of contraction and hardening of the
tumor, this treatment seemed powerless to arrest pulsation entirely, and
the patients, as the disease had ceased to increase, were sent about their
business. In every such instance in which the patient was followed up,
a final cure was found to have taken place, and it had always occurred
suddenly and after some unusual effort, when a new, painful sensation
would be felt in the tumor, and presently all pulsation would be found
to have ceased. Here, I take it, a fragment of clot had become detached
and plugged the distal outlet of the half-cured aneurism.
This method of cure is only applicable to aneurisms in which a certain
amount of clot has already formed, and of which the walls present, as
yet, no evidence of thinning or softening, so as to endanger rupture by
handling. Dr. Bontecou, of Troy, recently tied the external iliac in a
case of inguinal aneurism, which had been ruptured by the manipulation
of a professional rubber, undertaken for the relief of pain." A prominent
medical man of Dublin caused the rupture of an abdominal aneurism in
his own person. He had known of its existence for ten years, and it had
undergone partial cure. The object of his manipulation was to convince
his attendants that it was a mass of hardened feces, for, when he grasped
the tumor and drew it away from the spine, its pulsations were arrested.
Shortly after they had retired to consult, he was found dying from
internal hemorrhage.” These examples teach us the necessity of caution.
Manipulation of an aneurism of the innominata or of the primitive
carotid might occasion cerebral embolism, and inflammation of the Sac
is always a possible contingency.
It has seemed to me that in one, if not both, of the remarkable cases
of apparently spontaneous cure of subclavian aneurism recorded by the
late J. Mason Warren, of Boston, the violence previously inflicted upon
the tumors was the real means of cure, by causing fragmentation and
distal impaction of organized coagula.” And this is also the most pro-
bable explanation of the success of Staff. Surgeon Reid in the interesting
case of popliteal aneurism in which, after failure of compression by ordi-
nary methods, he effected a cure in fifty minutes by the application of
an Esmarch bandage.” His patient subsequently died within the year of
visceral disease; and, in describing the condition in which he found the
1 New York Med. Journ., 1876, p. 281. * Holmes, ut supra.
* Surgical Observations, etc., Boston, 1867, p. 424. * Lancet, Sept. 25, 1875.
566 VAN BUREN,
cured aneurism, Dr. Reid speaks of the manifest displacement of the
fibrinated laminae which it contained, which laminae were probably due
to the previous attempts at its cure by compression."
I have been able to find no very recent cases in which the use of
coagulating injections has led to satisfactory results, except a case ascribed
to Plagge, of Darmstadt, who cured a traumatic aneurism, just below
Poupart's ligament, by injection of extract of ergot, alcohol, and glyce-
rine, continued daily for three weeks, with an ice-bag applied to the
tumor in the intervals.” The use of ergot is ascribed to Langenbeck,
and the absence of details detracts from the value of the case. In the
case of Dr. Dutoit, of Berne, the cure of an aneurism supposed to be sub-
clavian, in a man of 40, is attributed to fifteen injections of a solution
of ergotin into the tissues immediately over and around the tumor, at
intervals of two or three days. This caused diminution or shrinking of
the tumor, and subsequently indirect digital pressure was employed to
confirm the cure.”
The danger of embolism, of which so many instances have followed the
injection of erectile tumors by the perchloride of iron, has apparently
inspired a fear of using this drug in the sac of an aneurism; whilst its
known escharotic qualities, and the hardness and irritating nature of the
magma of iron and blood-salts with coagulated albumen and blood-cor-
puscles resulting from its use, have deterred surgeons from employing it,
through well-founded apprehension of inflammation in and around the sac.
In the case of Lenoir, after a third injection which, like the previous
ones, was apparently ineffectual, solidification of the tumor took place
unexpectedly, and inflammation forth with developed itself in the sac,
and resulted fatally.” Here coagulating injections failed, but inflamma-
tion caused consolidation of the aneurism, and unhappily also the death
of the patient.
In cases where coagulation by the perchloride has succeeded, the re-
sultant mass takes on an almost calculous hardness, fails to be absorbed,
and either becomes permanently encysted, or excites suppuration to se-
cure its expulsion as a foreign body.
The question is pertinent whether the tissues would tolerate any better
a clot produced by the persulphate of iron.” This substance, which is not
escharotic, has been used by the late Dr. Isaacs, of New York, and also
by Drs. Minor, Hutchison, and Enos, of Brooklyn, with success in in-
jecting varicose veins.” In July of the present year, Dr. J. C. Hutchi-
* Lancet, Aug. 5, 1876. Dr. Reid says in substance that the portion of the cavity of
the aneurism apposite its mouth was occupied by several layers of laminated fibrin.
Some of these were partially separated from the others and approximated towards the
centre, the interspace thus caused being filled by an amorphous, softer, cheesy coagulum.
* Amer. Journ. Med. Sci., April, 1874, from Lond. Med. Record.
* Langenbeck's Archiv, Band. xii. No. 3.
* Broca, op. cit.
* Or subsulphate, as I believe it should be called. I mean the salt of iron which is the
basis of Monsel’s solution.
* I learn from Dr. James M. Minor, and also from Dr. Squibb, of Brooklyn, that in ex-
periments with this salt of iron they have been impressed with its great harmlessness, and
even with its healing properties when in contact with the tissues. Dr. Minor has published
six cases in which it has been used successfully—one, a pulsating (erectile) tumor, and five
cases of varicose veins. See American Medical Times, July 1st, 1860. He employed a
Pravaz syringe, and a solution containing four parts of distilled water to one of the salt,
which, he thinks now, was too strong, as Dr. Jos. C. Hutchison, of Brooklyn, since informs
him that he has used it successfully in a solution of thirty to one, without exciting ulcera-
tion in any case. (Private communication of this date.)
T R. E.A.T MENT OF A N E U R IS M. 567
son, at the Brooklyn (N. Y.) Hospital, injected a large and increasing
aneurism of the abdominal aorta in a sailor of thirty-two, three times, at
intervals of two or three days, with thirty minims of a solution containing
about half a grain of this salt. Death followed within a fortnight with
symptoms of inflammation of the sac (i. e., local tenderness, increased
temperature, 103°, frequent pulse), and subsequent rupture. There was
much stratified fibrine in the sac, apparently recent. (From notes of
case as recorded by house surgeon.)
Brainard, of Chicago, cured an orbital aneurism by injecting a solution
of lactate of iron, after ligature of the carotid had failed; but destructive
inflammation followed." Bourget used the perchloride successfully in
what seems to have been a cirsoid aneurism following injury, in a boy
of twelve, after failure by galvano-puncture.” Desormeaux had similar
success in an adult.* Pétrequin lost a case, but apparently from causes
unconnected with the injection.
Embolism has not occurred in any of the cases of orbital aneurism
treated by coagulating injections.
Broca records his success in the injection of large vascular trunks of
cirsoid aneurism of the scalp, where accurate pressure could be made
upon the vessel on either side of the portion injected."
Our best hope for the future success of the operation of Pravaz would
seem, at present, to depend upon the results of experiments with the
persulphate of iron, in solutions of different strength, in cases where ac-
curate pressure can be made on both the cardiac and distal aspects of the
aneurismal sac. .
Closely allied to the use of coagulating injections as a remedy for aneu-
rism is the idea of inserting foreign material into its cavity in order to pro-
voke, mechanically, the deposit of fibrinous clot. The earlier attempts in
this direction, inaugurated by Moore, of Middlesex Hospital,” London,
who employed fine iron wire, and whose example was followed by Domville
and Murray, failed in each instance, because the wire produced inflam-
mation of the sac—a result which was no doubt anticipated. Dr. Levis,
of Philadelphia, ingeniously substituted an animal substance for the
more rigid and irritating metallic wire, and inserted twenty-four feet
nine inches of horsehair through a fine needle canula into a subclavian
aneurism, in a man of twenty-seven, at the Pennsylvania Hospital in
October, 1873. The tumor became hard, and the pulsation in it and in
the radial artery, ceased at once. The man died during the month from
internal hemorrhage, when it was discovered that the sac of the aneur-
ism had already ruptured previous to the operation, and that a part at
least of the walls of the cavity into which the horsehairs had been
inserted was formed of lung tissue. Notwithstanding this untoward
condition, their presence had caused the formation of hard clot, and ob-
structed the flow of blood into the axillary artery, solidifying the portion
of the tumor which projected above the clavicle, and causing entire
cessation of the radial pulse. There were no evidences of inflammation
caused by the foreign body.”
The conclusion can hardly be avoided, in this interesting case, that if
Lancet, 1853, vol. ii. p. 162. * Gazette Médicale, 1855, p. 772.
Rivington's paper, ut supra, p. 288.
Bulletin de la Société de Chirurgie de Paris, 1859.
Med. Chir. Trans., vol. xlvii.
Translations Pathological Soc. Phila., vol. v. p. 79, 1876.
:
568 V AN BU REN,
there had been a true resisting sac to the aneurism, a cure would have
followed.
This operation has been repeated by Mr. Bryant, of St. Bartholomew’s
Hospital, London, who introduced twenty feet—three hairs at a time—
into a rapidly-growing popliteal aneurism, “with the effect of causing
almost complete consolidation of the tumor. The man survived the ope-
ration five days, dying from ulcerative endocarditis, a condition that
existed before the operation.” This surgeon considers these results as
quite sufficient to justify a repetition of the operation."
If we succeed in getting a preparation of catgut somewhat more per-
manent than that now in use for ligatures, but still capable of blending
ultimately with the tissues, the use of this substance would be still less
likely to provoke inflammation or suppuration.
Finally, there is still a variety of aneurism to which experience has
taught us that the Hunterian operation is inapplicable; but the lesson is
being learned slowly. I refer to the cases in which an abnormal opening
has been formed between an artery and vein—what we call arterio-venous
aneurism, a term properly used whether any tumor be present or not.
This affection is almost invariably the result of a wound, and is charac-
terized by an exaggerated and peculiar thrillº often perceptible in the
neighboring veins, and also by enlargement in calibre of the arteries
involved, and thinning of their walls.
The Hunterian ligature has been wrongly applied to the cure of this
affection, as is proved by the occurrence of gangrene or secondary hemor-
rhage in all the cases in which it has been done in the lower extremity,
and in some, cases in the upper. Unfortunately it has had the sanction
of Scarpa, Hodgson, Physick, and Liston. The rarity of its occurrence
explains the delay in accumulating experience enough to reverse this
authoritative endorsement. But on the other side we have Dupuytren,
Breschet, Mott, and Norris; and, in addition, we have this great fact,
which experience has taught us, that this form of aneurism is not usually
progressive, so as to threaten life and to justify the use of a remedy
attended by risk. This is exemplified in a man of forty, whose case was
recently reported to the Clinical Society of London by Mr. Hulke, of the
Middlesex IIospital. Three years previously, in Missouri, a Derringer
pistol had exploded as the man was putting it in his right hand trowsers
pocket, and a bullet had traversed the thigh, wounding both vein and
artery at a point about six inches below Poupart's ligament. There was
little bleeding at the time, and relief was ultimately sought some years
afterwards because the limb was weak and painful, and its surface
affected by eczema and ulcers. From the point of injury upwards, the
femoral artery and vein were greatly dilated, and the risk in attempting
| The Practice of Surgery, etc.; London, 1876, vol. i. p. 435.
* Nélaton has the credit of pointing out the fact that, whilst the murmur of an ordinary
aneurism can be heard only after the systolic impulse, and is therefore interrupted, the pul-
satory thrill of an arterio-venous aneurism is continuous. It is intensified by the systolic
impulse, but does not intermit. This circumstance should always arrest attention, as indi-
cating the existence of venous communication. I have not verified the statement of syste-
matic writers that, in varicose aneurism (7. e., where a distinct tumor has formed), the inter-
rupted bruit resulting from the passage of the blood in and out of the aneurismal tumor
can be heard distinct from the continuous thrill caused by the opening into the vein. The
“rasping bruit” is heard also in cirsoid aneurism, but everywhere equally; whilst in arterio-
venous aneurism it is loudest at one spot, viz., near the point of communication. There
is also less forcible pulsation in the artery below the point of communication in most
instances where an artery opens directly into a vein; and a tendency to dilatation of arte-
ries above.
TRE AT MENT OF A N E U R IS M. 569
to tie the former above and below the abnormal opening was considered
too great. Compression, direct and indirect, was patiently tried and
found useless, except in benefiting the eczema and ulcers. Ligature, as
for simple aneurism, was seriously thought of, but deferred. Meanwhile
the patient received so much relief by wearing an elastic laced stocking
reaching from the foot to the groin, that he willingly accepted the advice
to content himself with this palliative treatment."
In a recent case, and in a young subject, the probability of a perma-
nently weakened limb would possibly justify an operation as for a
wounded artery, as in the cases of Spence and Annandale, of Edinburgh,
and the use of an Esmarch's bandage would greatly facilitate such a pro-
ceeding. But in an old ease, the number and size of the enlarged and
tortuous vessels all carrying arterial blood, the enfeebled vitality of the
limb, through habitually defective blood-supply, and the thinned walls
of the arteries, unite to render all operative interference difficult, and, as
regards gangrene and secondary hemorrhage, especially dangerous,” as
pointed out by Breschet in 1838.* &
As long ago as 1848 I sought to aid in establishing this point of prac-
tice. The late Valentine Mott tied the external iliac artery in a young
man from Alabama, for an arterio-venous aneurism in the same locality
as in the case just related, two years and a half after the gunshot wound
by which it had been caused. The patient had complained of lack of
power, and more or less pain in the limb, but mainly of the exaggerated
pulsation and continuous vibratory thrill over the course of the vessels.
After the operation the limb fell into gangrene at once, and the patient
died on the sixth day. I had an opportunity of dissecting the parts, and
found two small aneurismal tumors formed out of the adjacent tissues,
besides a direct communication between the femoral artery and vein.
Impressed by this grave reverse, I collected all the recorded cases within
my reach in which arterio-venous aneurism of the lower extremity had
been treated by ligature on the Hunterian plan, and found that gangrene,
or secondary hemorrhage, had occurred in all of them. In twelve cases,
the external iliac was tied in five, and gangrene followed in all; the com-
mon femoral in two, and gangrene followed in both ; the femoral artery in
five, and gangrene occurred in two of these cases, and hemorrhage in all.”
Subsequently Norris deduced a similar result from the analysis of the
cases of Hunterian operation for arterio-venous aneurism in his tables of
collected cases of ligature of the femoral and external iliac arteries; and
considering this result in connection with the clinical fact that arterio-
venous aneurism in most instances tends to lose its progressive character
and become stationary—causing only inconvenience, and not danger to
life—this excellent surgeon recorded his opinion that sound surgery con-
demns a resort to operative measures in the treatment of such cases, “so
' Trans. Clin. Soc. London, vol. viii., 1875, p. 175. Similar cases of arterio-venous
aneurism of indefinite duration, without material progress, must have presented themselves
to most surgeons of experience. Norris quotes a case of Dupuytren's of twelve years’ dura-
tion, and speaks of another he saw in Velpeau's wards in 1835, of twenty years' standing ;
and still another of “long continuance, which inconvenienced though it did not distress the
patient.”—Contributions to Practical Surgery, etc., Phila. 1873.
* Prof. Donald McLean, of Ann Arbor, dissected out and tied the popliteal artery and
vein in an old case of arterio-venous aneurism (traumatic) above and below the point of
communication, but lost his patient. (Private Communication, May 22, 1876.)
3 Mémoires de l'Académie de Médecine de Paris.
* Cases of inguinal aneurism, with remarks. New York Journal of Medicine, vol. ii.
(new series), 1848, p. 168.
570 VAN BUREN,
long as the infirmity can be made at all bearable by the use of com-
presses, laced bandages, and other like measures.”
I regret that my time will allow me to say nothing of traumatic
aneurism, especially as there are several most creditable American cases
by which its treatment might be illustrated, in which in the neck, and
even behind the ramus of the lower jaw—that most dangerous of all
localities for a deep punctured wound—the tumor has been laid open and
the vessel successfully tied above and below the wound in its walls. I
may mention particularly the cases of Prof. Briggs, of Nashville, Ten-
nessee,” of Prof. Donald McLean, of Ann Arbor, Michigan,” and also the
more recent case of Dr. G. E. Frothingham of the same city.”
I am conscious that I have already taxed your patience too long with
these imperfect notes; and I am equally aware that the extent of the
subject has precluded the possibility, in such limited space, of reasoning
up to very clearly defined conclusions. The treatment of aneurism at
the present day clearly does not consist, as thirty years ago, in a choice
between ligature and compression, but it involves judicial weighing of
the claims of many remedial measures, the number of which is con-
stantly increasing, and the selection of those which offer the best chances
of safe and certain cure ; and, where the chances of cure are uncertain,
duty requires us to try those remedies which give the best promise of
ameliorating symptoms and prolonging life. With the new methods of
treatment at our command—to alleviate, if not always to cure—I will
venture to assert that, whilst some of the operations on the great arteries
sanctioned by distinguished names have failed to fulfil the hopes of their
projectors—without any diminution, however, of the lustre of those
names—Surgery is, nevertheless, richer in her aggregate resources; for
there is no form of the disease which the well-trained surgeon of the
present day can truly call incurable, or for which his art does not offer
at least some hopeful resource.
Finally, I would submit the following conclusions for the considera-
tion of the Section :-
I. Tufnell’s treatment of aneurism by rest, position, and restricted diet
offers a valuable resource in thoracic and abdominal aneurism.
II. It should always be tried in innominate, subclavian, subclavio-
axillary, and iliac aneurisms, before resorting to measures attended by
risk to life.
III. For aneurisms of the subclavian and iliac arteries, the Hunterian
operation, with our present means of preventing secondary hemorrhage,
is not justifiable. &
IV. For reasons formally set forth by Holmes and Henry Lee, the “old
operation” cannot properly be formally substituted for the Hunterian
operation in these cases, but should be held in reserve for special cases.
V. It is the most safe and surgical resource in gluteal aneurism, if the
circulation can be commanded by the hand in recto.
VI. The mode of cure by embolism, aimed at in the method of manipu-
Contributions to Practical Surgery, Phila. 1873, p. 312.
* Nashville Medical and Surgical Journal, March, 1871.
* Peninsular Journal of Detroit.
* This case, which Prof. Gross in Amer. Journ. of Medical Sciences, April, 1876, p. 442,
attributes to Prof. McLean, of the University of Michigan, I learn from this gentleman,
belongs to Dr. Frothingham; Prof. McL. participated in it only as consulting surgeon.
TRE AT MENT OF A N E U R IS M . 571
lation, is a not unfrequent explanation of what is called spontaneous
cure of aneurism. -
VII. The value of Esmarch's bandage in the treatment of aneurism is
probably not fully estimated.
I. In view of the promising features presented by the cases of
Lewis and Bryant, in which horse-hair was introduced into an aneuris-
mal tumor, the repetition of this operation, or the substitution for the
horse-hair of Lister’s prepared catgut, or other animal substances, may
be properly tried.
DISCUSSION ON DR. WAN BUREN’s PAPER.
After the reading of the preceding paper, Mr. JoDLIFFE TUFNELI, of Dublin,
said:—I have brought with me from Dublin a number of alcoholic specimens,
together with photographs and drawings, which show some of the cures which
have occurred under the plan of treatment which I advocate in cases of internal
aneurism. In following out the idea of the cure of aneurism by compression,
I have found that it is not necessary to completely arrest the flow of blood
through the sac, but that a simple diminution of the force of the circulation
is all that is required. I have also found that the object can be attained by
reducing the force and frequency of the heart's action, by placing the patient
upon his back and by regulating the diet in such a way as to secure nutrition,
and yet produce a decided lowering of vitality. A moment's calculation will
show that if the number of pulsations be reduced from 86 to 56 in the minute,
a gain will be secured of about 43,000 fewer pulsations in the day, a lessening
of force which no one at first glance would fully realize. For the successful
carrying out of this plan, certain conditions are necessary. Thus, (1) the
aneurism must be upon the anterior wall of the artery, as those upon the pos-
terior wall are frequently of the dissecting variety; (2) the sac must be entire,
and (3) the blood must possess the proper fibrinating power. In those cases
in which a hemorrhagic diathesis exists, and the patients bleed profusely from
trivial injuries, the method is of course inapplicable. The difference in the
force with which the blood is driven through the vessels is easily noticeable in
one's own person, if the test is made between the reclining and the erect
posture. I believe that the majority of cases of internal aneurism would
recover if the patients would be content to lie in bed for three months and
submit to the restrictions of diet, etc., which I have recommended.
In the treatment of aneurisms in the lower limbs, I have succeeded in effect-
ing a cure by simply elevating the heel about six inches. I have, by this
method, produced consolidation of a popliteal aneurism the size of a hen's
egg, in twelve days, and the man is now doing full duty in the Royal Guards.
I have here alcoholic specimens of several aneurisms cured by the plan which
I have proposed : one is an aneurism of the thoracic aorta, in which the sac is
filled with fibrinous layers; another, of the abdominal aorta, was cured in
forty days, but soon afterward a dissecting aneurism formed lower down upon
the vessel, and bursting, caused death, the first tumor being entirely solidified.
In a third, in which the internal iliac artery was affected, both the aneurismal
swelling and the degenerated artery became obliterated.
[The specimens referred to were then exhibited, and other cures were illustrated by
drawings.]
Dr. J. H. Pool.EY, of Columbus, Ohio, said:—An opportunity is offered by
one of the recent advances of surgery for us again to consider the old ope-
ration of laying open an aneurismal sac and tying both ends of the artery.
This is the Esmarch bandage, which would not only act as a compressor, but
would also give time to cut freely into the sac and leisurely hunt for the vessel
572 VAN BUREN,
without fear of hemorrhage. In traumatic aneurisms, I believe that this is
the most promising form of treatment, as these are practically wounded
arteries.
Dr. ALFRED C. Post, of New York, said:—Although the plan referred to by
Dr. Pooley is undoubtedly a good one for aneurism of the traumatic variety,
it would not be applicable to those of the idiopathic form. In the former case
the walls of the vessel do not constitute the sac of the tumor, in the latter the
vessel is diseased, and is likely to be in the same condition for some distance
both above and below. In laying open the sac, in such a case, the artery
itself would be opened and the ligature could not be properly applied within
the sac. Even if the artery could be reached within the sac, this diseased con-
dition of the coats would render secondary hemorrhage almost a matter of
CO tu l'Se.
Dr. GEORGE A. OTIs, U. S. Army, said:—I understood Prof. Van Buren
to refer to a case of ligation of the subclavian artery as a solitary example
of shot-wound of the subclavian, in which the accident had not been fol-
lowed by immediate death. The annals of surgery present other such cases,
and several have been recently published. Prof. Billroth, in his Chirurgische
Briefe zur Schusswunden, has cited several cases in which he was able to
secure the right subclavian by ligature, after the above-mentioned injury, in
the hospitals near Mannheim, in the Franco-Prussian War, 1870–71. I have
endeavored to establish, in the fifth chapter of the Surgical History of the
War of the Rebellion, that shot-wounds of the subclavian are not altogether
beyond the resources of art, and have adduced five cases reported by reliable
observers in which the fatal result after shot-injury of this vessel was delayed
for several days, the artery having been secured in two instances by ligature.
In one of the cases, the left subclavian was transfixed by a splinter from the
shattered clavicle. I think that even in the presence of such supreme danger
as is caused by an arterial lesion so near the heart, operative interference may
sometimes be essayed.
Dr. John Ash HURST, Jr., of Philadelphia, said:—There is another set of
cases in which the “old operation” may be properly preferred to the Hunterian
method, and that is in certain cases in which the aneurism has suddenly
become diffused. No doubt when this accident occurs in a case of popliteal
aneurism, amputation is the safest mode of treatment, but in a case of femoral
aneurism, laying open the sac and tying both ends of the artery may be advan-
tageously substituted, as has been successfully done by Messrs. Birkett and
Cooper Forster, of Guy’s Hospital. Again, if an aneurism, in any locality,
has ruptured externally, or has been accidentally opened through a mistake in
diagnosis, the “old operation” may be the most available mode of treatment.
Hemorrhage during the operation may be prevented by using, as suggested by
Dr. Pooley, the Esmarch bandage, or, which I confess I think quite as good,
the ordinary tourniquet. In axillary aneurism, the subclavian artery may be
compressed over the first rib, through a preliminary incision, as advised by
Mr Syme; and in iliac or inguinal aneurism, bleeding may be prevented by
using the aortic compressor, for the introduction of which surgeons are so
much indebted to our President, Professor Lister.
I have lately had occasion to study the statistics of the operations of tying
some of the larger arteries, and have been much impressed by the fact that as
cases have accumulated the percentage of mortality has greatly increased.
Thus, as regards the internal iliae artery, when the late Dr. George W. Norris
published his classical paper, there were known but six cases in which this
1 Dr. Norris erroneously attributed a seventh (fatal) case to the late Dr. J. Kearney Rod-
gers, of New York; a mistake in which I confess to have followed him in my work on
the “Principles and Practice of Surgery,” in company with other systematic writers; and
which has only recently been corrected by the laborious research of Dr. Otis, in the second
volume of his Surgical History of the War.
TREAT M E N T OF A N E U R IS M. 573
vessel had been tied, and, of these six, four had ended in recovery ; but while
the whole number of recorded cases has since risen from six to twenty-five, the
recoveries have risen but from four to seven, so that the death-rate has in-
creased from only thirty-three per cent. to seventy-two per cent. Similarly,
Dr. Norris collected sixteen cases of ligation of the common iliac artery, with
eight recoveries and eight deaths, a mortality of fifty per cent. ; while there
are now recorded sixty-one cases, with of thirteen recoveries and forty-eight
deaths, a mortality of seventy-nine per Jent. These figures, it seems to me,
speak very strongly in favor of bloodless methods of treatment, such as that
which has been so beautifully illustrated to us to-day by the specimens shown
by Mr. Tufnell, and which I, for one, am quite ready to agree with him in
calling the “successful method of treating internal aneurisms.”
Dr. S. FLEET SPEIR, of Brooklyn, said:—I would invite the attention of the
Section to the “Artery Constrictor,” which I have devised, and for which I
claim the advantage of both effectiveness and safety. It consists of a mechani-
cal arrangement for closing two jaws, one of which is curved so as to admit of
its being passed beneath the artery, while the other forms a tongue, or male
blade, and is forced down into a groove on the inner surface of the first. The
advantage claimed for the groove is that it is so narrow as only to admit the
external coat of the vessel along with the tongue, and that consequently the
middle and inner coats must give way, and then retract and curl up so as to
plug the artery with its own contents, and favor speedy coagulation. In this
respect the “Constrictor” differs from Travers’s instrument. I have used the
“Artery Constrictor” successfully upon the femoral artery, in a case of popli-
teal aneurism, and also upon the common carotid in a case of supposed dilata-
tion of the innominata, in which, however, it was found that the aorta was
involved. In this case I tied the subclavian and constricted the carotid.
[Dr. Speir's instrument was then exhibited.]
The President, Mr. LISTER, of Edinburgh, said:—I can testify to the value
of Mr. Tufnell's method in many instances. One case I particularly recall
which occurred in the practice of Mr. Syme, in which a patient, in whom it was
proposed to tie the femoral artery for an aneurism of the popliteal, was placed
in bed for a few days preparatory to the operation, and, although no particular
attention was paid either to the lessening of the heart's action or to diet, yet,
when he was brought to the operation table, the pulsation in the tumor was
found to have entirely ceased. In regard to the distinction which has been
drawn as relating to the traumatic or idiopathic nature of the affection, I do
not think that this is a matter to be so much considered as the question which
is the best and safest operation in the particular case, and the settlement of
this question will depend more upon the position of the aneurism than upon its
cause. In the case of popliteal aneurism, for instance, ligature of the femoral
at the very apex of Scarpa's triangle, as practised by Mr. Syme, is a very suc-
cessful operation, whether the tumor be traumatic or idiopathic in its origin;
but ligation of the brachial for an enlargement of the vessel at the bend of the
elbow, will probably fail to effect consolidation on account of the free anasto-
mosis in this part. This intermingling of vessels is sometimes so intimate
that occluding the brachial may not even destroy the radial pulse for one mo-
ment. In the arm, again, laying open the sac is attended with less danger than
is the same operation in other portions of the body. Other important elements
in deciding upon the form of operation are: The character of the tumor, whether
fusiform or sacculated, and also the condition of the walls of the vessel. It
should be remembered that the artery is just as likely to be diseased at a dis-
tance from the tumor as in its immediate neighborhood, since the location of
an aneurism is usually the result of accident or some mechanical cause.
Should the Hunterian operation fail in anenrism at the elbow, I should cer-
tainly try the old operation.
With regard to the aortic compressor, or abdominal tourniquet, I would say
574 WAN BUREN, TREATMENT OF ANEURISM.
that, although I formerly supposed it to be original with myself, I afterwards
found that it had been previously used by Professor Joseph Pancoast, of Phila-
delphia, who is entitled to whatever credit pertains to its introduction. As to
the danger in the application of this tourniquet, referred to by Professor Van
Buren, I think that it is due to the misapplication of the instrument. An
inexperienced person, finding the artery beating below, may screw down the pad
vigorously, while the difficulty really is that proper adjustment has not been
effected. In such a case the intestine may easily suffer, but I guard against
this by always placing a sponge beneath the pad.
I would like to say a word as to Mr. Holmes's allusion to the late Mr. Syme's
advocacy of the ligature, as evidencing an “unaccountable prejudice” in its
favor. The fact is that Mr. Syme lost but one case of femoral ligation out of
forty, and that one from pyaemia. His other unsuccessful case was one in
which a vascular tumor, not properly an aneurism, was treated by ligation, but
proved fatal from hemorrhage. Mr. Syme always cleaned the artery very
thoroughly before applying his ligature, and he tied the femoral below the apex
of Scarpa's triangle, because, as he said, there are frequently very large
branches given off from the femoral instead of from the profunda.
Professor Van Buren has said that one of the advantages of the antiseptic
ligation of arteries is the avoidance of secondary hemorrhage. This is true,
but there is also gained another important desideratum, namely, the dimin-
ished danger of diffuse inflammation. In ligation of the subclavian, if the ope-
ration were done thoroughly antiseptically, it would make no great difference
even if the pleura should be opened, for the danger is not from such a punc-
ture, but from suppuration, and when this is avoided the operation becomes a
far safer one.
Dr. A SHHURST said:—I must say one word as to the history of the aortic
compressor. I had the pleasure of being present when Professor Pancoast
first used an abdominal tourniquet in amputation at the hip-joint (in 1859), and
have myself since used, with satisfaction, the identical instrument, which is
still extant in Philadelphia, in hip-joint amputation. But with all due regard
to national pride as American surgeons, I do not think that we can afford
to let the modesty of our President, Professor Lister, deprive him of the credit
which is justly due him in this matter. The instrument which was used by
Professor Pancoast was simply a large-sized Skey’s tourniquet, and it is infe-
rior to Professor Lister’s ingenious clamp, or compressor, being more difficult
of application, and of more complicated construction. Moreover, Professor Pan-
coast's use of the instrument was hardly known out of Philadelphia, and did
not attract the attention of surgeons generally ; so that although as a matter
of fact he undoubtedly preceded Professor Lister in the employment of
mechanical compression of the aorta, to the latter is as undoubtedly due the
credit of having perfected the mechanical means of effecting such compression,
and of bringing the method before the profession all over the world as a
practical resource in surgery.
Mr. TUFNELL said:—I would just mention that, many years ago, a similar
instrument was devised by Mr. L’Estrange, of Dublin, for the compression
treatment of aneurism, and is still preserved in the museum of the Royal Col-
lege of Surgeons of Ireland."
On motion, the conclusions of Dr. Van Buren's paper were adopted as
expressing the opinion of the Section.
* [It may be added that in Mr. Birkett's and Mr. Forster's cases of diffused femoral aneu-
rism, treated by “the old operation,” the aorta was compressed by a tourniquet “recom-
mended by Dr. Humble, many years ago, for compressing the abdominal aorta in cases of
post-partum hemorrhage” (Trans. Clinical Society of London, vol. i. p. 38), so that the ques-
tion of actual priority in the use of an aortic compressor probably cannot be settled.—
EDITOR.]
THE PATHOLOGY AND TREATMENT OF MORBUS COXARIUS.
BY
LEWIS A. SAYRE, M.D.,
PROFESSOR OF ORTHOPAEDIC SURGERY AND OF FRACTURES AND DISLOCATIONS IN THE BELLEVUE
HOSPITAL MEDICAL COLLEGE, NEW YORK, ETC.
MR, PRESIDENT AND GENTLEMEN:—
The time allotted me for discussing Morbus Coxarius, its causes, symp-
toms, and treatment, is so limited, that I can only briefly refer to the
first two, and for more minute information must refer you to my pub-
lished writings on this subject, where more definite and full information
has been given; and I shall occupy a portion of the time with a practical
illustration of the plan of treatment in each different stage of the disease,
as being the best manner of conveying the largest amount of information
in the time that has been allotted to me.
Morbus coxarius, or hip-disease, as it is generally called, is more fre-
Quently observed in childhood and early youth than at any other period
of life, although it may occur in the infant or the adult. It is generally,
if not always, the result of some direct injury to the joint involved, either
(1) by a blow or concussion of the head of the femur against some portion
of the acetabulum, producing an extravasation of blood in the network of
vessels underneath the articular cartilage of one of these parts, and ending
in caries and necrosis; (2) by some strain or overstretching of the joint,
producing rupture more or less complete of the ligamentum teres, and its
vessels and nerves, thus interfering with the nutrition of the head of the
femur, and inducing necrosis; or (3) by excessive violence and over-exer-
tion, producing free perspiration and synovial secretion, which is sud-
denly checked by an exposure to damp and cold, thus producing a syno-
vitis which not unfrequently ends in suppuration.
The young infant is protected by the watchful mother or the careful
nurse; and the adult has generally sufficient prudence to protect him-
self; but the reckless, romping, healthy child indulges in wild sports
without discretion, and slight injuries are unnoticed until serious con-
sequences have resulted, and often until so long a time has elapsed
between the receipt of the injury and the development of symptoms suf-
ficient to attract attention, that the cause of the difficulty is entirely for-
gotten, and the constitutional effects of long-continued irritation and
suppuration are mistaken for the cause of the disease, instead of the
Tesult.
Until within a very few years, every author taught that the disease
was necessarily connected with a strumous condition of the system, and
could not exist without it, and that it was therefore necessarily of con-
stitutional origin, and never occurred in the robust and healthy. This
doctrine I believe to be incorrect; in fact, by a careful examination of my
recorded notes of many hundreds of cases of morbus coxarius, I find that
by far the larger number occur in children of perfect health, and born of
healthy ancestry, and the simple reason is that children of this class are
more active and daring, and therefore more exposed to accidents and in-
576 SAY RE,
juries, than sickly strumous children who seldom have energy enough to
expose themselves to any danger. But even the strumous constitution
requires some local injury to the part itself, in order to develop the dis-
ease, and therefore I am inclined to regard the disease as almost always,
if not always, of traumatic origin.
Of course the sickly strumous child, having less recuperative power and
vital force to resist disease, will have it developed from a much less exciting
cause than would be required to develop the same trouble in the healthy
and robust; but even among the strumous I believe that, if sufficient
care is taken in the investigation, the disease will nearly always be traced
to some slight injury which was considered of so little importance as to
pass unnoticed at the time, and that months afterwards, when the seri-
ous consequences of this slight injury have been fully developed in the
well-recognized hip-disease, the universal belief in the doctrine of its con-
stitutional origin has prevented the surgeon from examining for any
other cause.
This has been the cause of the fatal error in the treatment of this dis-
ease ; for, of course, as long as we believe that the disease depends upon
constitutional taint, all our efforts will necessarily be directed towards
correcting this constitutional poison or element. The result of all such
treatment has been either death, after many months or years of suffering
and exhaustive suppuration, or else recovery with more or less deformity,
and with imperfect motion, or anchylosis more or less complete. Whereas,
belief in its traumatic origin (no matter what the constitutional con-
dition may be) will direct our treatment to the part involved, and, if the
disease is early detected and properly treated, will result in the vast
majority of cases in recovery with lºerfect motion and without deformity.
For convenience of description, I will divide the disease into three dis-
tinct stages, as each represents a different pathological condition of the
parts involved ; and, as the symptoms vary to a greater or less degree, so
does the treatment applicable to each –
I. The stage of irritation.
II. The stage of effusion.
III. The stage of rupture of the capsule, or perforation of the aceta-
bulum.
In the first stage, or the stage of irritation, before effusion has occurred
within the joint, the symptoms are not well pronounced, and it often
requires a very careful investigation in order to recognize the disease.
Generally, the first thing noticed is that the child appears very slightly
lame when he first gets out of bed in the morning, or when he first moves
about after some hours of rest. This limping or halting gait is so slight
as hardly to be observed, and, after a few minutes of exercise, may dis-
appear altogether until the following day, or until after a few hours of
rest, when it will again make its appearance on the first attempt at move-
ment. The patient may sometimes complain of pain even in the early
stage of the disease, but it is generally referred to the knee. Even in
this early stage, however, if the child be properly examined, the disease
can always be detected.
By stripping the child naked, and standing him on a table or on the
floor, with the back towards you, the first thing noticed will be that the
child bears his entire weight upon one limb, the other being slightly
bent at the knee and hip, with its natis lower and more flattened than
on the opposite side, while the corresponding gluteo-femoral crease is
M O R B U S CO X A. R. I. U.S. 57.7
lower than the other, is less distinct, and nearly obliterated at its outer
angle. If you now let the child walk around the room, he may not
limp at all, or not sufficiently to attract attention, in this early stage of
the disease; but when you bring him back to the position as first de-
scribed, and let him stand a moment or two, you will find that he inva-
riably resumes the position of sustaining his whole weight upon the
Sound limb. (Fig. 1.) *
You next lay the patient on his back upon a table, floor, or some other
Solid plane, covered only with a blanket, and lift his lower extremities
until the entire spine touches the plane (Fig. 2), and twist the pelvis one
way or the other until a line drawn from one anterior superior spinous
process of the ilium to the other will be crossed at right angles by
another line drawn from the centre of the sternum over the umbilicus to
the centre of the symphysis pubis.
When the spinal column touches the plane, and the two lines above
mentioned are at right angles to each other, the spinal column is slightly
straighter than normal; but it and the pelvis are at right angles, and, if
no disease exists within the hip-joint, the limbs can be brought down
upon the plane, so that the popliteal spaces can be made to touch the
latter without disturbing the relation of the lines described, and without
lifting the spinous processes from the plane. If you therefore hold the
suspected limb in your hand in such a manner as to keep the spinous
processes on the plane while the other lines are at right angles with each
other, you will observe that the well limb can be pressed down to the
table so that the popliteal space will touch. (Fig. 3.) The diseased limb
can be pressed down nearly to this position, but, before the popliteal
space touches the plane, you will notice that the pelvis becomes tilted,
making a curve in the lumbar vertebra, so that the hand can be passed
between the child's back and the plane. (Fig. 4.) In flexing the limbs,

37
578 SAY RE,
the well one can be completely flexed, so that the knee will touch the
thorax ; the diseased one cannot be flexed to this extent; and before the
knee touches the thorax the pelvis becomes lifted from the plane. Ab-
duction and external rotation may, possibly, at this early period, be
carried nearly to their normal extent without much pain, but adduction
and internal rotation are much more limited. Pressing the head of the
femur into the acetabulum, by concussion at the knee or pressure over
the trochanter major, will give pain, providing the pressure is made so
that the head of the femur shall sweep around all portions of the aceta-
bulum, the pain being made manifest the moment the parts come in
contact in which the disease exists. Extension, even though very slight,
in the proper direction, gives instant relief from pain, while pressure
causes it as instantly to return.
Atrophy of the muscles of the thigh, from tonic contraction caused by
reflex irritation, will often be found even in the earliest stages of the dis-
ease, so that the measurement of the two limbs will often differ by from
one-eighth to one-fourth, or even half an inch. Rigidity of the muscles
is one of the earliest symptoms observed, and is always present until the
disease is entirely arrested. -
If the disease be detected in this early stage, and properly treated, I
am satisfied, from an extensive experience, that the great majority of
cases will entirely recover, with perfect motion and without deformity.
If the disease be not detected at this stage, and properly treated, it pro-
gresses until effusion takes place within the joint; and, in order to
accommodate this increasing effusion, the limb becomes more flexed,
more abducted, and more everted, or outwardly rotated—to unfold, so to
speak, the capsular ligament, thereby enabling it to accommodate itself
to the increased amount of fluid within.
This is the second stage of the disease, or that of effusion. The adduc-
tor muscles become more rigid and contracted under the influence of
reflex irritation; constant efforts are made to draw the thigh inward,
but without avail, as it is impossible for the limb to yield to their tractile
force, because the effusion within the capsule compels it to assume the
position above described. . e -
This stage of the disease is attended by the most acute and agonizing
pain, the slightest attempt at motion, concussion, or compression causing

M O R B U S CO X A. R.I.U. S. 579
the most extreme torture; even the jarring of the bed, stamping upon
the floor, the slamming of a door, or anything that causes the least
movement of the bed upon which the little sufferer lies, may be followed
by an increase of pain. At this period of the disease the attendant is
frequently awakened at night by a sharp, shrill, agonizing shriek. The
nurse runs to the child, and probably finds it asleep. She will have
hardly left the bed before the same thing occurs again; and this is often
repeated a number of times during a single night. The inflammation of
the joint produces reflex contraction of the muscles, thereby adding to
the pressure between the diseased surfaces of the bones, and promoting
absorption of the same, as also the peculiar deformity connected with
this disease. The muscles are kept in this state of constant contraction
in order to prevent any motion in the joint; but this incessant, constant,
unremitting effort so exhausts the patient that finally he falls into a
moment’s slumber, from sheer fatigue, when, the muscles being relaxed,
the limb changes its position, thereby producing motion in the joint, and
causing such instantaneous pain that the muscles instantly give a
spasmodic contraction, followed by the piercing scream to which I have
alluded.
Of course, at this period of the disease, it can hardly be mistaken for
any other, or misunderstood; but upon stripping the child, and examin-
ing him as I have directed that he should be examined in the first stage,
he will be found to present, both in the erect posture and in the recum-
bent position, precisely the same appearances as in the first stage, only
in a more marked degree (Fig. 5), the chief differences being that the limb
will be more flexed, abducted, and everted, or rotated outward, and the
joint more fixed ; in fact, any attempt to move the limb in this stage of
the disease is futile, the entire pelvis rolling upon the opposite acetabu-

580 SAY RE,
lum as if the diseased joint were positively anchylosed, though the sup-
posed anchylosis is only apparent, being wholly due to muscular rigidity.
If the disease be not arrested at this stage, it goes on to ulceration of
the capsule and effusion of its contents into the cellular tissue of the thigh,
or else to perforation of the acetabulum and escape of the fluid into the
pelvic cavity, pressing off the internal periosteum before it.
At this point begins the third stage of the disease; and as soon as the
capsule is ruptured, or the acetabulum perforated, and the contents of
the joint escape, either into the cellular tissue of the thigh, or into the
pelvic cavity, the limb at once assumes an entirely different position. It
now becomes adducted, inverted, and more straight at the knee; the pelvis
on the diseased side becomes raised (whereas in the first and second stages,
it was lower than on the sound side); and the limb is shorter. The
gluteo-femoral crease is higher than upon the opposite side, whereas, in
the previous stages it was lower, or entirely obliterated. (Fig. 6.)
-º-º-º:
—ºr tº . ~~~. S.; , ;
&Sº 3
i SºS - . SS -
If the rupture through the capsule is very large, so that the contents
escape rapidly, this change in the position of the limb from that of the
second to that of the third stage may take place in a single night :
while if the opening is small and fissure-like, and the contents ooze out
slowly, the change of form may not be completed for several days. In
some cases, even when the capsule has ruptured, or the acetabulum
been perforated, the limb will remain in the position of the second stage,
owing to adhesions which may have formed, or to the head of the bone
being locked in the opening through the acetabulum. The pain is greatly
relieved upon this rupture of the capsule and escape of its contents, but
the disease has only advanced one stage further in its progress.
It has been thought by many authors that, when this change takes
place, the head of the femur is absolutely luxated from the acetabulum, and
that this luxation is due alone to spontaneous muscular contraction. The

M OR BUS CO X A R I U. S. 581
sudden change in the distortion, from flexion, abduction, and eversion,
with elongation, to shortening, inversion, and adduction, has caused this
belief in the occurrence of positive luxation, but in the sixty-three cases
in which I have exsected the hip-joint, I have never seen luxation upon
the dorsum of the ilium except in one single instance, and in that the
dislocation was produced a few days before the operation by bending the
limb in the effort to remove the patient from the bed, and was therefore
due to the carelessness of the nurse, and mot to spontaneous muscular
contraction. The absorption of the head and neck of the femur, pro-
duced by constant pressure, diminishes its size, while the ilium being
also pressed upon, becomes eroded and absorbed, thereby immensely
increasing the size of the acetabulum. (Fig. 7.) But while this inter-
Fig. 7.
stitial absorption has been going on within the acetabulum, there has
been at the same time periostitis upon its upper and outer borders, caus-
ing the formation of new Osteophytes; and the capsular ligament, attached
to these new deposits, has thus been gradually pushed upward and back-
ward on the dorsum of the ilium, immensely increasing the size of the
joint, but still retaining within its embrace what is left of the head and
neck of the femur. It might therefore with propriety be called a dis-
placement of the acetabulum, but not a luxation of the head of the thigh-
bone. -
This may appear a small point to cavil about, but accuracy in observa-
tion is essential for obtaining correct knowledge of the pathology of any
disease, and unless our pathology is correct, our treatment will be neces-
sarily empirical.
The pus or other fluid having now escaped from the capsule, the
patient is greatly relieved from the pain, but the disease still progresses.
Constant muscular contraction produces interstitial absorption of the
head and neck of the femur, and of the acetabulum, and the pus, which
has escaped into the cellular tissue, burrows in different directions,
according to the position which the patient maintains, forming extensive
abscesses which finally make their way to the surface. These sometimes
open behind the trochanter, sometimes at a long distance from it, opening
either upon the outer or inner side of the thigh, or on both ; and even.

582 SAY RE,
as I have seen in cases in which the acetabulum has been perforated,
making their way between the internal periosteum and the ilium, and
forming openings above the pubis; so that the third stage of hip-disease
may be accompanied with external fistulous openings in various direc-
tions, and with very great exhaustion from extensive suppuration.
We are now prepared to study the treatment of morbus coxarius, which
of course varies according to the stage in which we find the disease; and
the reason that I have dwelt so particularly upon the diagnosis of the
affection in its earlier stages, is because, as I have before stated, proper
treatment at this time, in the great majority of cases, will be followed by
perfectly satisfactory results.
In the first stage of the disease, if the symptoms of inflammation be
very acute, and pain and tenderness very great, absolute and perfect rest of
the joint is most essentially requisite. In the hearty and robust patient,
in vigorous health, leeches or cups, or some other form of local depletion,
may be necessary ; ice bags, surrounding the joint, often afford the great-
est possible relief, while in other instances hot fomentations, the exact
opposite, will give the greatest ease. There is no rule with which I am
acquainted, that will guide you in the application of heat and cold,
except the feeling of the patient, and this can only be determined by a
practical test. The remedy which gives the greatest relief, and is the
most agreeable to the patient, is the one to employ. In addition to these
local measures, extension (very slight, but continuous) in the lime of the
deformity, should be made by means of a weight and pulley, secured to
the limb by strips of adhesive plaster, and a roller. The adhesive strips
should always extend above the knee, to avoid traction upon this articu-
lation. The pulley should be attached in some manner to the bed, the
foot of which should be elevated ten or twelve inches, so as to make the
body act as a counter-extending force. (See Fig. 8.)
Fig. 8.
º §[[{KRRIE
šºgºs-3-
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When the extension is first applied, the traction should be made in
the line of the deformity, and the direction should be changed by slow
degrees, day by day, until the limb is gradually brought into its natural
position. It is sometimes necessary to apply a second extending power,
at right angles to the limb, to remove the pressure of the head of the
femur against the inner surface of the acetabulum. This is readily done
by passing a handkerchief around the upper and inner part of the thigh,
securing in its outer loop a cord to which is attached a weight playing
over a pulley at the side of the bed.
If the bowels are constipated, cathartics as a matter of course are indi-





M O R B U S CO X. A R I U. S. 583
cated ; and all the secretions and functions of the body must be care-
fully looked to and kept as nearly in a normal condition as possible.
This plan is to be pursued until the more acute symptoms have sub-
sided ; but as the disease is chronic in its nature, time, as well as rest, is
a very important element in its treatment. And as long confinement in
bed is injurious to the general health, we must contrive some mechanical
appliance which will give the necessary amount of extension and counter-
extension to relieve the joint from pressure, while at the same time it
allows it to have free motion, and permits the patient to take exercise
in the open air.
In some cases, when the disease is very acute, and the child very small,
this is best effected by placing him in a wire cuirass (Fig. 9), which is a modi-
l
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fication of Bonnet’s “grand appareil,” and which will be found very useful.
When this instrument, or any other fixed apparatus, is employed, it is ne-
cessary that the patient should be taken from it very frequently; and all
the joints should be carefully moved, lest too long-continued rest may ter-
minate in anchylosis, not only of the joint diseased, but of all the other
articulations thus permanently deprived of motion. I am aware that Dr.
Thomas, of Liverpool, has denied this doctrine; but having seen the
result in a number of cases, I must be pardoned if I insist upon placing
more confidence in my own personal observations than in the theories of





























584 SAY RE >
any one. Perfect rest, too long continued, even of the diseased joint, is
decidedly injurious, as there is danger of its resulting in anchylosis;
hence the objection to plaster of Paris, or any other fixed apparatus, in
the treatment of this affection. The disease is essentially within the
joint, the capsular ligament not being involved ; hence, all that is required
is extension and counter-extension, just sufficient to prevent the diseased
surfaces from coming in contact; while at the same time motion is per-
mitted, to keep the capsular ligament and other parts not involved in a
healthy condition, by allowing the free use of this their natural stimulus.
If the child is large enough to run about, and the thigh sufficiently
long to give attachment to the adhesive plasters, then the short splint
(Fig. 10) is altogether preferable. I have used this splint for many
years, and having tried all others, I find it altogether the best wherever
it can be applied, as it allows free flexion at the knee, and is, therefore,
more comfortable in the sitting posture. If the patient is ten or twelve
years of age, and too heavy to bear the weight of the body upon the
instrument without breaking it, or if too much tension is produced upon
the skin by the adhesive plasters, then crutches will be necessary when
the short instrument is used. If the child's thigh is too short, and he
is too small, to receive a sufficient amount of extension by the use of
the short splint, then the long splint, which I here show you (Fig. 11),
is much to be preferred, and with it, if properly applied, the patient will
be able to walk without the use of a crutch.
The short splint and its various modifications, together with the long
splint with its abducting joint and rotating screw, and their mode of
application, have already been so fully described (in my work on Diseases
of the Joints), that I shall barely refer to them here.
The short splint (Fig. 12) consists of a curved cross-bar, surmounting
the crest of the ilium or entire pelvis, well padded on its inner surface, and
to its two extremities are fastened a perimeal band or bands, for counter-
extension, and on its outer surface a ball-and-socket joint, from which

M O R B U S CO X. A R I U. S. 585
runs an iron rod or bar down the outer side of the thigh to within about
two inches of the lower end of the femur. This outer bar is divided into
two sections, one running within the other, and gauged or controlled by
a ratchet and key, which can make it longer or shorter. At the lower
Fig. 12.
| Innºuillº
- - - “Tº
extremity of this outer bar is a projecting branch going around to the
inner surface of the thigh to receive the attachments of the plaster, here-
after to be described. Both of the lower extremities terminate in
cylindrical rollers, over which the tags of the plasters are attached to the
two buckles placed at the lower ends of the instrument.
In applying the instrument, it is first necessary to have the adhesive
straps to which it is to be fastened properly secured, and this is done as
follows. When using the short splint, which is only worn during the
day, night-extension is necessary, which is effected by means of weight
and pulley: for this purpose a strip of adhesive plaster, to the lower end
of which a stout piece of webbing is sewed, is placed on either side of the
leg, extending from the malleoli to above the knee, in order to avoid
traction on the lateral ligaments of the knee-joint ; this is secured by a
well-adjusted roller, leaving the pieces of webbing projecting for the
attachment of the extending force. (Fig. 13.) Next, for the application
of the instrument, triangular pieces of plaster, in which are cut several
slits converging toward the apices of the pieces, are placed on both the
outer and inner side of the thigh, first measuring with the instrument so
that the tags which have been sewed to the apices of the plasters will
exactly conform to the places of attachment upon its lower extremities.
Having secured these with a roller, using care at the upper part of the
thigh to reverse each alternate strip of the plasters in carrying round the

586' SAY RE,
roller (Fig. 14), and with another turn taking in the other strips—braid-
ing them in, basket-shaped—run the roller down the thigh again and Sew.
Pig. 13. Fig. 14.
In applying the instrument, first buckle on the straps at the lower
extremity of the femur. Then pass the strap under the femur to the
buckle at the outer side of the instrument for the purpose of keeping it
in place. We now pass the perimeal band around the perineum, and
buckle it snugly, but not too tightly. We next insert the key into the
ratchet, and make gradual extension, until the patient is made perfectly
easy, and until compression can be made upon the femur against the
acetabulum without pain. It is sometimes necessary to employ two
perineal bands, and then the cross-piece at the top nearly surrounds the
Yelvis. -
| If the disease has arrived at the second stage before we see it, and the
effusion is very great, which will be indicated by the abduction, flexion,
and eversion of the limb–sometimes even fluctuation can be detected—
the patient must be kept in bed and the extension applied to the limb
exactly in the line of the distortion, which will be in the line of flexion
and abduction. This line of extension is to be changed day by day, by
slight degrees, until the limb is brought as nearly as possible to the
straight position. Blisters applied occasionally over the joint may
hasten the absorption of this effusion. Firm strapping with adhesive
plaster around the joint and compression with a sponge and roller may
also be applied for the purpose of aiding absorption ; of course, extension
being used before this compression is employed. It is barely possible
that the effusion may be so great as to paralyze the absorbents, and that no
treatment will decrease the effusion. Under such circumstances aspira-
tion of the joint is not only advisable, but the proper treatment, and


M O R B U S CO X. A R I U. S. 587
will be immediately followed by a restoration of the joint to its natural
position. -
When the limb has been brought to nearly its normal position, then
the treatment by the short or long splint, according to circumstances, is
the same as in the first stage of the disease, the plasters being re-adjusted
as often as necessary. Good adhesive plaster (Maw's, of London, I have
found to be the best), properly applied, will frequently remain in position
from two to four months, seldom requiring removal oftener than once
in six weeks or two months.
If the disease has gone to the third stage, capsule ruptured, abscesses
formed and not yet opened, it is necessary to puncture these abscesses at
various points where they are nearest the surface to prevent the pus from
burrowing. The limb then being adducted, the extension, as a matter of
course, must be exactly in the opposite direction from what it would have
been in the second stage of the disease, and the limb gradually abducted
until it is brought parallel with the other, when the splint, either long
or short, is requisite, to be modified by the abducting screw, which I have
been in the habit of using for many years with great advantage. In
numerous instances, even when the disease has progressed to this stage,
by the use of the splint the patient is enabled to improve the general
health by out-door exercise, which frequently results in perfect recovery,
and in some cases with a moderate degree of motion. The majority of
the cases, however, that have arrived at this point before proper treat-
ment has been adopted, are apt to recover with more or less complete
anchylosis; in fact, anchylosis should be considered in this stage of the
disease a very favorable termination.
The long splint (Fig. 11) which we sometimes have to use, differs from
the short one, in the following particulars:–
In the first place, it extends the entire length of the limb, receiving
the weight of the body at a cross-bar under the foot, and upon two
perineal straps which are attached to an iron girdle which very nearly
encircles the pelvis. Where the adduction is great and the joint fixed,
it will be necessary also to apply the abducting screw, and in some cases,
when the inversion is very great, a screw for the rotation of the foot
outward is also necessary. The long bar, reaching from the pelvis to the
bottom of the foot, is hollow, and has another bar running inside of it
furnished with a ratchet and key, by which we make extension, and
which is locked in the same way as in the short splint. The cross-bar
at the bottom of the instrument is covered with leather to keep it from
making a noise on the pavement while walking, and a strong leather
strap is passed beneath two iron rods above this latter for the purpose of
buckling on to the adhesive strap upon either side of the leg to make
extension.
In applying it you take two strips of strong moleskin adhesive plaster,
from two to four inches in width, according to the size of the patient,
and the entire length of the limb, the upper extremity of the plaster
being divided into strips for two or three inches. Strong webbing, an inch
or two in length, with buckles, is sewed fast to the lower extremities
of the plasters. These plasters are then placed on either side of the leg
in such a manner as to leave the buckles a little above the ankle-joint, and
secured by a snugly-adjusted roller, so applied as to leave the tags with
buckles attached hanging loose, the roller being carried up over the knee,
and as far up the thigh as can be done with convenience, when the upper
split ends of the plasters are reversed and braided in with the roller as it
588 SAY RE,
turns down the thigh, securing it smoothly. The stocking is next pulled
up on the foot, and holes cut on either side for the buckles to pass through,
and the shoe then applied, and corresponding holes cut through it for
the same purpose.
The instrument is now placed on the outer side of the leg, with the
cross-bar at the bottom brought in front of the heel of the shoe, and se-
curely buckled to the tags above described. The pelvis-belt is next
brought around the hips, and secured by the buckle upon the opposite
side, and the perineal bands attached as firmly as need be. The knee-pad
band is then slipped up or down until it is made to rest opposite the
knee, where it is passed round the leg and buckled fast. Extension is
now made by the key upon the ratchet until free compression is borne
without pain. The abducting screw is then to be used, and daily turned,
for the purpose of abducting the limb.
If the limb be strongly flexed, an additional power is applied at the
posterior part of the instrument at the knee, running up the back of the
thigh, and secured to the posterior portion of the pelvis-belt, and made
tighter as Occasion may require for the purpose of extending the limb.
This latter strap should be always elastic, for the purpose of keeping up
a constant tractile force, and at the same time allowing of flexion when
the patient wishes to sit down. A fixed or leather strap, as used by
Taylor, prevents any motion whatever at the hip, and simply anchyloses
the joint.
By this means many cases that have gone to the third stage of the dis-
ease may in the course of time recover, with tolerably good form and a
moderate degree of motion, without any further operative procedure.
(Fig. 15.)
If, however, notwithstanding your treatment, the disease progresses,
and suppuration increases, the joint becoming more and more impaired,
showing a case of progressive caries, we then have no remedy except in
eacSection.

M O R B U S COXA RIU S. 589
Nature's only way of curing these cases after they have arrived at this
point is by the slow exfoliation of the carious bone, and, if this is limited
in amount, she is often successful; but if involving the entire head and
neck of the femur, with more or less of the acetabulum, as it frequently
does, the process is a very tedious one, and the patients often succumb
before nature completes the cure; and even in the most favorable cases
healed by nature in this way, they have been left always with permanent
deformity and imperfect motion—in fact, with a very much less useful
limb than those which have been cured by exsection. I have now per-
formed this operation sixty-three times, and can, therefore, speak with
positive assurance upon the subject.
The operation is very simple, indeed, and in itself attended with
almost no danger. The patient being anaesthetized and laid upon the
well side, an incision is made from a point midway between the crest of
the ilium and the top of the trochanter major, the knife carried firmly
down to the ilium, and drawn with a single sweep downward and out-
ward over the posterior edge of the trochanter major, and then curved
forward and inward, making a crescent-shaped incision of some four to
six inches in length, according to circumstances, and carried fairly down
to the bone in its entire extent. The wound is then held open with spa-
tulas, and a narrow firm-bladed bistoury is carried around and close to
the femur just above the trochanter minor, and at right angles to the
first incision, dividing only the periosteum, but in both directions, as
far around the bone as can be reached, one-half or three-quarters of its
circumference. By this circular division of the periosteum you avoid the
danger of tearing it off from the femur below the point where section is
to be made. If the first incision has not divided the periosteum com-
pletely, then carry your knife again through the first incision from the
top of the trochanter major down to this cross-incision just described,
pressing it firmly through the periosteum down to the bone. The peri-
osteal elevator is then placed in these two triangles, and the periosteum
peeled off from the trochanter major, carrying with it necessarily the
muscular attachments to it. This can be very successfully done until
you reach the digital fossa at the neck of the bone and behind the tro-
chanter major, where the blade of the knife will be necessary to divide
the tendinous insertions of the rotator muscles. The capsule being freely
opened, the head of the bone will now be easily lifted from the acetabu-
lum by strongly adducting the limb and depressing it, thereby tearing
off the internal portion of the bone from its lining periosteum, when the
finger can be glided around the bone, and with a finger or chain saw it
may readily be removed below the trochanter major. By this means the
periosteum will not be peeled off from the bone below the point of sec-
tion with the saw, as is too often done by luxating the bone too forcibly.
If upon the first section it is found that the caries has extended still
further down the femur, you can very easily separate it from its perios-
teal attachments, and whatever amount of bone is necessary can be re-
moved in the same manner with the saw. Under no circumstances
should bone forceps be used in the section of so large a bone. The tro-
chanter major should always be removed, even if it is not diseased, as
otherwise it would occlude the opening and prevent the escape of the
discharge; and by peeling it from its periosteum, as I have before de-
scribed, the attachments of the muscles are all left for future use.
When the head and neck have thus been removed, you have a fair
opportunity to explore the acetabulum, and to remove all the carious or
590 SAY RE,
necrosed bone by scraping and gouging. If the acetabulum be perforated,
which I have frequently found to be the case, with a little care the
necrosed bone can be chipped off down to the point at which the perios-
teum is attached. I have only in one instance found the internal perios-
teum perforated.
After washing the wound carefully with warm water, fill it with
Peruvian balsam ; a small plug of oakum should be inserted to the very
bottom of the acetabulum, and left dependent from the wound. The
upper and lower ends of the incision are then brought together by
stitches, and if necessary adhesive plaster, and the patient placed in a wire
cuirass (Fig. 9) with a window opposite the place of incision. As it is
of the greatest importance that this dressing should be done with care,
I will describe to you my mode of doing it.
The cuirass being properly prepared and well padded, the patient is
laid in it so that the anus is opposite the opening, and free from any
possibility of obstruction. The well leg is the first one to be dressed.
By making it perfectly straight and screwing up the foot-rest until it is
brought firmly against the heel of the patient, having a pad between
the foot and the iron rest to absorb the perspiration, the instep is then
well padded with cotton or a blanket, and a roller is carried firmly round
it and the foot-rest, running up over the limb ; but before going over
the knee a piece of pasteboard, or leather, or several pieces of folded
paper, are placed over the leg, knee, and thigh, and the roller carried
firmly over this extemporized splint for the purpose of preventing the
slightest bending of the knee, when the roller is carried up the entire
length of the thigh, around the perineum and over the outer arm of the
instrument, and several times back around the perineum, and then across
the pelvis, by which means the well limb is made a firm counter-extend-
ing force.
Two strips of adhesive plaster from two to four inches in width, ac-
cording to the size of the patient, are then placed upon either side of the
limb which has been operated upon, and secured with a nicely-adjusted
roller over the foot and up the limb and thigh, as far as the abscesses on
it or the wounds will permit, being careful to leave a sufficient length of
the plasters, at the lower extremity, free for the purpose of applying
them to the foot-rest when extension is made. The foot-rest is then
screwed up to meet the heel of the shortened limb, and these strips of
adhesive plaster are brought down around the foot-rest and securely
fastened. The foot-rest is then extended by the screw, slowly and grad-
ually, at times waiting a few moments for the muscles to yield, which
have been so long contracted, until the limb is brought down to its full
extent. It sometimes happens that, from long contraction of the adduc-
tors and the tensor vaginae femoris, subcutaneous section of those ten-
dons and fascia will be requisite before the limb can be brought to its
proper position, even after the head of the femur has been removed.
After the limb is brought into this position a roller is carried from the
foot over its entire surface; a large wad of oakum is placed around the
wound to absorb the discharge, and the roller is carried firmly over the
wound, inner surface of the thigh, and around the pelvis. I place great
stress upon this latter part of the dressing, as we thereby compress the
tissues and prevent the burrowing of pus, the oakum, which has already
been placed in the wound, allowing of free drainage, no matter how
tightly the roller may have been applied.
Immediately after the patient is dressed in this way, and has recov-
M O RIBU S CO X A. R. I U. S. 591
ered from the anaesthetic, he is capable of being stood up against the wall,
or riding out in a carriage or boat, and can take his daily exercise in this
way. I have, in several instances, had patients removed a long distance,
some miles, in fact, within an hour of the operation and without the
slightest inconvenience or pain. This dressing will probably not require
to be changed for from forty-eight to sixty hours, or until sufficient
Secretion has been formed to moisten the dressings, when the Oaken plug
can be removed without hemorrhage. If this dressing does not come
away easily, warm water injections will readily float it out. The wound,
made clean, is again filled with Peruvian balsam and dressed as before.
After this it may require dressing once or twice a day, according to the
amount of discharge, and the child should be removed from the entire
instrument as often as it is requisite. The well leg should be removed
from the instrument at least once a week, and free movements given to
all the joints, ankle, knee, and hip, otherwise we may anchylose them,
although they are not diseased. The wire cuirass should be used from a
month to two months, or more, according to necessity, after which the
patient can be put upon the long or short splint, and allowed to exercise,
thereby increasing his prospects of perfect motion of the new joint.
In many of the cases which I have exsected, the motion has been as
perfect and complete as in the normal joint, and in one case, that of Adolph
Rousell (Figs. 16, 17, 18), the motion is greater in that joint than upon
Fig. 16. Fig. 17. Fig. 18.
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the opposite side, and the limb less than a quarter of an inch shorter than
the other, although it was sawn three inches below the top of the tro-
chanter major, the head and neck having been entirely absorbed, and
the acetabulum perforated. (Fig. 19. The four small pieces of bone are
fragments from the acetabulum.) Only one of my exsections has recov-
ered by anchylosis, and that was from neglect in the after-treatment, I









592 SAY RE,
never having seen the patient after the operation for two years, and the
gentleman who had it in charge having had no experience in the treat-
ment of this class of cases. All the other patients that recovered have
more or less good motion, and infinitely less deformity than those which
have recovered by nature’s process.
Fig. 19.
If the surgeon has not the opportunity of obtaining the wire cuirass,
the after-treatment can be carried out just as successfully by applying
extension and counter-extension, while the patient is in bed. But, of
course, the patient loses the advantages of out-door exercise and fresh air,
which in many instances will be found to be of vital importance.
From the foregoing observations, I am led to the following conclu-
S1O]] S : —
I. That morbus coxarius is a disease most frequently met with in early
childhood, or the age of reckless indifference.
II. That it is almost always of traumatic origin, and not necessarily
connected with a vitiated constitution.
III. That rest and freedom from pressure of the parts involved, while
at the same time the rest of the body is allowed free exercise in the open
air, and a nutritious diet, is the best treatment that has yet been dis-
covered for this disease.
IV. That if this plan of treatment is adopted in the early stages of
this disease, the majority of cases will recover with nearly if not quite
perfect motion, and without deformity.
V. That in the advanced second stage of the disease, when absorption
of the effused fluid cannot be effected, then it is better to puncture or

M O RIB U S CO X. A R IU S. 593
aspirate the joint, and remove its contents, than to leave it to rupture by
ulceration. º
VI. That in the third stage of the disease, when the treatment recom-
mended in this paper has been properly applied without satisfactory im-
provement, but progressive caries continues, then excision of the diseased
bones is not only justifiable but in some cases absolutely necessary. •
VII. That the operation of exsection of the hip is easily performed,
and in itself attended with little or no danger.
VIII. That after exsection of the hip-joint, in cases of progressive
caries, the recovery is much more rapid and certain, and infinitely more
perfect as to form, motion, and the usefulness of the joint and limbs,
than when left to the slow process of nature.
On motion, the Discussion on Dr. Sayre's paper was postponed until the
next meeting of the Section, in order to afford the members an opportunity of
witnessing a practical demonstration of the modes of treatment recommended,
upon several patients who had been courteously placed by Dr. W. H. Pan-
coast at Dr. Sayre's disposal.
Accordingly, the next day, at 11 A. M., many members of the Section assem-
bled in the surgical amphitheatre of the Philadelphia Hospital, when the first
patient presented was a stout woman suffering from hip-disease in the first
stage. She had been under treatment for some time in the hospital, and had
been almost cured ; but the splint had been removed too soon, and the disease
had been re-developed. The night extension and short splint were reapplied by
Professor Sayre in the manner described in his paper.
The second case exhibited was one in the first stage very far advanced. The
patient presented the characteristic symptoms of this stage of the disease, but,
as no instrument of a proper size was at hand, the case was referred for future
treatment.
The third case presented was one in the stage of effusion, or the second stage.
The patient was wholly unable to stand or bear the slightest pressure; weight
extension in the line of deformity was applied.
The fourth case was one in the third stage of the disease, and the following
history was elicited : Thomas S., aged six, had been a healthy, active boy until
about eighteen months ago, when he was knocked down and kicked in the
region of the left hip. Soon after this he began to limp, but complained of no
great amount of pain, that which he did experience being referred to the knee.
During this time he was seen by several physicians, who did not discover any
disease. He continued to become more and more lame, and at the end of six
months a swelling made its appearance on the upper and outer part of the left
thigh. He then began to complain of pain which was spasmodic in character,
and always increased at night. The swelling was punctured, and, after poul-
ticing for a few days, discharged a large quantity of pus. He has gradually
lost flesh, and has become pale. This case was kindly furnished by Dr. J. M.
Barton, clinical assistant to Professor Gross.
Present condition.—Extremely emaciated and anaemic ; left thigh flexed,
adducted across the middle of the opposite one, and fixed. (Fig. 20.) There is
an opening in the outer part of the thigh, about the junction of the middle
and upper thirds, which discharges considerably. The orifice has all the
appearances of leading to dead bone, which is detected by the probe. A large
abscess over the trochanter major is yet unopened.
Upon consultation with Mr. Adams, of London, Professor Lister, of Edin-
burgh, Professor Hueter, of Griefswald, Professor Hjort, of Christiania, Profes-
©
tº)
594 SAY RE,
sor Hingston, of Montreal, Professor Post, of New York, and others, exsection
of the head of the femur was decided upon, as affording the only chance of
recovery.
*}
޺
t
While chloroform was administered by Dr. Sayre's son, Dr. Sayre said that
his plan of using chloroform was entirely at variance with that taught in the
books, and with the doctrine of most authorities, viz., that air must be inhaled
with the anaesthetic, Air, he said, was the antidote to the anaesthetic, and as
long as it was introduced anaesthesia would be prevented; he therefore care-
fully excluded all air not saturated with chloroform, and found that five, ten,
fifteen, or twenty drops thus administered, according to the age of the patient,
produced prompt anaesthesia, without that muscular resistance and contortion
of the body which followed its administration mixed with air. If, by any pos-
sible contingency, this small quantity should produce dangerous or unpleasant
symptoms, a few artificial respirations, effected by compressing the chest, would
exhale the small quantity of poison, and thus avoid any fatal result. When
chloroform was given in the usual way, i. e., mixed with air, anaesthesia was not
produced until a large quantity had been inhaled, in some cases many ounces,
the patient during this time struggling violently; and the damage done to an
inflamed joint by these struggles more than counterbalanced the good resulting
from the anaesthetic. If, under these circumstances, failure of the heart or
respiratory organs took place, the system was so saturated with the chloro-
form that resuscitation by artificial means was almost impossible.
The administration of the drug in the present instance confirmed the cor-
rectness of Dr. Sayre's statements.
The operation was performed in the manner described in Dr. Sayre's paper,
and the child placed in the wire cuirass (Fig. 21); great stress being laid upon
the importance of careful dressing, after-treatment, and nursing. Dr. Sayre
remarked, as he stood the child in the cuirass against the side of the amphi-
theatre, “now this child is ready for transportation.”
Professor LISTER, of Edinburgh, being called upon by Professor Pancoast to
address the company, spoke to the following effect:—We must all regard it as
an extremely fortunate circumstance that Dr. Sayre has had at his disposal
a series of cases so well adapted for illustrating his admirable diagnosis and

M O R BUS COXA RIU S. 595
treatment of the various stages of hip-joint disease. As these subjects are to
be brought before the Surgical Section of the Congress this afternoon, it is
needless for me to allude to them in detail on the present occasion, but I can-
not refrain from expressing the admiration which I feel, in common I am sure
with all present, at the mode of execution and the immediate results of the
excision of the hip-joint which we have just witnessed. Dr. Sayre, indeed, has
made no attempt at display, and he emphatically endorsed a remark of mine
that the days of such exhibitions in surgery were over. For when pain and shock
are prevented by anaesthetics, and when all loss of blood is avoided, whether by
the use of a tourniquet, Or, as in this instance, by the skilful manner in which
the incisions are planned and carried out, mere rapidity of operating becomes
a matter of absolute indifference, except that the work is probably somewhat
better done if a little more time is spent upon it. Nevertheless, gentlemen,
we have seen an extremely skilful performance, not only as regards the opera-
tion, but also in the application of the highly ingenious apparatus used for the
after-treatment. The manner in which the sound leg, firmly fixed upon the
cuirass, is made to serve as a perfectly efficient means of counter-extension, is
indeed beautiful; and to see that boy who was but a few minutes ago a mise-
rable crouching object, and on whom a capital operation has since been per-
formed, standing erect before us upon this apparatus, with a smiling counte-
nance, is as astonishing as it is delightful.
I feel that this demonstration would of itself have been a sufficient reward
for my voyage across the Atlantic, and I beg you to join with me in a cordial
vote of thanks to Dr. Sayre. -
Professor Lister's suggestion was instantly seconded, and a resolution of
thanks to Dr. Sayre unanimously adopted.
The following notes of the subsequent history of this case are furnished by
Dr. D. J. Holla ND, Resident Physician at the Philadelphia Hospital :—There
was not the least untoward symptom following the operation. The patient
was given the pyrophosphate of iron and iodide of potassium, in small doses,
three times daily, and for the first few nights a few drops of laudanum, as an ano-

596 SAY RE,
dyne, though there was comparatively little pain. The limb was dressed every
day, and a new tent placed in the wound ; after the first month, passive motion
was instituted. The patient's appetite gradually increased, and at no time had
he any fever. His condition was excellent throughout, and within six weeks
the wound had closed by granulation.
Two months after the operation, the patient was exhibited before the class at
Bellevue Hospital as the most successful case upon record. There was at this
time good motion. The cuirass was now removed, and Dr. Sayre's long splint
substituted. Within a week the child became accustomed to the splint, and
could walk without any exertion, and there was almost no shortening. He was
discharged from the hospital, wearing the splint, November 11, 1876. (Fig. 22).
The following note has been received from Dr. J. M. Barton, under whose
care the patient came again after his discharge from the hospital :—
Professor SAYRE:
Dear Sir:-I examined the boy Shields to-day, and found that there was five-
eighths of an inch shortening; that the small of the back and the popliteal
space readily came in contact at the same time with the hard table on which
he was lying; that the foot could be raised eighteen inches before the pelvis
moved ; and that the limb readily passed a few degrees to each side of an imagi-
nary line at right angles to a line connecting the anterior superior spinous pro-
cesses, so that the boy could quite readily bring his limbs parallel, though he
makes much more extended motion than that by moving his pelvis.
All the above motions, as well as pressure sufficient to move the boy upon
the table, were totally painless. The limb rotated well; and the foot could be
made to touch the table by its external edge, the boy lying upon his back, and
could be rotated inwardly enough to touch the opposite foot.
There was about one fluidrachm of discharge in the twenty-four hours, and
the boy’s general health was excellent, and his appetite ravenous. .
Respectfully,
J. M. BARTON,
201 S. Eleventh Street, Philadelphia.
Jan. 18, 1877. sº

M O R B U S CO X. A R I U. S. 597
DISCUSSION ON DR. SAY RE's PAPER.
At the next meeting of the Section, the President having announced that
the discussion of Dr. Sayre's paper was in order, Dr. ALFRED C. POST, of New
York, said:—In regard to the danger which attends excision of the upper
extremity of the femur, I would say that the operation in early childhood is
comparatively free from risk, but at later periods of life a very considerable
proportion of fatal cases has occurred. Yet in many cases the danger of the
operation is less than the danger of leaving the disease to pursue its own course.
Even in some instances in which the operation is not necessary for the preser-
vation of life, yet, if the case be allowed to go on to a natural cure, after having
reached an advanced stage, such an amount of deformity will result as will
render the limb an encumbrance, and in these cases the operation is of very
great benefit to the patient.
Dr. S. D. GROSS, of Philadelphia, said:—I came here this afternoon simply
as a listener, but it strikes me that the second conclusion of Dr. Sayre's paper
is entirely at variance with the received opinions of the profession, or at all
events with my own experience. Many cases of coxalgia, according to my
observations, have been cases in which it was impossible to trace as a cause
anything like an injury. I have given special attention for many years to
these cases of coxalgia: I have inquired “ has the child received any injury—
a blow, or a fall, or a contusion, or anything of the kind 7” and in the great
majority of instances the answer has been “no.” I am quite certain that the
majority of my cases—and they have been very numerous—have been of this
character. That the disease may be developed or excited under the influence
of traumatic causes is unquestionable; but I maintain that in the great
majority of instances the affection is of spontaneous origin, and that it is
not necessary for a blow, or a fall, or any such injury to produce the disease.
This is my experience. In regard to the conclusion that it is not necessarily
connected with a vitiated constitution, my teaching has certainly been greatly
at fault if I err in this respect; I maintain, as the result of my dissections,
that this affection cannot occur in a child or in any person whose constitu-
tion is not in a state of degradation, or who is not laboring under some con-
stitutional taint. I believe that it is impossible for a person to contract con-
Sumption without a predisposition to it. So, in relation to hip-joint disease,
consider, if you please, the nature of the suppuration which occurs in coxalgia.
The surgeon finds an abscess, and puts his knife into the part; what is the
character of the matter that issues? Manifestly the same kind of matter that
is expectorated by a patient laboring under pulmonary consumption. This
is beyond all question. I have never seen any other kind of matter escape.
This, I think, settles the question that the affection occurs naturally in per-
Sons predisposed to such diseases. It cannot arise in persons healthy in other
respects. There must be a constitutional vice as a predisposing cause. The
body must be in a state of debility or feebleness. This is my belief, nay,
my solemn conviction. This degraded state of the system may arise from
hereditary predisposition ; the parent may have had scrofulous disease of the
neck or spine, or some syphilitic taint; the predisposition has been trans-
mitted, and the system has become degraded in consequence of the transmitted
taint. The child has hip-joint disease, just as in other circumstances it might
have had disease of the lungs, or tubercular phthisis, or disease of the spine.
Indeed, we not unfrequently find more than one of these affections coexisting
in different parts of the body.
The hip is affected in any particular case, simply because it is a weak point.
The child may have taken cold, and the disease fixes itself in that locality. It
might have fixed itself in the ankle-joint, or in the spine. The child may have
received a blow, or a fall, or what not, but I maintain that that part is in a state
of predisposition at the time when this takes place. I maintain that it is im-
598 SAY RE,
§
possible for a child, born of healthy parents, well nourished, well taken care
of, unless there is a previous predisposition or some degradation of the consti-
tution, to have coxalgia, pulmonary consumption, or diseased spine.
Dr. HENRY FRASER CAMPBELL, of Augusta, Georgia, said:—In regard to the
explanation of Dr. Gross, as to why the child has hip-joint disease instead of
lung disease, I would say that scrofulous affections are developed in various
forms at different ages. I agree that this disease is frequently produced by
traumatic causes ; I might go further and say that most cases which I have
seen have been the result of some fall from the bed, or some carelessness of the
nurse, or some twist of the child's limb or joint. But the same fall or twist,
or the same carelessness, would not produce such a result in a healthy child,
without any disposition to scrofula—in a child that had no syphilitic parent-
age. I recall one case in a very scrofulous child, in which an ordinary fracture
of the arm resulted in the exfoliation of the entire bone. But this never would
have Occurred had that child not been of a scrofulous constitution. I believe
that coxalgia may be one manifestation of scrofula, in childhood, just as at a
later period of life tuberculosis of the lungs is another manifestation of the
same general vice.
Dr. W.M. H. HINGSTON, of Montreal, said:—I formerly believed that scrofula
or struma had everything to do with common coxalgia, but of late years I have
come to think that it has little to do with that affection. Some years ago, in
reading the papers of Dr. Sayre, Dr. Bauer, and others, I asked myself whether
I was not in error in regard to the constitutional nature of this disease, and
whether we were never wrong as to its treatment. In the large hospital at
Montreal, the largest in Canada, to which I was surgeon for fifteen or sixteen
years, I collected a number of cases which I published a few years ago—
twenty-nine cases I think—and of those twenty-nine cases, I believe I could
trace twenty-six to traumatic injury. And the treatment to which we have
resorted is I think conclusive upon this point, differing as it does so much
from the treatment formerly adopted. Without any constitutional treatment
whatever, local measures suffice in a great number of cases. Again, we often see
one child, out of half a dozen, having morbus coxarius, while the other children
of the same father and mother are not affected with the disease. Now, is it
the most sickly one that is affected 7 Not at all. In four cases out of five it
is the healthiest child of the whole family. The child has a predisposition to
the disease, but it is a predisposition to climb and to fall about. The sickly
child rarely has hip-disease. I believe also that the affection is more common
among boys than among girls, because they climb more ; and it is more com-
mon also at that period at which children are cut loose from their mother’s
apron-strings, and are allowed to run about. As soon as they acquire sufficient
intelligence to take care of themselves, the disease becomes rare; it is only
in the period between infancy and adolescence that it is frequent.
Dr. E. M. MooRE, of Rochester, said:—Like Dr. Gross, I have often asked
whether or not there has been any injury, and I have largely failed to find any
recollection of such an occurrence to which the disease might be attributed. But
then we all know that these little bodies are constantly tumbling around, falling
and straining themselves, and I have asked myself how is it that this particular
joint, and no other joint, should be the one affected Ž It seems to me that the
explanation of the fact has not yet been given. In the hip-joint we have a surface,
small as compared with the ankle-joint, and very little larger than the shoulder
or elbow-joint; and yet at this particular point in the body we have an immense
mass of muscles surrounding the whole, and these huge muscles take hold of
the bone whenever there is an injury inflicted, as they do in any other locality.
So we have a reflex action set up in these cases, these muscles taking a sort of
tetanic hold, might and day, to steady the joint. Why? Because nature is
determined to secure rest, which is the cardinal cure of everything. So these
muscles hold the bone up, and the surface is so pressed upon that whenever
there is the slightest degree of inflammation, it must continue. Day by day
M O RIB U S CO X. A R IU S. 599
it will increase, while the child has forgotten the fall, until perhaps a deep-
seated abscess is formed in the tissues. Dr. Gross asked whether we ever saw
anything not like a scrofulous discharge from these abscesses 7 I answer, No ;
and the reason is that they are chronic abscesses, but there may not be the
slightest evidence of scrofulous disease. In the same way we were formerly
taught that Pott's disease originated from scrofula, but I have seen it traced
directly to falls in cases in which no scrofula could be found for three or four
generations backward. Again, we are told that these diseases originate from
a deposit of tubercle, and the mere fact of finding tuberculous disease in con-
nection with these affections is received as affording proof of their origin. But
the connection may be reversed. It is what our medical friends are every day
coming more and more to do. If there is no consumption but such as comes
from hereditary taint, I ask why men who pick mill-stones never live above
forty years. They do not expect a longer duration of life. I had one man,
with a family dependent upon him, to tell me that he did not expect to live
beyond forty years, but he was more fortunate; he lived to forty-five years,
and then died of consumption. The grinders of needles and axes die of con-
sumption. But is it of hereditary taint 7 It is because the particles of steel
get into their lungs, and then produce chronic inflammation. These facts
force themselves upon us. We all appreciate and understand perfectly well
the force of hereditary taint, but it is unsafe to say that such is always the
cause of tuberculous disease. I have myself become thoroughly convinced that
a large number of cases of consumption can be traced to disease of cancellated
bone. I recall one case of a young man of nineteen years who had inflammation
of the tarsus, and a year afterwards presented evidences of tuberculous dis-
ease. I could not with the utmost care trace any consumption in that man’s
family. I am firmly convinced that a large number of cases of Pott's disease,
which are followed by consumption, come from inflammation of the bone, and
not from hereditary taint; because a large number of cases of the same affec-
tion which are cured can be traced to injury.
Dr. GEORGE CUPPLEs, of San Antonio, Texas, said:—In regard to the ques-
tion, why the hip-joint is more often affected than any other, I would say that
perhaps a physiological fact may throw some light on the subject ; this is the
circumstance that the long bone of the body, the femur, is the last to be com-
pletely ossified.
Dr. T. G. RICHARDsoN, of New Orleans, said:—I would like the positive
advocates of the local origin of coxalgia to explain why a severe injury in an
adult is never followed by hip-disease. You cannot mention a case of the kind
which has been followed by this affection. Then, too, I deny that the age of
childhood, or the age of carelessness, is the age at which the hip-joint is most
liable to injury, as is shown by the fact that we seldom or never have dislo-
cation of this joint in childhood. Then, again, I call on those who maintain
that coxalgia originates from traumatic causes to explain why it is that in
cases of congenital dislocation of the femur we sometimes find hip-disease.
Mr. WILLIAM ADAMS, of London, said:—I am satisfied that, in a large
proportion of cases, it will be found that the exciting cause of hip-disease
has been some slight injury; yet years of practice have taught me that there
are cases in which the disease occurs without any injury. We used to be
taught that hip-joint disease often originated as a bone disease, but my own
belief is that it is usually the result of a ligamentous lesion. We have very
few post-mortem examinations of cases in the first stage of hip-disease to
refer to, but, in those which are reported, we find that an inflammatory
condition of the ligamentum teres and a slight exudation into the synovial
membrane were noticed;' and I believe that, in seeking the cause of the
! [See report of post-mortem examinations, made by Aston Key and by Mr. Adams
himself, in Chelius's System of Surgery, edited by South and Norris, Philadelphia, 1847,
vol. i. p. 290.-EDITOR.]
600 SAY RE,
affection, we may look to an injury or wound of the round ligament, as from
some strain, or twist, or jump, when the muscles of the child are in a relaxed
condition. The injury, however slight, causes subsequent inflammation, the
extent of the disease depending much on the constitutional condition of the
patient. This inflammation may lead on to secondary bone disease, or, in
other cases, and in particular states of the constitution, we may have primary
bone disease. + w
Dr. D. HAYES AGNEw, of Philadelphia, said:—It is important in discussing
this subject to understand what we mean by the term traumatic injury, as
preliminary to the whole question. Now, if it is necessary that a joint should
have a powerful twist, or wrench, or that a blow should be inflicted upon it, or
that the patient should be projected from some height—that is one thing;
but, if it is meant that a child by jumping down, for instance, two or three
steps, or by tripping on the floor in walking over a carpet, can in such a way
receive traumatic injury—that is another thing. My impression in regard to
hip-joint disease is this: It is impossible to follow a child in all its move-
ments. Most of the time the child is out of the notice of its mother, in the
care of nurses, many of whom are exceedingly careless. The child may
receive a great many slight injuries which may yet be quite sufficient to
produce such a contusion or such an irritation of the joint as, in a child
predisposed (for I must confess that there is after all a predisposition, which
may remain latent if the child be kept absolutely at rest), may kindle up the
slumbering elements and bring on the disease. I see a great many of these
cases, and I must say that I usually find it not difficult to trace behind all a
constitutional predisposition. In the family, perhaps, one child may have
phthisis, and another enlarged glands, and another hip-joint disease, and
another knee-joint disease. But, in most cases, the immediate cause of the
disease is some external injury of the joint.
Dr. SAYRE said:—Both Dr. Gross and Dr. Campbell agree that some little
injury may produce the disease. That is all that I claim ; I do not assert that
it is necessary for a child to be run over by a railroad car. If coxalgia is con-
stitutional, I would ask why it is that, having recovered from hip-joint disease,
the patient becomes perfectly well, and sound, and hearty 7 why is it that
simply having hip-joint disease cures the constitutional taint 7
Dr. GROSS said:—The difference between Dr. Sayre and myself seems to be
simply this : He says that hip-disease is almost always of traumatic origin,
and not necessarily connected with a vitiated constitution. I, and those who
think with me, do not deny that injury may excite the disease; on the con-
trary, we confess that it frequently does so ; but we maintain that the disease
is always necessarily connected with a vitiated condition of the system.
Dr. J. A. GRANT, of Ottawa, said:—I must acknowledge that for many
years I entertained similar opinions to those now expressed by Dr. Gross;
but in one or two cases observed during the last few years, in the hospital at
Ottawa, where I see many cases of hip-disease, I have been forced to a
different conclusion. One case came under my observation about three years
ago, which I investigated most closely, and in which I failed to trace the
slightest predisposition of a scrofulous character, either in the boy, or in either
of his parents, or in any of his ancestors. In another case that came under
my notice, the disease arose purely from irritation or excitement in the joint,
entirely independent of scrofulous complication. We must acknowledge, of
course, that persons laboring under a scrofulous taint are much more liable
to irritation, and to the development of this disease, than others; but we
must also acknowledge, from the peculiar construction of the hip-joint, that it
is one extremely susceptible to irritation, whether in a scrofulous constitution
or in a constitution not of scrofulous character. I am of those who adhere to
the view that we may have coxalgia occurring in an individual entirely inde-
pendently of scrofulous taint. Q
M O R B U S CO X A R I U. S. 601
Dr. J. H. PoolEy, of Columbus, Ohio, said:—I will go further than Dr.
Sayre's proposition, and say that I believe the disease is not only not neces-
sarily connected with a strumous diathesis, but never connected with it except
by the accident of coexistence. What is scrofula 2 Take all the gentlemen
in this room, one by one, and make each man give his description of Scrofula,
and you will have as many separate descriptions as there are separate
describers. We hear a great deal about scrofula, and hardly know what we
mean. I not only endorse the proposition of Dr. Sayre, but I would have
framed it in stronger language.
Dr. HUNTER McGUIRE, of Richmond, Va., said:—I think I can reconcile in
one or two words the different views expressed in regard to the occurrence of
scrofulous pus in hip-joint disease. I cannot believe that anybody here ever
saw any other kind of pus in coxalgia than scrofulous pus, but it does not
necessarily follow that coxalgia is of strumous origin. I was taught five and
twenty years ago, and I think I have profited by the teaching since, that
scrofula resulted very frequently from pain or irritation, or from the priva-
tions of life, such as insufficiency of food and clothing; so that, if a little
child gets a fall, rapid coxalgia may follow, and then, in consequence of the
pain and loss of appetite, struma may be developed, and there will then be
scrofulous pus.
Dr. JoHN T. CARPENTER, of Pottsville, Pa., said:—The point at issue, it
seems to me, is the local origin of constitutional diseases, upon which Professor
Niemeyer has laid so much stress. I published a paper recently, in the Trans-
actions of the Pennsylvania State Medical Society, in regard to the diseases
of miners. Miners are subject to phthisis, and rarely live over 45 years.
That disease, which we always believed to be constitutional, is caused by
nothing but the inhalation of coal dust. We find solid carbon in the patients’
lungs. The men die, and the old women live in the villages. Now, if their
sons leave the mines and go into the agricultural districts, they live as long as
other people. Here is a local origin of constitutional disease, and so it is
with coxalgia. Every one of us knows that the first sign of constitutional
disease in cases of coxalgia is an irritative fever, and thereafter sinuses form,
and there is a discharge of pus, and phthisis may follow. The struma does
not exist in the case until after long suffering and long disease. It is the
consequence, and not the cause. Children whom I have treated by Dr. Sayre's
method are now healthy and happy, and have never had any phthisis, or
scrofula, or anything of that kind. -
Dr. WILLIAM BRODIE, of Detroit, said:—Some years ago, when Dr. Sayre's
views were first promulgated, I had occasion to see a great many cases of this
disease in Detroit, and, with my friend Dr. Pitcher, had occasion to examine a
great many people who came in from the surrounding country, all supposing
that they were going to be cured by the new method. Some of these patients
died of their coxalgia, and some from other causes. A great many post-mor-
tem examinations were made, and I came to the conclusion that the disease
commenced in the cartilage, and that, when this was absorbed, the bone itself
became affected. I noticed in these cases the presence of a low grade of con-
stitution, as if the patients had suffered from typhus, or were in an impover-
ished condition from cold. We know that children frequently lie exposed at
night, or get into water, or get chilled in other ways, and then the external
surface is affected, and a low grade of inflammation produced, which results
in suppuration of the cartilage. I have always considered hip disease as
scrofulous in its nature, but I believe that it originates in inflammation of the
cartilage.
The President, Mr. Joseph LISTER, of Edinburgh, said:—The question
whether this disease is or is not constitutional, must not be allowed to deter-
mine absolutely the treatment to be adopted. We must not say that because
a disease is constitutional, that it is therefore hopeless to produce a permanent
cure by treating it with local means. Take cancer, for example; that may be
602 SAY RE,
in many cases constitutional, yet we know also of many cases of cancer which
recover if operated upon early enough. There is a local manifestation of a
hereditary taint, but if we take away the local manifestation, there may never
be any other. This is the case also with struma. Glandular abscesses in the
neck are strumous, and yet how many persons live to be healthy and sound
after having these ! It seems to me that if we have such a disease as struma
at all, we have that disease in morbus coxarius. A child came to me in Glas-
gow to be treated for disease of the tarsus. He was treated with a long splint,
and after a while, though still lying in bed, with the splint, several weeks after-
wards, morbus coxarius showed itself. In that child there was a constitutional
tendency which developed itself without traumatic cause. But I admit that
traumatic causes are frequently operative, and we know the constant liability
of children to be affected by traumatic causes. w
Dr. GROSS said:—Have you ever seen suppuration in disease of the hip-joint,
in which there was not scrofulus pus?
Mr. LISTER said:—I must confess that I have. In affections dependent upon
strumous disease, there are great varieties of pus. The treatment which I have
adopted has been, if there has been flexion of the limb, to extend it on a long
splint, and keep the patient at rest. In the great majority of these cases in
Edinburgh, perfect cures are obtained. In Glasgow, a considerable number of
the cases are cured, but not so many as in Edinburgh. Then, again, in Man-
chester the number of cures is a minority. Now I believe the reason for this
is that Edinburgh is a more healthy place than Glasgow, and that Manchester
is a less healthy plage than Glasgow.
Dr. SAYRE said:—I can hardly find language to express my feelings of regret
whenever I am compelled to differ in a professional point of view from my dis-
tinguished friend Dr. Gross. But we must not let personal friendship, or per-
sonal respect and veneration, guide us in the expression of our opinions upon
points of science. It seems to be conceded that an injury is often the exciting
cause of the disease. Now, with regard to the matter of predisposition, I say
that the ordinary teaching has been erroneous, and I believe that the doctrine
has led to bad results in treatment. If the disease is necessarily of constitu-
tional origin, it cannot be cured by local means. You must get rid of the con-
stitutional poison or taint. If it is of constitutional origin, the development of
some constitutional cause, the treatment ought to be constitutional, to affect
the blood and the whole body. What has been the result of the belief in the
constitutional origin of hip-disease ? The use of internal remedies to correct
the constitutional taint, and of local applications to the parts that are simply
irritating. Dr. Gross has referred to the character of the pus: I happened to
be present at an autopsy in a case of hip-disease in Berlin, made by Prof. Vir-
chow, where an examination was made of the lungs, and heart, and intestines.
In the specimens taken from that case there was not a trace of tubercular matter
to be found. It was simply a case of pure chronic coxalgia. The pus was
not of the kind referred to by Dr. Gross. Had that case been carefully exam-
ined and properly treated, in my judgment it would not have terminated
fatally. The trouble was a local one, and the constitutional effects of the
local trouble were mistaken for its constitutional origin. Prof. Gross will
remember seeing a little child whose hip I exsected in Brooklyn. If there
ever was a strumous condition, that child’s condition was certainly entitled to
be called so. In fact the child was almost dead at the time of the operation.
It had lain in an exhausted condition for five or six years, with continued
suppuration, yet by removing the cause of the trouble, without any constitu-
tional treatment, or medicine of any sort or kind except something to eat and
fresh air, from being a dead child, the child is running about to-day in perfect
health. I sent its picture as a Christmas present to Dr. Gross himself. Now,
in reply to the remarks of Dr. Richardson about cases of congenital disloca-
tion, I may say that congenital dislocation has never been seen, although it
has been described by Dr. Carnochan and others, and I believe that I am justified
IMO R B U S COXA RI U. S. 603
in saying that the term is a misnomer. There is no congenital dislocation,
but an arrest of the development of the acetabulum, the bone having never
been completed. It is a congenital displacement, from an arrest of develop-
ment, but not a congenital dislocation. The dislocations that occur in the
adult are immediately recognized and attended to, and after reduction the
parts are kept at rest until all danger of inflammation has passed; whereas the
slight injuries which cause hip disease in the child are overlooked, and atten-
tion is not called to them until, by continued irritation, inflammation has
supervened; and the general health frequently becomes involved before the
slight local injury is recognized. Moreover, in the adult the head of the femur
is much less vascular than in the child.
Dr. HINGSTON said:—We are told that hip-disease may originate from in-
juries to the cartilage and bone, and also from ruptures or injuries of the liga-
mentum teres. Now, I am wholly prepared to admit that in the first set of
cases local treatment would probably suffice to effect a cure, but I wish to know
if the same degree of probability applies also to cases originating in lesions
of the ligamentum teres?
Dr. SAYRE said:—I can answer that question by a practical illustration.
Five or six years ago a case of coxalgia was brought to me by Dr. Jourdon
for excision. There was an open abscess, which had gone through all the
various stages, the disease having originated from a blow two and a half years
before. At the time I saw the case the child was hardly in a condition in
which it was deemed advisable to operate, and so I thought it better, in order
to save the child, to get it in a better condition. In the mean time, to make
the child as comfortable as possible, and put it in a condition for treatment, I
brought it out of its surroundings, and got it out of doors to build it up a
little. When the time came for the operation, the child was so much better
that I concluded to give it a chance without excision. I made a free incision
into the joint, and took away a comparatively small portion of the bone only.
Repair took place; the child got entirely well; and ran around a year and a
half without any splint, and with only slight deformity, and with a tolerable
degree of motion. Some year and a half ago, through exposure, the child got
into a very bad condition, and the physician in attendance informed Dr. Jour-
don that it was going to die. The child did die, and I have the specimen. The
head of the femur and the ligamentum teres have entirely disappeared ; a new
covering had been formed, of what I do not know, but it was smooth, hard,
and cartilaginous. So that that child lived two or three years without any
ligamentum teres at all.
Dr. Post said:—With regard to the necessity of resorting to excision, we
all have known of advanced cases of the disease in which there has been a
favorable result. I was called, two or three years ago, to see a patient in
Jersey City. The knee was thrown up almost to the chin. It was impossible
to place the child in a position even approximately straight, in consequence of
the extreme pain which the effort gave him. He was almost ready to die from
the constitutional disturbance attending the advanced stage of the disease.
He was placed under the influence of ether, and the limb brought into as
straight a position as possible. It was during cold weather, when there was a
fire in the grate, and I put a poker in the fire, and made a thorough application
of it behind the great trochanter. Improvement began from that time; and
some time afterwards the child was brought to me free from deformity. Here
was an entire recovery, and this case goes to show that excision is not always
absolutely necessary.
Dr. SAYRE said :—I have only advised the operation in cases in which the
disease progresses in spite of proper treatment.
Mr. LISTER said:—I think that a distinction between the stage of effusion,
and the stage of suppuration, would be more in accordance with the general
pathology of the subject. I believe the last stage of hip-joint disease is inva-
riably the stage in which suppuration is present. Where effusion exists
604 SAY RE, M ORB US COXA RIUS.
without suppuration, a permanent cure may result by drawing off the fluid.
If the case has gone on to the condition in which sinuses present themselves,
I should be prepared to endorse the proposition that excision is the proper
treatment; but if there is suppuration without an external opening, I am
bound to express my strong conviction in favor of merely opening the abscess.
I know of numerous cases in which the abscesses have been treated anti-
septically, and in which the patients have recovered. Certainly in these cases
the treatment had better results than if excision had been resorted to. I
remember one patient, a healthy young woman in Glasgow, whose two limbs
became exactly alike, except that there was the mark of the small incision
made in opening the abscess; and this result was a great deal better than if
excision had been adopted.
Dr. HINGSTON said:—I wish to ask Dr. Sayre if he can tell from the position
of the sinuses, whether the acetabulum or the head of the bone is diseased ?
Dr. SAYRE said:—I cannot ; the pus will, in either case, gravitate in the
easiest direction.
On motion, the conclusions of Dr. Sayre's paper, with the exception of the
second, were adopted as expressing the opinion of the Section. With the
second conclusion, the Section could not unanimously agree.
REPORT OF A CASE OF SUB-PERIOSTEAL EXCISION AND
DISARTICULATION OF THE ENTIRE INFERIOR
MAXILLARY BONE FOR PHOSPHORUS
NECROSIS.
BY
JOHN W. S. GOULEY, M.D.,
PROFESSOR OF DISEASES OF THE GENITO-URINARY SYSTEM IN THE MEDICAI, DEPARTMENT OF THE
UNIVERSITY OF NEW YORK, SURGEON TO BELLEVUE HospitaL, ETC.
THE record of the case I have the honor of presenting was intended to
be incorporated in a paper on extirpation of the entire inferior maxillary
bone, which I have in course of preparation, and in which I am desirous
of including as many as possible of the illustrative cases contributed by
surgeons of different parts of the United States and of foreign countries.
I venture to report it now in order to recall attention to the subject, and
thereby elicit information regarding cases, the notes of which I have not
as yet been able to obtain, and also to gain access to unpublished cases.
The following is a list of names of surgeons whose cases have appeared
in divers journals and surgical works, or have been communicated to me
by the operators. The operations were done for tumors, as well as for
necrosis; some of them were intra-buccal, but the majority were by ex-
ternal incision, at one or at two sittings, by one or, as in three instances,
by two different surgeons at a considerable interval of time.
Name of Operator. Residence. No. of Cases.
Valentine Mott, New York, l
John G. Perry, England, . l
James Syme, Edinburgh, l
Signoroni, . . Padua, . . . 1
J. F. Heyfelder, St. Petersburgh, 3
Ackley, tº e ſº Cleveland, l
J. M. Carnochan, . New York, . l
Maisonneuve, Paris, . . . 2
J. R. Wood, New York, . l
G. C. Blackman, tº Cincinnati, |
J. H. Pooley, senior, . New York, . l
Pitha, . sº e º 'º Prague, l
Borelli, Turin, . l
Langenbeck, Berlin, l
Holmes Coote, . London, I
Rizzoli, tº º º Bologna, . I
John Adams. . . . London, l
Thomas Smith, London, l
March, Albany, l
A. B. Mott, New York, . 2
Boker, Philadelphia, l
Weir. . . New York, l
J. J. Hull, New York, . I
Trélat, Paris, . 2
Obalinski, Cracow, º º l
Miner, . . . . . . New York, . . . . . . . l
Carnochan and Pancoast, New York and Philadelphia, . l
606 G O U LEY,
Name of Operator. Residence. No. of Cases.
Enos and Cochrane, . . Brooklyn, . l
Hodgen and Mudd, . . St. Louis, . l
Willard Parker, . . . New York, l
J. Mason Warren, . . Boston, 2
Maunder, . . . . . London, l
Westmoreland, . . . Atlanta, . l
Dr. Blackman (American Journal of Medical Sciences, October, 1856)
mentions Walther, of Bonn, Marsh, of Cincinnati, Hutton, of Dublin,
Gauwesky, of Westphalia, Cusack, of Dublin, and Liston, of London, as
having each once excised the entire inferior maxillary bone, but I have not
as yet found the original accounts of their cases."
The subjoined notes of my case embrace the principal points I am de-
sirous of obtaining from surgeons whose cases have not been published.
Mary N , aged nineteen, came to this country from Ireland when nine
years old. At the age of thirteen she was employed in a lucifer-match factory,
where she remained for more than two years. Within a few months after enter-
ing the factory she had a decayed right inferior molar tooth extracted, and
resumed work on the following day. But this does not appear to have caused
any trouble. A year and a half afterwards another inferior molar was removed,
also from the right side, and as before she at once went to work. Very soon
after this she was attacked with phlegmonous periostitis, accompanied by inor-
dinate swelling, which rapidly extended and involved the whole jaw. The
abscess opened spontaneously at a number of points along the base of the jaw,
on both sides of the face, and also in the buccal cavity. She lost successively
the molars of the right side and the two left incisors. The fetid pus which
continually issued from these various fistulous openings was so profuse as to
greatly drain her vital powers. Her appetite and strength soon failed ; she
became anaemic; and her condition was worsening so steadily that, at length,
she applied for treatment to a surgeon who made an incision along the right
ramus, and removed a sequestrum which aſterwards proved to be the coronoid
process. This operation was of little use, as only a very small part of the dead
bone was removed.
I found the patient at St. Vincent's Hospital, early in March, 1864, still fur-
ther reduced in strength by her great suffering and by the profuse discharge
already referred to. The right side of the face was paralyzed from division of
the facial nerve at the time the incision was made to remove the coronoid pro-
cess. The jaw was extremely rigid and mastication impossible. For nearly a
year the patient had lived entirely on fluid food, and with it always swallowed
a considerable amount of pus. All the sinuses led to dead bone. She was
much disfigured by an enormous under jaw, made up of an unusually large
involucrum with the overlying soft parts greatly swollen. On consultation
with my colleagues, I proposed to remove the whole of the involucrum, as well
as its contents, by external incision, as it did not seem expedient to attempt
to save such an unwieldy bony mass, and because it was believed that its extir-
pation would not only remedy the existing deformity and distress, but also
greatly facilitate the ingestion of proper food. To this proposition they
assented, and, on March 19, 1864, I proceeded to operate after the manner
described below.
The patient having been etherized and placed on her back, with the head
! I shall be greatly indebted to those who will have the kindness to indicate to me in
writing the operators whose names may have been omitted, and to furnish me with facts
regarding such unpublished cases as may have come to their knowledge. Each case must
be one of disarticulation of both condyles, and ablation of the whole body of the bone,
whether done at one or more sittings, by one or more surgeons. Communications relating
to the information solicited may be addressed to 311 Madison Avenue, New York.
E X CISION OF INFE RIO R. M. A. XII, L A R Y B O N E . 607
elevated, an incision, including only the thickness of the skin and superficial
fascia, was begun in front of the left ear, carried downwards along the poste-
rior border of the ramus to the angle, thence close under the body of the jaw,
and continued around until it reached the right ear, at a spot corresponding
to its starting-point, so that, in a front view, nearly the whole line of incision
was out of sight. The left facial artery and vein were soon exposed, tied
above and below, and divided between the ligatures. The dissection was then
carried to the bone, and the periosteum separated with a blunt steel knife, begin-
ning at about an inch to the right of the median line, under the chin, and extend-
ing up to the coronoid and condyloid processes. To avoid its sudden retrac-
tion, the tongue was secured by a strong ligature, passed vertically through its
Substance in the median line near the apex, and confided to the care of an assist-
ant. The periosteum of the buccal surface of the jaw was detached from below,
as it could not be reached through the mouth on account of the rigidity of the
parts. The whole left side having been so far enucleated, a chain saw was passed
into the gap between the right central incisor and left canine, and the bone
sawn through a little to the left of the symphysis. Then, seizing this partially
liberated segment with the left hand, and depressing and rotating it outward,
the temporal and external pterygoid muscles were made tense, and successively
divided with the Scalpel close to their insertions. Further use of the knife was
rendered unnecessary by the previous destruction, by disease, of the capsular
and adjoining ligaments, and the bone being free was laid aside. The right
segment was detached from its position by a process similar to that described
above, but the capsular and other ligaments, which were intact, were divided
with the scalpel from before backwards. The vessels, on either side, requiring
ligatures were the facial and their submental and masseteric branches, the
pterygoidean, and the inferior dental.
The lips of this extensive wound were brought together by six fine silken
sutures, on each side, and a few strips of adhesive plaster; and the ends of the
ligature which held the tongue were brought out, one at each corner of the
mouth, and secured to the cheeks by adhesive plaster.
Before the patient recovered from the effect of the anaesthetic, a dose of ten
minims of Magendie's solution of morphia was administered hypodermically,
and this was repeated twice daily for five days, during which time she lay in
a somnolent state and had to be roused to be fed. Her diet consisted of beef-
tea and milk-punch. She said afterwards that during those five days she had
experienced no pain whatever.
The greater part of the wound healed primarily, and the sutures and the
ligature confining the tongue were removed on the third day. Four weeks
after the operation, a slight facial erysipelatous blush appeared, but soon sub-
sided under the application of evaporating lotions and the internal adminis-
tration of chloride of iron. In May, 1864, the patient was discharged from
the hospital, the remainder of the wound (at the seat of the cloacae) having
nearly healed.
The patient called upon me on June 5, 1865, feeling quite well and strong.
Her appetite was excellent, her food consisting chiefly of hashed meats and
potatoes, eggs, bread and butter, and cream. She had gained very much in
weight, and her condition was all that could be desired under the circum-
stances. I last saw her in September, 1871, seven and a half years after the
operation, when she was in excellent health, and when I took the opportunity,
as I had done before, of making a careful examination of the parts with a view
of ascertaining the extent of bone production, which I found to consist of a
thin rim or plate including the mental portion, and the body and part of the
ramus on either side, all of which existed in June, 1865.
The pathological description of the parts removed will be given elsewhere.
I have lately learned that the patient was in 1874 seized with variola, from
which she died, and that no autopsy was made.
608 G OULEY, ExcISION OF INFERIOR MAxILLARY BONE.
It is unusual, in cases of phosphorus necrosis, to find an involucrum,
but in the case just reported there was a large one, and, on the other
hand, very little of the “pumice-stone deposit” so frequently seen. This
is probably to be accounted for by the existence of violent phlegmonous
periostitis in the preceding year.
Another point to which I wish to call attention is the method of
making the incision. Various lines of external incision have been sug-
gested from time to time, but I wish particularly to elicit the opinion of
the Section in regard to the intrabuccal operation, which, as applied to
the entire bone, is said to have originated with Signoroni, in 1843.
It is generally considered safer to divide the operation of extirpating
the lower jaw into two sittings, removing one-half at a time; but Hey-
felder advises that the whole operation should be done at once. Nearly
all the cases included in my table were operated on at different sittings,
the intervals in some instances having been as long as six months. I
have, however, tabulated them as single operations, as the removal of
the second half of the bone is but the completion of a previously unfin-
ished proceeding. .
DISCUSSION ON DR. GOULEY’s PAPER.
After the reading of the preceding paper, Dr. J. C. HUTCHISON, of Brook-
lyn, said:—I think that the intrabuccal form of incision is an unsafe one for
the removal of malignant tumors, since there would then be a greater proba-
bility of leaving behind some portion of the diseased tissue, but for the re-
moval of sequestra, or even of the bone itself, I consider it perfectly feasible.
It is even more applicable to the upper than to the lower jaw, as external
incisions in the region of the superior, are more difficult to conceal than those
in the region of the inferior, maxillary bone. I have myself, by this plan,
broken up and removed the whole upper jaw, together with the malar bone
and even the orbital plate.
Dr. FREDERICK HYDE, of Cortland Village, N. Y., said:—The circumstances
of the individual case, the location of sinuses, etc., should determine the form
of incision. For the removal of sequestra I usually employ the intrabuccal
operation, but for other cases I make such incisions as seem best suited to
the accomplishment of the object. -
The President, Mr. LISTER, of Edinburgh, said:—I was yesterday shown a
specimen, in the Museum of the Pennsylvania Hospital, from a case in which
more than half of the jaw had been removed by Dr. Hunt, from within the
mouth ; and I was informed that the patient had recovered with very slight
deformity. I do not think that the intrabuccal incision is permissible in ma-
lignant disease, but for other tumors it may be practised when the circum-
stances of the case admit of its use. An external incision, however, gives the
operator much more freedom for both sight and manipulation, and, especially
in the male, I should prefer its employment in the majority of cases in which
the entire jaw was to be removed; even in females the scar can be partially
concealed behind the ramus and beneath the base of the jaw. The method of
Maisonneuve, which consists in making the incision further forward and thus
avoiding the facial nerves, is also a good one, and I have recently removed
half of the jaw by a median incision, the resulting scar being but slight.
609
THE CAUSES AND GEOGRAPHICAL DISTRIBUTION
OF CALCULOUS DISEASES.
BY
CLAUDIUS H. MASTIN, M.D.,
OF MOBILE, ALABAMA.
IN investigating the etiology of calculous affections, it will be neces-
sary briefly to examine the composition of the secretion in which they
take their origin, to see what is the normal condition of the fluid, so
that we may observe any changes which take place in its departure from
a standard of health. In this research, we must consider the relation
between healthy or normal urine, and urine which has been changed by
blood alterations; we must observe the causes which produce those
changes, and then decide upon the probable causes which induce the
formation of urinary calculi.
Healthy urine is composed of certain constituents, water being the
menstruum which holds in solution the organic products of digestion
and assimilation. First among those ingredients characteristic of
healthy urine, which are furnished from destructive assimilation of the
tissues and separated from the blood by the liver and the kidneys, are,
urea, uric acid, creatine, coloring matter, and odorous principles.
Secondly, and derived chiefly from the food during the process of assimi-
lation, are, hippuric and lactic acids, together with certain accidental
constituents, and also some inorganic products—saline combinations
which have been separated from the blood, such as the sulphates, the
phosphates, and the chlorides, of which the bases are respectively soda,
potassa, lime, and magnesia; soluble salts which have been introduced
into the economy along with the food, and have undergone decomposi-
tion in the system, or such as have entered into new combinations during
the process of destructive assimilation, as is especially the case with the
sulphates and the phosphates. In addition to these, we find certain
ingredients derived from the lining membrane of the urinary passages,
as the débris of epithelium, from the kidneys; mucus, from the bladder;
and phosphate of lime, the result of the decomposition of mucus and
pus in cases of cystic inflammation.
We know that, during health, the composition of the blood is con-
tinually changing by the introduction of new matter through the process
of digestion, the primary assimilation of the food; and that it is con-
stantly being altered by the presence of waste or effete material, the
result of the breaking down of the tissues in the course of nutrition, or
secondary assimilation. Then we find constant changes going on, the
result of excretion by the liver, the skin, and the kidneys; changes
which control and govern the healthy condition of the urine, and any
departure from which produces certain pathological alterations, which
are either general or special. We also know that, in disease, the blood
is constantly undergoing change in its component parts, receiving new
material of a morbid character through the process of either primary or
39
610 MASTIN,
secondary mal-assimilation, or through the co-operation of both ; the
first representing the process of deficient digestion, the latter of faulty
nutrition. The blood is necessarily changed when these morbid matters
are not properly eliminated, as is the case when we have mal-excretion
by the kidney, liver, skin, or other secreting and excreting organs.
Now, as general pathological changes depend upon some general sys-
temic disorder, as, for example, fever, rapid waste of tissue, anaemia, etc.;
So also special changes depend upon some special unnatural ingredient
present in the circulation and showing itself in the urine, as, for instance,
albumen or sugar; or some natural constituent may be present in unna-
tural proportion, and thus form a leading feature in disease; or again
this natural constituent may become so altered in its physical condition
as to produce a particular morbid state, as when uric acid in combination
with soda gives rise to gout, or when uric acid, oxalate of lime, earthy
salts, and such materials, produce calculous concretions.
Whenever we have mal-assimilation in the process of nutrition, one of
its consequences is what Liebig has termed “destructive metamorphosis”
of the tissues: and, as the various tissues are composed of certain chemi-
cal constituents, we have as the result of their disintegration particular
chemical agents which bear upon and constitute a diathesis. For exam-
ple, when those textures which are rich in albuminous material are
broken down, they furnish an amount of lithic or uric acid which sur-
charges the blood, and gives us the expression, “a gouty diathesis.”
Like changes taking place in the destructive metamorphosis of highly
nitrogenous tissues, as the muscular structures, or even where obstinate
constipation has locked up in the alimentary canal the excrementitous
residue of ill-digested food, urea is formed too rapidly for elimination,
and it is also found in excess in the urine. Then, again, when the brain
and nervous system become overtaxed from any cause, a consequent
prostration follows, and, abounding as they do in phosphoric acid, the
result of this destructive metamorphosis, so to speak, is an excess of the
phosphates, and we have what is known as the “phosphatic diathesis.”
Here we find the débris of the nervous system adding an undue propor-
tion of phosphoric acid to the blood, a combination resulting with its
alkaline and earthy bases, and, as a consequence, a deposition of the
phosphates in the urine. In certain conditions of the bladder, as in
cystitis of long duration, or in enlargements of the prostate where a
change has taken place in the mucous membrane, these salts become
precipitated, and phosphatic calculi result; injuries to the spine, from
which paralysis follows, produce similar results.
Eollowing this course of investigation, we see that when there has
been a destructive metamorphosis of the gelatinous tissues, there is a
conversion into oxalic acid, which, entering the circulation, gives an
“oxalic acid diathesis,” with a tendency to deposit of oxalic concretions.
In like manner, we could trace the formation of sulphuric, hippuric, and
lactic acids, and show that a destructive metamorphosis or transformation
of the tissues in general will produce the chlorides.
We also observe that, during the process of digestion, changes take
place in primary mal-assimilation, by which certain constituents enter
the blood in the same manner that they do during the process of secondary
mal-assimilation, or destructive metamorphosis of tissues. These changes
are referable to the stomach, duodenum, and chyliferous organs, and thus
it is that we find lactic or uric acid the result of imperfect digestion of
albuminous food, urea following an excess of nitrogenous material, or
C A LC U I, O U S D IS E A S E S. 611
the phosphates resulting from an undue proportion of alkaline ingesta
uniting as a base with the free phosphoric acid contained in other articles
of food which were eaten at the same time. Then, again, we find that
certain articles of food supply certain chemical constituents which enter
the circulation during the process of digestion ; for example, oxalic acid
is derived from special articles of diet, as sorrel, rhubarb, tomatoes, and
similar articles, and this acid, acting on the lime contained in hard water
which may be drunk at the same time, furnishes the oxalate of lime, one
of the varieties of urinary calculi. In the same way an excess of sul-
phuric, lactic, and hippuric acids, is formed from articles of food in
which they respectively abound.
Without pursuing this line of thought or reasoning further, we now
turn to the process of mal-excretion, and perceive that certain structural
or functional alterations of either the kidney, liver, or skin (the great
depurating emunctories of the system) may interfere with their healthy
action, and, through a faulty process of elimination, cause an excess of the
urinary constituents to remain in the blood, thus constituting a diathe-
sis referable to the particular ingredient which may predominate. Where
uric acid is the morbid product, we have a blood change giving the
expression of a uric acid or gouty diathesis, which may under certain
circumstances develop a gout, and under others precipitate urinous salts
in the pelvis of the kidney, and give rise to sand or gravel. For during
the process of elimination, uric or lithic acid is separated from the blood
in combination with a base, as soda or ammonia; the former necessary
for the production of gout, the latter for the formation of gravel; and as
both of them are soluble in the urine only when they are not in excess,
and when the urine is at the normal temperature of the body, it follows
that they must become precipitated whenever they exist in abnormal
quantities, and whenever the urine is changed in temperature.
If from any cause we have a structural alteration of the kidney by
which the proper excretion of these substances is prevented, they must
as a consequence be either retained in the blood, or stagnate, so to speak,
in the tubules of the kidney, and thus give us the disease of that organ,
as a cause for the effect. In the same manner, the skin, acting as a great
depurating organ, eliminating effete material from the blood, becomes by
any arrest of its particular function (either from disease or accidental
causes) a factor in the production of certain pathological conditions, as
for example, rheumatism and nephritis; and certain structural altera-
tions of the liver give rise to functional irregularities, which leave spe-
cial morbific matter in the circulation, and thus produce a blood altera-
tion which may aggravate an existing diathesis; for, when “oxidation
is imperfectly performed in the liver, there is a production of insolu-
ble lithic acid and lithates instead of urea, which is the soluble product
resulting from the last stage of the oxidation of nitrogenous matter.”
We see this even in health, when individuals surfeit themselves by an
excess of food which is over rich in nitrogenous principles.
There are some persons who, from habit, are remarkably prone to form
lithic acid in the liver, and, when this tendency exists for a series of
years, a diathesis is formed which controls the system, and the constant
production of the lithates establishes either gout or calculus; for when-
ever a diathesis produces in one person the lithate of soda, and in another
plain uric acid, it can with propriety be said to give rise to two different
affections, two different series of phenomena which spring from one and
the same root. Hence it is that we infer the identity of the causes of
612 - MASTIN,
gout and calculus; the same causes which operate in the production of
the one, bear upon the formation of the other. Therefore as gout depends
measurably upon lithaemia, so also urinary calculi depend for their origin
upon certain functional derangements of the liver acting in concert with
special affections of the kidneys, such as catarrhal inflammation of the
urinary passages over-stimulated by an acid state of the urine.
Next in frequency to uric acid, the oxalate of lime is the most important
constituent entering into the formation of urinary calculi, at one time
forming the entire concretion, at another only the nucleus around which
other urinary salts may collect. This is not one of the normal constitu-
ents of the urine, but is found frequently as a deposit, being probably
produced through uric acid from the nitrogenized material of the food
or tissues—oxalic acid combining with the lime in the economy and
forming the oxalate of lime. Time will not permit me to enter into the
various theories advanced as to the production of this substance in the
system, and hence I will not refer to them.
This product is never present in the form of sand, as is the case with
uric acid, but often exists in microscopic calculi composed of dumb-bell
crystals aggregated together; we detect it also in the system in almost
every form of debility, often in febrile affections, and most usually asso-
ciated with an excess of urea. When this condition exists, we have what
is termed “oxaluria,” a condition of the system referable to some inter-
ference with healthy respiration; possibly produced by chronic bronchitis,
emphysema of the lungs, affections of the liver, or exhaustion of the
nerve centres from either mental or physical labor, or, in some individuals,
the result of excessive alimentation during a too sedentary life which
interferes with healthy digestion and assimilation. It is evident that
this particular substance is the result of a retrograde metamorphosis both
of food and tissue, and hence it is unnecessary again to refer to its pro-
duction from special articles of diet. There is, however, one circum-
stance deserving notice, which is the uniform constancy of the relative
proportion of Oxalic and uric acid, a condition which exists uniformly
and which suggests the inference that the same causes are at work in
the production of both ; especially is this the case when we notice the
remarkable correspondence in the proportion existing between the nuclei
of the two varieties, showing that they are very closely allied, and that
the tendency to form one or the other in different individuals depends
solely upon some particular idiosyncrasy.
Cystic and xanthic oxides are so very rare that we will not consume
time in their investigation, but close this portion of our subject with a brief
notice of the phosphates, which do exist in normal urine; uncombined,
however, they are insoluble, being only held in solution by the presence
of free phosphoric acid. Hence it is that calculi composed of the phos-
phates are not very common as constitutional calculi, and as nuclei they
aré exceedingly rare.
It is not necessary to consider the circumstances which cause the pres-
ence of the earthy phosphates in the urine, but it is essential to investi-
gate the conditions which determine their precipitation; these depend
entirely upon an over-alkaline state of the urine, which has been ren-
dered so by the presence of ammonia, the phosphate of ammonia and
magnesia being precipitated as crystals from the urine in combination
with the phosphate of lime; here the ammoniacal condition does not
arise from an increased excretion of ammonia, but is the result of the
decomposition of urea, setting free carbonate of ammonia and water.
C. A. L. C U L O U S D IS E A S E S. 613
This state is favored by any persistent obstruction to a thorough evacu-
ation of the bladder, producing an irritated or inflamed condition of the
mucous membrane, and causing it to secrete a muco-purulent discharge;
this discharge contains an alkaline pus which is acted upon by the phos-
phoric acid present with the phosphates of ammonia and magnesia (which
are held in solution in the urine only by the excess of this acid), and the
salts are precipitated in the form of insoluble phosphates. Such con-
ditions are favored by enlargement of the prostate, which prevents com-
plete evacuation of the bladder, the retained urine becoming decomposed,
and the free ammonia given off, increasing the cystitis and reacting upon
the pus, forming an adhesive gelatinoid mucus which cements and binds
together the precipitated phosphates in a mass. In the same way the
presence of gravel or foreign bodies in the bladder produces cystic irrita-
tion with its resulting ammonio-phosphatic deposits, and thus calculi of
this nature are formed.
We have now shown that all calculi are either of local or constitutional
origin; that local calculi depend for their cause upon some disease either
primary or secondary within the bladder, whilst constitutional concre-
tions are dependent upon some vicious action—some error of assimilation
inherent to the system ; and constitute by far the larger proportion of all
urinary deposits. For convenience of description, we will divide calculi
into two classes: the first including all those formed of uric acid and the
urates of ammonia, soda, lime, and magnesia, with the rarer forms of uric
or xanthic oxide, and fibrinous and blood calculi; the second, embracing
the various phosphatic deposits and the combinations of the oxalates.
In examining different collections of calculi, it has been discovered that
three-fifths of all calculi met with in adults of all ages are composed of
uric acid and the urates, nearly two-fifths are phosphatic, and only some
three or four per cent. are oxalate of lime ; three-fifths, then, are the pro-
duct of urine abounding in an acid, of which they are the expression ; the
remaining two-fifths are the products of urine, generally alkaline, mostly
ammoniacal, of which they are the result. It follows, then, that the
urates, the oxalates, and a few of the phosphates, which are formed in the
kidney, must be the result of certain constitutional derangements; whilst,
on the other hand, the phosphates, which, whether pure or mixed, are
produced solely in the bladder, must be the consequence not of constitu-
tional but of local disease within the bladder itself.
IIereditary Influence.—In 1776, just one hundred years ago, Scheele
discovered uric acid; and so frequently is it now observed to form the
leading constituent of urinary concretions, that, with Dr. Owen Rees,
who has examined the subject most closely, we may safely state that,
“without its presence, calculi would become much less common than
they are.” This being true, we first consider calculi in reference to this
constituent. In doing so, we perceive that in all those cases in which
uric acid is in excess, a particular diathesis exists—a diathesis which
may have been acquired, but which in all probability has been intensi-
fied by Some pre-existing habit of the system referable to hereditary
causes; in fact it may be safe to state that it nearly always depends
upon a previous vice of constitution which is entirely hereditary, for if
we examine the history of one of these cases, we will almost surely find
hereditary causes at work in its production, and, as Sir Henry Thompson
has remarked, “either gout or calculi will be traced in the family of
nearly every patient who presents himself for treatment.”
| Sir Henry Thompson, Preventive Treatment of Calculous Diseases; London, 1876.
614 MASTIN,
We all recognize the hereditary tendency of gout—a fact too well
established to admit of a question; therefore, as gout depends in a very
great degree upon the formation of urate of soda in the system ; and as
five-sixths of all renal concretions and vesical calculi which have recently
descended from the kidney are composed of uric acid (substances so very
nearly the same), we infer that hereditary influences have controlled the
one as well as the other. It is very true that hereditary tendencies vary
in force in different families; that some members manifest the peculiar
diatheses under which they labor, at one period of life, whilst others of
the same family develop the same disease at another, and that particular
circumstances, or accidental causes, control the pre-existing tendency,
and either hasten or retard the affection ; thus, for example, we see some
members of a family suffering from gout in youth, others in middle life
or old age; and likewise we find some who develop a calculus in infancy,
others not until adult life; or gout and calculi may alternate, one gene-
ration producing the one, and the next the other; or then again we may
meet a person with gouty symptoms and deposits of chalk stones, which
after a lapse of years subside, when a uric acid gravel may form in the
kidney. Here we certainly have a manifestation of two different effects
which arise from one and the same cause. I am aware that hereditary
influences, as causes of calculi, have been questioned by many of our
best informed investigators of this subject; but in view of such facts as
have been produced from the concurrent testimony of Civiale, Le Roy
d’Etiolles, Thompson, and others of like reputation, I am led to believe
that hereditary influences stand first in the scale of causes which produce
calculous affections.
Seeking a cause for this particular diathesis (uric acid), we find it in a
great measure due to defective assimilation in the organs forming the
primae viae; we see the stomach failing to digest food in a proper manner;
primary mal-assimilation furnishing improper materials for the healthy
constituents of the blood ; the liver defective in its action, and failing to
excrete its due proportion of the urinary salts; the solid constituents of
the urine becoming augmented; and the over-worked kidneys unable
to eliminate the excess of uric acid from the super-saturated blood, the
remainder being thus precipitated in crystalline form. Uric acid being
very insoluble, unless in a large proportion of water, and that too at the
normal temperature of the body, it follows that whenever the solution
becomes denser, or its temperature lowered, the uric acid must be pre-
cipitated and left in some portion of the urinary organs, forming in the
kidney renal calculi which afterwards become vesical.
As we have seen a certain diathesis cause an excess of uric acid and
the urates, so likewise it can be shown that other trains of circum-
stances will provoke diatheses which produce the other varieties of cal-
culus. º
Climatic Influences.—Climate doubtless exercises more or less influence
in the production of these affections, for in very changeable regions
calculous diseases are more common than in those localities where a more
equable temperature exists. This is especially the case in the temperate
zones, whilst in very cold or hot countries the disease is not so frequently
met with. Still there are certain districts of the earth's surface, bounded
by the same lines of latitude and longitude, and subject to the same
climatic influences, that develop the disease in one section, whilst in
another section similarly situated it is never encountered. This is
especially noticeable in England and the United States.
C. A.L CU L O U S D IS E A SES. 615
Calculous affections are much more frequent in Kentucky, Ohio, Vir-
ginia, Tennessee, and North Carolina, than in any other portions of the
United States, although we have a vast area of territory similarly located,
geographically, geologically, and climatically, in which stone is rarely
if ever encountered. The same may be said of England, where calculus
is very common around Norfolk and Manchester, while in other regions
which are within the same latitude, and subject to the same temperature,
it is almost unknown. This is also the case in Hindostan and those
portions of China in the vicinity of Canton ; there, calculous disorders
abound to a greater degree than in any other parts of the globe. These
countries are noted for their variableness of temperature, which is one
of the causes assigned for the frequency of this disease; and it may be
possible that a due regard to a change of clothing is not sufficiently ob-
served at such times as these changes occur, and that this neglect may
have an important bearing upon the subject; for when the skin is not
properly protected, its functions become disturbed, and the kidneys are
required to perform an excess of labor.
Poverty.—The poorer classes are more liable to the affection than the
rich ; and it may be noted that they are worse fed and worse clothed
than those in more affluent circumstances. Upon such a class of the
population, climatic changes have a more depressing influence, and in
this way may prove a cause of the affection.
JFood.—The belief that food is one of the causes of calculous affections,
is probably not altogether without foundation; for we find certain articles
of ingesta, already mentioned, which have a tendency to induce acidity
with flatulence, and thus directly produce dyspeptic troubles which may
light up a diathesis lying dormant. Tyspepsia being one of the most
usual of the causes of calculus, almost any article of food which deranges
the function of assimilation, may stand in relation of cause to the effect.
Highly nitrogenous food, when combined with acescent ingesta, increases
the deposition of uric acid, and lessens the formation of the phosphates
in the urine; again, an almost exclusively animal diet contributes to
the rapid formation of uric acid, and, in persons who labor under a calcu-
lous diathesis, lays the foundation of stone. . We believe that the various
articles of diet which are considered productive of calculous concretions,
are so secondarily, first producing irritation in the alimentary canal, fol-
lowed by dyspepsia with mal-assimilation of the food, and thus becoming
the remote cause of the affection ; it is not probable that food properly
digested is ever the cause of calculus.
Water.—Excepting in the case of oxalate of lime concretions, it will
be safe to assert that water does not exert any direct effect upon the
production of calculus. It is very true that, in the case of the oxalic
variety, water may furnish a proportion of lime, which being acted upon
by the acid, will produce the oxalate of lime deposit, but in regard to
the other varieties, we see no sound reason urged, why it should be con-
sidered as a direct factor in their production. The assertion that water
is a cause of calculus, is not sustained by the facts in the case, analyses
of the calculi themselves proving that none of them correspond in chemi-
cal composition with the salts which exist in the waters drunk in those
districts where the calculi make their appearance.
It is self-evident that the only way in which water could have any in-
fluence in the formation of calculi, would be by causing a deposit of those
salts which exist naturally in the urine itself; and to this end they would
have to be of alkaline reaction, and this would favor only a phosphatic
616 MASTIN,
deposit ; but even this view is not sustained by experience, for, on the
contrary, alkaline waters, such for example as those of Vichy and Vals,
and others of like constituents, enjoy a reputation for counteracting a
calculous tendency, and even for dissolving the stone when formed. Then
again the water of the Seine abounds with carbonate of lime, and were
we to attribute to its use the calculous affections which are so frequent
in and around Paris, we would naturally expect to find calculi composed
of carbonate of lime; but both observation and analysis prove that car-
bonate of lime calculus is the least frequent of all varieties.
The same may be said of other regions where stone is prevalent. The
sandstone districts of Kentucky and Tennessee, where soft water is used,
furnish just as many cases of calculus as do the limestone sections where
hard water is commonly drunk; and in Alabama, where stone is but
seldom encountered—there having been only some fifty to seventy-five
Operations performed upon her natives since the settlement of the State
in 1817—it is a fact worthy of consideration that the greater number of
cases has originated in a belt of country running east and west through
the State, just above and including Tuscaloosa ; a pure sandstone region,
with the softest and best water in the State. On the other hand, the
northern and eastern sections abound in blue limestone, and the water
is very strongly impregnated: yet we rarely, if ever, hear of a case of
either gravel or stone within these limits. Again, in middle and south-
ern Alabama, the base of the soil is what is known as “rotten limestone,”
and the water strongly alkaline; this is also the case in eastern Missis-
sippi, and still we have been unable to obtain reliable information of even
a half dozen cases of stone having ever occurred in these regions.
The testimony of Dr. James Guild, of Tuscaloosa, who has been the
leading physician and surgeon of that vicinity for the last forty years,
and who has probably operated for stone a greater number of times than
any other surgeon in Alabama or Mississippi, is, that his cases have all
come from the sandstone districts where soft water is commonly used.
Many other interesting examples could be brought forward to prove
that water does not directly favor the production of calculous affections,
but the time allotted for the reading of this paper will not permit an
extended investigation of the subject. It may be well to suggest, how-
ever, that hard water as a constant drink may secondarily become one
of the causes of stone, by deranging the digestive organs.
Evercise.——Deficient exercise is an important factor in the production
of these concretions; they being more frequently found among those who
are engaged in sedentary pursuits than in that class which leads a more
active life. Inhabitants of large and densely crowded cities, as Paris,
for example, who are confined within doors and live chiefly upon a stimu-
lating diet of a highly nitrogenized nature, with deficient respiration and
neglect of necessary muscular exertion, become fit subjects for the inva-
sion of dyspeptic troubles, which, when supervening upon an hereditary
diathesis, favor the formation of uric acid, with its sequelae gout and
calculus.
Respiration.—Respiration, which is in a great degree controlled by the
amount and character of exercise taken, exerts indirectly a powerful in-
fluence over the production of the urinary salts. We have shown that
a large proportion of all urinary concretions are composed of uric acid,
and that this acid is usually precipitated in the form of one or another
of the urates. We know that, in health, there are only about eight
grains of this acid excreted per diem, whilst of the well-known substance
C A L CU L O U S D IS E A S E S. 617
urea (which, on account of its greater solubility, is never precipitated)
there is nearly half an ounce separated from the blood daily by the kid-
neys. Now, chemical analysis shows that the only difference between
these two substances is the varying amount of carbon and oxygen present
in their composition ; uric acid being represented by the formula
C.N.H.O., while the composition of urea is C.N.H.O.. If then the prin-
cipal difference is made up by carbon and oxygen, the elements of car-
bonic acid, we naturally refer an excess of uric acid in the circulation, to
that process by which carbonic acid is produced, and we know this to be
respiration. Hence we infer that deficient exercise, by interfering with
free respiration, healthy digestion, and assimilation, favors the produc-
tion of calculous concretions.
Age.—Next in order, age seems to exert an influence in the production
of calculi, the urine of infants being more abundantly supplied with
uric acid than that of adults; which condition is doubtless the result of
the rapid changes to which they are exposed, only a few hours after birth,
cold, light, and deficient or improper nourishment, tending to disarrange
the proper performance of the functions of their various organs. Taking
into consideration their defective digestion, errors in their diet, the irri-
tation of dentition, with the consequent excitement of the brain and
nerve-centres, we find them in the very pathological condition most favor-
able to the formation of a diathesis which, when acted upon by heredi-
tary influences, will produce these deposits.
It is not probable, however, that calculous affections are a great deal
more frequent among infants and young children than among adults,
although statistics would lead us to infer that such was the case, since
these go to show that operations for stone have been performed oftener
upon children than upon adults, and more frequently upon the aged than
those in middle life; but when we investigate the subject, we find, as
Mr. Coulson has remarked, “that an error has crept in from not using the
proper precaution to distinguish between absolute and relative numbers.
To determine liability, the absolute numbers should be corrected by the
numbers of persons living at the several periods of life enumerated.
Thus, if all persons under twenty were affected with stone, and all over
seventy were affected with the like complaint, it is evident that the lia-
bility would be the same, though the absolute number of persons attacked
would be very different.” Then, to enable us to determine the liability
of children of a certain age to stone, we must correct the absolute num-
bers by the numbers of persons of all ages living at the several periods of
life enumerated. Corrected in this manner, statistics would most proba-
bly show that young persons are much less liable to calculous affections
than is generally believed. In fact, we have observed that in India,
where stone is exceedingly prevalent (more so, perhaps, than in any other
Section of the world), old men are more liable to the disease than any
other class of the population.
Seac.—Sex has been considered as exercising some influence over these
affections, simply because stone in the bladder is comparatively infrequent
among females. This is no doubt chiefly due to the fact that they have short
and large urethrae, without prostatic portions, thus affording a ready exit
to the nuclei of stone which pass to the bladder after having been formed
in the kidney. We are not aware of any reason why the female is not
as liable to the formation of calculous concretions within the kidney, as
the male; for women are subject to the same general laws and affections
which produce the disease in the other sex. Indeed they are liable to,
618 MASTIN,
and frequently suffer from, attacks of calculous nephralgia, and are often-
times the victims of gout, when exposed to the same exciting causes and
when governed by the same hereditary influences which produce these
diseases in men.
Race.—On the other hand, race evidently does exert a direct bearing
upon the formation of these concretions. In America, where we have
ample opportunities of examining the subject, it has been shown that cal-
culous affections are exceedingly rare among the negro population, and
that gout is seldom, if ever, seen in the black. During the past year, I
have been engaged in collecting statistical information of American litho-
tomies, and in examining the various reports in reference to this point, I
find that out of some 3039 reliable cases which I have to this date tabu-
lated, there are only 102 operations reported as having been performed
upon the negro, and only 31 upon the mixed blood or mulatto. Similar
observations have been made among the native African tribes, and stone has
not been found as a frequent affection. Dr. Thomas Winterbottom states,
in his Medical History of the Native Africans around Sierra Leone, that
“notwithstanding the excesses committed by the pagan nations of Africa
in the use of spirituous liquors, etc., I have never heard of an instance of
gout among them, nor is it probable that they are acquainted with the
disease;” again, he says, “except gonorrhoea, I have never met with any
affection of the urinary passages, such as gravel, calculus, etc.” This is
further corroborated by the testimony of Dr. Livingstone, who states
that “stone in the bladder and gravel are unknown ; I have never met
with a case, though the waters are often so impregnated with sulphate
of lime that the kettles quickly become encrusted with the salt, and
some of my patients who were troubled with indigestion, believed that
their stomachs had got into the same condition.”
This apparent immunity from the affection cannot be due to color, for
we find some of the dark-skinned races, as for instance the Asiatics, ex-
ceedingly prone to the disease; and in the peninsula of Hindostan,
especially in the central and upper provinces, stone is met with probably
more frequently than in any other locality of equal extent on the earth.
In a paper upon this subject, by Dr. Curran, of the East India Service, it
is mentioned that “from Peshawur to Calcutta the diathesis is general
and almost universal;” and we note that at the Medical Missionary So-
ciety’s Hospital, at Canton, Dr. J. G. Kerr operated for stone more than
300 times in the short space of three years. Other instances of the remark-
able frequency of this operation at the hands of the native surgeons of
India could be cited if it were necessary to do so.
Like the negro or black man, the aboriginal tribes of North America
seem to be peculiarly exempt from stone affections; whilst, on the other
hand, the white races are its constant victims—a fact which evidently
can be used as an argument to prove the influence of race in the produc-
tion of a diathesis favoring the formation of stone. If not, how else
shall we explain the fact that the negro and North American Indian
are exempt in a great degree from an affection to which the white man,
and his darker complexioned Aryan brother of Asia, are so liable 7
Habits.—It is possible that habits and modes of life of the white races
may influence in a great measure the production of the disease, exposed
as they are to all the cares and excitements of civilization; inhabiting
sections of the globe subject to sudden vicissitudes of climate, with all
* Livingstone, Missionary Travels and Researches in Central Africa.
C.A.L CU L O U S DIS E A SES. 619
the errors of a life which is not led in accordance with the great laws of
nature, it is reasonable that we should find stone more frequent with
them than in those races which live in a comparatively natural state.
On the contrary, the negro and American Indian are not only
accustomed to a life in the open air, and to a diet suited to their diges-
tion, but having the finest teeth, they masticate their food properly, and
thus still further favor healthy digestion. Their skins are more active,
and, as great depurating organs, eliminate much effete material which
in other races must pass off by the kidney. It is also probable that
Some inherent principle exists in the negro which in a great measure
exempts him from this disease, just in the same way that he is to a
degree exempt from certain fevers and other affections. What that
principle is, I am at a loss to suggest. The inhabitants of India live
principally upon rice and other cereals—materials rich in nitrogenous
matter, and, being careless in guarding themselves against sudden changes
of temperature by suitable raiment, they invite as it were the formation
of a uric acid diathesis; and any exciting causes which supervene to
disturb the normal relations of the urinary constituents must naturally
tend to produce calculus.
Occupation.—Certain occupations seem to exert an influence in prevent-
ing or producing these affections, seamen and soldiers being peculiarly
exempt ; SO much so, that it is a noticeable truth that the disease is
rarely met with in persons who follow either of these modes of life.
Civiale in his large experience saw only three cases among sailors; and
Mr. A. Copland Hutchison states that, in the British Navy, with a
number of patients estimated at 86,000, there were only eight cases of
stone encountered in sixteen years, and that three of these were afflicted
with this disease before entering the service. The records of the Green-
wich Naval Hospital, during a period of twenty-seven years, show that
not a single operation for stone had been performed. This is equally
true of the American Navy, as there is not a single case reported at our
Naval Bureau ; and the testimony of Dr. W. S. W. Ruschenberger,
Medical Director, U. S. N., whose experience in this service extends
over fifty years, is that he has known of only one operation, and that
his personal observation has been confined to but one calculous sailor,
who had the disease at the time he enlisted.
A similar exemption seems accorded to soldiers, if we receive the
statements of Sir James M*Grigor, which show that out of 340,000
patients, among Soldiers serving in the Peninsular Campaign, no case of
calculus was met with from 1811 to 1814. Like results are obtained
from the French and Russian Army records; and the experience of our
late civil war is that there have not been more than two cases of calcu-
lus recorded as the result of a systemic condition; although probably the
richest collection in existence of stones having bone nuclei, has been
collected for the Army Medical Museum, at Washington, through the
indefatigable energy of that accomplished gentleman, Dr. Geo. A. Otis,
of the Surgeon-General’s Office.
Without definite facts to guide us in forming an opinion, we believe
that the most probable cause of the infrequency of stone among seamen
and soldiers, is that they are generally men in the prime of life, there being
comparatively few of either children or old men among them—classes
which are considered the most liable to stone; again, the rigid examina-
| M.S. letters to writer.
620 MASTIN,
tion of recruits for both services, naturally excludes all those suffering
from that state of constitution which would favor a formation of such
deposits. We cannot, therefore, consider that occupation, per se, exerts
any protective influence against calculous concretions.
Moral and Physical Emotions.—Very different is it with moral and
physical emotions; they evidently exert a powerful causative effect in
the production of these affections, and, if time would permit, some very
interesting examples could be adduced to prove the effect of the passions
—fear, anger, joy, and grief—over the normal secretion of the urine.
Dr. Debout D’Estrées, in his treatise on the “Causes of Gravel and
Stone,” narrates quite a number of clinical cases, showing the effect of
mental excitement and depression ; and M. Bouchardat, in his Memoir
upon Gout, gives instance after instance in which violent emotions have
produced polyuria; while Civiale himself often remarked how frequently
severe exercise and great trouble of mind were followed by the forma-
tion of much red sand in the urine.
Poreign Bodies.—We now come to a fertile cause of calculus, which is
the presence of foreign bodies introduced into the bladder, either by
accident or from design; they irritate and inflame the mucous membrane,
thus causing the secretion of an alkaline mucous or purulent fluid by
which the urine is rendered alkaline, and hence a precipitation of the
phosphates around the foreign body which acts as a nucleus.
Injuries to Spine and Urethral Stricture.—Injuries of the spinal cord
produce phosphatic deposits, and thus become one of the causes of vesical
calculi; and it has been asserted that stricture of the urethra favors the
production of these concretions. In relation to the latter cause, I am
inclined to believe that its effect has been over-estimated ; for, after hav-
ing carefully investigated this point, I am struck with the fact that
authentic cases of calculus, resulting from urethral stricture, are exceed-
ingly rare. My friend, Prof. Fessenden N. Otis, of New York, says, in
a MS. letter on this subject, “in over five hundred cases of stricture, to
which I now refer, I have met with but (3) three cases in which stone
was coincident with stricture.” In my own experience with stricture of
the urethra, I find, among the notes of over three hundred cases, that
there are but (2) two in which calculus and stricture have been asso-
ciated ; one of them occurred in an old man sixty years of age, suffering
from enlargement of the prostate; the other in a youth in whose urethra
a small uric acid calculus was lodged in a pouch posterior to the stricture.
It is not improbable, however, that, in very close strictures of long
duration, an arrest to the passage of urine may produce vesical irritation
and inflammation, causing the secretion of a muco-purulent discharge
from the bladder, which will favor such deposits.
Colloids.-Besides the presence of urinary salts, there is something
more required for the formation of calculi, for in their natural state the
salts are not capable of entering into the agglomerated condition essen-
tial to such formations; nor should we consider calculi as mere precipi-
tates of ordinary crystalline and amorphous deposits held together by
plain mucus. Some other agency is necessary, and this will most proba-
bly be found in the presence of the colloids—certain glutinous products,
the result of subacute inflammation of the urinary passages, the kidneys,
the ureters, and the bladder itself; they evidently exert an influence
over precipitated crystals, changing their forms into amorphous, or, as
| Les Causes de la Gravelle et de la Pierre, par le Dr. Debout d'Estrées; Paris, 1876.
CAL C U L O U S ID IS E A S E S. 621
Dr. Vandyke Carter" designates them, “submorphous structures,” which,
in the presence of an animal basis, become embedded in the colloid
matrix, and thus form calculous masses.
The experiments of Mr. Ord” prove that crystalline forms, when asso-
ciated with a colloid, are altered by two processes—first, by modification
of surfaces and angles; and secondly, by a corresponding rearrangement
of the molecules themselves. He proved that the strength of a urate
solution, with a concentration and excess of the acid supplied, controlled
the form of the resulting crystals, and that uric acid, in many of its as-
pects, verged upon the nature of a colloid. He found that albumen
exercised a more powerful influence than any other substance in produc-
ing a change of crystalline form, and a disposition to assume an agglome-
rated condition. Still, we find it difficult to say what is the chemical
nature of the animal basis which, in the living being, causes uric acid
to change its pure crystalline form to some other, more prone to agglome-
ration. But, judging from the experiments of Mr. Ord, we conclude
that it is albuminous, and, as “mucin” is derived from these formations,
probably mucin is the cement.
The general conclusions which we deduce from these experiments are,
first, that albumen and the other colloids, when placed in the presence of
uric acid, cause its crystals to be deposited in the shape of small, thick,
sub-cuboidal bodies, without curved faces, and sometimes as dumb-bells
or spheroids; secondly, that grape sugar and other crystalloids cause the
acid to be thrown down in long tabulated or foliaceous crystals, with
flat sides and sharp angles and edges—forms essential to the process of
agglomeration into masses.
Oxalate of lime crystals are in like manner altered in form by the pre-
sence of a colloid; but it seems to be requisite that the colloid should be
denser than for the same change in uric acid. This fact led Mr. Ord to
draw the inference that, as small calculi which pass from the kidney in
nephralgic colic are generally of the oxalic acid variety, they are doubt-
less formed in the recesses of the kidney, where the colloid medium is
denser than in other portions of the urinary tract.
The triple phosphates are less frequently influenced by the presence of
the colloids than the other varieties, and consequently they are less dis-
posed to form spherical or agglomerated masses.
In the urine we find four groups of substances which are capable of
moulding urinary salts into conglomerate masses, and thus of favoring
the formation of calculi, viz., mucus, urea, coloring matter, and salts.
Standing first among them is mucus, a colloid prone to decomposition,
and active as a ferment in promoting putrefaction of organic substances
when associated with them in solution; now “an excess of this mucus,
altered in character in the urinary passages, or an effusion of albumen,
fibrin, or blood, as often results from congestion of the kidney, or from
irritation of the urinary tract, will furnish a colloid medium with which
uric acid, the urates, or oxalates (themselves perhaps in excess), will com-
bine in the manner before described and thus form a calculous mass.”
The microscopic examinations of urinary calculi, by Dr. Vandyke Car-
ter, sustain the views advanced by Mr. Ord, that the spheroidal forms of
crystalline masses are not entirely due to the mechanical influences at
| Microscopic Structure and Mode of Formation of Urinary Calculi, by H. Wandyke
Carter, M.D.; London, 1873.
* W. M. Ord, M.B., London, M.R.C.P., St. Thomas Hospital Reports, vol. i., 1870;
also Medico-Chirurgical Transactions, vol. lviii., 1875.
622 MASTIN,
work in their formation, and show that there has been a molecule dis-
turbing power acting in the presence of the colloid medium ; and also
that the form and cohesion of the crystalloids in the formation of calculi
may be accounted for by Mr. Rainey's theory of molecular coalescence in
the production of shells.
From the microscopic examinations of urinary calculi by Dr. Carter,
and the experiments upon urinary salts by Mr. Ord, we are led to the fol-
lowing conclusions: All crystals of urinary salts are modified in shape
when they are deposited in a colloid medium; the animal basis of uric
acid tends to produce this change; and like causes bring forth the same
alterations in the crystals of the other salts. The necessary conditions
favorable for the operation of molecular coalescence may at any time be
brought into action ; and wherever there is an excess of mucus which
has been altered in character in the urinary passages, or an effusion of
albumen, fibrin, or blood, from congestion of the kidneys, or from irrita-
tion along the urinary tract, we have furnished a colloid with which uric
acid or the other salts will combine in the manner described. Such a
state of system is found during certain fevers, inflammations, etc., where
the urine becomes loaded with sediment, and the first nucleus of a gravel
begins; this being accomplished, the little nucleus becomes surrounded
by a thin layer of protective mucus, in which continued layers in mole-
cular coalescence are deposited, and a calculus is formed.
We do not desire to be understood to say that calculi are accidental
formations, dependent wholly upon bare physical causes, but rather that
they depend for their production upon an association of hereditary influ-
ences with certain physical causes; and that the defects of structural
development which we find in certain hereditary conditions probably
produce certain elements which are formed into calculi through the
agency of the colloids, these being themselves the result of such an heredi-
tary state or condition. It seems necessary for the formation of calculi
that these conditions should remain constant and unvarying for a period
of weeks, months, or years, thus furnishing time for the slow growth of
these concretions.
Time will not permit me to refer to the changes which take place in a
calculus after the nucleus is formed in the kidney, and during its passage
through the urethra and its lodgment in the bladder; I will, therefore,
close with a brief notice of the geographical distribution of calculous
affections in North America.
Geographical Distribution of Calculi.-Calculus is not universally found
over the Western Continent, there being certain localities where it is met
with much more frequently than in others; and then again there are sec-
tions where it is almost entirely unknown. The central portions of the
United States have furnished more cases than any other parts, whilst the
extreme Southern and Northern States rarely produce a case. Along the
Gulf coast, the Canada line, and the Pacific shores, stone is very uncom-
mon; as it is also in the Canadas, the British possessions, and Mexico.
In the United States, we find it more frequently in an area of country
comprised within the boundaries of Tennessee, Kentucky, Ohio, Indiana,
Missouri, Western Pennsylvania, Virginia, North Carolina, and Georgia,
than elsewhere; there is also a tract of country adjacent to and including
Salt Lake City, Utah, where the disease is said to be remarkably com-
mon. On the other hand, stone is comparatively infrequent in Alabama,
New York, Maryland, and Illinois; whilst in New Jersey, Delaware,
and the New England States, it is so rare that there are very few sur-
geons who have operated for stone in those States. The Warrens, of
CAL CU L O U S I) IS E A SES. 623
Boston, have performed the greater number of all the operations for this
affection which have been done in New England; and that number is
very small when we take into consideration the density of the popula-
tion, and the lapse of time since the settlement of the country. The
States bordering on the Gulf of Mexico—Florida, South Alabama, Mis-
sissippi, Louisiana, and Texas—are almost entirely exempt from calcu-
lous troubles: not more than two or three cases have occurred in Florida;
scarcely more in either Southern Alabama, Mississippi, or Louisiana;
although in Southwestern Texas, along the Mexican line, quite a number
of stone cases have occurred, and have been taken to San Antonio for
treatment; but in all other sections of the State the affection appears to
be remarkably infrequent. It is a strange circumstance that in the State
of Minnesota calculous affections, in the form of nephralgic colic, are
exceedingly frequent, whilst stone in the bladder is so very rare; yet
this is true, and after a very extended correspondence with the leading
physicians and surgeons of that State, I have been able to hear of only
three operations for stone upon persons who have resided there. The
same may be said of Arkansas, with the difference that gout and cal-
culus are so very seldom seen that they have not been classed among the
diseases of the State.
Taking into consideration the recent settlement of Iowa, and its scat-
tered population, it is a little remarkable that stone has been met with
so frequently as is shown to be the case by the number of operations
reported. To this date I have been unable to gather any reliable in-
formation as to the frequency of calculous affections in the far West; but,
from the data before me, I am led to infer that they are uncommon.
Some few cases of stone have been operated upon at San Francisco, but
it has, so far, not been ascertained whether they were of foreign or
domestic origin.
In closing, it may be interesting to notice that almost the entire tract
of country in which stone has been found to abound, belongs to the
carboniferous and sub-carboniferous formations, in which gypsum, lime-
stone, marble, and cretaceous deposits abound ; regions the most produc-
tive of any others of the temperate zone, furnishing all the varieties of
nitrogenous and non-nitrogenous materials of food, both animal and
vegetable, the very kind of aliment most calculated to derange the
digestive organs.
In summing together the probable causes of calculous affections, we
lace—
p I. Hereditary influences which control a diathesis.
II. Digestive troubles produced by an excess or deficiency of proper diet.
III. Sedentary life, with indulgence in stimulating food, by which
healthy nutrition and assimilation are altered to mal-assimilation and
mal-excretion.
IV. Climatic changes, deficiency of clothing for the proper protection
of the body, and an arrest of the healthy function of the dermoid tissue.
V. Want of harmony between the great secreting and excreting
organs—the liver, skin, and kidneys—with catarrhal affections of the
uropoetic viscera, which favor the formation of a colloid medium.
VI. Injuries of the spinal cord, by which a proper nervous influence
over the mucous membrane of the urinary organs is lost.
VII. Foreign bodies present in the bladder, producing cystitis with
its consequent muco-purulent discharge, and becoming nuclei upon which
the phosphates are precipitated.
624
SUBCUTANEOUs DIVISION OF THE NECK OF THE THIGH-
BONE FOR ANCHYLOSIS AT THE HIP-JOINT.
|BY
WILLIAM ADAMS, F.R.C.S.,
PRESIDENT OF THE MEDICAL SOCIETY OF LONDON, ETC.
MR. PRESIDENT AND GENTLEMEN:
THE observations which I propose to offer to-day for the consideration
of the Surgical Section of the International Medical Congress, refer to
the operation of subcutaneous division of the neck of the thigh-bone for
anchylosis of the hip-joint, with malposition of the limb ; an operation
which was first performed by myself in London at the Great Northern
Hospital on the first of December, 1869. I propose to refer to the expe-
rience which we have gained during the past six years, since its first
performance, as far as I have been able to collect records of the cases
operated upon ; and to offer some observations on the mode of performing
the operation, the selection of appropriate cases, and the results to be
obtained as to the permanent condition of the limb, i. e., whether anchy-
losis in the straight position is to be the result, or whether we are to
endeavor not only to rectify the deformity, but to obtain a false joint
at the seat of operation with free voluntary motion of the limb.
Anchylosis of the hip-joint may result from any inflammatory affection
of the joint, and formerly, or I would rather say in our own time, under
the teaching of Sir Benjamin Brodie, and the generation of surgeons now
just passing away, this was the result which all surgeons desired to see
as the termination of hip-joint disease, as well as other joint affections.
Their treatment was directed to the production of this result by long-
continued and absolute rest, with the application of straight and im-
movable splints. In connection with the subject of anchylosis, it is
important that it should be borne in mind that its prevention in a large
number of cases, and prevention is always better than cure, is due to the
advance of American Surgery; and that Professor Sayre, by disproving
one of the old surgical maxims of the English school, that absolute and
long-continued rest, and recumbency with a long straight splint or
some other form of splint to maintain absolute immobility of the joint,
are essential to the cure of the disease—and by substituting his apparatus
acting on the principle of maintaining motion during the treatment of
the affection—has added a great practical improvement to the modern
treatment of hip-joint disease.
As the result of the more severe forms of hip-joint disease, however,
anchylosis must necessarily take place, unless resection has been per-
formed, and must be regarded as the best possible compromise, and the
best termination of a very formidable disease which threatened even the
life of the patient, provided always that the anchylosis has taken place
with the limb in a natural and useful position. In the hip-joint, the best
position for the patient in which anchylosis can take place, is with the
thigh slightly flexed, without any adduction or abduction of the limb;
SUBC UT AN E O U S DIVISION OF THIGH - B O N E . 625
a little shortening is easily compensated for, and the patient can sit down
without much inconvenience in a chair. Anchylosis with the thigh in
a perfectly straight position, i. e., so straight that, when the patient is
lying on his back on the ground, there is no arching whatever of the
spine in the lumbar regions, is attended with very serious inconveniences;
the patient cannot sit on a chair except when resting on one buttock on
the edge of the chair, the anchylosed limb being stretched out with the
heel resting on the floor, and as a result of this habit, in cases of long
standing, the knee-joint bends preternaturally backwards; this is in-
creased by a habit sometimes acquired of crossing the sound leg over the
anchylosed limb. This condition of straight, it might almost be called
over-straight, anchylosis is rarely met with, but I have been consulted by
two patients, one a married lady, and the other a gentleman about forty
years of age, who suffered so much from this condition of straight an-
chylosis that they were both anxious to submit to the operation of divid-
ing the neck of the thigh-bone, if motion could be obtained, but as I was
unable to promise this, and they had become habituated to the incon-
veniences, nothing was done. I may mention that it was not only the
inability to sit on a chair, which annoyed these patients, but they told
me that the bowels could only be relieved in the standing position, so
that they were anxious to submit to any operation promising relief if
motion could be obtained.
Anchylosis with the limb in a deformed position is, however, the con-
dition for which surgical aid is generally sought. In the great majority
of cases of anchylosis of the hip-joint, contraction of the joint with the
limb in a deformed position is found to exist; in some cases, simple
flexion of the thigh having occurred with very little adduction or abduc-
tion; in other cases, severe adduction with a comparatively small amount
of flexion, and again, in others, the distortion will be found to depend
upon flexion with abduction, or adduction, of the thigh, in about equal
proportions. The inconveniences will vary according to the extent and
the direction of the contraction, being greatest in those cases in which
flexion and adduction are combined, so that the knee of the anchylosed
limb is drawn across the opposite thigh ; more especially when this occurs
in females.
There can be no doubt that an urgent necessity for surgical interfer-
ence exists in many of these cases, and it was in the city in which we
are now assembled that the first operation, having for its object not only
that of rectifying the deformity, but of obtaining motion by the estab-
lishment of a false joint, was performed by Dr. J. Rhea Barton in the
year 1826." A large external incision was made, and the bone sawn
through between the two trochanters. The deformity was rectified, and
the case proceeded favorably. It is said that useful motion was ob-
tained, but that seven years afterwards anchylosis took place, and the
man died of phthisis nine years after the operation. This proceeding,
somewhat modified, was afterwards repeated by J. K. Rodgers and others,
but the next operation of importance for this class of cases was one also
performed by a distinguished American Surgeon, Dr. L. A. Sayre, of
New York, who removed a transverse section of the femur, of elliptical
form, just above the trochanter minor, by means of a chain saw, the
“On the Treatment of Anchylosis by the Formation of Artificial Joints,” in the North
American Medical and Surgical Journal, April, 1827, with further remarks in the American
Journal of the Medical Seiences, vol. xxi.
40
626 A DAMS,
external incision being necessarily of large size. This operation Dr. Sayre
successfully performed on June 11, 1862, and as late as April, 1868, the
patient is reported as able to walk with free motion of the limb. Dr.
Sayre repeated this operation on November 6, 1862, and the case pro-
ceeded favorably at first, but abscess with some necrosis of bone occurred,
and the patient died of tubercular deposits in the lungs with pneumonia
on May, 17, 1863. It was found, however, that a very perfect artificial
joint had been formed, and that so far the object of the operation had
been accomplished.
I shall next refer to the case in which I divided the neck of the femur
subcutaneously at the Great Northern Hospital in London, on December
1, 1869." A case of bony anchylosis of the hip-joint with the leg in an
extremely deformed position came under my care at that time, the leg
being flexed at a right angle, and abducted, in a man aged twenty-four.
It occurred to me that the neck of the thigh-bone was the spot to which
attention should be directed, and that if I could divide the neck of the
bone by means of a very small saw passed through a wound not much
larger than that made by an ordinary tenotomy-knife, and thus preserve
the true subcutaneous puncture, I should be able immediately to cure the
deformity, and might, perhaps, succeed in obtaining motion. The instru-
ments used were a long tenotomy-knife, and a very small saw three-
eighths of an inch in width, and with a cutting edge an inch and a half
in length, made by Mr. Blaise, of 67 St. James Street, London. I entered
the tenotomy-knife a little above the top of the great trochanter, and,
carrying it straight down to the neck of the femur, divided the muscles
and opened the capsular ligament freely. Withdrawing the knife, I car-
ried the small saw along the track made—preserving this by pressure of
the fingers—straight down to the bone, and then across the anterior sur-
face of the neck, the flat side, and not the edge, of the saw being applied
to the bone as it was gently carried along its anterior surface; the edge
of the saw was now turned upon the bone, and by a very wiggling saw-
ing movement the section of the bone was accomplished in five minutes.
No hemorrhage followed, and I immediately applied a compress of dry
lint, retained in position by strips of adhesive plaster and a bandage.
As soon as the bone was cut through, the leg moved freely in all direc-
tions; but, before it could be brought into a straight position, it was
necessary to divide the tendons of the long head of the rectus, and of the
adductor longus muscles, and to cut through the tensor vaginae femoris
muscle. The limb was fixed in a straight position, and bandaged to a
long interrupted Liston’s splint. No inflammation whatever followed the
operation; no swelling, or redness of the skin, or any deep suppuration,
but the wound healed slowly, two or three drops of pus in the day oozing
from the track of the wound or the granulations at its orifice for three
weeks. This did not prevent my applying weight extension on the
fourth day, and commencing passive motion. At first the progress en-
couraged the hope that a false joint would be established and motion
retained. After a few weeks, however, the limb began to stiffen at the
hip, and all attempts at movement were so painful that I abandoned the
idea of obtaining motion, and kept the limb in a straight or nearly straight
position for bony anchylosis, which took place, the man obtaining a very
tuseful limb. At the present time this man is able to walk any reason-
| British Medical Journal, December 24, 1870; and also a pamphlet, “A New Operation
for Bony Anchylosis of the Hipjoint;” London, 1871. -
SUBCUT AN E O U S DIVISION OF THIGH-B O N E. 627
able distance without stick or crutch, and earns his living by an active
occupation. I have mentioned the details of this, the first case, because
it very fairly represents the general course of events in others.
Deviations in several respects will have to be made in particular cases;
for instance, the exact point of puncture and the direction of the same
will require to be varied in reference to the altered relation of the thigh-
bone to the pelvis, i. e., whether the thigh is simply flexed upon the pel-
vis, or flexed and adducted, or abducted. The altered direction of the
neck of the bone, thus produced, must be very carefully calculated by
the surgeon before making the section, which should be at right angles
to the long axis of the neck; great care must be taken to avoid cutting
obliquely through the neck, or in a direction parallel with the shaft of
the bone, a mistake easily committed if the altered direction of the neck
and shaft of the bone be not carefully considered. A good general direc-
tion in the majority of cases seems to be to place the saw, just before
commencing the section, parallel with Poupart's ligament, and from
three-quarters of an inch to an inch below it. I, have found in the dead-
house that this direction will generally enable the operator to cut through
the neck a little below the articular margin of the head of the bone.
Then with regard to the number of cases which have been operated
upon up to the present time, and their results: I possess the records of
twenty-four cases, including five operated upon by myself; four by Mr.
Bryant, of Guy’s Hospital; two by Mr. Sydney Jones, of St. Thomas's,
and one by Mr. Croft, of the same hospital; two by Mr. Jessop, of Leeds;
two by Mr. Lund, of Manchester; one by Mr. Hardie, of Manchester;
one by Mr. Maunder, of the London Hospital; one by Mr. Willett, at
St. Bartholomew’s; one by Mr. Jowers, of Brighton; one by Mr. Furneaux
Jordan, of Birmingham; one by Mr. Jonathan Hutchinson, of the Lon-
don Hospital; one by Mr. Brodhurst, at St. George's, and last, but not
least, one of the best and most successful, in which motion has been re-
tained, by Dr. Sands, of New York. Out of these twenty-four cases only
one death, from pyaemia, has occurred, and that in an extremely unfavor-
able case, in a very strumous boy, aged eight years, operated upon by
Mr. Croft, at St. Thomas’s Hospital. In another case, the last operated
upon by myself, deep-seated, chronic suppuration followed and gradually
exhausted the powers of the patient, a very strumous girl, aged eighteen
years, who died eight months afterwards, having suffered from albumi-
nuria and phthisis.
Such a result bears good testimony to the general safety of the opera-
tion, and although the dangers even of subcutaneous sections much
increase with the magnitude of the operation, these may be kept within
their narrowest possible limits by the judgment of the operator in select-
ing his cases, and the skill shown in the performance of the operation.
With regard to the selection of cases there can be no doubt that
the most favorable are (1) Cases of rheumatic anchylosis, because, in
rheumatism, no destruction of bone ever exists, and the head and neck
of the bone always remain of their full natural size. (2) Cases of anchy-
losis after pyaemic inflammation, more especially in its subacute form,
from which the patient generally recovers. In these cases destruction of
bone rarely if ever exists, the cartilage only being more or less destroyed.
(3) Cases of anchylosis after traumatic inflammation, in healthy adults,
such as follows wounds of the joint, and gunshot wounds in the neighbor-
hood of the joint. As a general rule, in these cases, little or no destruction
of bone occurs even after acute suppurative inflammation. (4) The most
628 A D A MS,
unfavorable cases for operation are those belonging to the strumous class,
because, as a general rule in these cases, disease of the bone, with de-
struction of the head and neck of the thigh-bone, to a greater or less
extent, takes place; and consequently, in the worst forms of this class,
the operation either cannot be performed, or would be attended with
such difficulties that it should not be attempted. In many cases of
anchylosis after hip-joint disease in children, however, especially those in
which there is little or no evidence of a strumous constitution, and in
which the disease has been arrested in an early stage, without the occur-
rence of suppuration, not more than superficial caries exists, and some-
times the mischief is limited to the articular cartilage. In these cases
the head and neck of the femur may be but little altered in form and
direction, and the operation can generally be performed ; and Mr. Bryant,
of Guy’s Hospital, has especially extended the operation with the most
marked success to this class of cases.
Originally my idea was that the operation should be limited to cases
of bony anchylosis, generally occurring in the adult ; but the ease and
safety with which Mr. Bryant has performed the operation in children
from eight to fifteen years of age, will induce me also to operate in simi-
lar cases.
When the operation of dividing the neck of the femur cannot be per-
formed in consequence of extensive destruction of the head and neck of
the bone, then the operation first performed by Mr. Gant at the Royal
Free Hospital in London, on December 10, 1872, should be adopted. It
consists in dividing subcutaneously the shaft of the femur just below the
small trochanter. The bone is cut from without inwards, and not always
completely through, a portion of the femur on the inner side being broken.
Instruments similar to my own are used. Mr. Gant has twice performed
this operation with success. -
Mr. Maunder, of the London Hospital, has also operated subcuta-
neously, or nearly so, in the same situation, but has substituted a chisel
for the saw—as, it appears to me, without any advantage—the small
saw being the more manageable instrument, and never more than one
introduction being required. Mr. Maunder has, however, very success-
fully employed this method in several cases.
The conclusions to which, I believe, we are justified in arriving from
what has been stated are—
I. That bones can be divided subcutaneously like tendons; and that
the operation of completely dividing the neck of the thigh-bone by a
small saw, introduced through a small subcutaneous puncture, is a well-
established surgical operation attended with very little risk.
II. That the long bones can be completely divided by the same method
in any part of their length with very little risk.
III. That in a large proportion of these cases the healing of the wound
takes place by the first intention, and that no swelling, redness, or in-
flammation follows. These cases of subcutaneous Osteotomy proceed as
favorably as subcutaneous tenotomy.
IV. That in some cases a little suppuration from the track of the
wound, amounting only to a few drops in the day, does occur for a week
or more after the operation.
V. That, in a very few cases, deep-seated suppuration occurs; but in
only one of these, so far as at present known, has death resulted from
pyaemia out of the twenty-four recorded cases. In one other case death
SUBC UT AN E O U S DIVISION OF THIGH-B O N E. 629
was accelerated by the operation, or rather by the prolonged suppuration
which followed. The patient died eight months afterwards from albu-
minuria and phthisis. .
VI. That the permanent result of the operation has hitherto generally
been to correct the deformity, and obtain bony anchylosis with the limb
in a straight position; but in several instances free motion has been ob-
tained, and remained only for a few months, when it has been gradually
lost. In a few cases free motion has remained for about a year, and we
hope will be persistent through life; but time and further experience are
necessary before this can confidently be stated to be a reliable result of
the operation.
DISCUSSION ON MR. ADAMS's PAPER.
After the reading of the preceding paper, Dr. ALFRED C. Post, of New
York said:—Many years ago I performed Dr. Barton's operation upon a young
man who had had coxalgia resulting in anchylosis in such an abducted and
flexed position that the genitals were hidden from view. I divided the neck
of the femur, according to Barton's plan, but on the second or third day the
limb became emphysematous, gangrene followed, and the patient died. At the
post-mortem examination, the femoral artery and vein were found hooked
Over the sawn end of the bone. Such an accidental complication would not be
likely to occur again, but Mr. Adams's plan of dividing the bone within the
capsule would certainly avoid it.
Dr. LEOPOLD SERVAIs, of Belgium said:—Anchylosis may result from vari-
ous causes, such as rheumatism, scrofula, syphilis, wounds, etc. The use of
an anaesthetic is necessary to distinguish between true and false anchylosis. I
am of the opinion that true anchylosis does not occur save in cases in which
suppuration has taken place. When it is necessary to divide the femur below
the trochanters, it is, I think, better to employ brute force, and break the bone,
as we then have but a simple fracture to treat. From experiments lately per-
formed in France, it has been proved that the femur is weakest at this point,
and consequently it will be likely to give way there. The breaking is not
difficult, as I have ascertained by fracturing the femur accidentally in other
operations.
Dr. LEWIs A. SAYRE, of New York, said:—I would ask Mr. Adams when he
begins extension, and how long he continues it 7
Mr. ADAMS said:—I have heretofore applied extension on the fourth day, but
shall in future be disposed to employ it at an earlier period. It should be
continued about as long as for an ordinary fracture, but, after a few weeks,
passive motion should be practised, and this should be continued once a week,
under chloroform, for a long time, in order to prevent the anchylosis which is
so liable to follow.
Dr. SAYRE said:—The cases upon which I operated are fully reported in my
book. One was the case of a female whose legs were so crossed as to interfere
with micturition. I took out a section of the bone, rounding off the surfaces,
and allowing the psoas and iliacus muscles to retain their attachment to the
lesser trochanter. The recovery was perfect, and, when the patient died from
other causes, a ligamentous connection was found to have been formed be-
tween the resected parts, and there was also a Y-shaped ligament and a form
of membrane resembling the synovial. The results of my cases have been
good, but I am decidedly in favor of Mr. Adams's operation, as the more
simple and safe one, provided anchylosis does not subsequently occur. Mr.
Adams's statement confirms my opinion that this result is quite probable, yet
the cases in which it does not take place are sufficiently numerous to make the
operation a desirable one. I shall in future use this method, but shall apply
680 ADAMS, SUBCUTANE OUs DIVISION OF THIGH-B on E.
extension at once, and make passive motion frequently. A divided bone,
tendon, or fascia, should be at once put in proper position, as the effused
lymph, being poorly vitalized, does not bear the process of subsequent stretch-
ing at all well. The danger of extending the muscles beyond their original
length, and consequently separating the bones, although possible, yet will not
deter me from putting on extension at once.
Dr. T. G. RICHARDSON, of New Orleans, said:—I recall a case in which I
fractured the neck of the humerus in trying to reduce an axillary dislocation
of long standing. I at once pushed the broken bone up into the glenoid cavity,
bound it firmly in place, commenced motion on the third day, and secured a
good and movable joint. - -
Dr. E. M. MooRE, of Rochester, said:—Dr. Bly, of Rochester, has made
some experiments upon the extensibility of living muscles. He has found that
the force required to stretch a muscle is very great, but that a weight of 300
lbs. will cause decided lengthening. The practical inference is that too
great extension should not be used after Mr. Adams's operation, lest the ends
of the bone be drawn too far apart.
631
REMARKS UPON PENETRATING WOUNDS OF THE ABDOMEN,
WITH THE SUGGESTION OF A CHANGE OF PRACTICE
IN SUCH CASES.
BY
L. A. DUGAS, M.D., LL.D.,
PROFEssoR OF SURGERY IN THE MEDICAL COLLEGE OF GEORGIA.
PENETRATING wounds of the abdomen are full of interest to the sur-
geon, not only because of their frequency, but also because of their
extreme fatality. The marked susceptibility of the lining membrane of
the abdominal cavity to morbid action, and especially to the absorption
of deleterious agents, together with the importance of the organs con-
tained, will account satisfactorily for the gravity of these wounds.
But the danger of these injuries varies according to their character
and to the organ implicated. It is, therefore, not a matter of indiffer-
ence whether the injury be a puncture, an incision, or a gunshot wound;
for, while punctured and incised wounds are more liable to induce
hemorrhage, they heal more readily by first intention; whereas gunshot
wounds are less apt to be attended with serious loss of blood, but will
almost invariably be followed by suppuration. In penetrating wounds
of the abdomen, our first concern then is with regard to hemorrhage,
which itself will depend upon whether a large vessel be opened or a
parenchymatous organ be injured ; for punctured and incised wounds of
large vessels, and of the liver, spleen, and kidneys, are usually attended
with rapidly exhausting loss of blood. If the patient escape this first
danger, the question presents itself as to what we should apprehend next;
and the determination of this question is of the utmost importance to the
patient, as his life may depend upon it.
Upon this point there exists among written authorities the most strik-
ing uniformity in the belief that peritonitis is the condition most to be
dreaded when primary hemorrhage has not carried off the patient, and
that the extraordinary fatality of these wounds is the necessary conse-
quence of this inflammatory action, whether induced by the mechanical
injury, or by the contact of atmospheric air, of effused blood, or of fecal
extravasation. And yet, when we come to examine into facts, we find
that the great majority of deaths occurs so early after the injury as to
render such an explanation exceedingly improbable and unsatisfactory.
Death, unless from hemorrhage, usually takes place within from twenty-
four to thirty-six, or at most forty-eight hours after the injury; a rapidity
entirely too great to be accounted for by any process of inflammation,
properly so called. No true inflammation ever runs its course to a fatal
termination in so short a time. Moreover, the peritoneum is not an
organ of such vital importance as to render its inflammation necessarily
fatal; and when death does attend this inflammation from other than
traumatic causes, dissolution rarely takes place in less than a week.
Again, it may be doubted that the peritoneum is as susceptible to
inflammation as is generally supposed. Indeed, with the light thrown
632 DU G AS,
upon this subject by the multiplied operations for ovarian disease, is it
not evident that the danger of a traumatic injury, per se, of the perito-
meum has been enormously exaggerated 7 Is it not also true, on the
other hand, that the mortality resulting from these operations has gradu-
ally lessened with the additional care taken by the surgeon to prevent
the retention of blood or other septicaemic materials in contact with the
peritoneum ?
With these preliminary considerations we now feel prepared to advo-
cate the doctrine that the frightful mortality of penetrating wounds of
the abdomen, and the rapidity with which the fatal result is brought
about, point directly and immediately to septicaemia or blood-poisoning,
as the only condition at all adequate to the production of such effects;
and that the blood-poisoning is the almost necessary consequence of the
plan of treatment recommended by standard authorities and carried out
in daily practice.
If the intestines protrude and are found to be wounded, we are advised
to cleanse, stitch, and return them into the cavity; otherwise the case is
to be trusted to nature, and perhaps treated by antiphlogistics with a
view to prevent or to subdue peritoneal inflammation. In the mean
time the blood necessarily effused, whether much or little, is left in con-
tact with the peritoneum, rapidly undergoes putrefactive decomposition,
and is as promptly absorbed. Magendie long since demonstrated the
wonderful celerity with which agents were carried into the circulation
through the serous membranes. But if the system may be contaminated
by the retention of blood alone in contact with the peritoneum, what
should we not expect from the addition of fecal extravasation. Assuredly
not inflammation, but most rapid septicaemic poisoning. In view of the
rapidity with which toxic agents reach the circulation through the peri-
toneum and other serous membranes, we may safely infer that the fecal
poisoning begins very soon after the extravasation, and that it must have
much to do with the rapid prostration so uniformly observed in such cases,
and usually attributed to nervous shock.
The awful fatality of penetrating wounds of the abdomen revealed by
statistical observations would seem to indicate the necessity for a change
of practice, and I have accordingly been teaching for a number of years
to the classes of the Medical College of Georgia the propriety of looking
upon septicæmia as the paramount danger of such wounds, and of taking
such steps as would be best calculated to avert this poisoning. The
recent occurrence of several fatal cases in my neighborhood prompts me
now to a more formal appeal to the profession for a reconsideration of
the principles by which we have been governed in such cases, and to sug-
gest that in all instances of penetrating wounds of the abdomen, in which
there may be any suspicion of the existence of effusion of blood or feces
into the peritoneal cavity, the surgeon should proceed immediately as
follows:—
(1) Induce anaesthesia.
(2) Lay open the abdomen along the linea alba, freely enough to make
a thorough inspection of the parts contained.
(3) Ligate all bleeding vessels as far as possible.
(4) Examine carefully the whole length of the alimentary canal, in
order to detect any wounds, and to stitch them. If the intestinal wound
be ragged, it should be trimmed down to a straight edge.
(5) In gunshot wounds reduce the channels of entrance as well as of
exit through the abdominal walls to the form of incised wounds, so that
PEN E TRATING W O U N DS OF A B D O MEN. 633
these may be closed and left to adhere by first intention. In some cases
it may be found necessary for this purpose to remove the uneven track by
a double elliptic incision.
(6) Cleanse the wounds and peritoneum of all extraneous materials,
and close the abdominal walls with suitable sutures and adhesive
plasters.
(7) Finally, control the peristaltic action with opium, and administer
such nourishment as will leave least fecal residuum, as milk, eggs, etc.
As supplementary to these suggestions it may not be out of place to
add that for anaesthesia I would prefer ether, as being less enervating
and safer than chloroform ; and that, for stitching the intestines, animal
ligatures, of catgut or violin-strings, wet with an antiseptic solution,
should be preferred.
These principles have been most successfully carried out by the writer
and others in cases in which the wounded intestines have protruded; and
yet we have allowed other cases to die simply because the abdominal
wound has not been sufficiently large to permit the bowels to come into
V le W.
If the practice now suggested be considered harsh and hazardous, I
would ask what can be worse than the authorized plan, which makes
death the rule and recovery the rarest exception ? Is it not time that we
should discard as groundless the fears heretofore entertained with regard
to the danger of opening the abdominal cavity ? No change of practice
in the class of wounds under consideration can make the chances of
recovery less than they are now ; and I feel confident that by adopting
the plan proposed we would so alter the results as to make recovery the
rule and death the exception.
634
ON OPENING THE SAC IN HERNIOTOMY.
BY
FREDERICK HYDE, M.D.,
OF CORTLAND, NEW YORK.
Both Paré and Franco, when performing Herniotomy, avoided open-
ing the hernial sac when its contents could be reduced without its divi-
sion. Their practice, however, continued to be exceptional until Petit,
in cases of large and adherent hernia, left the sac entire, and till Key and
Preiss adopted the method as a rule in all cases. It has been held by
some surgeons that Sir Astley Cooper's plan was to leave the sac
unopened in all cases. We think it will be found, from his recorded
observations, that the examples in which he practised and advised leav-
ing the sac entire, were such, in the main, as he termed, “old large rup-
tures.” In his Lectures on the Principles and Practice of Surgery,
edited by Frederick Tyrrell, will be found, in his terse description of
the operation of incising the stricture in the inguinal form of the dis-
ease, all the details of opening the sac to the extent of “freely exposing
its contents.” He says, “if the stricture be seated in the neck of the her-
nial sac itself, of course the division of the part exterior to it will not
relieve the strangulation ; in this case, the sac must be opened carefully
at the upper part, only so as to allow a division of the stricture.” He
also alludes to the advantage of “ dilating the stricture without cutting
the sac itself, as it exempts the intestine from all danger of injury from
the edge of the knife.” He advises, too, that the sac should not be
divided higher than an inch below the abdominal ring, as its division
near the abdomen makes the wound more difficult to close, and exposes
the patient to greater danger from peritoneal inflammation. In his
description of the operation for femoral hernia, Sir Astley concludes his
directions for opening the sac in these words: “We should further divide
the anterior part of the sac upwards and downwards.” In strangulated
umbilical hernia, he says that the peritoneal covering should be cut into,
and divided in the same way as when operating for other herniae. “In
very large umbilical herniae, when strangulated, the umbilical opening
should be dilated upwards without dividing the sac.”
From this brief reference to the doctrines and practice of this eminent
surgeon on the question at issue, it will be seen that he generally opened
the sac, and that while he expressed the belief, at least on one occasion,
that herniotomy without its division might become the more successful
and general operation, yet through his long and distinguished professional
life, it was with him an exceptional rather than a general practice.
Petit's operation, called the minor operation, was adopted by Key in
its most extended application. In discussing its merits, he says that in
the majority of cases, in which patients die after this mode of operation,
the death is caused by peritoneal inflammation consequent upon the
exposure of an inflamed or strangulated portion of bowel. He says, too,
that it is not so much the wound in the peritoneal sac that disposes to
inflammation, as the exposure of the bowel to conditions to which it has
OPENING THE SAC IN HE R NIOTO MY. 635
hitherto been unaccustomed. He also affirms that the inflammation fol-
lowing the operation for hernia spreads from that part of the bowel that
has been strangulated, and does not have its origin from the incision of
the sac, even if there are two wounds inflicted upon it, one to expose its
contents, and another, higher up, to cut the stricture. Sir William Law-
rence dissents from the opinion of Key, that recorded cases are “so largely
caused by the operation of exposing the intestine, and its attendant expo-
sure to air and light, change of temperature, and handling,” and says that
it is the presence of the stricture which affects the parts, not like the
slight violence of the operation for a few minutes only, but uninterrupt-
edly for hours, and sometimes days, disturbing the circulation, making
an impression on the intestine as if it had been tied with a string, and
sometimes causing ulceration of the internal tunics, or of the bowel in its
whole thickness. Here, then, is the chief issue between Key and Law-
rence; the former objecting to opening the sac, not so much from the
fear of wounding it, as of the exposure of its contents to new circum-
stances—as air and light, change of temperature and manipulation—the
latter fearing the effects of the stricture, acting continuously for a longer
or shorter period, with efforts at taxis, and not the exposure of the con-
tents of a divided sac for a few moments; and declaring that under all
circumstances he is still disposed to continue the practice of opening the
sac, believing it to be the most safe.
Luke, who advocates Petit's, or the minor operation, in describing it,
refers to the different sites and textures in which the stricture may be ;
gives some rules to govern the diagnosis, admitting that the girding of
the parts may be found, in the inguinal hernia of the male, at any point
from the internal abdominal ring to the scrotum ; and adds, finally, with
regard to the necessity of opening the sac, when the stricture is caused
by its thick and indurated neck, that, instead of a complete opening, only
the exterior tissues of the thickened, hardened neck should be incised ;
when, he asserts, the neck of the sac is so far dilatable that the anterior
pressure of the hernial contents will allow their return by the taxis, and
directs that, in case the first efforts are not successful, this partial division
is to be renewed, when by repetition of the process the strangulation may
be relieved without entire opening of the sac.
Chelius, after having divided the covering down to the sac, directs
that it should be “cut into, and the opening of the sae increased upwards
and outwards throughout its entire length.” He also says that the mode
of operating in which the hermial sac is not opened at all, but only the
abdominal ring dilated, so as to return the hermial sac together with the
intestine, is in general to be rejected, and that the not opening of the
sac is to be most especially confined to those cases in which it is certain
that in a recently produced, or extraordinarily large rupture, or in a
rupture entirely adhering to the neck of the sac, the strangulation is
seated in the abdominal ring. Twenty-five years ago, Skey, in describ-
ing the operation of herniotomy, used these words: “By proceeding
slowly through the various coverings, we reach the sac of the peri-
toneum. Sometimes the sac is drawn so tightly over the contents as to
be separated from them with difficulty. We select for this purpose the
lower part, which is usually somewhat distended by gravitating fluid,
and here it may be opened without danger.” In the fourth American
edition of Fergusson’s Practical Surgery, in the account of the operation
for strangulated inguinal hernia, it is directed that, after having divided
all the overlying tissues, so as to lay bare the outer surface of the sac,
636 HYDE,
“a small aperture should be cautiously made in this membrane, which
should then be more fully laid open.” Fergusson also says that, “ in
large protrusions, it would unquestionably be highly desirable to return
the contents without exposing the peritoneal surface. In the majority
of such cases the stricture may be divided without penetrating the sac,
but in some instances, even after this has been dome, the protrusion can-
not be returned in consequence of adhesions.”
Prof. Gibson, in the sixth edition of his “Surgery” describes the man-
ner of opening the sac as “an important part of the operation of herni-
otomy.” He refers to the operation of dividing the stricture outside of
the sac, with his objections, and directs that the sac should be opened in
inguinal, femoral, and umbilical herniae. Miller, in discussing the ques-
tion of opening the sac, says, “were it applied indiscriminately, nothing
could well be conceived more pernicious.” In the operation for femoral
hernia, he says, “usually the opening cannot be avoided.” In Erichsen’s
description of the general operation of herniotomy, he says, “the sac,
having been exposed, must be carefully opened towards its anterior as-
pect, and if it be a small one, at its lower part.” When operating for
the inguinal form, he says, “if it be found after the division of the fascia
that the stricture has been removed, and the hernia can be reduced, it
would, of course, be unnecessary to lay open the sac, and the safety of
the patient will be considerably enhanced, and particularly if the opera-
tion is performed for an old scrotal hernia of large size, by not doing
so. . . . If, however,” he adds, “as will happen in the majority of in-
stances, in inguinal hernia, it be found that the stricture is in the neck
of the sac itself, it must be carefully opened.” In concluding his de-
scription of the more common operation for femoral hernia, he says:
“When the sac has been reached, it must be carefully opened.” In um-
bilical hernia, the stricture should, if possible, be divided without open-
ing the sac. He further says that the operation without opening the
sac may be practised in all forms of hernia, but is much more readily
done in some varieties of the disease than others. It is especially appli-
cable in cases of femoral hernia, in which the stricture is commonly out-
side the sac. In inguinal hernia, it is not so easy to perform Petit’s
operation; indeed in the majority of cases, the surgeon will fail to remove
the stricture in this way.
Thomas Bryant says: “When the hernia cannot be reduced without
opening the sac, the whole must necessarily be explored.” It will be
thus seen that the question of opening or not opening the Sac, turns upon
the necessities of the individual case. After some arguments against
opening the sac, he adduces some statistics in favor of the minor operation,
but adds that it must be remembered that, as a rule, the cases in which the
sac was not opened were of a more favorable kind than those in which
it was opened. In describing his plan of operating to cut the stricture
outside the sac, he says that if no indications of reduction show them-
selves, or if part of the contents of the sac have disappeared, but not
with the characteristic jerk, or if some portion has been left behind, the
sac must be opened. “In all operations for femoral hernia, the reduc-
tion of the hernia without opening the sac should be preferred, and in
recent herniae this minor operation is generally successful. Should it
fail, and the sac have to be opened, no harm can possibly have been
caused by the proceeding, for the incision can readily be enlarged if ne-
cessary, the sac opened, and its neck divided.” In describing the pro-
cedures of herniotomy, Gross directs how to recognize the sac, and then
O PEN IN G T H E S A.C IN H E R N IO TO MY . 637
adds, “An opening just large enough to admit the point of the director
is now made, when, the instrument being carried upwards and then
downwards, the sac is divided to the required extent.” Referring to the
advantages and disadvantages of division of the stricture without the
sac, he concludes in these words: “It would not be proper in the exist-
ing state of our knowledge to pronounce a decisive judgment upon a
subject of so much importance as this unquestionably is ; we must wait
for further data, and in the mean time adopt the rule to lay open the
proper hermial sac whenever there is any reasonable doubt in regard to
the site of the stricture. Having divided all the fascial layers down to
the sac, in femoral hernia, it may happen that the stricture is seated
within the sac, particularly if the hernia be large and old, and, when
this is the case, the sac must of course be laid open, its division being
effected in the same manner as in inguinal hernia.”
Hamilton writes: “The sac being fairly exposed, a small fold may be
raised at its most depending point, and an opening made large enough
to introduce a director, and upon this the incision may be enlarged.”
Division of the stricture outside of the sac, if practised, should be reserved
for exceptional cases. In femoral hernia, the sac being reached, opened,
and the contents examined, then follows the treatment of the stricture.”
He adds that division of the stricture outside of the sac is probably more
often applicable to femoral hernia than to either of the forms of the in-
guinal variety. “In umbilical hernia,” he says, “when it has been
necessary to open the sac, the result has generally been fatal. It is advi-
Sable, therefore, always to attempt the reduction by division of the stric-
ture outside of the sac.”
Our object thus far has been to place, side by side, the opinions and
practice of the eminent surgeons to whose names we have referred, with-
out a recapitulation of the arguments by which their conclusions are
reached upon the questions at issue. The external operation has been
before the profession, at least since its earnest espousal by Petit, in 1718.
It found strong advocates in Monro, Key, Luke, and some others, but
had not occupied the attention of surgeons generally until near 1833.
It is true that, by the English surgeons, the minor operation was first
most thoroughly tested, but for a considerable period it has been more
or less under consideration by surgeons in all countries. It is now more
than a century and a half since it became a favorite operation with some
British surgeons, and for the last thirty or forty years it has been prac-
tised in Great Britain, on the continent of Europe, and in the United
States. Has the minor operation acquired for itself that reputation as
an exclusive mode of treatment for strangulation which its earliest or
later strong advocates predicted for it?
We think that it will be found that a majority of surgeons who advise
non-opening of the sac, reserve certain conditions as incompatible with
the minor operation, and admit that in those cases division of the sac is
positively required. Then, again, believing the case one favorable to
leaving the sac entire, but finding as the operation progresses that reduc-
tion cannot be accomplished, they finally resort to cutting the sac.
Among all the surgeons who prefer the minor operation, we do not call
to mind one who denies the necessity for opening the sac when the stric-
ture exists in the latter structure. -
In the statistics on this question, in which the results appear more
favorable for the non-opening of the sac, it is conceded that the cases
638 HYDE,
were of a more promising character for either mode of procedure; this,
we think, raises the question, whether the conditions of a case which
entitle the minor operation to be preferred, can be recognized before the
operation. While some of the average conditions of strictured inguinal
and femoral herniae may be pretty well determined before exposure of
the interior textures, the writer's experience compels him to say that
more of the important relations of the structures, as well as their patho-
logical conditions, cannot be so well known while in this occult state.
If a century and a half, or more, of well-directed surgical acumen had
determined the fixed, uniform, pathological conditions in the disease
under review, then could our diagnosis enable us much better to say
when a strictured protrusion could be successfully reduced with its sac
intact. The majority of examples of hernia, it is true, embrace prima-
rily only definite anatomical structures; but from the first day of their
history their relations are liable to change, and, with these, occur func-
tional aberrations and structural alterations. The age of the patient;
how far the disease is congenital or acquired ; whether it is indebted in
any way, and if so how far, to strictly traumatic causes; the site of the
rupture; the contents of the protrusion; the distance it has gone from
its normal home and the direction taken ; the volume of the mass; acci-
dents to which it may have been subjected; the varying of the sac from
extreme tenuity and pliancy to great thickening and induration; its
range of contiguous relations to either or both its surfaces; the more or
less frequent transit of the contents through the abdominal apertures in
either direction; and occasionally the permanent extra-abdominal situa-
tion—are some of the circumstances which will, to more or less extent,
influence the case when strangulation exists, bearing directly upon its
treatment, both by the taxis and herniotomy, and which will determine
largely the results of the latter. The history of all forms of hernia is
made up of varying conditions which we believe must contribute to
pathological changes, and aid in individualizing cases to an extent to
entitle each and every one to its own consideration.
These are some of the reasons why the operator cannot predict posi-
tively what are the morbid changes in a given case of the disease, as long
as these are hidden from his vision. With his increased facilities for
observation he is all the more certain of disappointment if he expects to
find marked sameness in the pathological appearances in a number of
examples of either of the leading forms of the disease, but more especially
of inguinal hernia. What surgeon, before he commences the operation
of herniotomy, is quite willing to specify what will be the departures
from normal anatomy, either in tissue or relation, until disclosed by his
incisions : While he is positive enough concerning the presence of some
of the conditions, he is obliged to admit that he is doubtful of others,
and these are most likely to be the important factors in the results.
These ever-varying phases, sure to be present to a greater or less degree
in a great majority of the examples in every variety of hernia, are never
to be ignored, but carefully analyzed and considered, whatever treatment
is chosen; and until we can make our diagnosis more satisfactory touch-
ing the interior state of the .sae and its contents, including their true
condition and relation, we shall be compelled to accept the major opera-
tion instead of leaving the Sac unopened. It will be conceded by all
authorities, we think, that no part of a hernial tumor or swelling is of
such high importance as the contents of the sac, and that these, more than
all others, are the textures both primarily and secondarily imperiled
O PEN IN G T H E S A C IN H E R N IO TO M. Y. 639
when strictured. These are the parts which our treatment seeks to re-
lieve as early as possible when in this state. The taxis having failed, the
girding point or points are found and divided. Has this been done out-
side and the protrusion returned, with or without manipulation, it may
be well, it may be otherwise. This will depend wholly upon the fitness
or not of the returned parts to occupy their original place in the abdo-
men. How is this to be known It may be said, because the hernia was
reduced so readily after the stricture was relieved. Does it follow certainly,
from this ready return of the mass into the abdomen, that it was free from
changes that would not permit it to remain there safely, or that it might
not in this returned state prove more serious to the patient than if allowed
a place outside the abdomen after the stricture had been divided ? Our
own observation has taught us that the readiness with which the protru-
sion is reduced after the minor operation is by no means reliable proof that
the returned parts are in fit condition to allow recovery, as proved by
inspection after death. But what does it mean when all stricturing tis-
sues exterior to the sac have been severed, and the hermia cannot be
reduced 2 We know no way to answer this inquiry but to open the sac
and expose its contents, when, if there be any form of internal binding,
it may be readily reached and overcome, and reduction accomplished or
not, as the state of the strangulated parts may warrant. In the opera-
tion of herniotomy, when the sac is made bare, how far will the vision
or tactile ability of the surgeon enable him to say what is the real state
and relation of its contained textures 7 We answer for ourselves that
it is scarcely more than inferred, and when we have succeeded in reduc-
ing an inguinal or femoral hernia in this way, our solicitude remains at
high pitch until sufficient time has elapsed to prove that all signs of
strangulation are well over.
What are the objections to opening the sac 7 Perhaps the one most
commonly urged is, that it increases the liability to inflammation in the
sac itself, and its extension along the peritoneal tissue. Allowing that this
texture is readily inflamed from slight causes, we cannot see as a rule how
the dangers incident to a small incised wound in the sac should be as great
as those incurred by returning the bowel in its average condition, in
this kind of cases. In the minor operation, provided there be no other
strictured point beyond that outside of the sac, how readily are the pro-
truded parts restored to the abdomen 7 Granting the usual proportion
of examples of adhesions of the sac more or less to structures extra-ab-
dominal, and that the contents are in a state to move freely within the
sac, then we think that the manipulations requisite for reduction having
to be made through the walls of the sac, the whole depending upon the
touch, are so much embarrassed that much greater risk of injury is in-
curred than by the wound necessary to bring at once into view the true
state and relation of the already, it may be, highly sensitive contents.
Again, when we think we succeed well in returning the contents wholly
into the abdomen, in cases of adherent and hypertrophied sac walls, by
careful watching, we may well doubt whether there may not be some
portion of intestine not quite within the abdomen. We remember that
more or less exudation has occurred during the period of strangulation,
and that a fold or process of intestine or mesentery, or even a portion of
omentum, may easily enough, in the midst of the more or less plastic effu-
sion, adhere both just below and quite within the upper aperture, and
so cause an incomplete reduction. In these examples much of the ful-
ness may disappear, leaving only so much as can well be explained by
640 HYDE,
the firm thickened sac, with often a marked feeling of relief so expressed
by the patient, but soon to be followed by an exacerbation of the symp-
toms of strangulation. Under most circumstances, our choice would be
to accept the risk of an incised wound in the hermial sac, rather than too
long trial of the taxis before the coverings have been divided, or its ap-
plication in the average state of cases after the stricture has been cut
without dividing the sac. We cannot see how a wound in the hermial
sac is likely to be followed by more inflammation, or any more serious
results, than a wound of the same tissue in any other place, beyond what
would be inevitable from the already morbid state of the within and ad-
jacent structures. When we call to mind how rare an event it has been,
in the clinical history of the operation in question, that incising the
hernial sac has added to the inflammation, or contributed in any possible
way to the untoward results of the case, we declare our conviction that
in a large majority of examples of inguinal and femoral strangulation,
the major operation is the safest. We put the question to all surgeons,
whether their cases of herniotomy which have been fatal, have not been
so from morbid changes already present before the division of the sac
and stricture ?
Another objection to this operation of opening the sac is, that it
exposes the contents to accession of air and light, with change of tempe-
rature, suddenly creating new relations which cannot be tolerated. We
cannot understand why the peril should be any more by the exposure in
this operation than in others in which a much larger portion of the peri-
toneal surface, with a far greater amount of visceral texture, is suddenly
brought in contact with the atmosphere, as amply illustrated in the
operation of ovariotomy, and other constantly occurring examples of
traumatic lesion of the abdominal textures. We believe that in a large
majority of instances, neither the liability of adding an increase of
inflammation by opening the sac, nor that of multiplying dangers by the
exposure to the air and light for a few moments, of the interior textures,
will add as much to the dangers as the untoward manner of applying
the taxis with the sac-wall entire, together with the great liability to
unfitness of the contents for a safe restoration. If it be said that the
views inculcated in this paper are at variance with a commendable spirit
of surgical conservatism, then we affirm our belief that it is a much more
conserving practice to expose by a well made incision the real state and
relations of the suffering tissues, by which every subsequent step for
relief can be aided by direct vision, than to adopt a procedure which
must be mainly directed without the aid of the surgeon’s eye, and com-
monly, if it effect reduction, requiring a more protracted tactile labor,
and always involving the risks of unrelieved strictures, and too often of
structures returned to the abdomen, which should have been left outside.
The writer, restricting himself to only the authentic clinical histories of
a considerably large number of cases, with their results, in which both
non-opening and opening the sac were practised, and to the pathological
facts furnished by autopsies in a majority of the fatal cases, cannot
truthfully arrive at any other opinion than the one already expressed.
It must be admitted that there are many surgeons whose opinions are
entitled to the highest respect, who would not adopt the major operation
as exclusively as we have indicated. The writer regrets to say that he
has met with more hindrance than he had anticipated in obtaining from
surgical practitioners their individual experience upon the respective
merits of the operations in question. It is the honest difference of senti-
O PEN IN G T H E S A C IN H E R N I O TO MY . 641
ment among surgeons which has chiefly led the writer to call attention to
this very important practical question, so that if he cannot reflect new
light upon his theme, other surgeons may be induced to make a more
free declaration of the results of their experience upon this important
subject through the legitimate channels of communicating professional
truth.
From what has been said, we conclude—
I. That the examples in which the minor operation is most successful
are those but slightly removed from a condition permitting reduction by
the taxis, and that the length of time during which strangulation has
existed is not of itself the true measure of the condition of the strictured
parts, these often presenting more morbid changes when strangulated but
a few hours, than in other instances of days’ duration.
II. That cases which furnish the most favorable results from the minor
operation, are also the most promising for opening the sac.
III. That there are many cases of strangulation in which the stricture
cannot be relieved without division of the sac.
IV. That our means of diagnosis are insufficient to enable us to say,
in a vast number of cases, whether the strictured parts are in a suitable
condition to be returned to the abdomen while the sac is entire.
V. That a due regard to the credit of herniotomy, when every variety
of inguinal and femoral strangulation is included, requires that the
major operation should be adopted in a large majority of patients in this
condition.
VI. That opening the sac in strangulated umbilical hernia is not to
be practised if reduction of the protrusion can be accomplished with-
out it.
41
SOME COMMENTS ON THE HISTORY OF NITROUS OXIDE GAS
AS AN ANAESTHETIC, AND ON THE ANALGESIO
EFFECTS OF RAPID BREATHING.
BY
ADDINELL HEWSON, M.D.,
SURGEON TO THE PENNSYLVANIA HOSPITAL, PHILADELPHIA,
IT would seem impossible that a suggestion of such a practical char-
acter, of such immense value to mankind, and made by such authority,
as that proposed by Davy of using inhalations of a gas to destroy pain
in surgical operations, should go absolutely unheeded for nearly half a
century, and yet such was really the case; for Sir Humphry Davy, in a
publication, in 1800, of “Researches, Chemical and Physical, chiefly
concerning Nitrous Oxide and its Inspirations,” suggested from inhala-
tions of that gas made by himself and others that “as nitrous oxide in
its extensive operations appears capable of destroying physical pain, it
may probably be used with advantage during surgical operations in
which no great effusion of blood takes place.” This suggestion he
never recalled or condemned during his subsequent brilliant career, when
everything emanating from his fertile brain was sought after and fol-
lowed with avidity and zeal. There was no pretext of want of desire for
such a means; the practice was almost universal of resorting to the
effects of alcohol and opiates to deaden and as far as possible destroy the
sensibility to pain during operations. The evil effects of the latter prac-
tice were also fully recognized, and yet, as I have said, this proposal of
Davy was absolutely allowed to go unheeded and to become forgotten,
for, when Dr. Horace Wells, a dentist of Hartford, Connecticut, in 1844,
thought of using nitrous oxide gas in extracting teeth, no one was then
ready to condemn it on the ground of previous failures, or because it had
been proposed so long before.
Wells's idea would seem to have arisen in his own mind on witnessing
an effect of the inhalation at a public exhibition given by a travelling
lecturer. On this occasion, one of the persons to whom the gas had been
administered, whilst under its influence, struck his foot, and on recover-
ing his consciousness it was discovered, by Wells's inquiries, that he had
sustained a severe bruise without being aware of it from any pain at the
time. This fact led Wells to the inference that the gas could produce
insensibility to pain, and he determined to test this by having a tooth
extracted while under its influence. The lecturer was invited to his
office to administer the gas, and during this administration Wells had
the tooth drawn without experiencing any more pain than is produced
on a person in a state of perfect consciousness by the prick of a pin.
This result led Wells to pursue the subject further; he tried the effect of
the gas in a number of cases of tooth extraction (about fifteen), but with
varying success; he then went to Boston and got permission from Dr.
Warren to make a demonstration of the process in tooth-pulling before
the class of the Massachusetts General Hospital. This attempt was an
A N A L G E SI C E FF ECTS OF R A PID BREATHING. 643
utter failure, and was called “a humbug affair.” Wells went home,
told his friends that the gas would not operate as he had hoped, “and
wholly ceased to experiment from the date of his failure in Boston (in
December, 1844), until the spring of 1847.” "
In the interval between these two periods, complete demonstration
had been made by Morton, his former partner in dentistry, of the power
of the vapor of ether to produce the desired insensibility. Morton had
no doubt had his zeal to discover some such agent excited by Wells's
previous successes; he would appear to have been impressed with the
idea that these were essentially the effects of imagination on the part of
the patient, for on September 30, 1846, he went to the laboratory of Dr.
Jackson, whom he knew well, having been a student under him and re-
cently in his house, and took from a closet an India rubber gas bag. In
reply to an inquiry of that gentleman, he said in substance “that he
meant to fill the bag with air, and by its aid extract the tooth of a re-.
fractory patient.” A conversation ensued upon the effects of the imagi-
nation and, among other things, of nitrous oxide, in producing insen-
sibility.” Jackson treated Morton’s proposition lightly; he told him to
go to an apothecary and procure sulphuric ether—the stronger the better
—which would produce the insensibility he desired. The ether was to
be spattered on a handkerchief and inhaled ; in a moment or two per-
fect insensibility would be produced. “Sulphuric ether,” said Morton
(so goes Jackson's account), “what is that ; is it a gas Show it to me.”
Jackson said he showed him some ether, and, after further conversation,
Morton went to procure it.” Morton and his friends subsequently
claimed that his expressed ignorance of ether at this interview was
merely assumed, to prevent Jackson from setting up any claim to parti-
cipation in his own search for painless dentistry. He showed by the
testimony of Dr. Gould and of Messrs. Weightman and Metcalf, that he
was before this time a dentist who was experimenting upon the relief of
pain in dental operations, and that he was familiar with the properties
of ether. Not only so, but by subsequent experiments he proved that to
be certain and safe which may have been thought by others previously
to be a possibility.
Morton possessed traits of character essential for success: he was ear-
nest and persevering beyond conception, as we are told by Professor
Bigelow, who was personally acquainted with him, a participator in
many of the steps in the early progress of the discovery, and who did
much to bring it before the medical public of this country and of Europe,
to assert its real value, and to point out the best methods of utilizing it.”
Morton possessed these traits to an extent evidently far greater than his
former partner, Wells, for, as I have before stated, the latter, disheartened
and discouraged by his failure at the Massachusetts General Hospital,
abandoned his investigations and searches “for more promising enter-
prises.” When Morton had got sufficient confidence by his trials with
ether, he went, like his partner, Wells, to the Massachusetts General
Hospital, in October, 1846, and made a demonstration there of his pro-
cess. This demonstration was an eminently successful one. Within
two weeks the whole world was ringing with wonder at the discovery.
| Bigelow's History of the Discovery of Modern Anaesthesia, American Journ. of Med.
Sciences, Jan. 1876.
* Bigelow, loc. cit., p. 171. 3 Ibid.
* Gross, Century of American Medicine, Am. Journ. of Med. Sciences, April, 1876.
644 HEW's ON,
By many its possibility was denied ; by others it was ridiculed ; by
others its claim to originality was attempted to be ignored; and, finally,
it was preached against from the pulpit, as I heard myself, as being, in .
one of its proposed applications, viz., to midwifery, an attempt to defy
the orderings of the Almighty.
Morton, at once, on his first success at the hospital, seeing in the thing
a source of great profit, wrote to Wells stating that he was about sending
out agents to dispose of the right to use his discovery, and offered him
an agency on shares. Wells, in his answer to this letter, says, “If the
operation of administering the gas is not attended with too much trouble
and will produce the effect you state, it will undoubtedly be a fortune
to you, provided it is rightly managed.” Here the question may very
naturally arise : Have we not in this answer of Wells a clue to the
causes of his abandoming his searches after anaesthesia . The adminis-
tration of nitrous oxide was “attended with too much trouble,” and he
had not rightly managed it to make it “a fortune” to himself; for our
(the medical) profession must not in judging of the conduct of two
members of another (the dental) profession overlook the fact that the
latter consideration can be entertained by them and not by us. The
former consideration, that of “too much trouble,” had no doubt always
been in the way of using nitrous oxide, from the day of Humphry
Davy’s proposal to that of Wells's abandonment of the idea. It was
indeed an obstacle to the general use of ether, at first, for then it was
supposed that it could not be confided to any but an experienced adminis-
trator for whose service an extra charge had to be made.
Morton’s demonstration that the secret of success with ether lay in the
full quantity of the vapor used was slow in being recognized, and
the dread of fatal asphyxia was so predominant in the minds of the
majority of practitioners, that for many years after the introduction of
anaesthesia the fact of its being unsuited to a large number of cases (other
than those of heart and lung disease) was considered to be beyond all
question. The partial recognition of this secret with ether, led many
(and possibly Wells amongst them) to the idea that the failures with
nitrous oxide had been from the insufficiency of the amount used. The
“traditional exhilarating gas bag and Davy’s exhilarating dose were
what had heretofore been used, and they were inadequate to produce
anaesthesia with any certainty.” The first demonstration of this fact
was in a breast excision performed by Prof. Bigelow at the Massachu-
setts General Hospital, in April, 1848, by means of about sixty gallons of
gas.” g
This, however, did not give nitrous oxide its true position as a so-
called anaesthetic agent, as for years afterwards it was ignored entirely.
This may have been from the enthusiasm which existed for ether and
chloroform (for the latter was proposed by Prof. Simpson, of Edinburgh,
in 1840), and yet the “too much trouble” in its administration also
undoubtedly exerted an influence against nitrous oxide. It was in fact
nearly nineteen years from the time of Wells's first experiment until G.
Q Colton, the same lecturer who had administered the gas to Wells on
that occasion, recognizing its real value and that the secret of its sue-
cess lay in an abundant use of it, secured the aid of a competent extrac-
tor of teeth and then made it known as a safe and popular agent in
! See Morton's letter of Oct. 19, and Wells's answer of Oct. 20, 1846.
* Bigelow, loc. cit. * Ibid., p. 168.
A N A LG E SI C E FF ECTS OF R A PID B R E AT HIN G. 645
painless dentistry." Before that time dentists advertised frequently “to
extract teeth under ether,” or “to administer sulphuric ether,” or
“chloroform,” but no one thought of or used nitrous oxide. It was
Said “not to be as successful as ether;” “not to be a safe agent ; “to
be more troublesome ;” but since Colton's successes we have “nitrous
oxide gas administered” advertised on a host of dentists’ windows, and
those dentists who do not administer it themselves, do not hesitate to
send their patients to establishments gotten up exclusively for that
purpose—many of them designated as “Colton Institutes” in recognition
of what Colton did to popularize the matter. More than this, since
then, the surgical profession has recognized the advantage of the use of
nitrous oxide gas over ether in a great variety of the minor operations of
surgery, notwithstanding the inconvenience from so much trouble in its
administration. Hosts of surgeons have experienced the annoyances and
inconveniences of using ether or chloroform in their office practice, from
the “post prandial” effects of those agents, and recognizing the absence
of such with nitrous oxide gas, have since then availed themselves with
avidity of the proximity to their own offices of a “Colton Institute,” or
of an administrator of nitrous oxide gas, to employ the gas in many
cases of ophthalmic surgery or of operations of short duration which
they could perform in their offices without detriment or inconvenience
to their patients, provided that they could do them in a painless way.
I confess myself to have been a full participator in this feeling, and
yet this was from no want of appreciation of the value of ether or chloro-
form ; all who have known me have always been aware of my being a
most enthusiastic friend to these agents, and especially to ether. I was
as a student a witness with my father of the first public demonstrations
of the use of ether in Philadelphia. He was at that time the honored
president of our most venerable medical society; he had held that posi-
tion for over twelve years, and was over seventy-three years of age, and
yet he was a most zealous student, always ready to adopt any measure
which held out a prospect of alleviation to the suffering of his patients;
but he was also possessed with the prudence and caution common to such
advanced years, and of this I had the full advantage in hearing his com-
ments after each clinic, and his discussions with his friends at home.
He had been educated in England before Davy's proposal was made,
when the practice of resorting to intoxication by alcohol and opium, as
a preliminary to major operations, was very common, and he was not
slow at the time to which I have referred to perceive the relations of
these with ether and chloroform in the cyanosed or carbonized state of
the blood produced by them ; and he considered the state caused by the
inhalation of ether as one of greater inebriation than that produced by
alcohol. He therefore argued that the vapor of the former should be
applied persistently until that extreme state was brought about, but not
so abundantly or exclusively as to induce a state of asphyxia.
Such a view then (my father died in 1848) was far in advance of that
held by the practitioners of that day. The cyanosing of, or retention of
carbonic acid in, the blood, was then looked upon as an accidental and
unfortunate circumstance in a case, and I therefore refer to his view as
an evidence of the advanced schooling I had on the subject. My zeal for
the use of anaesthesia whilst a student on one occasion subjected me to what
was meant to be a severe censure before a class of fellow students. It
* See Thomas's Manual on Nitrous Oxide, p. 17.
646 HEW so N,
was on the occasion of prolonged efforts of over two hours to reduce a dis-
located hip-joint at the clinic of one of our most conservative institutions,
and when whiskey and laudanum had been most freely used; several of
the class, myself amongst them, had been asked to lend a hand at the
pulleys, and we had all failed. I, on failing, said sotto voce, to the surgeon,
“Doctor, why don’t you give him ether ?” And he turned round in a
most excited manner to the class of nearly two hundred students, and
exclaimed, “Gentlemen, one of your number asks me why I won’t give
this man ether ? I would as soon cut his throat.” Within twelve hours
after this, the ether was given to the man, and his hip reduced, appa-
rently in a moment of time ; but I, as an interloper, was there amongst a
few to witness the result.
For the past twenty-four years, as a hospital surgeon in Philadelphia
(at the Hospital of the Protestant Episcopal Church, at Wills Hospital,
and at the Pennsylvania Hospital), I have never lost an opportunity of
using anaesthetics, and no one can, therefore, even insinuate that I have
been wanting in appreciation of their value. In private practice I have
used freely ether, chloroform, nitrous oxide gas, and local anaesthesia (by
the atomizer, and by ice and salt and kindred articles), and yet I am free
to confess, as I said before, that I have longed for some easier method, or
some method free from after annoyances, with which I could save my
patients, especially in minor operations or physical explorations, from
pain. It is, therefore, very certain that I most gladly availed myself of
Dr. Wm. G. A. Bonwill's first suggestion to me that simple rapid respi-
ration would produce insensibility to pain, if prolonged for from three to
five minutes, and carried on in as rapid a manner as possible during that
short space of time. I tried it first in a case of necrosed femur, where
there was a state of great hyperaesthesia, and where I was particularly
desirous of avoiding the production of pain; and when (in my office) I
did not want to resort to ether or the like. Here I had most perfect
success, using the probe freely with the sounding-board appended to it,
and still causing my patient not a particle of suffering. I repeated the
experiments with like cases in the wards of the Pennsylvania Hospital,
then tried the procedure in other minor cases, but not always with the
satisfactory results that I obtained in the first of them ; the failures,
however, were not such as to deter me from the further pursuit of the
subject.
My former experiences, with the first attempts at anaesthesia with
ether, were such as not to suffer me to become disheartened here. Who
is there, who went through the early history of ether, who cannot recall,
as I before intimated, the many failures to produce complete insensibility
with that agent then, which would not be suffered to occur at the
present day ? It was then a novelty, and those who used it were igno-
rant of all the essentials for its invariable success. Such I felt was the
case with my experience with rapid respiration; I had a good deal to
learn even in what looked like a very simple affair, and seemed to
require no experience or even judgment in its use. My first attempt to
demonstrate its value before the class at the Pennsylvania Hospital
showed this very clearly. I then had brought into the clinic room two
boys for explorations with the probe, on whom I had tried the process
in the ward with most satisfactory results. The first one of these was
remarked by me at the time before the class as “a bright little fellow,
who looked at me very cheerfully on that day, and in this respect was
very different from what he had been at the beginning of our interviews
A N A L G E S I C E FF ECTS OF R A PID B B E A T H IN G. , 647
some days before;” he then had dreaded the probing. He had been before
the class more than once, and had had on one of those Occasions ether
administered for an exploration by my predecessor, who then uncovered
the tibia by a free incision, and, demonstrating most clearly its necrotic
state, removed a large portion of it by the chisel and forceps, aided by
the trephine. The little fellow, on the occasion of my lecture, espied, as
he came into the room, the ether bottle and a lot of instruments on a
side-table, and nothing could induce him to believe that it was not my
purpose to deceive him, and to perform some operation with the instru-
ments when he should become insensible. He, however, started to
breathe rapidly, but kept glancing constantly at the table till I had it
removed out of his sight; but his dread was too predominant; he began
to cry, and finally positively refused at all to breathe with any exertion
or rapidity. I left him and turned to the other boy, who had never been
in a clinic before; but he, participating in his companion's dread, followed
his example, evidently for the purpose of making a like escape from hav-
ing anything done with his case.
The reporter of my lecture on this occasion, Dr. T. H. Bradford, one
of the residents of the Pennsylvania Hospital, then volunteered to try
the process before the class. “It was his first attempt, and was made
sitting erect, with his right hand resting upon a table. Breathing
rapidly was attended first with a tingling sensation of the surface, espe-
cially of the fingers, and a feeling as though the surface was all swelling.
Then (in about three minutes of time from the beginning) there followed
a dizziness or compression in the head, with consciousness well preserved,
but with a feeling of inability to resist, or to act in an independent way.”
I had directed this gentleman, before he showed the least sign of loss of
sensation or consciousness, to raise his left hand as soon as he felt me
touching him on the right. At this point, when he began to become
cyanosed, he raised the left hand, and, continuing the motion, got to
swinging the limb from the shoulder, much to the amusement of the
class, and so afforded a very positive proof that he was not perfectly
himself. In the continuation of his report," he says: “IHe remembered
well being frequently asked by [me] the doctor, if he was hurting him,
but had no recollection afterwards of the pin sticking him, much less of
its having been firmly imbedded in his flesh, as he found it when he had
ceased the rapid respirations, and the anaesthetic effect had passed off.”
The failure with the two boys was clearly the result of emotional
excitement and want of will on their part ; obstacles to success readily
anticipated in any such attempt, but which do not present themselves
now in the use of ether, chloroform, or the like, for with them we do
not hesitate to, and can, compel the patient to take the anaesthetic ; we
are independent of his will; but such was not considered to be the case
with those agents when they were first used. It was then thought
necessary to have co-operation from the patient. I saw many a case in
the early period of anaesthesia, where the attempt was abandoned for
want of this. It is not at all possible that we shall ever be so indepen-
dent with rapid respiration. Confidence in its success will, however, as
it has done already with me and my patients, diminish the frequency of
such a cause for failure; I have profited well from this part of the lesson
of that day. But the failures then also gave me, by the opportunity
with my assistant, to see that complete anaesthesia was not to be sought
! Medical Times, March 4, 1876.
648 HEW's ON,
by such a procedure, and likewise, very positively, that it was not essen-
tial for our purposes, for it must be remembered that I was not in search
of an anaesthetic agent to supersede those like ether and chloroform, but
one most convenient to destroy the sensibility to pain, and that alone.
The destroying of pain merely was certainly more desirable than the
state of full anaesthesia from ether, with its accompanying loss of all
consciousness and will. Appreciating this advantage, then, from the
rapid respiration, I had the opportunity at the following clinic of demon-
strating it in a most satisfactory manner. During that clinic it was
announced to me that a man was in the receiving ward—had just come
in—with, it was supposed by the nurse, a dislocation of his shoulder.
Without going to make any preliminary examination, I directed him to
be brought before the class. As he came into the clinic room, I called the
attention of the class to his carriage; to the manner in which he sup-
ported the injured limb at the elbow, by the other hand ; to how he
leaned forward on that side; and to how the shoulder was depressed
and the elbow projected away from the body—all affording very good
grounds for the supposition that his shoulder was dislocated. When he
was stripped, these appearances were still more marked, and during the
undressing he seemed in great pain. Then I announced to the class that
I would proceed to demonstrate the existence or non-existence of disloca-
tion, without inflicting any further pain on the patient, and without
touching him. I then directed him to breathe rapidly, assuring him that
it would remove his pains. He did it promptly, and in the usual time
began to show its effects. I then told him to raise the hand of the injured
limb and place it on his head. This he did without any signs of suffer-
ing. Then, whilst he was still urged to keep up the rapid breathing, he
was directed to place the same hand on the opposite shoulder; then
down by his injured side; and finally behind his back. All these move-
ments he made, sluggishly it is true, but with an absence of all indica-
tions of pain. I, of course, then made free comment on the advantage
we could have in all such cases with this mode of destroying pain, over
that by ether or the like. -
This condition of “insensibility to pain with conservation of intelli-
gence, of consciousness, and of voluntary movement,” recognized by re-
cent authors, by the term of Analgesia (from a, privative, and axyso, I
feel pain), in contradistinction to the loss of all these conditions to be
designated by the generic term of Amaesthesia, or what I called a few
moments ago complete anaesthesia, was shown at the French Academy
of Sciences, in March, 1872, by M. Guibert, to follow the partial use of
chloroform inhalations, some time after a hypodermic injection of mor-
phia; and he then advocated the state as sufficing for obstetrics and
minor surgery. The non-recognition of the occurrence of such a state,
or the want of appreciation of its value for such purposes, has, I know,
led many to condemn a resort to rapid respiration ; and then again, many
perceiving the preservation of intelligence, of consciousness, or of volun-
tary motion, have condemned the process as incapable of producing
insensibility to pain. They have evidently not been aware of the re-
searches of Bernard, Guibert, and others in England, as well as in France;
on this subject. The fortuitous experiment with my assistant, Dr.
Bradford, as I intimated before, was the first circumstance to open my
eyes to the value of the distinction. With the use of ether, and the like,
I was always accustomed to look for perfect insensibility of the conjunc-
tiva as evidence of my patient being fitted for me to begin any operative
A N A L G E S I C E FFE CTS OF R A PID B R E A T H IN G. 649
procedure. With that condition we all know there is always the perfect
loss of those mental and voluntary conditions which belong to complete
anaesthesia. (The combination of a previous hypodermic injection of
morphia with the anaesthetic, as suggested first by Bernard, holds out no
inducement for a resort to such in the cases to which I have been re-
ferring.)
In my earliest trials of insensibility by rapid respiration I had not
thought of Guibert's distinction of the two states. In many of these
the object was to avoid suffering in trifling operations——operations
strictly of minor surgery; but, after Dr. Bradford’s trial, I could not re-
frain from seeing its value beyond cases of dislocation, even in really
major operations about the pharynx, on the tonsils, uvula, posterior
mares, and Eustachian tube, as well as on the tongue and maxillary bones;
for in these the anaesthesia from ether and chloroform, when attempted
to be used, has always to be abandoned (particularly in the most exten-
sive of them) on account of danger of strangulation from the absence of
any volition by which the patient can expel the blood from the mouth.
The mode of effecting insensibility to pain by rapid breathing is also
not at all in our way as we proceed in these operations, which cannot be
said when ether is used. In such cases we can, as I know from experi-
ence, also keep up the insensibility produced by rapid breathing to the
end of the operation, even when there are frequent and prolonged inter-
ruptions from hemorrhage, by urging the patient, immediately after or
during such, to blow out as rapidly as possible. In some such instances
I have noticed the patient, either impressed with the advantages or act-
ing mechanically as some would suppose, carry on this breathing most
earnestly until assured there was no further necessity for it. Here we
have also another advantage: we can always stop the procedure. I
have never seen a case in which I could not, and have, therefore, in in-
stances where it became desirable to interrupt the insensibility, always
effected it very readily; and this advantage is a very great one even in
other cases than those of operation about the air-passages. Thus, for in-
stance, as Guibert says, analgesia has advantages for obstetrical cases. I
have in my own experience seen the advantage of this breathing process,
not only in the insensibility with co-operative action on the part of the
patient in ordinary labor cases, but also in the facility of terminating it,
as, for instance, in the supervention of flooding where it becomes de-
sirable to remove all causes of muscular relaxation, which cannot be
done immediately where other processes of insensibility have been used.
Here I know that I have been able to save patients’ lives, where I feel,
in these special cases, it would have been impossible to do so if they had
been under the influence of ether or chloroform. All instrumental labor,
as I know, can be carried on with perfect satisfaction under this process.
Most operations about the uterus, the vagina, the bladder, and the
rectum, are also disarmed by this process of one of their terrors to the
female, as they cannot be as surely in the case of ether or the like, viz.,
that of unnecessary exposure. I have frequently, in the past year, dilated
the uterus by an Atlee's or Ellinger's dilator, straightened and replaced
it, explored it by a Simpson's sound and other means, dilated the vagina
by a trivalve speculum, and dilated the urethra and rectum, in the former
of these last two instances to the extent that I could pass my index finger
into the bladder, and in the latter so that I could pass three or more
fingers into the bowel, with my patient lying quietly on her left side (in
the ordinary obstetric position), evidently satisfied that she was not being
650 HEWSON,
exposed, and with friends about her able to assure her that the operation
was performed in such a manner. All such operations I have been able
to perform in this way without pain, and many of them are as severe
tests as could be required of the analgesic effect of rapid breathing.
It has been universally recognized that the relaxation of the sphincters
is one of the best evidences of amaesthesia, and experienced surgeons early
taught that it required more thorough etherization for operations in
these parts than in others on account of their hyperaesthetic condition.
Any one who has attempted the rapid dilatation of the urethra—the
recently proposed cure for irritability there in females suffering with
many forms of womb trouble, which Professor Charles D. Meigs used to
describe as a pure sphincterismus—can sustain that view. On one day, in
February last, I performed this operation most successfully in three dif-
ferent cases, the patients living ten miles apart. In two of them I tested
the rapid breathing, and in the other I used no means whatever, on
account of disinclination on the part of the patient, to prevent the pain.
The former have no recollections of having gone through a severe opera-
tion, and have frequently expressed themselves as being most willing to
undergo the procedure again should it be required, whereas the last de-
clares that nothing could ever induce her to submit to such pain again,
although the operation gave her the desired relief.
Amongst my operations for fistula in ano, under this means, I had one
case which had been operated on once before by the bistoury, and with-
out any anaesthetic. This patient actually laughed when I told him the
operation was done, and at first he was disposed not to believe me. In
his case I used the old-fashioned instrument for the purpose, a Syringo-
tome, one that has been used for this purpose by my ancestors for over a
hundred years. It is nothing but a steel, sickle-shaped blade, a quadrant
of a circle of two and a half inches radius, with a long and very flexible,
silver probe-end. It renders the operation a very simple and quickly
performed one. My operation was not through the track of the former
fistula—it had been well cured—but for one on the other side of the anal
orifice, and which seemed like a very much less serious affair than the
first evidently had been. All these circumstances are worthy of being
noted in a report of this man's comparison of the two operations. In
my operation he had no pain; in the other, he said, he had had a great
deal.
I could prolong this paper, already sufficiently long for the character
of such communications, by entering into details of a variety of cases
other than those to which I have alluded; but I have certainly given
enough of facts to induce others to give the method a fair trial, and if I
shall have succeeded so far, I shall be perfectly satisfied ; my purpose has
been to earnestly fix the attention of the profession to this subject, with
the conviction on my own part that the plan will prove a desideratum, even
with the many means of anaesthesia which we possess." It is to be earn-
estly hoped that none will show themselves too ready to condemn or
| Here I would again most distinctly repudiate all idea or purpose of even proposing to
substitute this for ether or chloroform in major operations (save those about the mouth).
I have used it in some such where it was not convenient or expedient to use either of those
means, or where, I will confess, it was my object to test this in a severe manner; and the
results, as I have mentioned, have been satisfactory, but not such as to demand its use
in the place of those means which can produce a more thorough insensibility or complete
anaesthesia than I have claimed for this.
A N A LG E S I C E FFECTS OF R A PID BREATH IN G. 651
ignore this process, as was the case in the early history of ether and chlo-
roform, from failures in the first attempts, much less from the inability,
as Some say, to see any philosophy in it, or, as some have expressed them-
Selves, from its being too simple a measure not to have been discovered
and used with satisfaction before this late date if there had been any
merit in it. We have seen the full value of such objections in our retro-
spect of the history of nitrous oxide and of ether, and surely no one at
the present day is going to suffer himself to be misguided by want of
zeal or by excessive conservatism in his profession. To prevent the occur-
rence of these, I will now give minutiae, as far as my experience will
allow me, as to the way of bringing about this insensibility to pain, and
also what facts I possess towards the modus operandi of the process, or
showing any rationale for it.
In operations about the air-passages, I may also say about the face and
Scalp, as well as about the ear, and even about the eye and its appen-
dages, the sitting posture is the one to be preferred. This, however, is
not, according to my experience, the most advantageous one for the
induction of the analgesic state by this method. In all instances where
I can, I now adopt the recumbent posture on one side, as in such a posi-
tion the desired state is I find more promptly induced. To prevent the
diversion of the patient’s mind from his part in the matter, it is frequently
beneficial to cover the face by a handkerchief: this may, in some in-
stances, prove disadvantageous, from the idea the patient may take up
that he is really to be etherized ; in other instances, it may be in that
way of service.
Following strictly Dr. Bonwill's directions, I always at first told my
patients “to breathe as deeply and as rapidly” as they could ; but study-
ing out their cases I was led to see that the rapidity of breathing was
the most essential part, and that its rate of frequency was unavoidably
at the expense of depth ; a deep or full breath of course requires much
longer time than one of an opposite character, and it is also essentially
an inspiration ; whereas a rapid breath partakes more and more, as it
is increased in frequency, of the characters of eacpiration. This is not to
be wondered at ; it is clearly due to the difference of circumstances of
the two movements. All the circumstances concerned in respiration
favor the act of expiration. Both the elasticity of the lungs themselves,
and that of the walls of the thoracic cavity, aid the expiratory movement,
whilst they offer a corresponding resistance to the inspiratory; and,
besides these, we have also to take into consideration the atmospheric
pressure over the surface of the chest which is not only favorable to
expiration, but which increases the resistance to inspiration as the
depth of the latter is made greater, and, according to Dr. Hutchinson’s
researches,” this is in an arithmetical progression. These conditions, it
would seem from Dr. Carpenter's calculations,” require a muscular power
in an adult man to overcome them in an inspiration made to its full
length equivalent to “not less than 1000 lbs.” All which is correspond-
ingly favorable to an expiration begun at the end of such an inspiration.
Even where my patients were progressing well in their efforts, and I
urged them “to breathe deeper and faster,” the effort for depth would
| See Dr. Bradford's report of my Clinical Lecture, in Philadelphia Medical Times,
March 4, 1876.
* Cyclopædia of Anatomy and Physiology, art. Thorax, p. 1056.
* See his Physiology, p. 512.
652 HEWSON,
always produce an interruption of rhythm of the velocity, and I then
got to urging them “to breathe faster and deeper;” then “to breathe as
fast” as they could ; and, finally, notwithstanding I had had the impor-
tance of the depth of the breathing impressed on my mind, I recurred
to my experiences with ether, chloroform, and other vapor, of the
advantage of urging the patient to blow out, and adopted with great
satisfaction here the plan of making my patients to expire as fast as
they could. The fact of the very circumstances of a deep inspiration
making an increase in the power to expire, became then very evident;
the patient would always, after blowing as fast as he could several times,
be compelled to take a deep inspiration ; here we demonstrated the
French “besoin de respirer,” against which the patient would show his
inability to exert any excess of counteraction, and found a satisfactory
proof that no effort of the patient’s will could carry the process to a
point of serious suspension of respiration. These advantages of expiration
over inspiration also come into play when we try to have efforts made
to exaggerate either for any length of time, especially if the patient has
become stupefied by such ; he then requires to be constantly urged to
go on with the breathing in as fast as possible, whereas, once started to
blowing out rapidly, he will continue the blowing when he becomes
stupefied, although not with the same earnestness, yet with the same
rapidity. From recent conversations with Dr. Bonwill, I find that he
has been led to adopt the same directions to his patients.
This altering, by an effort of the will on the part of a patient, the
frequency and character of the respiration in the manner described, has
an effect of course on the frequency of the heart’s action, but this is, I
may say, not directly related to the frequency of breathing, but corre-
sponds rather with the exertion made by the patient. The force of the
pulse does, however, here, as with ether, chloroform, etc., furnish evidence
of the impression being made on the nervous system, never, however,
to an extent like that of either of those agents, and to a decided extent
only when the utmost impression to be made has been effected. This
change is one of diminution in the force of the heart, and is essentially
like that of a natural sleep, but is as much more marked than the latter
as that by chloroform is over that by ether. It never can become exces-
sive for the reasons we have given. Bourdon long since' declared that
no one can by any exercise of the will over the breath destroy the heart’s
action. One can therefore continue, without any fear or hesitation, to
urge the patient to keep up this breathing process. It generally requires
from three to five minutes of constant urging to breathe in this manner,
at a rate of from forty to fifty or more inspirations in a minute, to bring
about the desired condition.
What will strike everybody, I am sure, as remarkable, anticipating
the influence of dread, is, that females always require less time for the
purpose than males, no matter what may be their age relatively. Those
of middle life always require more time than either the young or aged.
The very young, those under ten years, are the most difficult to manage,
chiefly, I think, through their fear; more time is also, I have always
noticed, required in a cold clear atmosphere, than in an opposite one.
The same class of patients, as a rule, takes five minutes in a cool room
of a winter's day to induce the same state of analgesia which would
need only three of a close summer's day. All these facts had been care-
* Recherches sur la Méchanisme de la Respiration.
A N A L G E S I C E FFE CTS OF R A PID B R E A T H IN G. 653
fully observed by myself before I had given the rationale of the process
any serious thought or consideration.
The first effect of this breathing, appreciable to an observer, is a
change in the color of the face; the lips, the cheeks, and the tint of the
face, at first brightened, generally become pallid, then leaden or bluish;
and with these latter changes the expression is altered and wanting in
animation. If the eyes are open, they have a vacant look, and their lids
begin to droop; the patient assumes the look of one much overcome by
fatigue, and then of one on the verge of an ordinary sleep. Then often
ensues, especially in an hysterical young girl, a state of very positive
muscular rigidity; before this however ensues, the state of analgesia has
been brought about, and is indicated by want of recognition of the
prickings of pins or the like, for the patient will always feel the abrupt
contact of obtuse bodies—even the touch of your hand—but will not
now experience any pain even from a bistoury or scalpel. The state of
rigidity, which I have just referred to, resembles much that of catalepsy,
and what is frequently noticeable in cases where anaesthetics are being
administered. The power to move is embarrassed by this; the will,
however, would seem to have persisted, as the patients tell you after-
wards, and may even show you during this state, by their efforts without
full ability to follow your directions in moving or suffering you to move
a limb. This rigidity of the muscular system is by no means of constant
occurrence, is often very slight and transient, and gives way. It is
clearly from the semi-asphyxiated state induced by the patient’s breathing,
for on ceasing to urge on him the rapid rate, he relapses into a quiet,
normal rate, and so, soon allowing his blood to recover from its intensely
purple hue, he comes out of this state, and gradually recovers his ability
to appreciate and remember the contact of foreign bodies and to move
away from them.
The subjective phenomena of this process are, as far as they go, essen-
tially like those from nitrous oxide, ether, and even chloroform. There
is, first, the swimming or confusion in the head, and the loss of perfect
or acute consciousness, attended with a sensation of tingling and disten-
sion of the surface—this latter beginning at the sentient extremities, and
the hands especially, and passing upwards, and closely following these
sensations comes the condition of analgesia, absence of appreciation of
painful impressions on those sentient nerves. It is, as I have before
remarked, to be particularly noticed that there is in this state the want
of appreciation of ordinarily painful impressions, and in this respect we
See the resemblance most marked to nitrous oxide; it will be remembered
that it was this effect of the laughing gas which attracted the attention
of Wells, and he showed that the analgesia may be there most perfect,
without the concurrence of the state of anaesthesia, although the distinc-
tion between the two states was not then known. These same subjective
phenomena, as I have intimated, occur in the administration of ether and
chloroform ; but they occur then in such rapid succession, and are so
soon followed by a profounder impression on the cerebral centre, that
there are no recollections of them afterwards, and this was more gene-
rally the case in the early history of the use of anaesthetics than it is now,
from the fact that there is not the care taken now to secure a free dilu-
tion of the vapor by atmospheric air that there was then ; the anaesthetic
state is now hastelled on as rapidly as possible by the mode of adminis-
tering the vapor, by giving it as undiluted as possible. In the
administration of nitrous oxide, as originally proposed by Sir H. Davy,
654 HEW's ON,
the air expired into the bag at the close of each breath is charged with
carbonic acid and carbonic oxide gases, and, as the nitrous oxide becomes
exhausted from the bag,these same gases are breathed in and breathed
over, again and again ; and how much, it may be asked, does the insensi-
bility from this administration depend upon these very gases of expired
air : Who indeed, on careful consideration of the prodromes of all
anaesthetics, will not be disposed to attribute those very prodromes to
the same physiological conditions 2 All modern anaesthetics, so called,
owe their property to their mode of impressing the nervous system, and
that essentially through the respiratory organs, intoxicating the blood,
and this acting secondarily through the circulating organs by which it is
conveyed to the nerve centres. The prodromes in all of them are most
marvellously alike in their individual features as well as in their order
of succession.
Ether and chloroform are hydro-carbons, so called, and their vapors
not only furnish those elements proportional to the specific gravity of
said vapors, but so relatively cut off the supply of oxygen by which
those same elements, hydrogen and carbon, already in, are to be elabo-
rated from, the venous blood of the lungs. Before they even impregnate
the blood of the lungs, they thus arrest or interfere with its means of
purification, and this they do clearly by cutting off the oxygen of atmos-
pheric air, for the moment you let that air in a state of purity take
their place, you have that elaboration resumed, and, more than that, you
have all the abnormal impressions on the brain made to disappear. Det
the patient, however, breathe an impure air, one charged with so-called
carbonic acid gas, for instance, and the difficulty of breathing continues,
and with it all the phenomena now recognized as belonging to the as-
phyxiated state show themselves in regular snccession, proportionate,
however, as Felix Ileblanc has shown, more especially to the quantity of
carbonic oxide so thrown into the circulating fluid of the brain and spinal
marrow from the lungs by way of the heart, thus affecting essentially
the blood corpuscles and making them inert ; may more, they are then no
longer, as Bernard has shown, carriers or capable of being carriers of
oxygen, the great vivifying as well as purifying element of the fresh air.
In 1854, Mons. Chenot" gave a chemical explanation of this action of
the oxide of carbon on the system. IIe there admits two consequences
of the action of the gas; he says when it penetrates the blood by the
lungs, it takes the oxygen of the blood and passes into carbonic acid gas;
and secondly it produces an exaltation of temperature which results in a
sort of inflammation of all the organs and tissues. But M. Chenot, as
Bernard remarks, is a metallurgist, and his theory is purely a chemical
one. Bernard had, prior to the date of Chenot's communication, in
fact as early as 1842, observed that animals, asphyxiated by the oxide
of carbon, had their venous blood made red like arterial blood, and
Troja had observed this same thing before Bernard. The last-named
authority, Claude Bernard, and we have no better on the subject, insists
upon this change of color of the blood, the peculiar reddening of the
blood corpuscles, and a reduction of the temperature, as pathognomonic
effects of carbonic oxide, as contrasted with those of carbonic acid intoxi-
cation of the blood, where on the contrary the color of the blood is blue,
and the temperature increased. The haemoglobin which constitutes the
* Chenot, Note sur l’Oxide de Carbon, Comptes Rendus de l'Académie des Sciences,
t. xxxviii. p. 735 et seq.
A N A L G E S I C E FFE CTS OF R A PID B R E A T H IN G. 655
coloring substance of the blood corpuscles, plays in them a purely
chemical part, and we are no longer allowed to believe that the cor-
puscles act mechanically, dissolving the oxygen; on the contrary, we
have the best proof that this substance (haemoglobin) forms a true
combination with the oxygen. Furthermore we now know that this
substance will combine likewise with other gases. The distinguished
German physiological chemist, Hoppe-Seyler, has studied such crystalline
combinations of it with carbonic oxide, nitrous oxide, bromide of nitro-
gen, the vapors of ether, chloroform, and the like, as well as those with
oyxgen ; and has shown that they can all displace the oxygen in its
combination. When we have ether used, it has been proved to act in
this way likewise, and as promptly whether the haemoglobin has been
previously in combination with oxygen, carbonic acid, or carbonic oxide
gases. The combination of haemoglobin with oxygen is less stable than
that with carbonic oxide, and the latter less so than that with bromide
of nitrogen. -
The phenomena attending these combinations in arterial blood, at the
expense of its oxygen, are, Bernard remarks,' attended by symptoms
constant in their character, and the first with them all is loss of sensi-
bility ; this is so marked where carbonic oxide is the combining agent,
that Gabriel Tourdes,” of Strasbourg, has compared its action to that of
chloroform and proposed it as an anaesthetic agent. Speaking of this
proposal of Mons. Tourdes, Bernard says “it is true that carbonic oxide
can be an anaesthetic, but in this way carbonic acid can also be one. But
the word anaesthetic, thus generalized, could be applied to a crowd of
different articles.” “Indeed,” he adds, “hemorrhage is thus an anaes-
thetic, since its first effect is to destroy sensibility. But I believe,” he
further says, “we ought to reserve the name for substances which pro-
duce anaesthesia without causing any great danger to existence.” In
his study of asphyxia from the fumes of charcoal, this same eminent
experimentalist (Bernard), besides pointing out the phenomena character-
izing the action of carbonic oxide and carbonic acid, has shown that the
latter is not destruction of the blood corpuscles as the former is, that it
is displaced in them by oxygen, and that the last-named gas converts the
lymph or white corpuscles into red corpuscles, in the lungs, by this very
action with haemoglobin to which we have been referring. By means of
the spectroscope, Bernard has been able to follow the action of carbonic
oxide in all its stages, and has shown that it is only when the blood
seems completely imbued by this gas that death takes place, and that,
when it is gradually introduced, it produces an anaemic state by this
destruction of the corpuscles being more rapid than their removal by the
oxygen of the air through the lungs. Death occurs from the damage
done directly to the heart. Death from carbonic acid can ensue only
when the supply of oxygen has been entirely cut off.
With such facts before us, we can have no difficulty in recognizing
that all agents which produce insensibility to pain, when applied through
the lungs, act essentially as before declared in the same way; and though
complete anaesthesia is not a state of asphyxia, we can see how the two
states may occur together; how the latter, occurring in attempts to in-
duce the former, may bring about a fatal result; and how the former,
carried to an extreme point of Saturation, may in itself cause death. We
1 Cinquième Leçon. * Gazette Médicale de Strasbourg, 1857.
* Op. cit. p. 420.
656 HEWSON,
have also no difficulty in comprehending how the state of analgesia al-
ways occurs from all these agents prior to any interference by them with
reflex actions.
There is therefore mo impropriety in turning our attention to the mode
in which rapid breathing can bring about this state of analgesia, although
the process is an extreme novelty. From what I have related as to my
own experiences of the facilities for inducing this state, it would seem
that it is not a condition produced by increasing the essential respiratory
function, viz., that of introducing oxygen into the blood and taking
carbonic acid from it. The position in which I have found the patient
most readily to be affected, that of reclining and resting on one side of
the chest, and the best manner for him to breathe, that by exaggerating
his efforts at expiration, are against such an idea. These rather imitate
the conditions consequent on a pleurisy or pneumonia, where we have a
diminution of the oxidation and of the decarbonization of the blood,
and where we have, to sustain this analogy, not only a diminution in
the depth of the inspirations, but an abnormal increase in their relative
frequency over that of the pulse, as likewise the peculiar buccal expiration,
so marked in them, and which the patient readily lapses into when we
urge him on in his rapid breathing. Starting out to blow fast, each in-
spiration gets less and less in depth, and the patient while increasing by
his will that part of the action called supracostal, and which is so char-
acteristic of woman’s breathing, involuntarily diminishes that of the
lower part of the chest. The greater familiarity of females with the
essentials of this mode of breathing no doubt, in part at least, will ex-
plain their greater facility in being inducted into the state of analgesia
by the process.
We have also as evidence against any increase properly of the respira-
tory function occurring, that the blood is positively cyanosed. This is
not only readily appreciated in the patient's hue of surface, but can al-
ways, according to my experience, be detected in the venous hue of the
blood which may escape in operations under this state, and also in that
of a new-born child when the process has been used in the birth. In all
instances where I have been able to test the point, I have likewise de-
tected a positive reduction of temperature occurring in patients whilst
in this analgesic state.
Again, we have the most definite proof that increase of frequency of
respiration positively diminishes the amount of carbonic acid thrown
out. Thus Vierodt' found that, if he respired only six times in a minute,
the quantity of carbonic acid was 5.5 per cent. of the whole air exhaled ;
with twelve respirations, it was 4.2; with twenty-four, it was 3.2; with
forty-eight, it was 3.0, and with ninety-six, it was 2.6 per cent.” Ac-
cording to experiments of Letellier, quoted by Kirkes,” about 100 per
cent. more of carbonic acid is exhaled by warm-blooded animals at 0°
than at 104° Fahr., and, if we take the mean results of Crawford and
Tavoisier, it may be found by an easy calculation that 20 per cent. more
of oxygen is consumed at 50° than at 82°Fahr. Such facts as these tend
very clearly to explain the difference I have noticed, as stated before, in
temperature and humidity as favoring the induction of this state on the
idea that it is rather from a diminution in the respiratory function, a cut-
| Physiologie des Athmens, p. 102. * Carpenter's Physiology, p. 524.
* Physiology, p. 135.
A N A.I. G E SI C E F FECTS OF R A PI D B R E A T H IN G. 657
ting off of the normal supply of oxygen and retaining the carbonic acid in
the blood to be sent to the nerve centres.
The variations which have been noted by numerous observers in the
exhalation of carbonic acid by the lungs as produced by age, sex, devel-
opment of body, states of repose, sleep, and watchfulness, likewise cor-
respond with the effects of those considerations whenever I have noted
them in my cases.
Every circumstance would therefore seem to indicate that this process
of inducing insensibility to pain is one essentially of diminished oxida-
tion and decarbonization of the blood, and recognizing such a state as
belonging to the initiation stage of all anaesthetics, when insensibility to
pain is positively marked, we have no necessity for begging any special
theory for this process, as in its action it readily comes under the cate-
gory of such agents, and is thus not either an absurdity or an impossibility
from a scientific point of view.
658
OBSERVATIONS ON THE TEMPERATURE OF
OSTEOSARCOMA.
BY
PROF. J. A. ESTLANDER,
OF HELSING FORS, FINLAND.
AMONG the many different species in the great group of diseases called
tumors, the sarcoma has always attracted special attention. During the
time that it was considered a form of cancer, it differed from the other
forms of this disease by its appearance in younger persons, and, since it
has received its present name, it has continued to make itself conspicuous
by its not very rare occurrence, the rapidity of its growth, and particularly
by the most awful speed with which it often destroys the organism. Its
history is therefore comparatively well elaborated, but, in the systems of
surgery which I have had occasion to consult, I have not found any
attention paid to one of its symptoms which seems to me to be very con-
stant, and to offer a considerable interest on account of its being inti-
mately connected with the nature of the growth ; I refer to the high tem-
perature which it shows when it has attained a certain size, and is rapidly
increasing. The following accounts of some cases will furnish a more
complete description of this symptom.
CASE I.—Matilda Holm, a workingman's wife, 28 years old, had always en-
joyed good health until towards the end of her last pregnancy, when she began
to feel pain in her right hip when walking. Three months previous to her admis-
Sion she was confined, and afterwards this pain became very severe, and, three
weeks prior to her entering the hospital, she began to feel a continuous and
intense aching which she sometimes felt down to the knee and foot. At
the same time she also observed a swelling around the crista ilii, and was
troubled with a sensation alternately of heat and cold in the body. In other
respects her state of health was normal. When the pain by degrees increased
more and more, she sought and obtained admittance at the Surgical Clinique
on Feb. 20, 1873.
At the time of her admission, her condition was as follows: Body well built,
strong, and not lean ; the internal organs normal. Around the whole crista
ilii on the right side, as well towards the inside of the belly as outwardly, a
large immobile tumor with lobulated surface, solid consistency, but indistinct
limits. The skin over the tumor was free, movable, and not tight, but tra-
versed by large subcutaneous veins. The tumor itself, but not the surrounding
parts, very tender to the touch. Crista ilii, not only the parts covered by the
tumor, but also the parts adjacent to it, easily permeable to the acupuncture
needle. A thermometer placed on the tumor and covered with cotton shows
37.8° centigrade, while the same instrument on the corresponding place of the
left side, and on the inner side of the thigh, shows only 36.8°, and in the axilla
37.2°, a result which reiterated measurings on the following days showed to
be constant.
As there could naturally be no question of any operation, the treatment was
only symptomatic. The tumor increased rapidly, and the patient's strength
sank in the same proportion. On May 11, the right leg and foot began to
get occlematous, and shortly afterwards also the other. May 24, a severe diar-
T E M P E R A TU R E O F O S T E O S A B C O M A. 659
rhoea appeared, and the patient died on the 28th of the same month. On post-
mortem examination, the sarcoma was found to extend backwards to the os
sacrum, and downwards to a little below Poupart's ligament. Half of the
ilium was destroyed, and the rest rarefied and friable; metastatic nodules
were found in the lungs and kidneys. The microscope showed the growth to
be a round-celled sarcoma.
CASE II.—Erland Engström, a farmer's son, 19 years old, had two years
before, noticed a small knob, hard as bone, on the right tibia somewhere about
the middle. In the succeeding spring it was as large as a hen's egg, and the
following Christmas as large as a man's fist, but after that time it began to
grow more rapidly, and moreover began to be painful. The movements of the
leg were not much impaired, for on May 11, 1875, the day he was received at
the Surgical Clinique, he had walked a distance of nearly seven English miles.
On his admission, the following was his condition : The patient, otherwise
in complete health, had on his right leg a tumor with lobulated surface, and a
consistency at some places more soft, at others more solid. The tumor ex-
tended from within an inch below the patella, close to the ankle-joint, and
occupied nearly the whole circumference of the leg, in such a way that it was
most developed in front, and behind had pressed the muscles from the bone to
which it was solidly attached. From above downwards it measured twenty-
five centimetres, from before backwards eighteen, and the circumference was
seventy-five. The skin was very highly distended, but every where free and
movable. The mobility in the ankle-joint considerably diminished, the foot
Oedematous, the inguinal glands on this side slightly swollen. A thermometer
placed on the tumor showed 37.2° centigrade, but on the corresponding part
of the left leg, or on the thigh, only 36°. Reiterated observations on the fol-
lowing days gave nearly the same results.
On May 21, I amputated the thigh, and the patient left the hospital on
August 16, with the swelling of the inguinal glands considerably diminished.
The tumor consisted of a compound mixture of osteoma, enchondroma, and
sarcoma, with here and there some small cysts. These three tissues were
generally so distributed that the first was in connection with and close to the
bone, the third more on the surface, and the second, which showed an exquisite
areolar structure, seemed to follow no rule, and had probably in the beginning
formed the whole substance of the tumor. The muscles of the leg, in form of
highly distended thick fasciae, covered the surface of the growth.
CASE III.—Johan Kujola, a farmer’s son, 32 years old, had noticed about two
years before that his right knee began to swell and get stiff, and, as during the
last months this swelling had rapidly increased, he applied and was admitted
to the Surgical Clinique on Feb. 22, 1876.
The patient's condition at that time was as follows: His constitution was
rather weak, but all the internal organs were healthy. Over the right knee-
joint, on the anterior and inner side, was a tumor closely connected with the
bone, as large as a child's head, and with no well-defined limits. In front it
had a lobulated surface, but on the inner side was covered with a lamella of
bone so thin that it broke into two pieces, on the first examination. The tumor
was pulsating, but the circumference of the bone, together with the tumor, could
neither by manual compression nor by Esmarch's bandage be reduced more
than about one centimetre. The movements of the knee, although somewhat
restricted, were not accompanied with any pain, and there was no collection of
fluid in the joint. The glands beneath Poupart's ligament were somewhat
swollen. The thermometer on the same day showed 39° centigrade in the axilla,
38.3° on the tumor, and 37 ° on the corresponding part of the other thigh ; and
the next day, in the axilla 38°, on the tumor 38°, and on the corresponding
part of the other thigh 36.5°.
As there could be no doubt of the diagnosis of strongly vascularized osteo-
sarcoma, and as the swollen glands could easily have been extirpated, I pro-
660 ESTLAN DER,
posed amputation of the thigh, but the patient refused to submit to the opera-
tion, and left the hospital on March 3. -
CASE IV.-Fredrika Petterson, a sailor’s widow, 60 years old, had seven
or eight years before noticed, on the front side of the right leg, a small knob
which was immovably fixed to the bones. As she felt no inconvenience,
she paid no attention to this growth until last September, when it began to
pain her. She then went to a physician, who found the tumor as large as a
small apple, with a scarcely perceptible swelling of the inguinal glands. On
Feb. 10, of this year, she came to the Surgical Polyclinique, and as I found
the size of the tumor as last mentioned, but the glands considerably more
swollen, I proposed to extirpate both. The patient did not consent, but when
the tumor shortly afterwards increased with great rapidity, the skin ulcerated,
and the pains became much worse, she returned and was admitted to the hos-
pital on May 11, 1876.
On her entrance, she presented a tumor firmly attached to the front part of
the right tibia, as large as a child’s head ; its consistence was soft, and at cer-
tain points nearly fluctuating. The skin over the base of the tumor was tightly
stretched, and had on the top begun to ulcerate. Beneath Poupart's liga-
ment there was a solid tumour as large as an egg, and, around, several lym-
phatic glands considerably swollen. The thermometer on the tumor constantly
showed 38.1°; on the corresponding part of the other leg 37°; and in the axilla
37.1° centigrade.
As I supposed that the tibia was so much involved that an extirpation was
no longer advisable, on the 15th of the same month I performed Gritti's exarti-
culation at the knee-joint, and, besides, extirpation of the inguinal glands; and
when I left home, on August 14, the patient was ready to leave the hospital.
By examination of the tumor I found it to be a spindle-celled sarcoma which
had destroyed the front part of the bone and entered into the medullary canal.
Between the skin and the glands there was no trace of suppuration.
CASE W.—Anders Mäkiaviitala, farmer, thirty-nine years old, had when a
child of two years been burnt by hot water on the right side of the front part
of the chest. At the age of twenty and some years, the cicatrix began to grow
out in the form of a red knob, which increased so slowly that by last autumn
it had only attained the size of a walnut. From that time onward it had begun
to grow more rapidly, and, after the top of it had sloughed off, the patient
had repeatedly had bleedings from it.
On his admission, on June 21, 1876, the state of the patient was as follows:
He was strongly built and well fed. The entire right pectoral region was occu-
pied by a cylindric tumor, nine and a half centimetres high ; its sides were
covered with a distended, red, and thin skin, and its top formed an ulcer thir-
teen centimetres in diameter. The tumor was movable and not connected with
the pectoral muscle, and felt at some points very soft, at others more solid.
No swollen glands were to be found either in the axilla or the supraclavicular
region. A thermometer on the ulceration at the top of the tumor showed
38.8° centigrade; on the corresponding part of the left side of the chest, 38°;
and in the axilla, 38.7°. After extirpation, on June 23, the tumor was found
to be a round-celled sarcoma. By means of skin-grafting the wound was nearly
healed when I left home on August 14.
The temperature was measured in the following manner: The quick-
silver bulb of the thermometer was fastened to the skin with strips of
sticking-plaster, and afterwards the instrument and the whole part of
the body covered with a thick layer of cotton. This manner of mea-
suring could not, of course, pretend to be very exact, if the question were
to ascertain the absolute temperature of any part of the body, but as the
sole question here is about the difference between two parts measured by
the same instrument and in the same manner, the result ought to be very
nearly true. The above related records show, then, that the temperature
TEMPERATURE OF osTEOSARCOMA. 661
of a rapidly-increasing sarcoma is commonly one and often one and a
half degrees of Celsius's scale, higher than that of the corresponding
region on the other side of the body.
The high temperature in the tumor might, perhaps, be supposed to be
a symptom of inflammation in the distended skin, but Case V., where
the skin to a large extent had ulcerated away and the thermometer was
placed on this spot, showed that it depended on the tumor itself, and in
the other cases, if there had been any inflammation in the skin, there
ought to have been perceived, somewhere under it, an abscess; which,
however, was not the case with any of the patients, although special atten-
tion was paid to this point. &
The above-described cases show that all the tumors were rapidly
increasing, and, as it may generally be considered a rule that a tumor
contains in the same proportion the more arterial blood the more rapidly
it grows, it might, therefore, be supposed that the high temperature in
these cases depended only on their rich supply of blood, particularly
since the case of pulsating tumor presented the highest temperature
among them. Without wishing to deny the importance of the arterial
blood in this respect, I think we can, perhaps, show the probable pre-
sence of yet another source of this temperature. When we consider that
even the best thermometers always show the temperature several tenths
of a degree lower than it really is, and when we add this difference to
the resulting temperature found with the tumors, we get as result a sum
considerably higher than the temperature of the arterial blood. This
authorizes the conclusion that this surplus is produced in the tumor
itself, and that thus the high temperature of a sarcoma is the effect not only
of its richness in blood vessels, but likewise of the active processes going
on in the elements of its tissues. It may be that this demonstration, as
supported only by a few observations, has not much more value than a
common hypothesis; but at all events it explains the relation between the
rapid growth of the tumor and its high temperature more completely than
the presence of a great quantity of arterial blood does. A teleangiectasis
contains relatively more arterial blood than any other tumor, and never-
theless it sometimes disappears by itself.
If we, following the most recent opinions, consider the fungus hæma-
todes in Case III. (which was not operated upon) as a sarcoma and not as
a cancer, then all the narrated cases have that feature in common that
they were all sarcomatous growths, for even the tumor in Case II. con-
tained this form of growth, although the greater part consisted of carti-
laginous and Osseous tissue. Iłut naturally this is not yet a proof that
only the round, or spindle, or giant-cells possess this peculiarity, for the
second of the reported cases seemingly leads to hint that on the contrary
even the cartilaginous tissue has the same; and it seems probable that it
belongs to every tumor whose elements are capable of a rapid increase in
number and development.
Of all the different parts of surgery which, during the last decade, have
been the object of scientific investigations, perhaps none has been so
greatly developed and changed as that which deals with tumors. For at
times previous it consisted only of a confusion of special observations, but
now it is a well-arranged field where every growth, no matter how vary-
ing its form may be, has its given place. But this change for the better
mostly regards their patho-anatomical structure, for their clinical history
is pretty nearly the same as before. I hope, therefore, that this small
contribution in the latter respect will not be entirely wanting in interest.
662
ON STONE IN THE BLADDER IN FINLAND.
BY
PROF. J. A. ESTLANDER,
OF HELSING FORS, FINLAND.
To facilitate the explanation of the peculiar conditions, with respect
to stone in the bladder, which exist in my native country, Finland, I
will divide all cases of this disease with respect to their etiology into
two groups. The first where there is no disease in the urinary organs
and the stone seems to be of constitutional origin, and the second where
the calculus clearly depends on a local disorder. When cases of stone
belonging to the first group frequently occur in one country, and are, on
the other hand, very rare or altogether wanting in another country,
then the endemic causes are clearly perceptible. But when the calculus
originates in diseases of the kidneys or in the many causes which pre-
vent the bladder from completely emptying its contents—as for instance
paresis of the muscles of the bladder, or obstruction of any kind in the
urethra, etc.—then the question arises, in what relation do these cases
stand to the general endemic causes : Are they absolutely independent
of them or not ? For my part I am inclined to answer this question to
a certain extent in the negative. It is true that the rich or so-called
upper classes of the different countries all over the world live pretty
nearly in the same manner, and are precisely by their manner of living
on One side more exposed to calculus, and on the other side more inde-
pendent of the endemic causes of the disorder, than the lower classes.
ISut still, as the influence of climate, water, temperature, etc., is never
completely to be avoided, the rich must, at least to a certain degree, be
subject to the same epidemic laws as the other classes of the population.
If I then suppose a country where no endemic causes of stone in the
bladder exist, there we should, as a general rule, entirely miss all the
cases of constitutional origin, and find the cases of local origin princi-
pally amongst the upper classes, and that less frequently than elsewhere.
This is just the case with Finland.
Some statistical figures, collected from the Case Book of the Surgical
Clinique, at the University of Finland, for the last forty-four years, will
show the truth of this in respect to the first group of calculous cases.
T) uring this time of nearly half a century, only one case has presented
itself, that being in a farmer of forty-one years, whom, in 1863, I operated
upon for a phosphatic stone in the bladder. This isolated fact is the
more remarkable, as several such operations have been performed in the
Clinique, but the patients always belonged to the Russian nation, parti-
cularly from the province of Jaroslaw. As Finland, with a population,
on December 31, 1875, of 1,829,919, has a surface of not less than 6783
Swedish square miles (Lapland included), and the means of communica-
tion between the different parts of the country have to within the last
ten years remained undeveloped, it might be supposed that cases of this
disease had occurred in any of the eight provinces into which the Grand
Duchy is divided, without presenting themselves at the Surgical Clinique
C AL CU L U S IN FINLA N D. 663
of the University, although it is the only special hospital in the country.
In order to gain a decided conviction that this circumstance had no
determining influence, I communicated by letter with the doctors super-
intending the hospitals erected by the government in each of those pro-
vinces, and they each and all returned the same answer: that in the last
ten or fifteen years during which they had been at the hospitals, they
had never met with a case of stone in the bladder.
Cases belonging to the second group of calculus have been exceedingly
rare amongst that part of the population which frequents the hospitals,
and have been principally limited to stones depending on paralysis of
the bladder. Not one single case of renal calculus is recorded in the
Case Book. But in my private practice I have had occasion to treat a
great many patients of that kind ; all from the richer classes. Amon
cases of vesical calculus, most of them depending on hypertrophy of the
prostate, about twelve may have occurred among my countrymen. I
have no precise data to judge of the frequency of stone in the upper
classes, but it seems to me that this number is remarkably small to
correspond with a practice of seventeen years, during which time I have
been the only ex-professo surgeon in the country.
From the facts I have just now stated, I think I am justified in con-
cluding that stone in the bladder occurs in Finland almost exclusively
among the upper classes, and originates most frequently in disorders of
the urinary organs. It seems as if the causes of so pronounced an immu-
nity for a whole country ought to be easily discovered, but such is not
the case. Here just as well as anywhere, where we have to do with the
etiology of diseases, the facts we observe are the result of many co-oper-
ating circumstances. As it would be out of time and place here to enter
into any long discussion of the different influences which c uld possibly
be considered as contributing to this immunity, I will only point out
the circumstances which seem to me to merit special attention in this
respect. The quality of the water is generally considered very important,
and to this matter we ought to assign the first place. The land consists
principally of granite mountains (ground even during the glacial period),
vast sandhills, and barren heaths, which the vegetation of many thousand
years has covered with a scanty crust of earth. The water of springs,
rivers, and lakes, therefore, contains only a very small quantity of alka-
line salts. As an instance I will quote an analysis made by Prof. J.
Chydenius of the water in the Wanda River, which supplies the water-
works of Helsingfors.
100,000 grammes contained 7 grammes of solid substance, whereof—
Chloride of sodium . * e gº g & . 0.63 grammes.
Carbonate of lime e G tº & ſº e . 1.88 € $
Carbonate of magnesia . e t g e e . O.81 6 &
Silicic acid . e e & * ğ © * . 0.48 & 4
Organic humus-like substance g & {. º . 2.55 6 &
Thus the purity of the water is very remarkable, and, as water forms
the principal part of the nourishment of a people, we certainly must con-
sider this quality as the main cause of immunity. Another cause might
be found in the food of the Finnish people, which generally consists of
cereals, fish, potatoes, and milk (nearly always sour), and very seldom
meat; in fact I do not think any other people consumes so much lactic
acid and so little meat. It would not perhaps be difficult to find out at
least the relation between meat as food and the uric acid which forms
the greater part of the calculi of constitutional origin, but I content
664 ESTL ANDER, CAL CULUS IN FINLAND.
myself with simply pointing out the most striking features of the Finnish
people's manner of living, hoping that a comparison with that of other
peoples enjoying the same immunity will, better than any hypothesis,
show whether those characteristic points exercise any influence in that
respect or not. There would yet remain some circumstances worthy of
notice, as for instance the habit of taking once a week a bath in a room
filled with hot steam—a habit which is as old as the people itself, and so
common that the poorest man never neglects it—but that I think I have
already too long claimed your attention for this subject.
SECTION ON DERMATOLOGY AND
SYPHILOGRAPHY.
P R E S I D E N T .
JAMES C. WHITE, M.D.,
OF BOSTON.
W I C E - P R E S I D E N T S .
S. ENGELSTED, M.D., EDWARD SHIPPEN, M.D.,
OF COPEN. HAG EN. U. S. NAVY.
S E C R. E. T. A. R. Y.
ARTHUR WAN HARLINGEN, M.D.,
OF PHILADELPHIA.
WARIATIONS IN TYPE AND IN PREVALENCE OF DISEASES
OF THE SKIN IN DIFFERENT COUNTRIES OF EQUAL
CIVILIZATION.
BY
JAMES C. WHITE, M.D.,
PROFESSOR OF DERMATOLOGY IN HARVARD UNIVERSITY,
IT has long been well known that some diseases of the skin are more
or less strictly confined to certain distinct geographical or anthropological
districts, and that others assume marked variations of type in different
countries. The number of such affections, however, is small. The im-
pression has been gradually taking form, of late, that similar variations
in type and prevalence exist much more generally among skin diseases
than has been hitherto recognized, nor is it strange that such a fact, if
fact it be, should have remained so long undetermined. The slow growth
of dermatology prior to the last quarter of a century; the babel-like
confusion in nomenclature which still hampers its various schools and
writers; and the lack of competent observers, except in a few of the
principal centres of the most civilized populations, have prevented the
collection and comparison of the necessary data from all parts of the
world, upon which the establishment of such facts must rest. It is not
my intention to consider this subject now under as broad a scope as the
title of this paper would suggest, but rather to present my views and the
facts which I have been able to gather relating to the differences between
these affections, as they occur here at home and in the countries which
afford means of comparative observation. In this narrower compass we
may, perhaps, wisely essay the first step towards the complete solution of
the question.
As just stated, this question of variation has only slowly forced itself
upon the perception of dermatologists. Owing to the entire absence in
America of any regular instruction in dermatology in our medical
666 J. C. WHITE,
schools, and of opportunity of clinical observation of skin diseases in our
hospitals and dispensaries, until within the last few years, those of us
here who have labored to supply such deficiencies, and have devoted our-
selves specially or exclusively to the study of dermatology, got our first
systematic and practical conceptions of skin diseases in the schools of
Europe; conceptions no doubt often tinged over-strongly in this or that
direction by the individual opinions and theories of some eminent teacher,
and which we have slowly more or less modified since then by more ex-
tended and broader personal observation ; still it was in foreign schools
that we first familiarized ourselves with the types of cutaneous disease,
and the impressions there gained we have retained as permanent stand-
ards for comparison with the results of our later and more practical ex-
perience at home. Gradually, perhaps too slowly in the case of those of
us whose reverence for a master's precepts has been strongly inherent, we
have become aware of differences of various kinds in some of the dis-
eases here and the same affections as seen abroad, differences in course,
in severity, in prevalence, in behavior under treatment, etc. These later
impressions have been almost wholly the growth of individual observa-
tion, and with the exception of a limited mutual interchange of opinion
on the subject in conversation or correspondence, and brief allusion to
some of the more noticeable variations in occasional papers, the question
of such differences has not been presented or discussed in a general way
by any of our dermatologists. Nor is this strange : we have been more
wisely spending our time, first, in creating opportunities of study, too
often in the face of indifference or positive opposition, until we may
justly claim to have established dermatology upon a firm basis; and,
secondly, in faithful observation, rather than in the preparation of crude
publications, so that we have been largely ignorant of each other's opin-
ions upon the subject. Dut now that the mature results of careful and
extensive home observation are, of late, more generally given to the
world; now that we have in our American Archives a special channel of
publication, such as only one other country can boast of; and now that
original and independent works on general dermatology, of which we
may justly be proud, have been written by members of this Section; now
is it for the first time possible to compare the results of our enlightened
and independent observers with those of our foreign brethren, and to
learn how far our previous vague and individual impressions are sup-
ported by facts drawn from wide fields of observation. And yet we
should not over-estimate the opportunities we even now possess for the
study of this question. It is to be regretted that they exist only in a
few centres of observation, separated but a short distance, and in the
midst of large cities with mixed populations; nor until trained derma-
tologists are more widely and uniformly distributed than at present, will
it be possible to form a reliable estimate of the prevalence and character
of skin diseases throughout our vast and varied country, or to study in
a satisfactory way the variations which these affections manifest among
the many races which inhabit it.
If any one of us who has had much to do with skin diseases in both
hospital and private practice in our larger cities, were now asked, what
are the most marked differences between these affections here and in for-
eign countries, he would probably reply that we miss altogether certain
diseases which are either very commonly, or occasionally, met with in
some parts of Europe, while others are far less prevalent here than there.
Moreover, we rarely or never see here such grave forms of some affections
V ARIATIONS IN TYPE AND PREW A LE N C E OF S KIN DIS E A SES. 667
as are of frequent occurrence in the old world. Again, certain diseases
are more common at home than abroad, or present certain modifications
in type which may be regarded as indigenous. Such, I venture to think,
would be the reply of all of us, as the result of entirely independent ob-
Servation; and yet if we were asked for the data upon which such con-
clusions were based, we should have to answer that they were largely
impressions, but impressions which would prove to be in the main cor-
rect, when tested by statistics. It is to determine, therefore, how reliable
are our opinions upon these points, as far at least as the test is applicable,
that I have brought together as many statistical reports bearing upon
the prevalence of cutaneous diseases amongst us as are available, for the
purpose of comparing them with well-known foreign tables. In making
up this home standard, I have preferred to use materials which are the
results of the observations of those of us who have had essentially the
same training in dermatology, and whose nomenclature and deductions
are, therefore, interchangeable, and if faulty uniformly so. They are drawn,
too, from similar sources in the large cities of Philadelphia, New York,
and Boston, and are therefore homogeneous in character. The figures
are taken from the published reports of free skin dispensaries prepared
by Dr. Duhring, in Philadelphia, by Dr. Bulkley, in New York, by Dr.
Wigglesworth, in Boston, and by the writer. They represent ten thou-
sand consecutive cases of diseases of the skin, affording thus an oppor-
tunity of contrasting the peculiarities of these affections, if such exist,
in these cities, and of forming a collection as numerous, I believe, as
has been tabulated for similar purposes by any one writer hitherto in other
parts of the world. I have not attempted to give the complete lists pub-
lished by these gentlemen, but have put down in the table only such
affections as bear possibly upon the subject before us, those of most com-
mon Occurrence, and the rarer forms of greatest interest. It is to be re-
gretted that we have not the published observations of dermatologists
also from our southern and western cities, so that a more completely
national representation might be offered ; but until our special branch of
medicine attains a more independent position in these parts of our coun-
try, we must accept this restricted report as the only one at present practi-
cally possible.
In examining this table for the purpose of ascertaining if there are
any notable differences in the relative occurrence of the affections therein
mentioned in the cities of Philadelphia, New York, and Boston, it must
be remembered that we cannot generalize too boldly from the results of
such an analysis. The element of variableness in the customs of their
respective populations, in professional etiquette even, and other non-
apparent circumstances, which all influence the attendance upon dis-
pensary practice, must make no little difference in the character of the
diseases treated in these cities, in addition to the more noticeable mat-
ters of race, manner of living, location, climate, etc., to which we should
naturally refer such variations. On the whole, it will be observed that
the affections do not vary greatly in prevalence; and some of the appa-
rent discrepancies may be easily explained. For instance, in Philadel-
phia, no cases of dermatitis calorica, or dermatitis venenata, are recorded,
and yet there can be no question that of the first variety, at least, cases
must occur; of dermatitis venenata, Boston has more than its share,
perhaps because the skin clinic of the Massachusetts General Hospital
draws its patients from a wider rural area than those of her large sisters,
and that her encircling flora abounds more than theirs in the poisonous
668 J. C. WHITE,
TABLE I. Showing the comparative frequency of the more common diseases of
the skin in 10,000 consecutive cases in American dispensary practice.
New York. Philadel- Boston. Boston.
I) l'. phia. Dr. Dr.Wiggles- D l'.
Diseases. Bulkley. Duhring. worth. White. Total. Percentage.
1617 cases. | 1267 cases. | 1862 cases. 5254 cases. ſ
Acne 154 116 246 378 894 8.9
Alopecia º 3 ...... 19 14 36 .36
Alopecia areata e g l 2 6 17 26 .26'
Chloasma . & e e 6 (, 22 16 50 5
Dermatitis calorica 9 ...... 5 26 40 4.
Dermatitis venenata 7 ...... . ...... 73 80 8
Ecthyma. & e e 7 3 3 58 71 .7
Eczema & e & e 520 535 447 237.2 3874 38.7
Epithelioma ë & e i & º e s ∈ S. 18 17 25 60 .6
Erysipelas . o ſº & 32 3 5 55 95 95
Erythemata . © & º 39 4 24 86 153 1.5
Furunculosis e g & 36 11 23 . 65 135 1.35
Herpes e d e e 16 2 20 29 67 .67
Herpes zoster . tº & 22 7 6 77 112 1.12
Ichthyosis . e g gº 3 12 1. 5 21. .2
Impetigo . & * * | * * * * * * : e. e. e s a tº 18 19 37 .37
Lupus . * $ e tº 10 3 10 ll 34 .34
Lupus erythematosus . & 2 8 12 6 28 .28
Pemphigus . & © º 3 l 2 15 21 .2
Phthiriasis capitis º tº 69 32 240 341 3.4
Phthiriasis vestiment. . g 32 * 38 50 120 1.2
Phthiriasis pubis. ge © l ll 7 19 .19
Prurigo g tº o †
Pruritus tº & & e 43 42 36 51 172 1.7
Psoriasis . g * § 70 75 71 157 373 3.7
Purpura . © º e 9 5 5 20 39 .39
Scabies * gº & wº 62 9 17 145 233 2.3
Scrofuloderma . & o 11 6 31 30 78 .78
Seborrhoea . & g © [ s gº e e º º 54 48 56 158 1.58
Syphiloderma . & * 137 136 100 340 713 7.1
Tinea tonsurans . * § 47 28 86 185 346 3.46
Tinea versicolor . As * 14 33 27 81. 155 1.55
Tinea favosa & * * 7 l 6 17 31 .31
Ulcers . e tº g º 25 23 33 317 398 3.98
Urticaria . & e 4% 59 33 37 136 265 2.65
Xeroderma . & & tº 1 ...... Il 13 25 .25
species of rhus. Epithelioma is apparently unknown in New York as a
skin disease, because the large surgical hospitals no doubt attract it
wholly to themselves. So, too, the table fails, without doubt, to repre-
sent the actual or proportionate occurrence of lupus, because it is so
commonly regarded as a so-called surgical disease. Again, ichthyosis is
apparently much more common in Philadelphia, perhaps because Dr.
Duhring may regard the cases placed apart by the other observers under
the title Xeroderma, as merely a variety of the former disease. Other
differences, however, cannot thus be accounted for. The erythemata,
for example, must be less prevalent in Philadelphia, for some inexplica-
ble reason, than in the northern cities, for but 4 cases out of the 153
were there observed. Some small part of this great variation may be
owing to difference of opinion in classification regarding some of the
varieties of the affection, but a small part only. Erysipelas, too, like
these other acute hyperaemic processes, seems to be of less common occur-
rence in Philadelphia. It is in the parasitic affections, however, that
V ARIATIONS IN TYPE AND PREVALEN C E OF S KIN DISE ASE S. 669
the greatest differences are to be observed. That scabies forms but
.7 per cent. of the Philadelphia cases against nearly 4 per cent. in New
York, and 2 per cent. in Boston ; and phthiriasis only 2 per cent. in the
first against 6 per cent. and 5 per cent. respectively in the two latter
cities, can be easily explained on the supposition, which is thus demon-
Strated to be a fact, that the former's clinic derives its material from a
different class than the immigrant populations which make up so largely
the patients of the two seaboard cities; but this does not explain the
remarkable predominance of one of the vegetable parasites over the others
in Philadelphia. Tinea tonsurans is elsewhere in America far more
common than the other vegetable parasitic affections, yet the table shows
that in Philadelphia tinea versicolor is of more frequent occurrence than
the others collectively. In the New York column there are 47 cases of
tinea tonsurans, 14 of tinea versicolor, and 7 of tinea favosa ; in Boston,
271 of tinea tonsurans, 108 of tinea versicolor, and 48 of tinea favosa;
while in Philadelphia there are 28 of tinea tonsurans, 33 of tinea versi-
color, and 1 of tinea favosa. We are less acquainted with the natural
history of the fungus of tinea versicolor than with those of the other
vegetable parasitic affections, and it may be that peculiarities of this sort
in its geographical distribution may throw important light upon its
nature.
Inasmuch as the statistics of dispensary and hospital practice afford
but a partial representation of the prevalence of cutaneous affections in
the whole community, I have prepared a table (Table II.) which presents
more fairly their distribution amongst all classes. It shows the relative
occurrence of 5000 consecutive cases at the out-patient department for
skin diseases at the Massachusetts General IIospital in Boston, and of
2000 consecutive cases in my private practice there, and illustrates the
two extreme classes of patients, those on the one hand mostly poor and
of foreign derivation, with the characteristic affections of poverty and
neglect of personal care; and, on the other hand, those who have the
means and leisure to seek professional advice for troubles which more
affect the looks than the health of the individual. These extremes largely
represent, therefore, the affections of squalor and of luxury; but, even
when the two classes are placed together, they fail to show fairly the
prevalence of cutaneous diseases amongst all classes. Most infantile
affections of the skin among the middle and upper classes, for instance,
remain under the care of the family physician, and only in exceptional
cases are seen by the specialist. This is true, too, with many of the
trivial and self-limited diseases among them.
As might be inferred, it is mainly with regard to the affections which
characterize the two extremes of the classes which make up this table,
that we find the most striking differences. Those diseases which affect
the personal appearance of the patient, and do not interfere with health
and labor, are naturally in far greater proportion in private than in dis-
pensary practice. Thus we see that acne forms 18 per cent. of the former,
and 6.9 of the latter; the various forms of loss of hair, included under
alopecia, over 10 per cent. in the former, and less than one-fourth of
1 per cent. in the latter; all the varieties of seborrhoea 10 per cent. of the
private cases, and only 1 per cent. of the hospital cases; and yet there are
no good reasons for believing that these affections are even as prevalent
among the rich and well-cared for as among the poor and less cleanly.
On the other hand, it is in the latter class that we find the animal para-
sitic affections positively more abundant, as likewise those which are
670 J. C. WHITE,
TABLE II. Showing the relative occurrence of the more common skin diseases
in dispensary and in private practice in Boston.
5000 consecutive 2000 consecutive
Diseases. cases at Mass. Per cent. cases in private Per cent.
Gen. Hosp. practice.
Acne 348 6.9 360 18.
Alopecia 13 .26 205 10.2
Alopecia areata 17 .34 27 1.3
Chloasma e 16 .32 38 1.9
Dermatitis calorica 26 .52 4 .2
Dermatitis venenata 73 1.4 18 .9
Ecthyma 55 1.1 5 .25
Eczema 2242 44.8 507 25.3
Epithelioma 25 .5 5 .25
Erysipelas 52 1.
Erythemata . 81 l.6 33 1.65
Furunculosis 65 1.3 9 .45
Herpes 28 .56 3 .15
Herpes zoster 73 1.4 9 .45
Ichthyosis 5 .1 3 .15
Impetigo 19 .38 2 .1
Lupus . © © ll .22 6 .3
Lupus erythematosus 6 .12 2 .1
Pemphigus 15 .3 3 .15
Phthiriasis capitis e 216 4.3 5 .25
Phthiriasis vestiment. . 48 .96
Phthiriasis pubis . 7 .14 l .05
Prurigo
Pruritus 50 1. 32 1.6
Psoriasis 152 3. 78 3.9
Purpura 19 .38 4 .2
Scabies 139 2.78 29 1.4
Scrofuloderma 27 .54 3 .15
Seborrhoea 55 1.1 200 10.
Syphiloderma 327 6.5 41 2.05
Tinea tonsurans 180 3.6 113 5.6
Tinea versicolor 81 1.6 20 1.
Timea favosa 17 .34 4. .2
Ulcers . 309 6.18 15 .75
Urticaria 132 r 2.6 17 .85
Xeroderma 13 .26 17 .85
|
caused wholly or in part by the action of external irritation, and those
which are more or less due to poverty of the blood and unhealthy ways
of living. Thus disturbances produced by lice form 5.4 per cent. of the
hospital cases, and only .8 per cent. of those in private practice; and
scabies 2.8 per cent. in the former, and 1.4 in the latter. The various
forms of dermatitis, due to the action of external causes mainly, were
twice as common with the former as with the latter. Eczema, which is
somewhat under the same exciting influences, formed 44.8 per cent. of
the former, and 25.3 of the latter; but it must be remembered, as above
explained, that the latter figures represent less fairly the absolute preva-
lence of eczema among the wealthy classes. Herpes formed 2 per cent.
of the hospital cases, and only .6 per cent. of the private. The varieties
of cutaneous syphilis, both acquired and congenital, were in the former
6.5 per cent., and in the latter 2.05 per cent. Ulcers 6.18 per cent. of
the former, and only .75 per cent. Of the latter. Urticaria 2.6 per cent.
V ARIATIONS IN TYPE AND PREVA LEN CE OF S KIN DISE ASE'S. 671
of the former, and .85 per cent. of the latter. In other orders of affec-
tions, which are apparently little under the influences of class and cus-
toms of life, we find a striking equality in prevalence in the two series of
cases. The erythemata, mostly forms of E. exudativum multiforme, were
alike in both, 1.6 per cent. ; ichthyosis.1 per cent. in the hospital cases,
.15 per cent. in the private; lupus .34 per cent. in the former, .4 per cent.
in the latter; psoriasis 3 per cent. in the former, 3.9. in the latter; and
yet even with these affections we cannot accept these comparative results
as representing absolutely their relative prevalence amongst all classes.
Let us now compare the combined results of our American table with
those of similar statistics in other countries. The most available mate-
rials for this purpose are Anderson's 10,000 cases from the Glasgow Dis-
pensary, Purdon's 3000 Irish cases, and 24,000 made up from the annual
reports of Hebra’s Vienna clinic; and the private cases published by
Wilson and Anderson, with 2000 of my own; making 47,000 hospital
and 13,000 private cases—in all, 60,000. Dr. Anderson’s cases are espe-
cially valuable as representing the prevalence of skin diseases in Great
Britain, not only because the number is the same as that in our Ameri-
can table, but because his nomenclature and classification are also essen-
tially identical with those of the American reporters. The statistics of
Wilson and Purdon are less valuable, because from want of such har-
mony it is impossible to make a reliable comparison of affections at all
complete. On this account I have been obliged, in the following tables,
to group several classes of disease under more general heads than in
Table I. •
Table III. shows the comparative prevalence of the more common
affections of the skin in American and European dispensary and hospital
practice; and Table IV. shows the same in special private practice here
and in Great Britain, as closely as differences in nomenclature and clas-
sification will permit the formation of reliable comparisons.
As will be seen, Acne appears to be three times as common with us in
dispensary practice as in Scotland, and nine times as much as in Vienna,
if the tables are to be believed ; or else our population is more sensitive
about its “complexion” than foreign nations, even among the lower
classes. The former conclusion is sustained in Table IV., which shows
that acne forms but 7.5 per cent. of private cases in Glasgow, and 5 per
cent. in London, against 18 per cent. in Boston. The Vienna statistics,
it must be borne in mind, represent more a resident than an ambulatory
class of patients. Alopecia, meaning loss of hair in general, forms 36 per
cent. of the dispensary cases in America, .56 per cent. in Scotland, and
.26 per cent. in Ireland, whilst it does not enter at all into the Vienna
tables, because it is not a sufficiently serious affection for hospital resi-
dence; among private cases it forms 10.2 per cent. of the Boston, 1.8 per
cent. of the Glasgow, and 4 per cent. of the London cases. Alopecia
areata, on the contrary, seems to be of much more common occurrence in
Scotland than here, for in the dispensary cases it forms .26 per cent. of
the American, and 1.5 per cent. Of the Scotch ; and among the private
cases 1.3 per cent. in Boston, 4.4 per cent. in Glasgow, and 2.7 per cent.
in London. Of its prevalence in Austria we can form no estimate. Chlo-
asma (the local distribution of melanoderma upon the face, moth or liver.
spot, as popularly called) formed .5 per cent. of the dispensary, and 1.9 per
cent. of the private cases here, against .03 per cent. of the former and .3 per
cent. of the latter in Glasgow. Ecthyma presented no differences of impor-
672 J. C. WHITE,
TABLE III. Showing the comparative prevalence of the more common affections
of the skin in American and European dispensary and hospital practice.
Scotch.
Amer’n. Ander- Irish. Austr'n.
10,000 SOm, Purdon, | Hebra,
Diseases. cases. Per cent. 10,000 Per cent. 3000 Per cent. 24,000 Per cent.
Boston, CA.SéS. Cà.S6 S. C3 Sé S.
Phila..., Glasgow Belfast Vienna.
N. York. Hosp. Hosp. Hosp.
Acne . . . . . 894 | 8.9 || 325 3.25 | ...... . ...... 263 1.
Alopecia . º & e 36 .36 56 .56 8 .26 |
Alopecia areata º e 26 .26 || 153 | 1.5
Chloasma º © e 5() .5 3 .03 |
Dermatitis º º e 120 1.2 27 27 ...... . ...... 244 1.
Ecthyma . e e e 71 .7 97 .97 6 .2 233 .9
Eczema . e e . 3874 || 38.7 2527 25.27 800 26. 2877 11.9
Epithelioma . e º 60 .6 38 .38 14 46 33 .12
Erysipelas º o º 95 .95 1() .l 22 .7 89 .36
Erythemata . g o 153 | 1.5 476 4.7 | ...... . ...... 210 .8
Herpes . º º e 179 1.79 32 .3 20 .6 178 .7
Ichthyosis º e e 21 .2 31 .3 l .03 56 .2
Ilupus . e & º 62 .6 198 | 1.98 i...... . ..... 738 || 3.
Pemphigus . e - 2I .2 13 .13 15 .5 53 .22
Phthiriasis º e º 480 4.8 327 3.27 107 3.5 3.186 13.
Prurigo . e e • I & e º e º e i º e º e º 'º 1 ...... . ...... . ...... 740 3.
Pruritus . e e º 172 1.7 39 .39 ...... . ...... 149 .6
Psoriasis . e o º 373 3.7 725 7.25 75 2.5 652 2.2
Purpura . e * º 39 .39 8 .08 4 .13 95 .3
Scabies . º & e 233 2.3 2527 25.27 497 | 16. 11,284 || 48.
Scrofuloderma . * e 78 78 27 .27
Seborrhoea e © o I 58 1.58 13 .13 ...... . ...... 25 .1
Syphiloderma . e & 713 || 7.1 493 || 4.9 299 || 9.9
Tinea tonsurans º e 346 3.46 142 1.4 53 1.7 80 .33
Tinea versicolor e e 155 1.55 106 1.06 18 .6 50 .2
Tinea favosa . * e 31 .3 156 1.56 15 .5 105 .45
Ulcers . © c e *398 3.98 433 4.3 ...... . ...... 190 .79
Urticaria º º © 265 2.65 147 1.47 43 1.4 200 .8
Xeroderma . e e 25 .25 ' ...... . ...... . ...... . ...... I
tance, although the term is too loosely used for close comparative analysis.
Eczema made 38.7 per cent. of the American dispensary cases, 25.57 per
cent. of the Scotch, 26 per cent. of the Irish, and 11.9 per cent. of the
Austrian; and of the private cases 25.3 per cent. in Boston, 34.8 per cent.
in Glasow, and 45 per cent. in London. It does not seem, therefore, that
there is any marked difference in its prevalence in Great Britain and
here at home, if the figures in both Tables (III. and IV.) be considered
together; and the inverse ratio established by a comparison of its preva-
lence in the poorer and richer classes here and abroad may be explained
by simple custom, as governing the relations between general and special
practice in the respective countries. The low percentage in the Austrian
column may be partly explained by the fact that those affected with the
milder forms of the disease do not seek hospital residence for relief, and
that cases of infantile eczema are diverted to the children's hospital.
With regard to the next two affections in the tables, Epithelioma and
Erysipelas, trustworthy comparison is impossible on account of variation
in local custom of referring such cases to the skin or surgical departments
of hospitals. The various forms of Erythema would seem to be less preva-
lent in America than in Europe, for here it occurred in the proportion of
1.5 per cent. in dispensary, and 1.6 per cent. in private practice, to 4.7 per-
VARIATIONS IN TYPE AND PREVALENCE OF SKIN DISE ASEs. 673
TABLE IV. Showing the comparative prevalence of the more common skin
diseases in American and European private practice.
Boston. Glasgow. London.
2000 1000 10 000
Diseases. consecutive Per cent. | consecutive Per cent. | consecutive Per cent.
C3,868, Ca,SeS. C3,888.
Acne . te te g * 360 18. 75 7.5 508 5.
Alopecia . e g e 205 10.2 18 1.8 414 4.
Alopecia areata . e & 27 1.3 44 4.4 276 2.7
Chloasma . e º tº 38 1.9 3 .3
Dermatitis . e ſº * 22 1.1 ! ...... . ...... 15 .15
Ecthyma . © g e 5 .25 ' ...... . ...... 42 .4
Eczema e & * & 507 25.3 348 34.8 4500 45.
Epithelioma e tº * } 5 .25 9 .9
Erysipelas . ge tº * | * * * * * * | * * * * * * | * a s is e e e º e s e e 12 .12
Erythemata tº wº º 33 1.6 99 9.9 219 2.19
Herpes iº g © e 12 .6 l .1 108 1.
Ichthyosis . e e © 3 .15 7 .7 46 .46
Lupus ſº e © e 8 .4 25 2.5 155 1.55
Pemphigus e & & 3 .15 3 .3 19 .19
Phthiriasis . & & • 6 .3 7 .7 23 .23
Prurigo . * * * | * * * * g c || e º ºs e º 'º 2 .2
Pruritus . e © º 32 1.6 11 1.1 61 .61
Psoriasis . ë & & 78 3.9 106 10.6 628 6.28
Purpura . e g e 4 .2 l .1
Scabies e & * iº 29 1.4 44 4.4 308 3.
Scrofuloderma . g g 3 .15 6 .6
Seborrhoea . g & * 200 10.
Syphiloderma . g & 41 2. 57 5,7 350 3.5
Tinea tonsurans º ſº 113 5.6 36 3.6 252 2.5
Tinea versicolor º © 20 1. 15 1.5 131 1.3
Tinea favosa g g g 4 .2 4. .4 3 .03
Ulcers g * {º * 15 .75 7 .7
Urticaria . tº ſº º 17 .85 5 .5 88 .88
Xeroderma & tº gº 17 .85
cent. in Scotland in the former, and 9.9 per cent. in the latter, and of
2.19 per cent. of Mr. Wilson's cases. In Austria, on the other hand, it
formed only .8 per cent. of the cases in the hospital. Herpes is consider-
ably more prevalent in America than in foreign dispensary practice,
forming 1.8 per cent. of the cases here to .3 per cent. of the Scotch, .6 per
cent. of the Irish, and .7 per cent. of the Austrian; but in private prac-
tice, as with eczema, an inverse ratio prevails, at least in London, the per-
centage being in Boston .6, in Glasgow .1, and in London 1. Ichthyosis.
shows no remarkable variations in the tables, .7 per cent, being the high-
est ratio presented by any country. Lupus, on the other hand, shows a
marked difference in relative occurrence, being much less common here
than abroad, a fact which is strongly impressed upon an American in
Europe by the chronic nature of the disease and the heroic means em-
ployed in its treatment. Of the dispensary eases it forms in America
but .6 per cent., in Scotland 2 per cent., in Austria 3 per cent.; and in pri-
vate practice here .4 per cent., in Scotland 2.5 per cent., and in London
1.5 per cent. The reports do not allow a proper subdivision into its two
distinct forms. Pemphigus shows itself about alike in both classes of cases
and in all countries. Phthiriasis is naturally everywhere almost exclu-
sively confined to the lower classes, and marks clearly the degree of deg-
radation in habits of cleanliness of a nation. It will be easily understood,
43
674 J. C. W. HITE,
therefore, why Austria with her dirty Slavonic races should present so
excessive a percentage of cases, 13 per cent. to 4.8 per cent. in America,
3.3 per cent. in Scotland, and 3.5 per cent. in Ireland, although the Vienna
figures comprise also the excoriations produced by fleas and bugs. Scabies,
too, affords of course another and much stronger illustration of the same
law. Of dispensary cases it forms amongst us only 2.3 per cent., in Scot-
land 25 per cent., in Ireland 16 per cent., and in Austria 48 per cent. ;
and in private practice in Boston 1.4 per cent., in Glasgow 4.4 per cent.,
and in London 3 per cent. Prurigo may be set down as an affection
almost wholly absent from this country, and in fact virtually confined
exclusively to certain parts of Europe. Not a single instance is recorded
among the dispensary cases in America, only a single one in Scotland,
whilst it forms 3 per cent. of the Austrian. In my private practice I am
not sure that I have seen a single case, whilst Anderson puts down two
instances in his list. Mr. Wilson’s statistics cannot be considered, as he
confounds the disease with simple pruritus. This latter affection seems
to be somewhat more prevalent here than in Europe, forming 1.7 per cent.
to .4 per cent. of the Scotch, and .6 per cent. of the Austrian dispensary
cases; and of the private cases 1.6 per cent. here, to 1.1 per cent. of the
Scotch, and .6 per cent. of the English.
Psoriasis is much more common in Scotland than elsewhere, according
to the tables, in both classes of patients; in the dispensary cases showing
7.25 per cent. to 3.7 per cent. American, 2.5 per cent. Irish, and 2.2 per
cent. Austrian ; and in the private cases 10.6 per cent. to 3.9 per cent.
American, and 6.3 English. Purpura, if the small number of cases
recorded permits comparison, seems to be rather more common here than
in Great Britain, both in dispensary and private practice. Scrofuloderma
is a term so indefinitely used by different writers that no legitimate con-
clusions can be drawn from the statistics presented. Seborrhoea, like
acne, appears to be much more common amongst us than elsewhere, the
term being used to include that scaly condition of the scalp so intimately
connected with alopecia. Of the American dispensary cases it forms 1.6
per cent., of the Scotch .13 per cent., and of the Austrian .1 per cent. ;
whilst in private practice it forms 10 per cent. of all cases. With regard
to the syphilodermata, it is clearly impossible to draw any inferences from
the figures presented in the tables as to the comparative occurrence of
this disease, because the existence of special departments and of adver-
tising quacks draws the cases almost wholly away from skin clinics. In
the Vienna column, for instance, the space is not filled, because the num-
ber of cases which find their way into the cutaneous wards is so trivial
compared with the immense number in the adjoining clinic of Sigmund.
In the skin department of the Massachusetts General Hospital, the cases
(Table I.) are almost wholly those of the wives and children of diseased
men. The Vegetable parasitic affections present some rather surprising
results: Tinea tonsurans is more common here than in other countries,
forming 3.46 per cent. against 1.4 per cent. of the Scotch, 1.7 per cent. of
the Irish, and .33 per cent. of the Austrian dispensary cases; and in pri-
vate practice 5.6 per cent. against 3.6 per cent. of Anderson's, and of 2.5
per cent. of Wilson's. Ilebra’s cases hardly represent the frequency of
its actual occurrence, because he did not recognize, when they were pub-
lished, the parasitic character of eczema marginatum, and a portion of
his cases of sycosis should possibly be included in the same class. Tinea
versicolor does not vary so greatly, but is less common in Ireland and
Austria than elsewhere. Tinea favosa is somewhat less common here
V ARIATIONS IN TYPE AND PRE W A LE N C E OF S KIN DISE ASE S. 675
than in Europe, and noticeably so than in Scotland. It is in Italy, how-
ever, that it especially flourishes. The ratio which these three affections
bear to one another in Scotland in dispensary practice is singular by com-
parison with other countries, for whereas with us tinea tonsurans forms
3.46 per cent., tinea versicolor 1.55 per cent., and tinea favosa .3 per cent.,
and in Ireland 1.7 per cent., .6 per cent., and .5 per cent., respectively; in
Scotland the percentages are 1.4, 1.06, and 1.56, or nearly equal. In An-
derson's private cases, however, their relative occurrence is more like
that observed elsewhere. Urticaria is somewhat in excess in America,
forming 2.65 per cent. of the dispensary cases against 1.47 per cent. in
Scotland, 1.4 per cent. in Ireland, and .8 per cent. in Austria; but in pri-
vate practice the difference is not so marked, the percentage being .85
in Boston, .5 in Glasgow, and .88 in London.
TABLE V. Showing the relative prevalence of certain rare forms of skin
disease in both dispensary and private practice in America and Europe.
A mer'n. Scotch. Irish.
10,000 10,000 3000 Austr'n.
Diseases. dispen- Per cent. dispen- |Per cent. dispen- | Per cent. 23,944 |Per cent.
sary sary sary hospital
Czł,86. S. Ca,SeS. C8, SéS. C3,868.
Cornu cutaneum 1. .01 2 .02 l .03
Elephantiasis Arab. 5 .05 7 .07 2 .06 36 .15
Elephantiasis Graec. o 2 .02 1. .0.1 ! ...... . ...... 3 .01
Keloid . e tº © 15 .15 5 .05 ...... . ...... l
Leucoderma º º l .01 4 .04
Lichen exudat. rub. • e e o e s e ] e e s e e o | e a se e e e e s a e e i e º e o e º I e º e º 'o e 7 .02
Lichen scrofulosorum . 2 .02 3 .03 ...... . . . . . . . 67 .23
Lichen planus sº . 1 .01
Melasma . e e e 3 .03 I .01
Molluscum contag. . - 13 .13 6 .06 5 .15
Molluscum fibrosum 3 .03 l .01 . . . . . . . . . . . . . . 5 .02
Morphaea. . . . . ...... tº & & © e - © e º ºs ..... 1 .03
Pellagra .
Scleroderma. 7 .07 I .01
Xanthoma .04
A merican Scotch. English. |
Diseases. 2000 pri- Per cent. 1000 pri- Per cent. 10,000 pri- | Per cent.
Vate Ca,SeS. Vate C3, Sé8. V 3, 16 cases.
Cornu cutaneum
Elephantiasis Arab. 2 .1 I .1 3 | .03
Elephantiasis Græc. . . . ...... . ...... I .1 20 .2
Keloid 2 .1 |
Leucoderma l .05 ...... . ...... 34 .34
Lichen exudat. rub. . . . ...... . ...... 1 .1
Lichen Scrofulosorum . . . ...... . ...... 2 .2 :
Lichen planus 2 .1 i
Melasma e 5 .25 .
Molluscum contag. 2 .1 : ...... . ...... 6 .06
Molluscum fibrosum 2 .1 ...... ...... 5 .05
Morphaea 3 .15 ...... . ...... 11 .11
Pellagra . . . . . ...... & a s a tº s , s s a s g g : 3 s sº s º º 1 .01
Scleroderma l .05 I .1 2 .02
Xanthoma . 4 .2 * @ e e g º * g e s sº tº 8 .08
If we now turn to Table V. we may learn the relative prevalence of
some of the rarest forms of disease of the skin in both dispensary and
676 J. C. WHITE,
private practice in America and Europe. The results are interesting
mainly because they show on the one hand how extremely rare are cer-
tain affections of the most marked type, and on the other hand how very
infrequent are other diseases in the countries thus represented compared
with their well-known prevalence elsewhere. We have here tabulated,
it will be remembered, 60,000 cases of skin disease. Among them in the
first category we find only 4 cases of cutaneous horns; 32 cases of mol-
luscum contagiosum, 16 of molluscum fibrosum, 15 of morphaea, 12 of
seleroderma, and 16 of xanthoma. In the second class above specified
the most notable instances are those affections which assume in certain
parts of the globe an endemic character; elephantiasis Arabum occurs
but 56 times, 36 of which are found in the Austrian column; elephanti-
asis Græcorum (leprosy) 27 times, of which 2 were American, 3 Scotch,
and 3 Austrian, and the remainder (Mr. Wilson's) nearly all imported
cases from colonial leprous districts. Pellagra occurred but in a single
instance. Two other affections, outside these two classes, should, per-
haps, be referred to specially, inasmuch as they have been so sharply
defined as distinct types by Professor Hebra; these are lichen exudativus
ruber and lichen scrofulosorum. Of the former not an instance is recorded
outside the seven Austrian, except one amongst Anderson’s private cases.
Lichen scrofulosorum occurs only twice in the American 12,000, and five
times in the Scotch 11,000 cases; while 67 instances are recorded in the
Austrian statistics.
The conclusions to be drawn from the above brief analysis of these
tables, which have a direct bearing upon the question immediately before
us, may, perhaps be best arranged as answers to questions, as follows:—
(1) What skin diseases of well-established character and recognized
occurrence in Europe are wholly absent in the United States?
(2) What affections are noticeably less prevalent here than in Europe 2
(3) What affections are more prevalent amongst us than in Europe?
(4) What modifications from the European types are observed in skin
diseases in the United States ?
(1) Wholly absent.—The most notable example in this class is Prurigo.
I mean by this term of course the affection which one sees so frequently
in the Vienna clinic, and which is marked by such pronounced features
that its individuality is unquestionable. I do not mean that jumble of
cutaneous disorders so frequently called by this name, secondary changes
in the tissues of the skin as the result of simple pruritus, animal parasites,
etc. One feels its absence from his practice after foreign study as a
positive void long after his return, but may even come in time to doubt
the truthfulness of his recollections and the very existence of the affec-
tion. Not a single case is recorded among the 10,000 American cases in
Table III., and but a single one among the same number in Scotland,
and I am giving here the results of the observations of those only who
have had ample opportunity of studying it in Vienna. In the table of
statistics of private practice, Anderson records two more cases. In my
own, none are set down; yet I have seen one or two patients, whose
cases in Vienna might perhaps have passed for doubtful, ill-defined
examples of the disease, but none who presented all its well-characterized
manifestations. T)r. Wigglesworth, of Boston, has reported a case which
he thought must be prurigo. On the other hand, we find in the Vienna
column of the table 740 cases, forming in fact 3 per cent. of all cutaneous
diseases treated in Hebra’s wards. How can we account for this striking
V ARIATIONS IN TYPE AND PRE V ALEN CE OF S K IN DIS E A SES. 677
variation in the prevalence of so well-defined an affection ; for its entire
absence from this country? I can offer no explanation. There is no-
thing in its pathology, or known etiology, to assist us in this direction.
Its prevalence is greatest in the country which, of all Europe, presents
the greatest diversity in races. We can only blindly congratulate our-
selves on the absence of this life-long and well-nigh incurable disease.
Among the rarer affections of the skin which are tabulated as to their
comparative prevalence in Table V., there are two which find no
place in the American columns, lichen exudativus ruber, and pellagra.
The first named is one of the rarest diseases even in the country where
its individuality was first recognized and announced, only about twenty
cases in all having fallen under Prof. Hebra’s observation, seven of which
find place in the Austrian column. Anderson records a single instance
among his private cases, making, with Hebra’s, only eight among the
whole 60,000. We know nothing of the causes, and but little of the
nature, of an affection which proved uniformly fatal until brought under
subjection by arsenic, but more extended observation may yet give it a
place upon our native list.
Pellagra, granting still its specific individuality, follows such sharply
defined geographical laws of distribution, that it is not surprising that
but a single case is recorded in the table and that under Mr. Wilson's
observation. It is improbable, with the marked contrast in respect to
the abundance and variety of food which our country offers to the regions
infected by this disease, that it should develop amongst us, but not impos-
sible that emigrants from its haunts may bring it to our shores. It
would scarcely establish itself here, however, as it has been slowly retreat-
ing from some of its oldest footholds in Europe during the last half cen-
tury.
(2) Less prevalent.—Our analysis shows that the following affections
have more or less claim to be considered in this class: Erythemata,
lichen scrofulosorum, lupus, leprosy, phthiriasis, Scabies, tinea favosa,
and alopecia areata.
The various forms of erythema seem to prevail less in the United
States than in Great Britain, at least. The causes of such disturbances
are so various and so often of extraneous character, that it is not strange
that considerable diversity in their prevalence, corresponding to varia-
tions in modes of living among different nations, should exist. Of lichen
scrofulosorum we know so little that it would be useless to conjecture
why the skins of strumous patients should be less liable to such disorder
here and apparently elsewhere than among the nations of the Austrian
empire, but such is notably the fact. Lupus, it will be seen by the
tables, forms one of the most striking examples of variation in compara-
tive occurrence upon this list. It is an affection, moreover, about
which false conclusions in this respect are least liable to exist; for it is
so grave in character, so enduring in course, and so imperative in its
demand for heroic means of cure, that scarcely a case is liable to escape
the observation of the dermatologist. Ilupus is a rare disease in America,
although if our figures were drawn from hospital records the statistics
might fail to support this opinion, because most chronic ulcerative and
destructive processes, especially those seated upon the face, are regarded
by surgeons as lupus. It is not only rare but, as we shall see below,
modified in type also from that so commonly observed in Europe. The
opinion is held, I am aware, by some American dermatologists that lupus
vulgaris is even less common than lupus erythematosus amongst us. Dr.
678 J. C. WHITE,
Duhring has found it to be so here, in Philadelphia, and Dr. Geddings,
of Aiken, whose valuable studies of this affection are so well known,
writes me that it is “much more common at the south than genuine
lupus.” Yet Tables I. and II. show that whatever be the case in the more
southern parts of the United States, such is not the fact when the figures
drawn from the three cities, Philadelphia, New York, and Boston, are
combined, for of the seventy cases forty were lupus vulgaris and thirty
lupus erythematosus.
Leprosy (elephantiasis Græcorum) according to Table V. would seem
to fall almost within the class of affections which do not occur amongst
us, two cases only being recorded therein, both of which, however, were
observed in native Americans. Yet we know that in the neighboring
province to the northeast there has long been a community of lepers,
and that in our western States annong the Norwegian immigrants the
disease exists. In our southern States, too, I am informed that it pre-
vails to some extent, and am indebted to my friend Dr. W. H. Geddings
for the following motes concerning its occurrence in his native eity,
Charleston, S. C. The first case of the disease came under the observa-
tion of his brother in that city some time between 1846 and 1849, but
he is unable to say whether it had occurred before that time. Sixteen
well-established cases have come to his knowledge since then, five of
them within the last ten years. In none of them was any hereditary
taint to be traced, no progenitor having been affected as far as known,
except that mother and daughter in one instance were attacked simulta-
neously and died about the same time. In two other instances also two
members of the same family were affected. These certainly are very
important data, and worthy of further careful investigation in connection
with the question of infection, which can be nowhere so favorably studied
as in an isolated region where hereditary taint is excluded. With regard
to the race and color of the lepers, four were Jews, eight were white
Christians, three were mulattos, and one a full negro. The wide-spread
occurrence of the disease outside our limits to the south, in tropical
America and its islands, and westward in the Pacific isles, is well known.
With such foci of foreign origin all around us, and even within our
borders, it is not improbable that the disease may some time become
endemic in the United States.
Phthiriasis and Scabies.—In the former, an affection almost wholly
confined to the lower classes, we somewhat lead Great Britain, according
to the Tables, but as compared with Austria, our cases are only one to
three. It is in connection with scabies, however, that the most remark-
able difference is to be observed. Since the close of our late war, during
which it attained a wonderful growth, it has again dwindled until it has
become a somewhat rare affection, even in our seaboard cities where im-
migration is constantly bringing fresh supplies to sustain it. While with
us, as Table III. shows, it forms only 2.3 per cent. of dispensary cases, in
Scotland it constitutes 25 per cent., and in Vienna 48 per cent. of the
same class, and in the Ospedale di S. Gallicano at Rome, one-half the
cases under treatment in 1873 were of scabies. The disease seems to be
diminishing also steadily in Austria, for, whereas in the Vienna clinic
in the year 1857, that of the first report included in our statistics, there
were 1695 cases, in 1873 there were only 322, a diminution due in part
to the fact that the various trades in Vienna are employing each its own
physician, instead of sending the infected to the general hospital. There
V ARIATIONS IN TYPE AND PRE VAL E N C E OF S KIN DISE ASE'S. 679
is no reason, however, why, with habits of cleanliness like our own, the
disease should not become as rare everywhere as amongst ourselves.
Tinea favosa, as stated in the analysis, is somewhat less common here
than in Europe, especially in Scotland, but it is in Italy that it finds
apparently its most favorable conditions of development. In the skin
hospital at Rome, above mentioned, Dr. Schilling reports 145 cases in
the year 1873, 93 in 1874, and 63 in 1875, or nearly 12 per cent. of all
the cases there treated. Such extraordinary preponderance implies either
the existence there in proportionate abundance of the extraneous sources
of contagion, or wonderful carelessness or ignorance concerning its com-
municability. Tinea tonsurans and tinea versicolor, on the other hand,
it may be stated, seem to be almost wholly unknown there. Such local
peculiarities in the prevalence of the vegetable parasites, may yet lead
to important discoveries in relation to their non-parasitic phases of de-
velopment.
Alopecia areata.--With no intention of entering upon the disputed
question of the nature of this mysterious affection, it is to be noted that
it is of less frequent occurrence here than in any of the European
countries from which we have drawn our reliable data.
(3) More prevalent. —The affections which are shown by the tables to be
in any marked degree more prevalent here than in Europe are, seborrhoea,
acne, urticaria, pruritus, the peculiar forms of efflorescence due to the
poisons of rhus and mosquitos, heat rashes, herpes, alopecia, and tinea
tonsurans (sycosis). The affections of the sebaceous glands seem really
to be more common with us in all classes than among European nations.
I have no explanation of the fact to offer, but I am aware that it will
be used as an argument by those who hold the opinion that acne is con-
nected with derangements of the digestive system, inasmuch as Ameri-
cans are supposed to be more “dyspeptic” than other people. However
this may be, for my part I have never been able to find any fault of the
internal economy which I could regard as an important primary factor
in the etiology of this disease in any general way. No more can I
explain the somewhat increased prevalence of seborrhoea of the scalp in
private practice here, over its occurrence in the same classes of society
abroad, in places where our statistics allow a direct comparison. The
more frequent occurrence of alopecia, as shown in Table II., is, perhaps
in proportion to, and in direct consequence of, this latter affection.
Urticaria and pruritus are both slightly more prevalent in the United
States than in Europe. Both are more or less intimately dependent upon
modifications of innervation, and it may be that our drier atmosphere
or greater extremes of temperature may account for such excess; cer-
tainly the latter affection in some of its forms is closely connected with
the winter season. Summer, too, with our intenser heat, it may here
be mentioned, produces far more frequently direct disturbances of the
general integument than in more temperate Europe. Prickly heat, heat
rash, or folliculitis dependent upon overwork of the sweat glands, is
universally prevalent, leading up to acute eczematous and furuncular
inflammations of the cutaneous tissues, which form no small share of our
practice during such a season as the summer just passed. Herpes zoster,
too, appears to be more common among dispensary patients here than
abroad, possibly through climatic influences, as there are good reasons
for believing that in some cases it is directly caused by impressions
received through the skin itself. Other forms of dermatitis occur
amongst us, which as the result of purely local excitants, in both senses
680 J. C. WHITE,
of the word, are not met with in Europe, but which on this very account
need only have mention here. They are the peculiar eczematous inflam-
mation produced by the poisonous species of rhus, so widely diffused
throughout the United States, and the multiform efflorescences provoked
by the stings of mosquitos in persons not previously inoculated with
their virus.
The vegetable parasitic affections present, as we have seen, very
unexpected variations in comparative prevalence in the countries included
in our tables. It is tinea tonsurans which seems to find its most favor-
able conditions of growth amongst us; and in its various manifestations
of ringworm of the scalp, beard, and general surface, of parasitic sycosis,
and so-called eczema marginatum, is quite a common affection. Among
domestic animals, too, it is not unfrequently observed. Were the facts
of such unequal distribution of cutaneous affections more fully recog-
nized, we should not witness controversies between dermatologists of
different countries concerning the prevalence or even the very existence
of certain diseases, nor have the authority of so eminent a master as
Hebra categorically expressed in denial of the occurrence of affections
which are almost daily met with here, because they are rarely met with
in Vienna. Of such character are his assertions in relation to tinea
sycosis, which may well be extremely rare in Vienna, and yet from diffe-
rent habits of barbers in shaving, perhaps, or from other causes, may
occur very frequently elsewhere, as it certainly does at least in Boston.
It is especially in connection with the vegetable parasitic affections
that one’s point of view should be very broad before venturing upon
such statements.
(4) Modifications.—Before discussing this division of our subject, it
should be distinctly stated that we have now left our tables, imperfect
as they are, behind us, and that our opinions in connection with it rest
almost wholly and necessarily upon impressions alone. As individual
observers we may naturally differ widely from one another, therefore,
upon such points. My own opinions will be stated, briefly and it may
be uncertainly, although I doubt not that others will have much more
decided and definite views upon the subject to express. I am aware, for .
example, that some of our best observers believe that many affections of
the skin assume a more acute or inflammatory type amongst us than
elsewhere, and that others are of the opinion that cutaneous diseases are
less tolerant of exciting and severe local medication than in Europe, and
that therefore what may be the best methods of treatment there may be
injurious even, if strictly followed here. I am not prepared to concede
these propositions; at least I do not think that I have sufficient evidence
to warrant the statement of any such convictions in this paper, even if
they were doubtingly entertained by me. That my judgment with
regard to the choice of remedies in skin diseases may differ somewhat
from that of some foreign writers and teachers, is indeed true, but I do
not on this account feel authorized to infer that the therapeutical or
physiological reaction of the American skin differs materially from that
of the European, for I know that I differ quite as widely from some of my
colleagues here at home upon important matters of treatment, and I must
confess too that, now that I come to record formally my opinions regard-
ing this part of our subject, I am not prepared to state my belief in the fre-
quency or degree of such changes of type in these affections as strongly
or generally as I thought I might do before considering the question so
immediately.
V ARIATIONS IN TYPE AND PREVALEN CE OF SKIN DISE ASE'S. 681
The number of diseases that I can specify as exhibiting such modifica-
tions to any noticeable extent is therefore extremely limited. They are,
moreover, diseases characterized by varied and extreme structural changes
of the cutaneous tissues, so that a comparison of the appearances pre-
sented as they occur here and elsewhere, is easy. The most conspicuous
example of such is undoubtedly lupus vulgaris. We have already seen
that it occurs far less commonly here than in Europe, and it may be that
the same law governs its course as well as prevalence. At all events, I
think there can be no question that we do not see cases here which
approach those so frequently met with in foreign clinics in severity of the
destructive process, or in extent of the surface affected. Such at least is
my own experience, and I have no reason to offer in explanation of the
fact. It might seem that it required several generations of accumu-
lated malnutrition or more positive constitutional evils to effect such
eventual disorders of cutaneous structure, and that on this account lupus
prevailed more abundantly and in its worst forms where poverty and
bodily misery were more common than with us; but I do not think that
the history of individual cases amongst us warrants any such conclusion.
I wish I could add that I have found a corresponding benignity of type
in its disposition to yield more readily to treatment, but corresponding
classes of cases have in my experience exhibited the same obduracy to
remedies here as in Europe, and perhaps the same tendency to relapse.
The same statements may be made with truth, too, in my opinion, of
the cutaneous syphilides, especially their later manifestations. We
rarely, if ever, see here cases of so grave a type as in European hospitals.
There seems to be a resistance to the destructive force of the disease, on
the part of the skin, which tends to prevent the formation of the worst
lesions within its tissues.
Leprosy, too, seems to feel the mitigating effect of some local influence
within our borders. In Trecadie it has kept up a lingering existence for
many years. With regard to its character among our Norwegian immi-
grants at the West, at present, I regret that I have no definite informa-
tion to impart; Prof. Boeck expressed the opinion, after his visit to them
a few years ago, that the disease seemed to be partially controlled ; its
course retarded to some extent by their change of residence. Whether
the interesting observations made by him while amongst them are
best interpreted under the theory of contagion or hereditability, is not
within the province of this paper to consider. As to the character of the
disease, as it occurs in our southern States, I am not informed.
Indeed, the best use that I can make of my conspicuous want of know-
ledge upon this and other points which should be considered under this
division of our subject, is to exhibit it frankly as an illustration of what,
I fear, may be a too common state of ignorance on Our part, and to indi-
cate how much definite information is yet to be acquired before we can
intelligently discuss it. Finally, I may add that no one can be so fully
aware as myself of the incompleteness of this paper in all respects, and to
how unsatisfactory an extent it fails to answer the questions it proposes.
I offer it merely as an introductory sketch, or skeleton chart, to show in
what directions we may best carry out the investigations which may
eventually lead to the full solution of the subject.
The following conclusions seem to be warranted by the data above
presented:—
I. Certain obscure affections, the etiology of which is little, if at all,
understood, even in those parts of Europe to which they are mostly con-
682 J. C. WHITE,
fined, may be regarded as practically non-existent amongst us. Such are
prurigo, pellagra, and lichen exudativus ruber.
II. Certain diseases, directly connected with and dependent upon
poverty and habits of personal uncleanliness, are less prevalent in the
United States than in those parts of Europe of which we have sufficient
statistical information for comparison. Examples of this class are the
animal parasitic affections especially.
III. Some cutaneous affections of grave character, which are dependent
upon or a part of serious constitutional disorders, are of less frequent
occurrence and of milder type amongst us than in Europe in general, or
those parts of it where they are endemic. Lupus, the syphilodermata (?),
and leprosy are the most marked instances of this class.
IV. Certain disorders of the skin, especially those of its glandular
systems, and those connected more immediately with its nervous system,
are apparently more prevalent with us than in Europe. The most notable
examples of the former are seborrhoea, acne, and possibly the heat rashes;
of the latter, herpes, urticaria, and pruritus.
DISCUSSION ON DR. JAMES C. WHITE's PAPER.
After the reading of the preceding paper, Dr. Louis A. DUHRING, of Phila-
delphia, said:—The subject treated of in the paper just read is one of great
interest, and the statistics contained in it show that there is a marked dis-
crepancy in the prevalence of skin diseases in the three great eastern cities of
this country, Philadelphia, New York, and Boston. How to account for these
differences is a difficult problem, and, on account of these differences, Dr.
White's conclusions should, it seems to me, be taken with reserve. The pre-
cise meaning of some of the terms employed should also be given with more
particularity; for instance, morphaea is a name susceptible of several meanings.
Dr. L. DUNCAN BULKLEY, of New York, said:—American statistics are not
as complete as could be desired. Morphaea is undoubtedly more frequent than
it is represented to be in the tables of Dr. White's paper. I have myself seen
it in a number of cases. I observe that no cases of prurigo are mentioned in
the paper. Heretofore, I have only reported cases observed at hospitals and
dispensaries, and have not reported those of my private practice. I have had
two cases of prurigo under my own observation in this country. I also believe
that, in the types of diseases of a congestive character, there is a marked dif-
ference between this country and Europe. I have in New York repeatedly
tried Hebra’s treatment for this class of cases, without success. I am of
opinion that in these diseases, as met with in the United States, there is the
general characteristic of nervousness, so peculiar to the American people,
which requires a treatment very different from that taught in the schools of
Europe. A merican physicians are discovering this every day; they are be-
coming more familiar with American characteristics as they grow older, and
are finding it profitable to forget much that they learned in the old world.
Dr. DUHRING said :—I have brought up the subject of morphaea in order to
ascertain the views of Dr. White on that disease. Dr. White and Dr. Bulkley
evidently understand it as Mr. Wilson has described it ; whereas I think that
Mr. Wilson has so confounded it that no one could recognize it from his
definition as a distinctive disease. Mr. Wilson confounds the old morphaea of
leprosy with the modern morphaea. I have discarded the definition of Wilson,
and also that of Kaposi, and have from experience adopted the view to which
Dr. Fox has inclined. Morphaea should be entirely disconnected from leprosy.
I have seen three cases of it, at a clinic in London, and five in this country.
As I understand the disease, its manifestations are of two kinds; the first
being the large or small yellowish circumscribed patch upon the skin, like
v ARIATIONS IN TYPE AND PREV ALEN CE OF S KIN DISE AS E.S. 683
a piece of fat or lard, in appearance resembling the well-known macular
form of leprosy, with which, however, it has no connection. Another form
entitled to the name of morphaea is the keloid so accurately described by Dr.
Addison. I have seen four cases of this disease in this country. It is an
extremely complex affection, requiring great detail and particularity in its
description. I have seen all the symptoms encountered in both forms of the
disease in one patient; I have seen the macular patches from the size of a pin's
head to that of a hand with those numerous symptoms of the so-called keloid of
Addison. I have also seen the macular manifestations, accompanied by reddish
or purplish streaks and striae atrophicae, and, moreover, band-like cicatriform
lesions. In a paper recently prepared by me, I have tried to give an accurate
description of the disease, but to attempt it here would occupy too much time.
Dr. BULKLEY said:—I would designate as morphaea just what Dr. Duhring
has described, and, with due deference to Dr. Duhring, would say that Wilson
gives a similar description.
Dr. DUHRING said:––Partial atrophy of the face should not be confounded
with morphaea, though it closely resembles the cicatriform form of the disease.
The subject is a very complicated one, and the clearest distinctions should be
made between the old morphaea of leprosy, the macular and cicatriform varie-
ties of the disease now designated morphaea, and unilateral atrophy of the face.
Dr. WHITE said:—I had a case which began with the round form of mor-
phaea. It was sent to England where Mr. Wilson saw it and called it morphaea;
then to Vienna where Hebra called it. Addison's keloid ; and, finally, returned
to this country and resulted in time in atrophy of the skin. In the paper
before the Section the word has been used in all the looseness of meaning
requisite to cover the variety of forms assumed by the disease.
Dr. DUHRING said:—I have seen the case referred to by Dr. White, and I
would call it unilateral atrophy of the face. The lesions are not confined to
the skin, but extend deeper and affect even the muscular tissues and bone sub-
stance. In one case of unilateral atrophy of the face which I have observed
for eight years, the tongue and roof of the mouth have dwindled upon one side
to only half the normal size.
Dr. BULKLEY said:—I have seen two such cases, in which the patches, or
arrests of development, resembled very much morphaea. I have also within a
few days seen a patient who has been put under galvanic treatment and is two-
thirds or three-fourths cured.
Dr. DUHRING said :—In the reported cases of unilateral atrophy of the face,
the disease has tended to increase from year to year, while in those cases of
morphaea which have come under my observation, the disease has tended to
spontaneous recovery; one young lady who has been the subject of a most
extensive morphaea, is now nearly cured, the patches upon her body having
undergone spontaneous involution ; this never occurs in unilateral atrophy of
the face.
Dr. WHITE said:—With regard to prurigo, I am well aware that many Eng-
lish writers do not concede that there is such a disease, maintaining that the
cases seen in Vienna are but poorly developed diseases of a secondary charac-
ter, in which the cutaneous lesions follow, and do not antedate, the subjective
features.
Dr. BULKLEY said:—I have seen two well-defined cases of prurigo in native
Americans. One occurred in a man who, after terrible suffering, died of the
disease. The other was the case of a child.
Dr. S. ENGELSTED, of Copenhagen, said:—Prurigo is very rare in Copenha-
gen, but is sometimes met with. It sometimes commences in childhood, and
is then incurable. It occurs only in the lowest grades of the population.
Dr. DUHRING said:—I agree with Dr. White, that this is a very rare disease.
I have seen but one case in this country (at Boston), that I thought was pru-
rigo ; I could not positively say that it was so, for I saw the case only once,
but if asked to name it I could call it nothing else. I was forcibly struck
with its resemblance to the Austrian prurigo. The whole surface was involved.
684 J. C. W. HITE, V ARIATIONS IN SKIN DISE ASE'S.
While attending the clinic at the Hôpital St. Louis, at Paris, I one day saw a
boy who had prurigo. Hardy said that he called the disease “strophulus
prurigineuse,” but it was undoubtedly the prurigo of Hebra. Hardy said it
was obstinate but curable. Evidently it did not, in Paris, take on that aggra-
wated form which is commonly seen in Austria. There is at present, in the
Philadelphia Hospital, a case very much resembling prurigo, but I would not
so call it. I doubt whether lichen ruber is more common abroad than here.
Lichen planus and lichen ruher I regard as one and the same disease, the
latter being the more advanced stage of the process; I would ask Dr. White
whether, in his experience, he has ever known lichen planus to run into lichen
ruber 7
Dr. WHITE said :—I have not.
Dr. DUHRING said:—I would ask Dr. Engelsted whether he has ever seen in
Copenhagen Hebra’s lichen ruber 7
Dr. ENGELSTED said:—I have not, but I have seen there lupus vulgaris.
Dr. DUHRING said:—Lichen ruber is as rare in Europe as here. I have seen
in this city a case of lichen planus which passed into what might be called
lichen ruber; it was not so severe as the cases I have seen abroad. Prurigo
is a common disease in Austria, but lichen ruber is rare. I must also differ
from Dr. White as to the severity of the syphilodermata, which I consider to
be as severe in type in this country as in Europe.
Dr. WHITE said:—Upon this point I have written only from my own obser-
vations in Boston of the severity of the disease, and have made no comparisons
with other cities.
Dr. ARTHUR WAN HARLINGEN, of Philadelphia, said:—I agree with Dr. Duh-
ring that Philadelphia has a pretty fair share of these cases, and that many of
them are of a severe type. There are no syphilitic clinics in this city; but,
judging from the tables of skin diseases, the proportion of the syphilodermata
is large.
Dr. BULKLEY said:—I coincide with Dr. Duhring's opinion that the disease
is not less severe here than in Europe.
Dr. DUHRING said:—Many cases have come to my notice undiagnosed and
consequently untreated. I can recall half a dozen frightful cases which have
come from the country districts untreated. In Vienna the disease is, as a rule,
recognized at once and treated, and hence it is checked before it reaches its
worst stage. One case which I can recall had been diagnosed as cancer, and
so treated for fifteen years.
Dr. BULKLEY said:—I have known five cases of elephantiasis Graecorum ;
two died within four or five years; another has been progressing eight or nine
years, and another four or five years. Two of these cases came from the
southern part of this continent. Those which occurred in native Americans
were very severe.
Dr. DUHRING said:—I was not aware that leprosy occurred in this country
at all unless it was imported. Before being convinced that it exists endemi-
cally, I should like to see a case thoroughly studied by a competent observer
and have it carefully reported. The disease occurs in Central America and
Mexico, in the Sandwich Islands, and also in California; but not, I think,
endemically. I have seen but one case in this country, and that was a Cuban,
who acquired it probably in Spain.
Dr. WHITE said:—Prof. Boeck thought that the disease, as found in the
Norwegian settlement in this country, had been checked by the change of resi-
dence. I have known of one other case, one of the tubercular form of the
disease, which resulted fatally in Boston.
Dr. VAN HARLINGEN said:—As to lupus, I think that statistics here show a
larger proportion of cases of lupus erythematosus than of lupus vulgaris; in
fact, the former may be considered a common disease, whereas the latter is
not so frequent.
Dr. DUHRING said:—The American type of lupus vulgaris is much milder
than the European.
685
WERRUGAS, A DISEASE PECULIAR TO PERU.
BY
GEORGE A. WARD, M.D.,
MEDICAL DIRECTOR OF THE OROY A RAII, WAY.
[CoMMUNICATED BY THE SECRETARY.]
IT is, I believe, pretty generally know throughout the world that Peru
is engaged in the gigantic enterprise of building a series of railways across
the snowy peaks of the Andes, in order to connect the Pacific ports with
the head waters of the Amazon ; and by this means to establish a shorter
communication with Europe, thus avoiding the inconveniences which
now result from a long and tiresome sea-voyage, as well as throwing
open to the world the untold wealth which exists on the Amazon and
its tributaries. This wonderful undertaking, conceded to be the greatest
engineering triumph of the century, is due to the energy, skill, and per-
severance of Don Enrique Meiggs.
On one of these routes, starting from the Pacific Ocean at the port of
Callao; passing through Lima, the capital of Peru ; thence up the valley
of the river Rimac ; and finally crossing the summit of the Andes by
means of a tunnel, at an altitude of 15,645 feet above the sea-level, vast
obstacles have been encountered, not only in the way of the many natural
difficulties to be overcome, but also from many and strange diseases, one
of which it is the purpose of this paper to describe; but before doing
so, a brief geographical description of the district in which this disease
prevails will be proper.
This district lies between altitudes of 3000 and 6500 feet, cases of the
disease occasionally originating a few hundred feet higher, though rarely.
In and about San Pedro Mamma, 3000 feet above the sea-level, we find
arid dry rocks; but on the river banks, wherever water has access, fine
pasturage for animals. The banana here grows luxuriantly wherever
cultivated ; as we gain altitude, we encounter fine groves of oranges,
figs, cherimoyer, peaches, guavas, and in fact every variety of tropical
fruit except the cocoanut ; as well as vegetables familiar to our northern
eyes, such as the onion, lettuce, cabbage, etc. At an elevation of 5280
feet, and 46 miles from the sea, the character of the soil changes, as the
valley becomes more narrow, the soil sandy and intermixed with granite,
the sides of the mountains steep and producing abundantly a variety of
cacti, but still susceptible to a high degree of cultivation wherever water
can be carried. At an elevation of about 6000 feet, we find the granite
in a friable, decomposing condition.
Running through this valley is a rapid mountain stream varying in
depth from two to six feet, and fed by springs and the melting snows
of the summit. The temperature at the altitude of 3000 feet is mild
and equable; as we gain 4000 feet the temperature is increased, and at
an altitude of 5280 feet we frequently encounter a temperature of 110°
Fahr. in the shade, in the middle of the day, and at night find it suffi-
ciently cool to require a couple of blankets on our beds, the range of
686 WAR D,
temperature frequently being as great as forty degrees Fahr. between 12
M. and 12 P.M. Approaching an altitude of 6000 feet, the temperature
again becomes more equable, and at an altitude of 8000 feet it rarely
varies ten degrees the year round.
The name popularly applied to the disease of which I am about to
speak is VERRUGAs. It is a disease usually preceded by an initial fever
of varying intensity, lasting from ten to thirty days, and accompanied
by excruciating pains of a rheumatic character, finally culminating in an
eruption of warts over the body; these occasionally proceed to suppu-
ration and ulceration, accompanied at times by profuse hemorrhage.
It is a disease confined to certain valleys in Peru; it has well-defined
limits, and is not found outside of those limits. Its range of altitude is
between 3000 and 6500 feet, and it is found in the valleys of the Rimac,
Pacasmayo, Chimbote, and some of the valleys on the eastern slope of
the Andes, and was probably the disease which struck terror into the
adventurous hearts of Pizarro's troops on their march into the interior
of Peru through the valley of Tumbez. I am informed that this disease
prevails on the eastern slope of the Andes, but always under the same
conditions of altitude, soil, climate, and natural productions.
It is a disease which affects animals as well as men; it is a disease
which recurs, one attack not exempting from a second, a third, or even
a fourth, if the person is exposed to the same influences. The eruption,
however, in the subsequent attacks, is not as profuse, nor the warts as
large as in the first, although no general rule is observed in this respect.
The disease obeys none of the known laws of the exanthemata, although
it is in many respects closely allied to them. Retrocession of the erup-
tion always produces very grave, and often fatal, symptoms, and usually
takes the form of congestion of the liver or lungs. In like manner,
should the eruption not make its appearance on the skin, or mucous
membrane of the mouth or nose, a fatal termination of the case may be
expected. Many have supposed the disease to be allied to syphilis, but I
do not so regard it. The disease cannot be communicated by inoculation,
for I have repeatedly tried on my own person, as well as on others, the
insertion of pus from an ulcerating verruga, but without avail. The
only analogy with syphilis is in the nocturnal pains and the occasional
persistence of a copper-colored spot on the skin after a large verruga has
proceeded to ulceration and cicatrization. The ulcers lack, however,
entirely the geometrical forms so characteristic of syphilitic ulcerations,
and these copper-colored spots are only left on the parts of the body
which are covered by the clothing; no matter how large a crop of
verrugas one may have had on the face, scars or discolorations rarely
remain.
In those cases in which the disease is heralded by an initial fever, two
types are presented ; the acute rheumatic, and the low typhoid, often
combined with an intermittent element which prevails extensively in
the verruga district. Patients thus affected require careful watching
from their extreme liability to succumb to the violence of the fever,
before the eruption makes its appearance.
In the excruciating pains, particularly affecting the joints, this affec-
tion is closely allied to dengue, a disease which occasionally occurs in
the Southern States of North America. In contradistinction to dengue,
however, one attack does not prevent another; the fever has a longer
duration ; the eruption is of a different character; hemorrhage only
W E R R U G A S. 687
occurs from the verruga itself; the duration of the disease is much
longer; it is not epidemic ; and it is an extremely distressing and often
fatal disease. It occurs as well among the strong and healthy as among
those who are weakened by previous disease, or who are of feeble habit
of body.
In regard to the cause, nothing is known. Many have supposed the
disease to be caused by the water of the valley; this cannot be the case,
as many people have simply passed through the infected district on
horseback, or in the train, without drinking one drop of water, and have
been as severely affected as those who have passed weeks and months in
the valley. Others, in their fear of having the disease, have drunk
nothing but wine or brandy during their entire period of residence, even
refusing coffee and tea; and have suffered just as severely as others who
have followed their ordinary mode of life. Some suppose that it may arise
from the turning up the ground along the line of railway, thus bringing
certain telluric influences to bear; this, however, cannot be the entire
cause, as the disease existed before the ground was ever disturbed. I
am inclined to the opinion that the friable, decomposed, and decompos-
ing granite, has an influence in producing this disease as well as the
intermittents which here prevail to so great an extent. I have known
a nursing infant pass one night in the affected district, and in three
weeks break out over the entire body with verrugas. The disease may
not show itself for weeks or months after exposure, though a change of
climate, and particularly a sea-voyage, is very liable to bring out the
eruption.
I remember particularly the case of an Italian, who had made some
money on a small contract in the infected district, and, returning to his
home in Italy, on the voyage, broke out with verrugas; on arriving at
his home he was immediately ordered into quarantine as a leper, and was
not allowed to enter the city until he had been pronounced cured by the
proper authorities. Many of the gentlemen connected with the railroad,
when home on visits to New York, California, or other parts of the
world, have been looked upon with very grave suspicion, not only by
their friends, but by physicians and surgeons whose word is law in regard
to medical matters.
The treatment of the disease is entirely palliative, and will be more
particularly illustrated in the typical cases presented. The bowels should
be kept open by mild laxatives, of which none are better than the tama-
rinds taken freely in the form of a drink; the infusion has a grateful,
subacid flavor, particularly agreeable in the semi-febrile condition of the
patients, and the addition of one of the alcoholic stimulants will usually
be advisable. Should there be indications of liver trouble, nothing is
better than blue mass or podophyllin. Hot vapor baths, or a resort to
any of the various hot springs, will have the effect of accelerating the
appearance of the eruption. I have sometimes found good effects from
the iodide of potassium, in ten grain doses three times daily, taken in
an infusion of Sarsaparilla, or, more agreeably still, in the compound
syrup of Sarsaparilla of the U. S. Pharmacopoeia. Should the pain be so
reat as to prevent sleep, morphia or chloral must be resorted to. The
blood is thinned, and deficient in haematin ; hence the necessity for the
use of iron, and, of all the preparations of this metal, I have found none
to equal the muriated tincture, given in ten drop doses, three times
daily, in a glass of port wine. This course of treatment, with a full
generous diet, and a proper allowance of alcoholic stimulants, will usually
688 WAR D,
in time bring out the much desired crop of verrugas. Exercise in the
open air, although exceedingly painful and at times impossible, is of
very great importance.
A great variety of native remedies has been used in this disease. I
have tried them all and found them all wanting. Of these remedies, the
best is an infusion of the Indian corn, taken in large quantity with the
native sweet wine of the country. This “agua mote,” as it is called, has
a diaphoretic and diuretic action, as have in a greater or less degree the
other native remedies, “uſſia de gato,” “maguey,” “norvillo,” etc. All
of these remedies are taken in infusion, and with an equal quantity of
sweet wine.
Should none of these measures avail to bring out the eruption, a change
of climate or a sea-voyage, or a resort to some of the famous warm baths
of Chili, will probably have the desired effect.
The literature of this disease is very scanty. Prescott, in his Conquest
of Peru, mentions it as one of the diseases encountered by the Spaniards.
Von Tschudi, in his work published in 1749, mentions it, and the
same author is said to have written an article on the subject in some
medical journal of Germany; these, with an article in a Dima newspaper,
and an article by Dr. J. M. Browne, U. S. N., in the Contributions to
Medical Science, U. S. Navy Department, vol. i., 1872, constitute, I be-
lieve, the entire literature of the disease. An idea of verrugas can best
be formed by the study of illustrative cases, of which I cite a number,
and, as will be observed, the symptoms in the various cases are diametri-
cally opposed to each other, scarcely any two cases presenting the same
features.
CASE I.—The first case of verrugas which I ever saw was in the northern
part of Peru, on a sugar hacienda. The patient presented himself to me with
what I supposed to be a node, just on the point of ulceration. I immediately
placed the man upon a course of iodide of potassium and iron, advising rest,
and poultices to the tumour which was situated upon the edge of the tibia.
This, however, did no good, and the tumour, after ten days’ treatment, showed
no signs of ulceration or pus. One day the superintendent happened to see
it, and without ceremony plunged in a lancet, making a gash about an inch
long, and then sent immediately for me to control the hemorrhage which his
unlucky thrust had caused. I succeeded in this by using pressure and the
perchloride of iron ; rapid ulceration then took place, and the man left the
hacienda and went to a hospital in Lima. About a year afterwards he came
under my observation in one of the hospitals of the line, suffering from caries
of the tibia and continued fever, of which he died. Upon questioning him, I
learned that before going to the hacienda he had been at work on the Oroya
Road, and that he had thus contracted the disease there.
CASE II.—A Chinese had received an injury of the spine, causing paralysis
of the lower extremities, and had been in the hospital for a period of about
five months, slowly but steadily gaining the use of his legs. One morning he
called my attention to some lumps on his legs, about as large as peas. These
lumps gradually increased in size and number, without pain, heat, or redness,
until many of them reached the size of hens' eggs, and till they were found
not only on the legs but on the arms and chest. The patient in the mean time
did not suffer the slightest inconvenience whatever, not one of the verrugas
proceeding to ulceration, but gradually subsiding as they appeared. His ap-
petite remained good, his urine was free and of natural color, and his bowels
acted daily and naturally. The only remedies given were the tinctura ferri
chloridi, ten drops three times daily, and a daily subcutaneous injection of
the fiftieth part of a grain of strychnia, which remedies were given for the
W E R R U G A S. 689
paralysis. I saw the patient frequently for two years afterwards; he was in
good health and condition, and with only a slight degree of paralysis re-
mainlng. -
CASE III.-This was the case of a Chinese who entered the hospital with all
the symptoms of rheumatic fever, complaining of pain in the joints, which
were swollen and tender, his tongue being covered with a dirty-white fur, his
bowels constipated, and his urine scanty and high colored, at times not more
than half an ounce being secreted in the twenty-four hours, and that soon be-
coming nearly solid from the contained urates. The fever was constant, the
pulse ranging from 110 to 120 in the minute, and the temperature from 102°
to 104° Fahr. The patient was placed upon the alkaline course of treatment
for rheumatic fever, with some slight improvement to the symptoms. Diure-
tics, however, produced but little effect upon the urine, and after having ex-
hausted all the means at my command, and, at the end of two weeks, the pa-
tient's condition continuing much the same, I resorted to a native remedy,
which consisted of an infusion of the legs of the common cricket. Four of the
legs of the cricket were bruised and infused in half a pint of hot water, and
when cold half an ounce of the infusion was given every four hours. This
produced immediate relief to the symptoms; the urine began to flow freely,
and there was an immediate abatement of the febrile movement, followed by a
profuse eruption of verrugas which proceeded rapidly to ulceration accom-
panied by free hemorrhage. The ulcers finally healed kindly under the use of
the carbolated cerate and powdered matico. Iron and alcoholic stimulants
were freely used to recuperate the patient's strength, which was much ex-
hausted by his long and painful illness which had extended over a period of
three months.
I was led to the use of the infusion of cricket legs by the recommendation
of Dr. H. Kinney, former Medical Director of the line, who highly extolled it
as a diuretic. I have used the remedy a number of times since, and with uni-
formly good results. I do not pretend to explain its modus operandi, but pre-
sume it to be analogous to that of cantharides, as in one case I observed some
tendency to strangury.
CASE IV.-My own case. I was attacked with wandering pains about the
body, just one month after taking up my residence in the infected district;
these pains particularly affected the joints, sometimes one and sometimes
others, the pains simulating those of muscular and articular rheumatism, but
without the inflammatory symptoms. These pains were of an intermittent,
shifting character; for instance, they would affect one joint, say of the little
finger, in the morning, and by noon would be located in the opposite hand,
knee, leg, or arm, and as rapidly change to other parts of the body, affecting,
however, particularly the legs below the knees. Suddenly all the pain left the
extremities and located itself in the right testicle, which became enlarged and
exceedingly painful, though without any inflammatory symptoms being devel-
oped. All the ordinary remedies useful in swelled testicle, excepting leeches,
were used to mitigate the pain and reduce the swelling, but without avail; but
the swelling, which had come on rapidly, after continuing for nearly two weeks,
subsided within twenty-four hours, leaving no ill effects behind. Immediately,
however, the right arm began to swell, and continued to do so until I thought
the skin would burst, so great was the tension; the tumefaction extending
from the fingers to the shoulder, and lasting for about ten days, then subsiding
as rapidly as it had come on.
During this time I was in perfect health, being able to ride about on horse-
back, eat well, and drink well, wandering pains, however, being felt through-
out the body, as well as the steady pain in the arm. After the subsidence of
the swelling in the arm, there was a let-up to all the symptoms, but this was
only the calm before the storm. Suddenly I was prostrated by congestion
of the liver, followed by jaundice and the discharge of a large gall-stone, which
brought me so near death's door that my coffin was actually prepared. Fol-
44
690 WARD, V E R RUGA S.
lowing this, appeared the eruption of verrugas over the entire body, and a sea-
voyage restored me to health. The first pains were felt on the first of March,
and the first verrugas showed themselves about the first of August, when they
continued coming and going until December, many of them ulcerating and
being the source of free hemorrhage.
The course of treatment which I adopted was simply palliative, treating
each symptom as it arose. My diet was of the most generous description, ac-
companied by the free use of brandy and wine, and I continued to go about
and attend to my professional duties, though at times the effort was most ago-
nizing from the intense pain. I gave a thorough trial to the corn-water with
sweet wine, but did not perceive that it had much more effect than would
naturally be induced by the ingestion of a large amount of fluid.
I have since that time had three other attacks of the disease. In the second
attack I suffered no pain; two or three verrugas made their appearance on
the skin, and a severe wetting caused their retrocession, producing extreme
irritation of the stomach, which was only relieved by a residence at the sea-
side and a careful use of iced champagne. In my third attack, three verrugas,
the size of pigeons' eggs, made their appearance without any premonitory
symptoms, causing no pain or inconvenience. Business compelling me to
make a long and tiresome journey on a hard-trotting horse, which, considering
that I had been out of the saddle for three months, was anything but agree-
able, a violent congestion of the liver and lower portion of the lungs resulted,
and was followed by the retrocession of the verrugas and a narrow escape from
death. In my fourth attack I suffered but slight pain, the eruption making
its appearance over the entire body, but none of the verrugas being larger
than a pin's head. I am now in the most perfect state of health imaginable.
This disease is particularly liable to attack the mucous membranes;
I have repeatedly seen verrugas coughed from the throat and lungs, and
have found them in the intestines after death. Should a verruga locate
itself upon the eye, it should by no means be disturbed, and only the
simplest remedies should be used to combat any sympathetic irritation,
allowing nature to take her own way to cure the disease. Troublesome
cases occur occasionally in which the verruga locates itself in the ure-
thra, causing mechanical obstruction to the passage of urine. The treat-
ment is obvious; the patient must urinate, and hence a catheter must
be passed, and retained if necessary, with a bandage upon the catheter to
restrain hemorrhage. -
691
ARE ECZEMA AND PSORIASIS LOCAL DISEASES OF THE
SKIN, OR ARE THEY MANIFESTATIONS OF
CONSTITUTIONAL DISORDERS 2
BY
L. DUNCAN BULKI,EY, A.M., M.D.,
PHYSICIAN TO THE SKIN DEPARTMENT, DEMILT DISPENSARY, NEW YORK, ETC.
THE suggestion of a local pathology of diseases of the skin is of com-
paratively recent date, and stands in bold contrast to the older humo-
ralistic doctrine, which ascribed all these diseases to a morbid entity, a
materies morbi, seeking exit from the system, and whose escape is bene-
ficial; and the positive demonstration within the present century of a
local cause of several cutaneous maladies (as dermatitis, the parasitic
affections, etc.) which had, for ages, been regarded as expressions of blood
states, is an achievement of which modern medicine may justly be proud.
This discovery of a local origin of certain skin lesions, and the fact of
the resemblance between some of the forms of dermatitis and the erup-
tions of impetigo, lichen, eczema, etc., have led some to claim, still
further, that most, if not all, of the diseases affecting the skin are either
the results of local external causes, or are local diseases originating in
idiopathically deranged action of the elements of the skin ; a view, the
adoption of which has undoubtedly been promoted by a natural reaction
from the too exclusive, humoral doctrines previously entertained.
It need hardly be said that in arguing a constitutional origin and
nature of eczema and psoriasis, I do not desire at all to return to the
older humoralistic doctrine of disease, but seek to keep entirely within
the bounds of recent chemical physiology and pathology, while at the
same time I by no means ignore the importance of local cell-action, as
will appear later. Nor does the recognition of a constitutional nature of
eczema and psoriasis, by any means necessitate a belief that it is danger-
ous to check or remove these diseases by local measures, for experience
has proved the contrary; it does, however, demand an investigation of
internal causes, and a removal, as far as possible, of systemic disorders,
since thereby elements of disease are removed and the general system
benefited, while the eczema and psoriasis are cured.
In the further presentation of the subject of the nature and origin of
eczema and psoriasis, it will be advisable to separate the two diseases
more or less ; I will, therefore, in each instance speak first of eczema,
and then make the application to psoriasis; because, although they re-
semble each other in many important particulars, and have many points
of contact, their dissimilarities are such as to cause confusion if they are
in every instance spoken of together.
The local pathology of eczema and psoriasis has rested largely on three
grounds: first, on the results obtained in the local treatment of these
and other diseases of the skin, especially in the larger hospitals in Europe,
notably those in Vienna; second, upon microscopical researches in his-
tology; and, third, as far as relates to eczema, on a clinical and micro-
692 B U L KLEY,
scopic study of the artificial eruptions produced on the skin by irritating
substances, idiopathically and experimentally. We will dispose of the
last of these first.
Now, while there is as yet no absolute proof that the pathological
process excited artificially in the skin differs essentially from that tak-
ing place in acute eczema, we need not conclude that eczema is of local
origin because its eruption resembles artificial dermatitis. If we accept
one artificial eruption as eczema, we must accept all as such, from the
large blisters following cantharides, heat, and cold, to the discrete, pustu-
lar eruption caused by croton oil or tartar emetic, or the slight erythema
of the mildest irritant. Moreover, many of these artificial eruptions
resemble erysipelas even more than they do eczema, and yet there will
be few who will hold that true erysipelas is a local disease of the skin ;
again, the eruptions of croton oil and tartar emetic resemble those of
smallpox and syphilis, without this being any argument against the
constitutional nature of these latter, while the eruptions produced by the
insect in scabies and by lice are frequently confounded with eczema.
These lesions are all purely local, there is simply a local response of
the cells and capillaries of the over-stimulated part; they are all but
forms and varieties of inflammation of the skin, and are properly termed
dermatitis, and bear no more relation to eczema than does the inflamma-
tion of a sprained joint to true rheumatism. In a very small proportion
of persons, such irritations may become the starting point of true eczema,
but in them I believe that the elements of the eczematous diathesis
may always be discovered. A demonstration of the essential difference
between these artificial eruptions and eczema is shown by the fact that
it is not uncommon to induce dermatitis, as by a blister, for the cure of
chronic eczema, as also of psoriasis.
It is necessary, threrefore, in the present study to remember the dis-
tinction between eczema and dermatitis, for undoubtedly much that has
been treated for the former is but the latter, and of course no argument
can be drawn from therapeutical results obtained in dermatitis as to the
local nature of eczema. In regard to psoriasis also, we have to clearly
exclude, not only the scaly syphiloderm, but also all syphilitic influence;
true psoriasis, the lepra of Willan, has nothing to do with syphilis, not
even in the way of a later hereditary transmission, as has been suggested,
nor must it be in any way confounded with the dry, scaly forms of
eczema, or with the true leprosy, the elephantiasis of the Greeks.
Before proceeding systematically to examine the several points regard-
ing the local or constitutional natures of these diseases, let us consider,
for a moment, the question of the possibility of a double origin of the
diseases under consideration, whether they can own two natures, being
sometimes local and sometimes constitutional. In regard to the skin
lesions in the contagious exanthemata and syphilis, no question exists that
their origin is solely and always due to the introduction of a poison,
which acts through the system, and that the cutaneous manifestations are
but one exhibition of their effect. Passing now to such general diseases
as gout and rheumatism, whose etiology is more deeply hidden, we do not
doubt that the local phenomena observed in each are always the result of
the same constitutional condition, some of the earlier links in the chain of
cause and effect being recognized in functional derangement of certain
organs, and a consequent sub-oxidation or imperfect elaboration of the
elements of food, and an absence of healthy disintegration of tissue; and
E C Z E M A. A. N. D. PSO RIA S.I.S. 693
when we speak of cold or external injury as being the cause of gouty or
rheumatic inflammatory action in a part, we understand readily that it
is only intended to signify that it was the exciting cause, which determined
that that particular spot should be affected, or that the disease should
develop at that particular time. The same line of thought might be
extended to other diseases, showing that it is irrational to deny the con-
stitutional origin of a disease unless its local nature can be established
in a manner answering every requirement, as is the case in the parasitic
diseases of the skin ; quite as impossible is it to exclude local causation,
when the constitutional nature fails to account for every condition.
Great error has, therefore, been made, I believe, by those who look
only or mainly at the local causes, and argue therefrom a local nature of
eczema, they forgetting the established principles in general medicine in
regard to predisposing and exciting causes of disease. This is verified
by the fact of the difficulty of producing a true eczema artificially, at
will, in a person not subject thereto either in self or family (if indeed
it can ever be done), and the impossibility of inducing a psoriasis by any
local means.
Our conclusions then, thus far, are that eczema and psoriasis cannot
be both local and constitutional diseases, that is, either exclusively, ac-
cording to the case; and that the eruptions resembling eczema, artificially
produced, are either ordinary dermatitis, with a strong tendency to
spontaneous recovery, or are true eczema in eczematous subjects, in whom
the exciting cause, instead of occurring in the ordinary way, has been
artificially supplied, just as a gouty person might, by measures volun-
tarily applied, induce a true gouty inflammation of a joint. As before
stated, we know of no claim to the production of psoriasis by local mea-
sures alone. .
In the present study of the question as to whether eczema and psoriasis
are local diseases of the skin or manifestations of constitutional disorders,
I propose to develop the following points:—
(1) The nature of the eruption in disorders of the skin which are
recognized to be constitutional, as the contagious fevers, syphilis, etc.,
drawing a comparison between eczema and psoriasis and these affections,
and showing their points of difference.
(2) The nature of local diseases of the skin.
(3) The microscopic anatomy of eczema and psoriasis, with a view of
comparison with that of the local skin diseases on the one hand, and
with that of the constitutional on the other.
(4) The clinical history of eczema and psoriasis, in so far as they bear
on the question, the points considered being (a) age, (b) sex, (c) location
of eruption, (d) relapses, (e) hereditary transmission, (f) gouty and
rheumatic symptoms, (g) urinary disturbances, (h) bronchitis, etc.
(5) The clinical history of some local diseases, to show the differen-
tiating elements between constitutional disorders and those believed to be
local, as epithelioma, verruca, keloid, parasitic and mechanical diseases
of the skin, etc.
(6) The effect of local treatment, and how far the success of local mea-
sures necessitates a belief in the purely local nature of the disease.
(7) The effect of constitutional treatment, and the internal and general
measures of service in eczema and psoriasis, to show how far their effect
proves that the diseases which they remove are constitutional.
694 BU L KLEY,
(1) In comparing eczema and psoriasis to the acknowledged constitu-
tional disorders affecting the skin, contagious fevers, syphilis, etc., we
must not, of course, press the similarity too far. We find, however,
certain resemblances, as in the symmetry of development of the lesions,
for eczema, if uninfluenced by local causes, will, when carefully studied,
be found to exhibit this almost as clearly as psoriasis, whose bilateral
disposition is so striking; the peripheral mode of spreading of eczema
resembles much that of erysipelas, and the scattered eruption of psoriasis
corresponds much to the mode of development of other exanthematous
diseases, including syphilis. Eczema also is not infrequently attended
with fever, in its more acute and general forms, and on the full, recent
development of psoriasis there is more or less of malaise and prostration,
and probably fever. The characters of the lesions in eczema and psoriasis
are not entirely unlike those of constitutional diseases, which are marked
by, first, congestion; second, exudation; and, third, if these former have
been sufficiently severe, desquamation. The lesions of eczema and
psoriasis are also superficial, and rarely, if ever, do they leave cicatrices,
when uncomplicated.
(2) In contrast with these stand the characteristics of local diseases of
the skin, marked by their utter want of symmetry (unless accidental),
their extension depending either on a recognized cause, or being unex-
plainable, as in keloid, epithelioma, etc.; local diseases very rarely
affect the whole integument, or even large portions, unless ichthyosis, of
whose true nature, however, we know very little, be granted as such.
Local diseases, moreover, acknowledge no constitutional connections nor
fever; while, finally, the congestive element of eczema and psoriasis
stands in striking contrast to its absence in local diseases, except, of
course, where it is called forth by local stimulation. I am well aware
that many cases of eczema present a number of the features of local dis-
ease, and that psoriasis occasionally is seen quite localized; but this is
the exception, whereas it is rare to find exceptions in regard to the local
diseases exhibiting any constitutional features; and, as we have con-
cluded that eczema and psoriasis cannot be at one time local and at another
constitutional, the weight of evidence, in this comparison, is decidedly
in favor of the latter.
(3) The study of the microscopic anatomy of eczema and psoriasis is
as yet in its infancy, and throws but little light on the etiology of these
diseases; but, for a comprehensive view of the subject, we will briefly
recall the main points in their histology, which will be seen to favor the
constitutional rather than the local nature of the affections. The first
anatomical change in eczema (reasoning from what is observed in arti-
ficial eruptions) is capillary congestion, resulting in capillary stasis and
exudation in the tissue of the skin, producing more or less oedema. In
some instances, not rare with us, the process stops here, or is arrested by
treatment, and we have only the erythematous state, followed by mode-
rate desquamation, the result of the impaired nutrition of the outer
layers of the skin, a state very similar to the epithelial shedding in scar-
latina, erysipelas, or measles. -
If the exudation is too great to allow of absorption, it seeks egress
through the external layers of the skin, or becomes organized as chronic
infiltration. Biesiadecki believes that the fluid of eczema gains exit
through certain spindle-shaped cells, which lie between the round and
polygonal cells of the rete, these becoming so altered as to convey the
fluid, as through direct channels. When the outer surface is still intact,
EC Z E M A. A. N. D. PSO RIA S.I.S. 695
the hard, horny epidermis resists further progress and a vesicle forms;
when the epidermal layer has been dissolved off or ruptured, the fluid
oozes from the surface. Charpy" gives a somewhat different account of
the genesis of eczema; still regarding the beginning of the disease as being
in the corium, and consisting in a congestion of the layer just beneath
the papillae, he believes that the exuded fluid is absorbed by the deeper
cells of the rete, in the intervals between the papillae; that these cells
become engorged until they rupture, whereby alveoles are formed ; and
that the increase of these alveoles terminates in the production of vesicles,
upon the rupture of which cul-de-sacs are formed, whose walls furnish the
further secretion.
In chronic eczema, the exuded plasma has become organized, and is seen
as cell infiltration of the corium ; the papillae are much enlarged ; the
lymphatics, both in the papillae and corium, are increased in size and
dilated (Neumann); the blood vessels are sometimes obliterated (Rind-
fleisch); and even the deepest parts of the skin are involved.
The anatomical and other relations of eczema have suggested to some
a likeness between this and catarrh of the mucous membranes, and it
may be well here to consider for a moment the nature of the mucous
affection called catarrh, in reference to the bearing of this resemblance
upon the nature of the diseases now under consideration. First, it must
be renuembered that it is no more proper to call all inflammations of the
mucous membranes catarrh, than it is to name all those of the external
integument eczema, or even dermatitis; the term catarrh but signifies
the exudative feature, and the word eczema implies much the same.
We have already separated and clearly differentiated many diseases of the
mucous membranes, and it is highly probable that future study will show
that there are many very different processes included in what is yet
called catarrh, and ultimately their nature and origin will, we suspect, be
as clearly defined as are now those of cutaneous diseases, or, it is hoped,
far more clearly. That this is true may be judged from our present
knowledge; thus, we have simple intestinal catarrh caused by the direct
irritation of indigestible substances, a mechanical affair corresponding
to ordinary dermatitis; we have an incontrollable diarrhoea, or catarrh,
from the irritation caused by the circulation of effete substances in renal
disease ; there is also a mechanical catarrh from portal congestion in
cirrhosis; we have also gouty affections of the various mucous surfaces;
likewise the catarrhal complications of measles, those of syphilitic origin,
etc., and I have long believed that much of the ordinary bronchial
catarrh was truly eczema of that surface. Therefore, in likening eczema
to catarrh of the mucous membranes, we by no means simplify matters
in regard to its local or constitutional nature. Moreover, the common
observation of catarrhal affections following a chilling of the surface,
does not indicate necessarily their local nature, due wholly to the cold,
for we see great differences in the results produced, dependent evidently
upon constitutional states, the congestion due to the action of cold on
the integument being only the exciting cause.
We will now consider for a moment some views in regard to the local
nature of eczema propounded by Dr. Tilbury Fox, in the Lettsomian
Lectures for 1869 and 1870.” He suggests that the capillary congestion
is a consequence of cell activity, arguing that mere capillary excitement
| Annales de Dermatologie et de Syphiligraphie. t. iii. p. 100.
* Eczema, its Nature and Treatment; London, 1870.
696 BU L KLEY,
cannot give rise to eczema, because otherwise the erythemata would con-
stantly overstep their limits. The element of the influence of the nervous
system is largely considered by Dr. Fox, who believes that this abnormal
state of the cells may be in response to “perverted innervation,” as sug-
gested by Hebra some time since; but while Hebra limited the action of the
nerve influence to the production of “congestion and other disturbances
of the circulation,” Fox considers its influence in inducing cell prolifera-
tion a very necessary point to be admitted in eczema. That the latter is
very true is shown by alterations of tissue plainly following and due to
nerve lesions, and the same might be expected from the distribution of
the nerve fibres even to the cells of the rete and epidermis.
But while a step in advance is made in recognizing the direct agency of
the cell elements of the skin in the production of eczema (and independent
cell activity can be no longer denied, as is shown in leucocytes), and
while the influence of the nervous system in the production of cell
changes is acknowledged, there is no proof that this cell change is really
primary in eczema and psoriasis, and independent of constitutional con-
ditions, and that it exists as a local affair; and this view finds little
support beyond theory. It is a field, however, in which research is
needed, and may perhaps be carried on with advantage, namely, the
microscopical investigation of the apparently healthy skin of markedly
eczematous subjects, both before and after local disease, as also a study
of its nervous relations, both clinically and histologically. Should
repeated, careful, and well verified microscopic studies demonstrate cell
change in the earliest erythematous stages of eczema, and possibly also
in the elements of the skin of eczematous patients before or after
disease, it would do much to enlighten what otherwise must remain
uncertain, namely, the part that the diseased tissues take in eczema,
how far they are primary and how far secondary. The skin is the most
favorable, if not the only, portion of the body on which very early
pathological changes can be observed and followed, and research in this
line may throw light upon the pathological histology of other organs.
That independent cell-action has much to do with inflammatory and
other changes in the skin, is evident from the results of mechanical and
chemical irritation, where, as in the case of the ordinary blister, the
intervention of any blood influence cannot be suggested with reason; and
that the cells are under very direct control of the nervous system is also
very plain from the lesions in zoster, elephantiasis Graecorum, those occur-
ring after nerve injuries, etc.; here the cells which under normal nerve
control absorb just enough nutriment to maintain their proper relations,
under perverted nerve control take on morbid action. Anatomical
studies of the nerve trunks and branches in eczema might perhaps assist
in our knowledge of its nature. *
Psoriasis has been less studied microscopically than eczema, and little
or nothing has yet been published of its genesis. The most striking
histological changes in sections from older patches, as is known, consist
in a great papillary enlargement, with thickening of the rete Malpighii to
a corresponding extent, or nearly so. The papillae are crowded with new
cells, disposed mostly about the blood vessels, with some infiltration of
the corium ; but the infiltration is not nearly as extensive as in chronic
eczema, as might be judged from the clinical appearances.
Wertheim, from a microscopical study of psoriasis, concluded that the
patches were due to some peculiar change in the capillaries of a circum-
scribed spot. Neumann considers that what Wertheim thought were
E C Z E M A. A N D PSO RIA S.I.S. 697
enlarged and blocked-up capillaries were cell groups around them, but
offers no suggestion as to the mode of origin of the patches. By the
kindness of my friend Dr. A. R. Robinson, of New York City, I have
had the opportunity of examining microscopically some sections from
psoriasis, which confirm Wertheim’s views, and throw some light on the
pathological histology of this disease. The earliest specimen was taken
from a papule of psoriasis but two weeks old, in which there had been
but little scaling. The blood vessels in the papillae were very distinctly
seen to be greatly enlarged, and in some places appeared to approach the
surface of the epidermis very closely ; in quite a number of places the
blood vessels had ruptured, and microscopic ecchymoses were plainly
visible. In specimens from rather older patches the blood vessels showed
very distinct budding processes, and some of the vessels appeared com-
pletely blocked up; there was little or none of the new deposit of cells
described by Neumann, and there was no possibility of mistaking the
enlarged bloodvessels for cell heaps around them.
It will be thus seen that the microscopic changes in eczema and
psoriasis do not differ so very much from those observed microscopically
in some other chronic skin diseases, and that histology contributes but
little to show the local nature of these diseases, except so far as relates
to the studies of Wertheim, further verified by those of Dr. Robinson;
and yet here no one can show that even those changes in the blood vessels
are primary. Fox, however, believes that psoriasis “consists primarily
and essentially in a misbehavior of the cell-elements themselves—a per-
version of the ordinary cell-life of the epidermis—a true tissue disease,
in which the trophic nerves probably play the chief part,” but, unfortu-
mately, gives no reasons for his interesting supposition. -
While this latter view finds little or no support in anything that has
yet been reported of the pathological histology of psoriasis, there is a very
slight foundation for it in a certain resemblance which can be made out
between psoriasis and a disease of well-recognized local nature, namely,
epithelioma, to which we would venture to devote a few words.
The elements which have suggested the comparison between the two
diseases are: a similarity in some of their clinical features and modes of
development, their anatomical disposition, the transformation of patches
on the tongue, called psoriatic, into epithelioma, the asserted family
relations of the two affections, and the occurrence of epitheliomatous
growths on the faces of young persons affected with psoriasis. In regard
to a similarity in their mode of development, the increase in both is by
peripheral extension, to the extent often of forming a ring, with healing
within. Anatomically, epithelioma is an outgrowth, or rather an in-
growth of epithelial elements, whether the more external ones of the
skin or those lining glands; we have, as yet, no studies with which I
am acquainted to prove it, but the true pathology of psoriasis may be an
epithelial hyperplasy of somewhat similar nature, and the lengthened
papillae seen in it may be the result of the ingrowth of the rete. We
have the same shedding of the Outer epithelial layers in psoriasis as in
epithelioma; on scraping both, by no means forcibly, not only are the
outer dried layers removed, but the softer and more succulent portion
next above the papillae is also separated, and we have in both the
bleeding, familiar to all. The presence of the fibrous papillae in psoriasis
prevents further progress in the scraping, or we might induce a destruc-
tion similar to that in epithelioma.
The only real histological support I have to offer to sustain this
698 BULK L E Y,
theory of the ingrowth of the epithelial layer in psoriasis, other than
the well-known increase of the inter-papillary portion of the rete, is
found in some of Dr. Robinson's sections, in which, in addition to the
capillary change already alluded to, the sheaths of all the hairs showed
outgrowths at their lower portions similar to those which have been
observed in lichen ruber.
The transformation of what has been called lingual and buccal
psoriasis into true epithelioma is now proven beyond doubt; of the true
nature of the former affection, and its relations to ordinary psoriasis,
however, we have little reliable information; it is certainly rare to find
these mouth lesions in psoriatic patients, and many who have them have
never had ordinary cutaneous psoriasis, and it is highly questionable if
there is the slightest relationship between them.
Gaskoin affirms very confidently the hereditary relations of psoriasis
and epithelioma. I have occasionally found both diseases in the same
families, in intelligent private patients, but have never been able to
satisfy myself of any relationship; the cases, however, have been far too
few, and the time which has elapsed since I first investigated the con-
nection, far too short, to form any conclusions therefrom. I have
recently treated a young man with well-marked psoriasis, who exhibited
perfectly developed epithelioma in front of the left ear. I would suggest
this relationship between psoriasis and epithelioma as a profitable field
for research, clinically and microscopically. If a relationship can be
established, the local nature of the former may be demonstrated ; for
the present, however, this is not proven, and the constitutional relations
of this disease, as well as of eczema, are so abundant and conclusive that
we must here grant them the weight of argument and fact.
(4) We will now turn to a consideration of the constitutional relations
of eczema and psoriasis, as exhibited in their clinical history. In regard
to the age at which they occur, eczema affects all, from the cradle to the
grave; none are too young, none too old to suffer from it. This is more
the character of constitutional than of local disease; cancerous affections
seldom, if ever, are seen in the young; warts (of the ordinary variety)
seldom in the old; keloid very generally in middle life, both extremes
being spared. The vegetable parasitic diseases rarely occur in the old;
whereas in them are found changes in the skin, and diseases therefrom,
not seen in young life. Psoriasis may be also said to prevail at all ages,
though less frequently very early or very late in life.
Eczema and psoriasis both occur about as frequently in the male as
in the female. In location, eczema spares no part of the surface, and,
I believe, may affect every portion of the mucous membrane as well,
while its development is very commonly symmetrical; these features are
true also of psoriasis, and are those of general and constitutional diseases
rather than of those of local nature. The tendency to recurrence in the
same parts might be claimed as a local feature, but, in regard to eczema,
the same exciting cause may be present again and again; and it must be
conceded that tissues are undoubtedly weakened by disease, and more
likely to be affected the second time than sound tissues; this is observed
in gout and rheumatism, as also in affections of the mucous membranes.
IBut relapses in eczema and psoriasis furnish more indications of a
constitutional than of a local nature, for fresh attacks of eczema are very
commonly found to follow a depression of vitality; and I believe that
this is true of psoriasis far more commonly than is generally conceded.
Moreover, these eruptions by no means occupy the same locations each
EC Z E M A. A N D PSO RIA S.I.S. 699
time. I have frequently observed that the spots of psoriasis fall almost
if not quite as often on new tissue as on the sites of a former disease.
There is no doubt as to the hereditary character of eczema and psori-
asis. Whether the heredity consists in any general, constitutional habit,
or whether it is simply a transmitted tendency to tissue-change, cannot
be shown at the present time; in favor of the latter may be cited the
transmission of mental and physical characteristics, cancerous disease, and
ichthyosis; as instances of the former, we have the inheritance of syphilis,
gout, and rheumatism, and the history of the occurrence of gouty, bron-
chitic, hepatic, and urinary troubles in the family of eczematous and
psoriatic patients, in such a way as to show a connection.
If the claim of an inherited, perverted tendency of tissue could be
established in eczema and psoriasis, which tendency lies dormant until
called into activity by some exciting cause, it would still fail to explain
alone why a cause which is at one time inefficacious, will, on another
Occasion, even in a much less degree, be sufficient to produce the disease.
This brings us to the study of the gouty and rheumatic symptoms, the
urinary disturbances, and the bronchitis of eczema and psoriasis. That
patients with these affections are the frequent subjects of the systemic
derangements connected with or tending toward gout and rheumatism,
as well as to the complete manifestations of these diseases, is very cer-
tain ; this observation is of ancient date, and is strikingly confirmed by
recent science. It is not very uncommon to find attacks of gout alter-
nating with those of eczema and psoriasis, and clinical study shows that
various disorders which may properly be classed under the name of func-
tional derangements of the liver are very common in the subjects of
these two diseases of the skin.
These systemic disorders are shown in the urine, which undergoes
functional derangement in a large proportion of the cases of eczema and
psoriasis. In a recent contribution to and study of the subject by the
writer, the following conclusions were reached : “Eczemic patients sel-
dom pass large amounts of urine, the tendency being to scanty secretion,
almost always unnaturally acid, with a specific gravity averaging above
normal. Free uric acid, the urates, and oxalate of lime, abound ; some-
times oxaluria is very persistent. Albumen is rarely seen. The urea
and uric acid are often below the normal standard, although they may
be in excess when a large portion of the integument is affected ; indican
has been found in pathological quantities. When the specific gravity is
high, it may be due to an increase in the sulphates. The chlorides are
diminished. Psoriasis sometimes alternates with phosphatic urinary
deposits in gouty subjects. The fixed salts are increased. The urine
shows generally a hyper-acidity, with deposits of uric acid, urates, and
oxalate of lime, the contrary being the exception. The specific gravity
is liable to great and unaccountable variations.”
It may be claimed that these urinary changes are observed in persons
also with no cutaneous disease, and that therefore there is no connection
between the two. I am not yet in a position to prove exactly what
changes in the urine necessarily accompany eczema and psoriasis, but
mention those that have been actually observed to show that patients
with these diseases are not in the perfect health often claimed for them,
and, although a casual examination will often fail to detect any disease
other than that of the outer integument, I assert that searching investiga-
! Archives of Dermatology, October, 1875, p. 1.
700 BULKI,EY,
tion will seldom fail to demonstrate elements of disordered health, very
commonly shown in the condition of the urine. And as these are
removed by appropriate remedies, the eczema and psoriasis improve, and
2)2Ce ()é?"SQ.
Not less striking, as indicative of the constitutional relations of eczema
and psoriasis, is the occurrence of bronchitis and asthma, conjointly or
alternately, in the patient, or in his immediate family ; the truth of this
is well attested by many writers.
The neurotic relations of eczema and psoriasis are also very interesting,
and indicate other than a local nature of the disease ; but the subject is
yet too recent and unsettled for more than a mention in this place: I
have elsewhere given a fuller study of it. Recorded facts, based on large
clinical experience, are needed greatly for the full and satisfactory deter-
mination of many of the points here alluded to.
(5) Enough has perhaps already been said in reference to the clinical
history of local diseases, but a few points may be again alluded to with
advantage in connection with what has just preceded. No constitutional
relations have been recognized, to my knowledge, in any of these ; con-
stitutional remedies have no effect upon them. Their unsymmetrical
character and irregular development have been mentioned, as also their
removal solely by local measures. Local diseases of the skin of external
origin are represented by the parasitic affections and dermatitis; idio-
pathic misbehavior of cells is exemplified by epithelioma and keloid ;
herpes zoster may be taken as a type of an acute local disease of the
skin dependent on nerve elements; and ichthyosis of a chronic, local dis-
turbance of general cell nutrition ; the clinical history of each of these is
familiar to all, and quite different from those of eczema and psoriasis.
Hebra, as is well known, has always stood as the representative of
local pathology and therapeutics, and it may not be uninteresting or
unprofitable to refer briefly to his present views in regard to the purely
local nature of eczema, as found in the recent, second edition of his
work.” That I may not be charged with misunderstanding him, I will
quote a section from the close of the long chapter on the Etiology of
Eczema (p. 462). After repeating what had been said in the former
edition to show the local nature of the disease, and after stating his dis-
belief in any diathetic cause, he says: “While, therefore, we cannot
accede to any peculiar or proper dyscrasia, we must, on the other hand,
confirm the fact that certain conditions of the human organism, partly
transient, partly permanent, at one time increase, and at another time
diminish its susceptibility to agencies producing eczema. These physical
conditions are called a disposition, or predisposing cause, momentum dis-
ponens, to distinguish them from the direct exciting cause of irritating
agencies, and we are obliged to recognize these elements in the etiology
of eczema, because experience confirms it.”
“For example, we see an eczema on the hands and forearms of a young
girl who has been engaged in washing soiled linen, and we declare that
the origin of the eczema is in the action of the lye, soap, hot water;
and friction. Now, at the same time with this girl, there are many
other females washing in the same lye, using the same soap, and living
under the same circumstances, without acquiring eczema. Indeed, this
! Archives of Electrology and Neurology, November, 1874, and May, 1875. Reprinted
by G. P. Putnam's Sons. New York, 1875.
2 Lehrbuch der Hautkrankheiten, Zweite Aufl. ; Erlangen, 1874.
E C Z E M A. A N D PSO RIA S.I.S. 701
very girl, who now has eczema, has been exposed to the same influences
previously without becoming affected. What is the cause of her present
susceptibility? A careful examination of her general condition will
give the explanation. The girl who before was healthy, robust, and
regular in her menses, has now lost her appetite, has become sluggish
and languid, her appearance is pale and bloated, her menstruation is
profuse; in a word, she has become chlorotic, and thereby eczematous.
The remedies suitable for the chlorosis are now employed; the appetite
and power of work return, the menses become regular, and the eczema
disappears in spite of the continued influences of the agencies causing
it. The same observation is made in reference to pregnant and nursing
women; also in those suffering from chronic sexual disturbances. The
latter must always be looked upon as favoring elements (a momentum
disponens, or predisposing cause) which induce a status minoris resistentiae,
and allow an otherwise ordinary skin irritant to become an exciting
cause, a momentum eaccitans.”
After again claiming that we need no blood explanation of eczema,
Hebra adds: “In order not to be misunderstood, we will, however, here
again state that every eczema is not caused by a local irritation, but that
it may be occasioned by diseases of the rest of the system.”
Such clear and unqualified statements as to the constitutional nature
and origin of eczema are unexpected from one so prominently known in
connection with local pathology, and show that his opinions have latterly
undergone considerable change. It must be remembered, however, that
at the time of the first edition of Hebra’s work, upon which his reputa-
tion as a local pathologist greatly rests, many of the crude theories of the
past had not yet been completely overthrown; and also that within his
experience many diseases which had formerly been considered constitu-
tional, had been demonstrated to be purely local, as scabies, the vegetable
parasitic diseases, plica polonica, etc., and that the success of local mea-
sures seemed to demonstrate to him that other affections were also local;
he has, however, the candor to acknowledge his mistake.
(6) We come now to one of the most interesting and at the same time
most disputed portions of Our investigation, namely the relative effects
of local and constitutional treatment as indicating the nature of eczema
and psoriasis. Hebra and Neumann declare, in the most positive terms,
that it is quite unnecessary to regard the constitutional relations of these
diseases, except when they are striking, and those who have followed the
Vienna School for any length of time can testify how completely this
idea is carried out there. External remedies and measures are used there
almost exclusively, it being the greatest exception to have any questions
asked in regard to the general health ; and internal medication, it may
safely be asserted, is very rarely, if ever, employed in the hospital, in
eczema and psoriasis, except by way of experiment; and yet these erup-
tions are removed in a very satisfactory manner. Does this, however,
prove the local nature of the disease ? In negation of this I need
but suggest how the stiffness resulting from gouty and rheumatic inflam-
mation is benefited by external counter-irritants and passive motion,
while the origin of the serous inflammation and fibrous thickening is re-
cognized as of constitutional origin. Syphilitic iritis may be subdued by
atropine alone, and tubercular laryngitis receive great benefit from topi-
cal treatment; the ulcers of dysentery may be cured, and the discharge
of leucorrhoea arrested, by local measures; and yet these diseases be mani-
festations of constitutional states.
702 BULKLEY,
But there is not the slightest influence exerted by local treatment in
preventing the return of eczema and psoriasis, whereas we know that
constitutional measures have considerable power to prevent relapses; this
is, as is well known, less true of psoriasis than of eczema, but mainly, I
believe, because of the neglect to carry out faithfully the proper measures
for a sufficient length of time after the disappearance of the eruption.
Again, in this country at least, local measures often fail to accomplish
the desired end until constitutional measures are resorted to in addition.
In considering the effect of local treatment as an argument for the local
nature of eczema, it is well to bear in mind the distinction drawn early in
this paper between dermatitis and eczema, for many cases treated as the
latter disease are entirely local in character, the result of local irritants,
possessing in themselves a strong tendency to heal when the irritating
cause is removed and the inflamed surfaces protected, that is, are cases
of dermatitis and not of eczema.
I believe true eczema and psoriasis to be constitutional states wherein
ordinary irritants give rise to inflammatory changes in the skin, which
form an important element of the disease, but which are no more its sole
element than are the cutaneous phenomena of the exanthemata, leprosy,
syphilis, etc. I believe also that single attacks of eczema, and of psori-
asis, too, correspond in nature very much to those of such diseases as
gout and rheumatism, in which the local changes have a greater or less
tendency to self-limitation, although the effects of the disease may long
remain. That is, as arthritic, pulmonary, or cerebral symptoms appear
to be the culmination of blood-processes which we know as gout and
rheumatism, so eczema and psoriasis are directly dependent upon some-
what similar, although as yet little defined, blood changes, the acute
symptoms corresponding to those of rheumatism and gout, while the
chronic local alterations in the skin answer to the gouty concretions on
and in the synovial membranes, and to the rheumatic thickening of the
valves of the heart or around joints long inflamed ; and, as in gout and
rheumatism, there is a tendency for the attacks to recur again and again,
the health in the mean time seeming to be perfect, so in eczema and
psoriasis the local phenomena may be manifested from time to time,
without any very apparent constitutional disorder between, while the
product of the disease, the cell infiltration, remains."
Now but little can be done to arrest the acute phenomena of eczema
by local means, other than soothing applications, and it is very difficult
to check a developing psoriasis by outward measures; but the results in
both may be removed by local stimulants, which induce cell activity
within the bounds of health. I speak more especially of these diseases
in adults, for infantile eczema exhibits more plainly the constitutional
elements whose great activity renders local measures often very futile.
While, therefore, the arguments are against eczema and psoriasis
being local diseases of the skin, it must be admitted that they become local
diseases in their skin lesions, and as such may be amenable very largely
to local treatment, as far as relates to the single manifestations of dis-
ease at any one time.
(7) Whatever may be the views of those who hold exclusively to the
value of local treatment in eczema and psoriasis, no doubt whatever
exists in my own mind, nor, as far as I can learn, in the mind of a large
! “The Management of Eczema,” by L. Duncan Bulkley, M.D., Trans. Am. Med. Asso-
ciation, vol. xxv. 1874, p. 121. Reprinted. G. P. Putnam's Sons, 1875.
E C Z F. M. A. A. N. D. PSO RIA S.I.S. 703
share of those who make skin affections a special study, that constitu-
tional measures are both valuable and necessary to the cure of most cases
of these diseases. And by constitutional treatment I do not mean arsenic
alone, nor any one specific remedy, for truth demands the acknowledg-
ment that specifics for diseases do not exist, unless it be with the two
exceptions of mercury for syphilis and quinine for malaria. But by
constitutional treatment I understand the employment of every measure
for the cure of disease, which cannot truly be called local treatment.
Now my experience has been, as already stated, that most patients
with eczema and psoriasis present anomalies in their urinary secretion,
and in proportion as this exists have I found the congestive feature of
the disease to be marked, and in the same proportion have I seen the
diseases benefited by cathartic and diuretic remedies. A not incon-
siderable number of patients with eczema and psoriasis are habitually
constipated, and the diseases, with me, resist all local and other measures
until this is remedied. Many are what is called bilious, and nitric acid
will do more to cure their skin diseases than any other means. It is
not at all uncommon, in this country, to find eczema and psoriasis in those
who are extremely nervous, and cases are constantly met with where an
enormous mental strain is keeping up the disease; here the constitutional
measure of rest, with perhaps change of scene and climate, is impera-
tively demanded, together with nerve tonics of various kinds. In dispen-
sary practice in this city a good portion of all eczematous and psoriatic
patients exhibit the features known as strumous or scrofulous, and are
more quickly and surely cured by the internal administration of cod-liver
oil than by any other remedy, local medication either being used not at all,
or playing a very unimportant part. Arsenic also is capable of entirely
curing, that is, removing, eczema, and that tolerably quickly, without
the use of any local measures whatever, as I have repeatedly witnessed
and elsewhere shown, and its power over psoriasis is acknowledged on
all sides. Iron is indicated in a large share of our eczematous and pso-
riatic patients; others require such remedies as rhubarb and soda ; and
the vegetable tonics play an important rôle in our therapeusis.
Diet, hygiene, exercise, and bathing, are all essential in my opinion
to a successful management of these diseases. I claim that patients
who have been thus carefully managed not only recover from the indi-
vidual attack under proper local measures much more quickly than when
the latter alone are used, but that they most certainly are in a better con-
dition to resist future attacks, and that relapses are far less frequent,
and I claim that the clinical history of the patients shows this. The
action of these measures is not local, is not directed to the skin; but by
virtue of the influence exerted on the general economy, as well as on
the affected tissues, they cure the diseases in question.
In this study I have not referred much to the opinions of writers on
dermatology, because, with the exceptions which I have mentioned from
time to time, the opinion is very general that eczema and psoriasis are
constitutional disorders. By a constitutional disorder, as we now under-
stand it, is not meant the existence of some peccant material or materies
morbi, which the system endeavors to throw off; nor that the discharge
Trans. Amer. Med. Assoc., vol. xxvii. 1876, p. 163; New York Med. Journ. Aug. 1876,
p. 113; Reprint, “The Use and Value of Arsenic in the Treatment of Diseases of the Skin.”
New York, Appleton, 1876.
704 BULKLEY,
is in any way curative or beneficial to the system ; nor that the removal
of the cutaneous lesion can in any way or manner act prejudicially to
the economy; but the expression, constitutional disorder, is understood
in the same sense in which it can be applied to gout, rheumatism, chlo-
rosis, leucocythaemia, scorbutus, etc. And it is used here in especial
distinction from local disease—that is a pure and specific disease of the
tissues of the skin itself, singly and alone—as the artificial eruptions,
parasitic diseases, epithelioma, verruca, keloid, etc.
There are several elements of causation in infantile eczema which have
not been touched on, partly because of want of time, and partly because
observations are wanting as to their true effects in producing the dis-
ease. One is the occurrence of the exanthematous diseases; it has been
observed by some that eczema followed soon upon these affections, and
it has been thought that they left such an impression upon the cell-ele-
ments of the skin that these readily took on eczematous action, simply
on the application of an external irritation. Now if they can have any
causative effect in eczema, the exanthemata can also induce psoriasis,
lichen, urticaria, etc. Whether, however, they act in any other way
than as depressants, leaving the body and tissues in an enfeebled state,
I cannot tell; it will be remembered that Mr. Hutchinson has recently
claimed that the later lesions of syphilis are but the remains of the earlier,
general, dermal phenomena. If the exanthemata had any real power to
impress any tissue change on the skin, which should afterwards result in
eczema, we could hardly conceive why this should happen in such a small
proportion of cases; for, of the multitudes who go through these inflam-
matory skin affections of childhood, but few suffer from eczema after-
wards; while many children have eczema long before undergoing one of
the exanthemata. We cannot therefore accept any argument as to the
local nature of these diseases drawn from the previous occurrence of the
exanthemata.
Vaccination is another process which we not rarely see followed by
eczema; do we suppose here a local cause (other than exciting), that is,
does it induce any change in the cells of the skin whereby they are more
prone to eczema 3 I believe not, because of the very general adoption
of vaccination, and the very few cases of eczema immediately following;
I need not in this presence state that there can, of course, be no blood-poi-
soning, no contagion of eczema by means of the lymph, even when taken
from a vaccinifer suffering from eczema ; we know of no transmission by
this means except that of syphilis, unless it be a tendency to carbuncular
inflammation, of which I have observed a number of cases, and which
my friend, Dr. Frank P. Foster, tells me he occasionally meets with.
The only agency which vaccination can exert in calling forth an eczema,
is, I believe, simply that of a local irritant, acting in the same way as a
burn or other excessive stimulation. I have seen psoriasis of a very
marked character develop for the first time immediately after vaccina-
tion, but the event must of course be looked upon as a coincidence, or
else we must conceive that the local tendency to cell-proliferation has
furnished the starting-point, the fire which kindled the train all ready
for ignition. The rarity of the observation of psoriasis immediately fol-
lowing vaccination shows the correctness of this view.
Equally useless and uncertain is it, in my judgment, to look upon den-
tition in any other light than as an exciting cause, not acting locally, it is
true, but probably as a reflex irritation, and as such I believe it to be of
more or less importance; but in view of the small proportion of teething
E C Z E M A. A. N. D. PSO RIA S.I.S. 705
infants who have eczema, and the infinitely smaller ratio of those with
psoriasis, other elements must be looked to for the real etiology of these
diseases; this is shown also by the frequent occurrence of these diseases
in those of older years, and before the teeth begin to appear.
Erroneous diet, however, I consider as an all-important and un-
doubtedly prolific cause of eczema in infants, a point which we cannot
here enter upon, except to mention it as of weight in favor of the con-
stitutional origin of the diseases under consideration.
That local causes are of very great importance in the etiology of eczema
in infants, as well as in adults, is beyond doubt; such causes are the use
of irritating diaper-linen, harsh bandages, too frequent and careless
washing and drying, incautious exposure of the face to cold air, hot
caps on the head, harsh attempts to remove the dried sebaceous matter
from the scalp, etc.; but that the disease very frequently does not get
well upon the removal of these irritants, and under local measures alone, is
certain, and that a proper study and direction of constitutional measures
will cure the disease, if proper local treatment is employed, is equally sure.
Psoriasis is observed so rarely in those of very tender years, that no
conclusions can be formed respecting it; if indeed the disease in infants
differs in any way from that of adults.
I have said nothing yet in regard to the relations supposed to exist
between scrofula and eczema and psoriasis. This is a very difficult sub-
ject and one which needs clearing up, there being thus far no sufficient
data upon which to base a scientific investigation of the matter; for,
although many authorities state that there is a connection, the evidence
of any causal effect is far from being established. Neumann states that
among 308 eczematous children he found but 30 who were rachitic and
70 who were scrofulous, while among more than 3000 scrofulous and
rachitic children he found none with eczema. d
For the proper study of this relation, we need to have the true position
of scrofula more clearly defined than at present, its causes and symptoms
more sharply drawn, and further statistical details, such as those of Neu-
mann, recorded. That quite a share of children with eczema, among the
poor, exhibit some of the features called scrofulous, that is pale, pasty
skins, light hair, eyes, and complexion, enlarged glands, ophthalmia,
otorrhoea, etc., is not to be questioned, but, that this state has any special
effect in causing eczema, other than its depressing power, cannot now be
proved. It is certain, however, that eczema and psoriasis exhibit some-
what different features when occurring in these subjects; the tendency
to pus formation is evident in the secretion from eczema, and in psoriasis
the scrofulous state is shown by a thickened and more yellowish condition
of the scales.
Although less commonly thought of, there is probably more connection
between what is called a scrofulous state and psoriasis than there is
between the former and eczema. Gaskoin thinks that phthisis plays
an important part in preparing the way for psoriasis, and I have been
rather inclined to think the same ; investigations are, however, needed
here. -
The results of this inquiry as to the local or constitutional nature of
eczema and psoriasis may be summed up in the following propositions:—
I. Eczema and psoriasis are diseases sui generis, and are not to be con-
founded in any way with other states; as, the former with artificial
45
706 BULKLEY,
dermatitis, and the latter with the eruptions of syphilis, scaly eczema,
or leprosy.
II. Eczema and psoriasis cannot own a double, independent causation,
or nature, at One time local, and at another constitutional ; but, with
Other diseases, they may have a twofold cause, namely, a predisposing
and an exciting.
III. Eczema and psoriasis in many of their features resemble the
accepted constitutional diseases more than they do those recognized as
local.
IV. The skin lesions of eczema and psoriasis, as also their micro-
scopical characters, more nearly resemble those of the general and con-
stitutional diseases affecting the skin, than they do those of purely
local diseases.
W. Eczema is very properly likened to catarrh of the mucous mem-
branes, but no argument as to its local nature can be drawn therefrom ;
it is very probable that some proportion of the mucous attacks called
catarrh are eczema and psoriasis of this tissue.
VI. Both eczema and psoriasis resemble gout and rheumatism, in
certain respects, and are dependent upon a somewhat similar, although
as yet unknown, constitutional cause ; much of the skin lesions, as
Ordinarily observed, must be looked upon as the local results of the dis-
eases, removable by local means.
VII. There as yet exists no microscopical or physiological proof that
eczema and psoriasis are the sole result of local cell disorder, either con-
genital, acquired, or due to perverted nerve action; although from our
present knowledge of independent cell activity, and from the intimate
connection between nerve elements and the cells composing the skin, it
is highly probable that cell action and merve influence are important
factors in eczema and psoriasis.
VIII. Local causes play a very important part in the etiology of
eczema ; they are probably inoperative in psoriasis.
IX. Certain relationships between psoriasis and epithelioma have
been claimed, which require much further investigation ; at present
they are not established, and are no proof of the local nature of psori-
àS]S.
X. The clinical history of eczema and psoriasis furnishes much evi-
dence of constitutional relations, mainly with states allied to gout and
rheumatism ; no direct causal connection has yet been demonstrated
between the scrofulous state and eczema and psoriasis.
|XI. Local treatment alone is often insufficient to remove the losions
of eczema and psoriasis, and cannot prevent or delay relapses; its success
does not demonstrate the local nature of these affections.
XII. Constitutional treatment, alone and singly, can cure many cases
of eczema and psoriasis, and prevent or delay relapses in a certain pro-
portion of cases; by constitutional treatment is intended every agency
not properly placed among local measures.
|XIII. The total weight of evidence and argument is that eczema and
psoriasis are both manifestations of constitutional disorders, and not
local diseases of the skin.
In closing this paper, already far exceeding the limits designed, the
writer would beg indulgence for its imperfections, of which he is fully
aware; some of these have been necessitated by the vastness of the
subject and the small amount of space afforded in which to consider
E C Z E M A. A N D PSO RIA S.I.S. 707
them. Many points which had been elaborated much more, have been
necessarily condensed or omitted, and many fields, an investigation of
which would have further developed the subject, have been left entirely
untouched; many have been barely alluded to, because of the scantiness
of reliable data. It is to be hoped that the investigation will be pursued
still further, for the etiology and pathology of these diseases may be
considered as at the foundation of all dermatology, and the importance
of some of the questions here raised can scarcely be overestimated.
The following are some of the points requiring further study: the
mode of the formation of vesicles in eczema, and the way in which the
exuded liquid reaches the surface; the state of the skin, histologically,
very early in eczema and psoriasis, as also after the disappearance of the
disease, and likewise of the skin of those subject to eczema and psori-
asis in places where no disease has yet appeared ; the nerve relations of
these diseases clinically, and the state of the nerves microscopically ; the
condition of the blood vessels very early and very late in these diseases,
especially in regard to Wertheim's view of a capillary change being the
cause of psoriasis; the resemblance between psoriasis and epithelioma,
clinically and microscopically, as regards also the development of what
are called psoriatic lesions of the mouth into epithelioma, and the true
nature of the former and their relation to psoriasis, if any ; also the
possibility of the origin of psoriasis in hyperplasy of the rete downwards
between the papillae; the urinary relations of eczema and psoriasis, also
their heredity, as relates to the diseases themselves, and also to other con-
stitutional manifestations; the asserted connection between the eruptions
of the exanthemata and eczema, especially in infants; the influence of
dentition in the production of eczema ; the effect of vaccination; and,
finally, the relations of scrofula to eczema and psoriasis.
708
THE VIRUS OF WENEREAL SORES, ITS UNITY OR
DUALITY.
BY
FREEMAN J. BUMSTEAD, M.D.,
LATE PROFESSOR OF WENEREAL DISEASES IN THE COLLEGE OF PHYSICIANS AND
SURGEONS, NEW YORK.
THE question, the discussion of which I have the honor to open to-day,
is expressed in the following terms:—“THE VIRUS OF VENEREAL SOREs,
ITS UNITY OR IDUALITY.”
In presenting this question, the first inquiry that suggests itself to
one’s mind is whether it is identical with the question of the “Unity
or Duality of Syphilis,” that, for the last twenty-four years, has excited
so much interest and discussion in the medical world. I reply that it
's essentially the same. To ignore this fact, to attempt to assume a new
departure, to consign the question of “unity or duality” to the tombs as
having no bearing upon our present views, would be a fraud upon medi-
cal history and a source of confusion to the student ; since those who
have so earnestly advocated the so-called “duality of syphilis,” have
never for a moment supposed that there existed two kinds of syphilitic
virus, but merely that there was more than one poison at work in the
etiology of a complex disease known for many years under the name of
syphilis; and he who now recognizes a duality of poisons in venereal
Sores, is a syphilitic “dualist” in the sense in which that term has been
employed. It will be seen, however, that the term “duality of syphilis”
has always been a misnomer, and the form of the question presented to
us to-day is most appropriately substituted for it.
I take it for granted that the question proposed to us is intended to
include the poison or poisons of every kind productive of venereal ulcers,
and that the term virus is to be used in its broadest sense, viz., that of
contagious principle or poison. When speaking of a special poison sup-
posed to be incapable of generation de movo, I shall call it a specific virus.
Allow me also to add that I shall use the terms chamere and chancroid
in the sense which is commonly received in this country—chancre as in-
dicating the initial lesion of syphilis, and chancroid as indicating the
“soft chancre” of the French school, and the “chancre” of the German
School.
Three views as to the origin of venereal sores have been entertained :—
(1) All venereal sores are due to a single, specific virus, the virus of
Syphilis. .
(2) Some venereal sores are due to the syphilitic virus, and others to
a distinct specific virus, known as the chameroidal.
(3) Some venereal sores are due to the syphilitic virus, and others to
the inoculation of the products of simple inflammation, in which latter
case no specific virus exists.
The clinical observations and artificial inoculations, which have been
brought forward, for and against these several theories, must be familiar
|U NITY O R D U A LITY OF W E N E R E A L SO RE S. 709
to those here present, and I shall therefore limit myself to reviewing
them and drawing my own inferences from them, as a basis for the dis-
cussion which is to follow. Indeed, any other course would be imprac-
ticable within the limits of this paper.
The view first mentioned, viz., that all venereal sores are due to a
single virus, the virus of syphilis, had been the prevailing one for nearly
three centuries prior to the year 1852. At the same time, it had not
escaped the notice of many observers that the results of contagion were
by no means identical; that, in some cases, the persons infected showed
no symptoms after the healing of their ulcers, while others developed a
train of symptoms, lasting through years, and even transmissible to their
children.
In the year 1852, Bassereau claimed a distinct cause or origin for each
of these two classes of cases. He founded his claim, first, on the his-
tory of venereal sores, whereby he endeavored to show that, although
contagious ulcers of the genital organs, communicated in sexual inter-
course, had been well known to the ancients, yet that the constitutional
disease which we call syphilis made its first appearance in Europe in the
latter part of the fifteenth century.
While believing this argument drawn from history to be a valid one,
I would not insist upon it in a discussion like the present, which should
be based upon scientific data. I will merely remark that this argument
will receive additional support, provided that it can be shown that the
chancroid is due to a poison generated by simple inflammation, and
hence that it must have existed at all times and among all nations.
Bassereau’s second argument was based upon the “confrontation” of
persons affected with venereal diseases, and he and others were able to
prove, in several hundred cases, that when the disease was local in the
giver it was also local in the recipient, and that when it was constitu-
tional in the giver it was always constitutional in the recipient ; in other
words, that the broad line of distinction separating a local disease on
the one hand from a constitutional disease on the other, was constant in
successive generations without limit.
It will be observed that this proof does not involve any differences
real or supposed in venereal ulcers themselves; it may be said to rise
above such consideration in that it ascends to the source and origin ; and
I do not hesitate to say that much of the confusion and contradiction of
opinion upon this subject has been due to the fact that observers have
confined themselves to investigating symptoms, which, though generally
constant, may yet be poorly marked or even wanting, and which often
require practised eyes and fingers for their recognition.
Now I maintain that this clinical proof adduced by Bassereau has
never been shaken, for, although local ulcers have been produced by the
inoculation of matter from syphilitic Sores, yet this is susceptible of, and
indeed requires, as we shall see hereafter, another explanation than an
identity of poisons, and, on the other hand, there has never been a single
authentic case in which syphilis has been produced by the inoculation of chan-
croidal matter from a person who has had only a chameroid and not syphilis.
Bassereau does not appear to have speculated on the cause of the dif-
ference in venereal ulcers. I do not find in his work the words “Unity
or Duality of Syphilis,” nor any expression of opinion as to the existence
of a specific virus for the local sore. He simply says that he is obliged
to recognize a different cause (une cause différente) for the local and con-
stitutional diseases.
710 BU M STE A D,
A school of dualists, however, soon sprang up, who departed from the
simple faith of their founder in attaching undue importance to the
characteristics of the sores themselves, and who claimed for the local
sore a distinct, special virus of its own.
One of the tenets of this school was that the secretion of syphilitic
lesions could not be inoculated with success either upon the person
bearing them or upon any other person affected with syphilis, and this
tenet, in the theory of dualism, was looked upon as vital.
It was not long, however, before it was successfully attacked and
Overthrown. Clerc, of Paris, Melchior Robert, of Marseilles, and others,
succeeded in inoculating the secretion of syphilitic sores upon the bearers,
with the result of producing ulcers, without incubation, bearing all the
characteristics of the chancroid, and inoculable in successive generations.
Mr. Henry Lee, of London, and Köbner and Pick, in Germany, also found
that a true chancre would become auto-inoculable, if it was irritated by
the application to its surface of powdered savine, or by having a seton
passed through its base, so as to render its secretion decidedly purulent.
Again, Boeck and Bidenkap, in Christiania, in their later attempts at
syphilization, took matter exclusively from true chancres, and obtained
the same result as when they had inoculated chancroidal pus. In five
cases reported by Bidenkap and Gjör, of Christiania, matter was taken
from ulcers obtained in the above manner, and inoculated by patients free
from syphilis upon themselves, and in only one instance did any general
symptoms ascribable to syphilis follow, and these were of a doubtful
character.
Gentlemen, the import of these successful auto-inoculations of syphi-
litic lesions as regards the question before us, deserves our serious consi-
deration. Let us inquire what they apparently proved, and what they
actually did prove. They apparently proved the identity of the syphi-
litic poison with that of the local sore. By their means, it was supposed
that the doctrine of duality was demolished, and the advocates of unity
were triumphant. Whether this conclusion was not too hasty, we shall
presently take occasion to inquire. But these experiments actually did
prove the absence of any distinct specific virus in the chancroid, incapable
of generation de novo; for here were chancroids artificially produced in-
dependently of any descent from chancroids.
You are well aware of the defence adopted by the dualistic school—
the mixed chancre, a sore combining both the syphilitic and chancroidal
specific poisons—which, it was asserted, would satisfactorily explain all
these cases and still leave the tenets of dualism, as at that time under-
stood, intact. This explanation was for a while regarded as satisfactory,
but it could no longer be upheld when such experiments had been
multiplied indefinitely ; when their number was so great that the chances
of the commingling of two kinds of specific virus and their simultaneous
inoculation was reduced to a homoeopathic absurdity; when an indu-
'ated syphilitic primary lesion could be taken at random, and, after due
irritation, its secretion could be successfully inoculated with the effect
of producing pustules and ulcers bearing every characteristic of the
chancroid ; and when the same result could even be obtained at will by
the inoculation of the Secretion from a purely secondary lesion, as, for
instance, a syphilitic mucous patch! If the chancroid was dependent
upon a distinct specific virus, its presence in all these cases was simply
impossible, and yet not a single shade of difference could be pointed out
between the result produced and that from the most emblematic chan-
U N ITY O R D U A LITY OF W E N E R E A L S O RE S. 711
croid ever met with in practice. Dualism was indeed henceforth demo-
lished, if by “dualism” be meant that each of the two kinds of venereal
Sore has a distinct, specific virus of its own. In the face of the experi-
ments referred to, I cannot believe it possible to defend in future any
such doctrine of duality.
But the last word had not been spoken in favor of a distinct origin of
the chancroid from that of syphilis, nor the last experiment made and
recorded which would decide the question before us to-day. Let us ex-
amine more carefully those experiments I have just referred to. What
was the matter so successfully inoculated 2 The pure, unmixed virus of
syphilis : By no means. It was a compound product, taken, to be sure,
from a syphilitic lesion, but a lesion irritated commonly to suppuration
by artificial means; containing possibly the germ of syphilis, but con-
taining also, and in fact chiefly composed of, pus. Which of these two
factors was responsible for the effect produced ; The syphilitic virus :
In that case this virus should have preserved its power of infecting the
constitution, and matter taken from these ulcers, and inoculated upon
healthy individuals, should invariably have produced syphilis, which has
been shown not to be true. Moreover, if it could be proved that pus
alone, free from all suspicion of syphilitic mixture, was capable of pro-
ducing the same result, then pus was the guilty factor, and there was no
such transformation as supposed by the unitists. Such proof we now
have as will be seen from the following cases:—
In 1865, Prof. Pick, at the suggestion of Prof. Zeissl, inoculated sim-
ple, non-venereal matter of inflammatory origin upon syphilitic subjects.
Taking the secretion from pemphigus, acne, seabies, and lupus, he inocu-
lated it upon persons affected with syphilis and produced pustules, not
preceded by incubation, and the matter of which was further inoculable
through several generations. Counter-inoculations upon the persons free
from syphilis who were the bearers of these affections, were without
effect. The same result was attained by Kraus and Reder with the pus
of seabies, and by Henry Lee with pus from a non-syphilitic child. The
late Mr. Morgan, of Dublin, also succeeded in producing pustules and
ulcers, identical in appearance with the chancroid and capable of re-
inoculation through a number of generations, by inoculating syphilitic
women with their vaginal secretions.
It would thus appear that the skin of syphilitic individuals possesses
a marked vulnerability, a peculiar aptitude to become inflamed when
acted upon by irritants; but this is nothing more than is seen in other
non-syphilitic subjects, whose vital powers are impaired by any cause
whatever. For instance, it is well known that among medical students
engaged in the dissecting-room, it is those who are run down by hard
study and overwork, who are most likely to become inoculated by fluids
from the dead body. Again, the idea which was entertained by some
that there must be a syphilitic soil for such inoculations to succeed upon,
is disproved by other experiments which I have to relate.
The earliest of these experiments, as far as I am aware, have never
been published, and were performed in the winter of 1867–8 by Dr. Ed-
ward Wigglesworth, Jr., of Boston, upon himself, while pursuing his
studies at Vienna. He has kindly furnished me with the following
history : After stating the grounds which led him to the conclusion—
original, it appears, with himself—that “pus pure and simple might be
*— —”
the cause of the chancroid,” Dr. W. Says:—
712 BU MSTEAD,
“I would state that I was free from all disease either hereditary or ac-
quired; that I had never had a sore of any kind or any local or constitutional
lesion of the skin or mucous membranes, and that I was merely a little run
down from overwork in the hospital. I took from an acne pustule upon myself,
pus, which I inoculated upon myself in three places on the anterior radial aspect
of my left forearm at the junction of the middle and upper thirds, first pricking
open the apertures of hair follicles and then rubbing the pus into them. The
result in the course of three or four days was three well-marked pustules. From
each of these I inoculated one new spot upon the same arm nearer the wrist.
The result was three new well-marked pustules. From each of the three of the
second series I again inoculated fresh spots still nearer the wrist, and again the
result was positive. The second series was hardly as well-marked as the first,
and the third series was slightly inferior in vigor to the second ; still all were
well marked, the nine sores being at the same time present upon my arm. On
removal of the crusts, perceptible ulceration of the skin was found to exist.
Zeissl, with whom I was studying at the time (1867–8), happened to be lecturing
upon dualism, and requested me to show my arm to the class to prove the
production of ulceration from properly inoculated, simple, healthy pus. There
were no buboes in my case, nor did the ulcerations require other treatment
than exclusion from the air by means of a simple dressing, and cleanliness.
The scars remain to the present day. I thus convinced myself and others—
“I. That the products of inflammatory action, if properly introduced into
the human integument, may cause local ulcers, closely resembling chancroids
and re-inoculable in generations.
“II. That this pus need not come from a syphilitic person or be inoculated
upon a syphilitic person. If taken from, or inoculated upon, a person debili-
tated by any disease as syphilis, the effect would doubtless be the same though
probably greater in intensity.”
Many years subsequent to these experiments of Dr. Wigglesworth,
which ought to have been made public at a much earlier date, Kaposi" pub-
lished the following statement: “My own experiments have taught me
that non-specific pus, such as that from acne and scabies-pustules, when
inoculated upon the bearers as well as upon other non-syphilitic persons,
will produce pustules whose pus proves to be continuously inoculable in
generations; that from these pustules losses of substance occur, which
heal with the formation of scar-tissue; and that as the number of pus-
tules produced increases, the inoculability of the pus derived from them
diminishes and finally ceases altogether.” •
It is not necessary for me to dwell upon the exact correspondence of
the result of such inoculations and that obtained by the inoculation of
so-called chancroidal matter.
The idea that the products of inflammation are the source from which
the chancroid springs, and that the simultaneous inoculation of these
products and of the germs of syphilis will account for the varying
degrees of ulcerative and other phenomena met with in varieties of
venereal sores, will strike many of you as novel, and it is easy to foresee
the objections which will naturally arise. It will be asked: Can it be
possible that the pus from acne, ecthyma, or scabies can give rise to a
sore equal in duration and severity to that produced by matter from a
typical chancroid 2 Comparative inoculations upon the same individual
with these two agents may even be adduced to show that this is not the
case. In replying to such objections, it must be frankly admitted that
we do not as yet fully understand all the laws governing the inoculation
' Die Syphilis der Haut, etc., p. 47.
UNITY OR D U A. LITY OF W E N E R E A L S O RE S. 713
of septic matter. We cannot, for instance, fully explain why one indi-
vidual should be more susceptible than another, why different parts of
the integument, as that of the chest, the arms and the thighs, should
develop ulcers so varying in their destructive tendency as is shown in
the practice of syphilization; why the secretion from purulent urethritis
and purulent conjunctivitis should be interchangeable, and yet have no
effect upon the mucous membranes of the mouth, nose, or ear; why a
chancroid of the prepuce should inoculate other points of that membrane,
and yet commonly spare the glans penis; or why one upon the os uteri
should allow the walls of the vagina in contact with it to escape; and so
with other instances that might be brought forward.
That the effect produced is to a great extent proportionate to the
ulcerative action of the source from which the matter is taken, is evi-
dent to any one who has performed auto-inoculation from indurated chan-
cres. If the chancre consist of a simple erosion with a watery secretion,
seated upon an indurated base, the first two or three, or even more,
attempts at auto-inoculation will probably fail; but as the surface of the
sore becomes irritated to suppuration by repeated pricks of the lancet,
these attempts will succeed, first in producing minute pustules and ulcers,
but subsequently, as the suppuration increases, others larger and better
developed. Taking these facts into consideration, it need not be
wondered at if comparative inoculations upon the same individual
with matter from a simple skin affection and from a chancroid of the
genitals, should show greater severity in the latter. But without enter-
ing further into this subject, I claim it to be sufficient to have shown
that the inoculation of the products of inflammation will produce an
effect identical in kind, even if not in degree, with that of matter from
the most typical chancroid; and this is my reply to the objections I
have named.
I have now, gentlemen, called your attention to the evidence drawn
from artificial inoculation in favor of a duality in the poison of venereal
sores, some of them being derived from the virus of syphilis, while others
are due to the products of simple inflammation. This view, which I
believe to be most consistent with our present knowledge of pathology,
and to be supported both by experience and scientific investigation, has
of late years found its advocates among medical men.
Thus Bäumler, in his recent able work on syphilis, after quoting ex-
perimental inoculations like those just given, says:–“The necessary con-
clusion is, that the poison of the soft chamere may, under certain circum-
stances, be produced de movo without the intervention of the syphilitic virus,
while the syphilitic poison propagates itself only in one continuous
series. Hence the chancroidal poison, or whatever in these experiments
produced the pustules resembling chancroids, cannot even be compared
with the syphilitic poison, to say nothing of regarding them as identi-
cal.”
In the recent and well-known debate upon syphilis before the Patho-
logical Society of London, that accomplished surgeon, Mr. Hutchinson,
came within one short step of the truth when he admitted the origin of
the local venereal sore to be “the products of syphilitic inflammation, but
not usually containing the germs of syphilis.” If he had omitted the
adjective, “syphilitic,” before the word “inflammation,” his expression
would have been consistent with the facts at present in our possession,
and he would have found it inconsistent with such facts to proclaim
71.4 BU M STE A D,
dualism as dead, since, as I have already shown, dualism is nothing
more than a duality of poisons in the evolution of venereal sores.
If the view which I advocate be the correct one, it suggests an inter-
esting analogy with the history of our belief as regards the nature of
gonorrhoea, an affection which in the last century was regarded as due
to the syphilitic virus. Ricord finally adduced convincing proof that
it had nothing to do with syphilis. It was afterwards supposed to
depend upon a virus of its own, the gomorrheal virus. We now know
that it may be caused by any simple irritant, but more especially by
the pus from the urethral and other inflamed mucous membranes,
whether originating or not in contagion. Such as the history of gonor-
rhoea has been, so, I predict, the history of the chancroid will be.
In the preceding remarks, I have only casually alluded to the evidence
in favor of a duality of poisons to be found in the symptoms presented
by venereal sores themselves, and by the lymphatic ganglia in anatomical
relation with them. The value of this evidence must always depend
upon the observer's knowledge, skill, and experience in venereal diseases.
How often do we witness the grossest errors in the diagnosis of venereal
ulcers made by men who are deservedly eminent in general practice :
Moreover, instances not unfrequently occur in which the symptoms are
ill-defined, and in which the most experienced will wait for further
developments before expressing an opinion. Hence, so long as the symp-
toms of the sores themselves were alone considered, the question of unity
or duality remained undecided. And yet, to my own mind, the evidence
founded on these symptoms is not to be despised, for in the great majority
of cases they are sufficient to enable us to distinguish the syphilitic from
the local sore, and the obscurity of some cases is readily explicable on
the ground of the simultaneous inoculation of the products of inflamma-
tion and the germs of syphilis, and the well-known immediate action of
the one and the incubation of the other.
One word as to the form of the question with which we started out.
It may appear to some that as the products of inflammation are various,
the question should read thus: “The virus of venereal sores, its unity
or plurality ?” T3ut this is a matter of small moment. If any one
prefers the latter reading, I have no doubt it will be accepted as an
amendment. The actual point at issue is whether the syphilitic virus
is, or is not, responsible for all the venereal ulcers met with in practice,
and this is sufficiently implied in the question as originally worded.
Gentlemen, I will not longer detain you. I must apologize for the
incompleteness and brevity of my remarks, necessitated, however, by
the short time at our disposal.
The conclusion which I have to offer you, is based, as I have endea-
vored to show,
(1) Upon clinical experience, more especially in the confrontation of
persons affected with venereal sores.
(2) Upon artificial inoculation. -
(3) Upon the corroborative evidence presented by the symptoms of
the sores themselves.
B'or convenience of discussion I shall divide my conclusion into the
following propositions:—
I. The virus of venereal sores is dual.
II. Some venereal sores are due to the inoculation of the syphilitic
Vl I'll S. -
U NITY O R D U A LITY OF W E N E RE AL SO R. E. S. 715
III. Other venereal sores are due to the inoculation of the products
of simple inflammation.
IV. These two poisons may be inoculated simultaneously.
DISCUSSION ON DR. BUMSTEAD's PAPER.
After the reading of the preceding paper, Dr. R. W. TAYLOR, of New York,
Said :—The Section is to be congratulated upon having presented to it such
an exceptionally perfect paper as that read by Dr. Bumstead ; it is certainly
the best exposition of the subject which I have ever listened to or read in any
language. And I am glad to be able to say that my experience coincides with
the observations of the distinguished writer. As bearing upon the distinction
between the virulence of the pus of a chancroid and that of an initial syphilitic
sore, I may refer to a case observed by myself of a man who in the first year
of syphilis contracted gonorrhoea, and, having a long, tight prepuce, suffered
from herpetic vesicles, which assumed the character of chancroids; buboes
formed in the groins, and the pus from these ran down the thighs and pro-
duced pustules, which were healed with great difficulty. The man's wife was
not then, nor is she at the present time, syphilitic, but she too suffered from
chancroids. Another case was that of a newsboy whom I saw at a dispensary
in New York; the boy was not in any degree syphilitic, and was believed to
have been up to that time virtuous, but was suffering from a bad sore upon
his leg; the pus ran down and produced ulcers similar to chancroids; this
boy by sexual intercourse subsequently contracted syphilis.
Dr. E. L. KEYES, of New York, said:—Dr. Bumstead's third proposition
presents the true question at issue. No doubt pus from simple inflammations
may produce ulcers upon persons in a condition to be easily impressed, but
such ulcers are not identical with chancroids. Pus is, of course, irritating,
and different kinds of pus have different effects; but I do not think it proved,
that simple pus applied to a healthy person will produce anything identical
with chancroid. The paper just read does not describe the ulcers said to have
been produced by simple pus, and I do not think that it has been shown that
they were typical chancroids. Urethritis is quite common among married
persons, and so are excoriations among persons with tight prepuces ; some
persons even cannot have sexual intercourse without producing herpetic
vesicles, but the resulting ulcers are not chancroidal. To say that ulcers from
simple pus are identical with chancroids, is going too far. If that were the
case, every one would be in imminent peril of becoming sooner or later a
victim to this affection. In a majority of cases, the pus of acne will not pro-
duce upon a healthy person an ulcer identical with chancroid.
Dr. BUMSTEAD said:—The time allowed for the reading of my paper excluded
a description of the sores mentioned in it; and I thought it sufficient to state
that Kaposi had been unable to discover any difference between chancroids
and the sores thus produced. I have said in the paper that the more healthy
the person, the less liable will he be to the evolution of the sores.
Dr. KEYES said:—I would ask Dr. Taylor when the chancroidal ulcers ap-
peared in the case which he has described ”
Dr. TAYLOR said:—I took very full notes of the case, but have them not
with me ; I can say, however, that the herpetic vesicles appeared about the
tenth day after exposure, and that they assumed the chancroidal appearance
about the twelfth or thirteenth day.
Dr. D. R. PoETER, of Kansas City, said:—I am a believer in dualism, but I
cannot believe that a chancroid can be produced from an inflammation not
chancroidal; nor do I see how it is possible for herpetic vesicles to turn to
chancroidal ulcers. I believe that chancroids are different from syphilis, and
that chancroids are always developed before the tenth day.
716 BUMSTEAD, UNITY, OR DUALITY OF VENE REAL SOR Es.
Dr. BUMSTEAD said:—Chancroids are always developed before the tenth
day, and the only way in which the development can be deferred is for the
virus to lie upon the surface some days without being taken into the tissues.
Dr. TAYLOR said:—There was no possibility of that in the case which I have
mentioned, for the patient washed the penis in warm water frequently, and the
continual wiping of the gonorrhoeal discharge would have been sufficient to
remove the virus from the surface.
Dr. KEYES said:—It is impossible for me to believe that a chancroid could
appear as late as eleven days after exposure.
Dr. L. D. BULKLEY, of New York, said:—I do not believe that the weight
of evidence sustains the proposition, and I believe that the chancroid has no
connection with syphilis.
Dr. CHARLES HEITZMANN, of New York, said:—There are some persons
very liable to pustules, and upon whom small lesions will produce them.
During many years that was my own condition. I have witnessed many
experiments in Vienna, but have seen no evidence of the analogy between the
sore produced by simple pus and chancroid.
On motion, the propositions appended to Dr. Bumstead's paper were adopted
as expressing the opinion of the Section, with the exception of the third, for
which, on motion of Dr. Bulkley, the following was substituted :–“Science
has demonstrated that suppurative inflammatory lesions, which resemble in
certain features what we know as chancroids, may be produced on various
parts of the body by inoculation with simple pus from various lesions.”
.”
717
LEPROSY AS OBSERVED IN THE SANDWICH ISLANDS.
BY
FRANK H. ENDERS, M.D.,
GOVERNMENT PHYSICIA.N.
[CoMMUNICATED BY THE SECRETARY.]
THE history of leprosy as it exists on these Islands is yet very obscure.
Its advent or origin cannot be traced with any degree of satisfaction.
Among the present generation it is known as mai-pake (Chinese sick-
ness), they contending that the first case ever known here was in a
Chinaman. The older class of natives formerly knew it under the name
of mai-alii (sickness of chiefs), and describe the disease as it existed then,
precisely as we find it here at the present time. Some of the older
foreigners, who have resided here for many years, and before the impor-
tation of the Chinese, recognize the present disease, or one closely resem-
bling it, as having existed here as far back as the year 1830. If this
be true, it is certain not to have been brought here by the Chinese.
The question of importance yet to be solved is, whether it is a disease
sui generis, or a form of syphilis peculiar to the climate and dependent,
to at least some extent, upon the habits and diet of the people.
It is no easy matter to arrive at a positive conclusion, for there is
reasonably strong evidence advanced for the support of both theories.
Since my residence upon the Islands, I have examined over four hundred
cases of the so-called leprosy, and I am as yet unable to determine which
of the two positions is the more tenable, or which view rests upon the
stronger evidence. One great trouble or difficulty rests in the fact that
almost every native either has, or has had, syphilis, acquired or inherited.
Of the large number examined, I have found but two in whom there
could be any doubt as to the pre-existence of syphilis, and in these two
exceptions close relationship could be traced to persons having leprosy.
Two forms or varieties of the disease are observed, viz.:-the anaes-
thetic and the tubercular. At the present writing, there is sitting in
my office a native woman about twenty years of age, married and hav-
ing two children, one six and the other three years old. She is of
medium height, weighs 146 pounds, and, to a casual observer, is a
picture of health. Scrutinizing her more closely, we detect two brown-
ish spots, one upon either cheek, which, to an experienced eye, tell
only too plainly the terrible fate that awaits her. Her left arm hangs
cold and lifeless at her side; this condition, she says, began about one
year ago, with a numbness in her fingers, which lasted for a few weeks,
since which time there has been an entire loss of sensation from the
elbow downwards. In her case there is not only cutaneous anaesthesia,
but a needle can be thrust through the skin, superficial fascia, sheath,
and muscle itself, without giving rise to the least pain. The extensor
and flexor muscles are relaxed, and can only be slightly contracted or
extended. The ligaments are very elastic, permitting the fingers to be
laid quite back upon the dorsum of the hand. The skin of the affected
718 ENDERs,
arm is dry, harsh, and flabby, all of the fatty matter has disappeared, and
the muscles are also atrophied. There is slight anaesthesia along the
course of the gastrocnemius muscle of the left leg. This patient has
had syphilis. There is no indication as yet of the existence of the dis-
ease in her children. She disavows having been associated in any way
with a leper.
In the tubercular form of the disease, the earliest indications observed
of its approach are tubercles upon the base of the tongue, falling off of
the eyebrows, and a thick, corrugated state of the skin upon the forehead
and cheeks. The ears become thickened, the helix being enlarged and
the lobe at times as large as a hen's egg. Ectropion is often found in the
incipient stages. Frequently the existence of these early indications
after a few weeks or months is followed by ulceration. The fingers and
toes drop off, this condition being accompanied by great distortion. In
some cases the bones of the fingers and toes become absorbed, except
small portions of the metacarpal and metatarsal bones, upon which the
nails remain intact. There is more or less insensibility of the skin, but
not so marked as in the other form of the disease. When ulceration of
the nasal mucous membrane takes place, the sense of smell is lost, the
vomer is absorbed, and considerable deformity of the nose results.
The present superintendent of the leper asylum, W. P. Ragsdale, a
half white whose father was a Virginian, is a very sensible, educated
man. He says that the first indication of leprosy apparent in his case
was an ulcer on the bottom of his foot which could not be healed. He
supposed this to be the result of syphilis, and so believed until the contrac-
tion of the flexor muscles, and the thickening of the skin on his forehead
and cheeks, occurred, when he recognized himself to be a leper.
Another frequent accompaniment of this disease in its tubercular form
is keloid tumor; in fact, by some physicians this is considered as pathog-
nomonic of the disease. Cataract is often found in both forms of leprosy.
There can be little doubt that the two forms are varieties of one com-
mon morbid condition. I have seen but two cases of elephantiasis
Arabum (Barbadoes leg), one in a native, the other from the island of
Tahiti.
Leprosy does not appear to be more frequent in one sex than in the
other, but it is often the case in women that as long as the menstrual
function remains perfect, the disease seems to be kept in abeyance. The
least disturbance or irregularity of menstruation which occurs, causes a
rapid progress in the disease. Conditions of society seem to have little
effect, the disease attacking high and low of native race. The disease
is confined almost exclusively to the native population. I have observed
fifteen cases among Mongolians and four among Europeans, the latter
being males of the lower order, living entirely with the natives, eating
poi and salt fish, and sleeping in overcrowded filthy huts. Each of these
white men presented undeniable evidence of the pre-existence of syphilis.
The disease is not confined to any locality, or elevation, but where
prostitution is most rife, there the most cases will be found. I believe
the disease to be hereditary, and in illustration of this fact I will give
the following cases which are well substantiated:—
A native woman on this Island bore five children by a leprous husband;
the disease was developed in each of these children, between the ages of eight
and twelve years, and they were taken to the Leper Asylum where they have
since died. The husband died from the same disease. The woman afterwards
married a healthy man, and has now three children past the ages at which the
L E P R O S Y IN T H E S A N D WIC H IS LA. N. D.S. 719
disease occurred in the other set. They are stout, healthy youngsters, with
no indication of the disease in their systems. -
A few weeks since the police brought to me a leprous woman, the mother of
four children, the eldest eight years of age, the youngest two months. She
was far advanced in the disease, her body covered with foul ulcers, with loss
of phalanges of one hand, corrugated skin, and ectropion, and she was suck-
ling the infant, which, together with the two next older children, was appa-
rently in good health. The eldest, a boy, bore evident signs of the existence
of the disease, having tubercles upon his tongue, ectropion, a bronzed appear-
ance of the skin, with slight thickening. As a rule, leprous women are sterile,
but in this case we find the contrary, although she had had the disease,
according to her own statement, for thirteen years.
I am strongly inclined to the belief that leprosy is not a disease sui
generis but an offspring of syphilis, although from New Brunswick,
Bermuda, Jamaica, Dominica, Guiana, Cape of Good Hope, and some
other countries, come reports to the contrary. I am compelled to believe
as I do until stronger evidence is offered by these writers for the support
of their theory. Dr. Stephenson, from Barbadoes, says:—I will not say
that syphilis can produce true leprosy, but it is more common in the
offspring of syphilitic parents. Dr. Hende, in his report from Mag-
pore, in India, ascribes a portion of the cases to syphilis. Drs. Reed and
Pollard, from Guiana, deny any connection between leprosy and syphilis,
while Dr. Van IIolsh, from the same place, says, “I believe leprosy to
be connected with syphilis, yea, to be the offspring of it.” Dr Trousseau,
of Honolulu, says, “I believe that in syphilitic patients there is a pre-
disposition to leprosy.” Dr. McRobbin, a member of the Board of
Health in Honolulu, says, “I believe leprosy to be an offspring of
syphilis.” The two last-mentioned gentlemen have had large experience
in this disease, and so strong is their belief in its relationship to syphilis
that they have stated that the eradication of syphilis from these Tshands,
would eventually cause the disappearance of leprosy, or, according to
the number of cases of syphilis allowed to run its course, through its
different stages, in such proportion will exist the number of cases of
leprosy. Here again, on account of the widespread existence of syphilis,
it is impossible to ascertain the extent of the contagiousness of leprosy,
if it be contagious.
In the general acceptation of the word, by indirect contact, none of the
medical men on these Islands believe it to be so ; as to direct contact,
there seems to be some doubt. The woman already referred to, who
bore five children by the leprous husband, still lives, and bears no signs.
or symptoms of the disease. . The wife of the present superintendent of
the lepers has had three leprous husbands, and now lives, and has lived
for many years, at the asylum, and yet bears no evidence of the disease.
Père Damien, a Prussian priest, and a most excellent man, has devoted
his life, during the last few years, to the welfare of these people, living
the same secluded life, ministering to them in sickness and in health,
working with and associating with them ; yet the blighting curse has
passed him by, and left him as yet unscathed.
Many cases might be noted to sustain the view of the non-contagious-
ness of the disease, yet I am strongly inclined to the belief that it is
oftentimes conveyed by direct contact, through sexual intercourse or
inoculation in other ways; several instances have been known, on these
Islands, of women who have married second and third husbands, after
the death of the first from leprosy, their later husbands sharing the same
720 EN DE RS,
fate as the first. Whole families, and those intimately connected or as-
Sociated with them, have thus become diseased.
The natives seem to have no fear of the foul pestilence, and can often
be found huddled together, men, women, and children, sick and well,
under the same covering; smoking the same pipe which comes poisoned
from the secretions of the leper's mouth ; eating from the same calabash,
when the hands and fingers are covered with ulcers. Dr. Manget, writ-
ing from Guiana, says: “I have met with only two cases in which, after
minute inquiry, I believed the disease to have been communicated by
direct contact.” Dr. Regnaud, of the Island of Mauritius, says: “I
have met with two instances in which the disease seemed to have been
transmissible, in one instance from the husband to his wife, and in the
other from a man to a child of his wife by a former husband.” Drs.
Pollard and Van Holsh, of T)utch Guiana, assert positively that it is
contagious. From Ceylon, Bombay, Madras, Bengal, Calcutta, Mag-
pore, and Benares, comes the report that it is not contagious.
A few years since, when smallpox was epidemic upon these Islands,
vaccination became promiscuous. Shortly afterwards, leprosy was largely
on the increase, and by many it was ascribed to this cause. The then
Minister of the Interior (a graduate of medicine, too), appointed laymen
to travel over the country and “vaccinate everybody.” The subjects from
whom the virus was taken were natives; it was transferred from arm
to arm ; and if leprosy is contagious, as this gentleman himself asserted
in reports to the Legislature in 1872, the people of this country can, to a
great extent, lay at his door the cause of the increase. In 1870, a law,
similar to the “social evil law,” in St. Louis, was enacted here by the
Legislature, and put in full force ; Dr. McRobbin, upon whom devolved
the duties of Medical Officer, with his usual zeal and earnestness, went
to work and accomplished much good ; but this law was doomed to the
same fate as that in St. Louis, and was repealed in 1872, the same idea
of “licensing prostitution,” as it was termed, prevailing here as there.
"That much good resulted, no one unbiassed by prejudice can fail to see,
and had the law continued in full force to the present time, its effects
would have been plainly visible, without the necessity for statistics to
tell us of the good accomplished.
The Leper Segregation, or Asylum, is located upon the Island of
Molokai, where all lepers are confined. The asylum comprises about
eight square miles. It is a low plain surrounded on three sides by the
ocean, which expends its mighty force upon this land, unbroken by reef
or shallow water. It is with great difficulty that a landing can be ac-
complished, and then only by the aid of experienced natives. Upon the
remaining side rises the lofty pali or precipice of Kalanpapa, 2000 feet
high. In the side of this pali is cut a narrow path by which the asylum
proper is reached. It is a serious undertaking, to go down and return,
as it must be done on foot, and a false step might land one more quickly
at the bottom than would be agreeable. Having accomplished the de-
scent in a quiet way, we find ourselves upon the flat or landing place,
where there are a number of native huts, occupied by lepers; here we
mount our horses and ride to the superintendent's house, about one and
a half miles away. From this place we have a splendid view of the
ocean, the pali, and the asylum. It is a grandly beautiful sight; one
well worth the fatigue and dangers of the trip. The asylum is com-
posed of 200 houses, in which live the lepers, alone, or with their fami-
lies and friends. Directly in front of us is the hospital, built of wood,
L E P R O S Y IN T H E S A N D WIC H IS LA. N. D.S. 721
and in a quadrangular form ; in this building are to be found the more
advanced cases of those not able to care for themselves ; nurses are fur-
mished, and they are well cared and provided for. There are 696 inmates
in the whole segregation; their houses are clean and neatly kept ; food,
both in quantity and quality, all that they can wish. The establishment
is well regulated and governed ; it is controlled by the Board of Health,
and its present condition is greatly due to the energy and zeal of the
Hon. S. G. Wilder, President of the Board. The number of cases of
leprosy now at large upon the Island is very small, and the disease is
evidently upon the decrease; and this decrease is, in my opinion, due to
the improvement in the number of cases of syphilis, brought about by
the Government and Board of Health, which furnish all natives with
medical attendance and medicines free of charge, and in this way induce
them to leave their old superstitious and harmful methods of treatment
by Kolumas, or native doctors. Since 1866, no less than 1570 lepers
have been received into the asylum, while 872 have died, leaving, at the
present writing, 698 inmates.
In an affection so grave, we can but feel how limited is our knowledge,
and how far beyond the resources of our art is this blighting curse.
Still, we may be able to do something, not to relieve pain—for the suf-
ferers usually pass through the several stages of the disease with but
little pain and suffering—but to stay the progress of the malady, and to
afford relief in intercurrent affections to which the debilitated condition
of the patients renders them peculiarly liable; as, for instance, pneumo-
nia, hepatitis, erysipelas phlegmonodes, conjunctivitis, etc.
The remedies which I have found most valuable in the incipient
stages of leprosy, are more particularly the protiodide of mercury, given
in doses of one grain daily, with half a grain of opium, and pushed to
slight ptyalism ; afterwards the liquor potassii arsenitis, twenty drops
daily, continued for some days, when, if circumstances are favorable, the
corrugations of the skin disappear, the eyes assume a better color, and
a vast improvement in the general appearance of the patient is observed.
This improvement may continue for weeks or months, when suddenly,
without any apparent cause except perhaps inclemency of weather, the
disease returns, and in all probability in an exaggerated form. In the
more debilitated cases, the tinctura ferri chloridi is given with benefit.
Drs. Donaldson and Boeck have found the internal use of mercury inju-
rious in leprosy, but, given as before stated, I have found no evil results
to follow ; on the contrary, at least a partial control of the rapid pro-
gress of the disease has attended this treatment in my hands.
As an external remedy, I make use of the ointment of the iodide of
sulphur, applied after washing thoroughly with warm water and carbolic
soap. In some cases, the itching of the entire surface of the body is very
severe, so severe, indeed, that the sufferers will, in their agony, tear out
pieces of flesh with their nails; in this condition, I find the best applica-
tion to be carbolic acid in the form of ointment, one part to four, which
generally gives relief.
DISCUSSION ON DR. ENDERs's PAPER.
After the reading of the preceding paper, Dr. L. A. DUHRING, of Philadel-
phia, said:—The paper is one of great interest, as it presents the question of a
relation between leprosy and syphilis, which has never yet been satisfactorily
46
722 ENDERS, LE PROSY IN THE SAND WICH ISLANDS.
answered. My own opinion is that there is no relation between the two dis-
eases. There is much division on the subject among those who reside in
countries where leprosy prevails. From the remarks in the paper, and from
my own observation, I would say that syphilis exists to a large extent in
the Sandwich Islands, and that many cases there classed as leprosy are com-
plications of the two.
The President, Dr. J. C. WHITE, of Boston, said:—The facts presented in the
paper are interesting, and many of them are novel to me. I know that syphi.
lis has for many years found a stronghold in the Sandwich Islands, and that
leprosy, recently introduced there, has spread most rapidly. The suggestion
of Dr. Enders concerning vaccination is valuable, as bearing upon the ques-
tion of contagion in leprosy.
723
ON THE TREATMENT OF SEBORRH(EA.
BY
C. HEITZMANN, M.D.,
OF NEW YORK CITY.
SEBORRHOEA, in the definition of Hebra, “ consists in a morbid secretion
of epidermis, which is impregnated with sebum, and either forms a greasy
coating or accumulates in scale-like masses upon a part of the skin which
is, in other respects, healthy.” This disease, so very common on the
scalp, where it bears the popular name of “dandruff,” and on the face,
especially on the nose, is, as dermatologists know, a very obstinate one,
and difficult to cure. It is easy to remove the accumulated, fatty, epi-
dermic masses, by rich applications of fat, by repeated washing with
water and soap, and by repeated shower-baths; but a real and permanent
cure can rarely be obtained by these means, even in those cases which
are in intimate connection with diseases of the womb, or with a general
trouble known as chlorosis, after the removal of such a primary or gene-
ral disease. A short time after the treatment, the fatty scales return,
the sebaceous masses gather again on the scalp and on the nose, and the
disease runs its course, leading, after many years’ standing, to atrophy of
the sebaceous glands and the root-sheaths of the hairs, and at last to
complete baldness. The latter result is very common with seborrhoea of
the scalp, and was known to Hippocrates. Besides, the skin affected by
seborrhoea is very liable to eczematous eruptions, especially when continu-
ously scratched on account of an itching sensation commonly produced
by an increased perspiration in summer time, or after excitement of the
organism. If the disease be present on the face, repeated applications of
irritating agencies, especially of the alcoholic solution of green soap, as
recommended by some dermatologists, almost inevitably lead to a chronic
dermatitis with induration and stiffness of the skin, a condition which
gives a singular aspect to persons who have suffered a long time from
seborrhoea of the face. If the disease be established on the nose, the
chronic inflammation very often leads to enlargement of the bloodvessels,
and the disease known as acne rosacea. Persons who have suffered in
their youth from seborrhoea of this part, by and by acquire an enlarged,
red nose, and in my experience are very liable to deforming eruptions of
acne rosacea, the more, of course, if alcoholic drinks be taken, even in
moderate quantities.
In the beginning of 1875, I was accidentally led to the local applica-
tion of a remedy, which, as far as I can say after a relatively short
experience, is capable of removing the disease radically. This remedy is
tar. In a case of chronic squamous eczema of the scalp, apparently the
result of seborrhoea, and complicated with a highly advanced baldness of
the part, I applied the tar tincture, and not only cured the eczema but
produced a new growth of hair, leading to a complete restoration of the
| On Diseases of the Skin, by Ferd. Hebra, M.D.; Edition of the New Sydenham Society
of London, vol. i., 1866, page 104.
7 24 HEITZ MANN,
normal state. After a treatment of about two months’ duration, the
patient was cured, and remains cured and full-haired up to the present
tlme.
The tar has been applied in seborrhoea of the scalp by Hebra, but only
with the intention of removing the almost intolerable itching sensation
by which the disease is sometimes accompanied. Furthermore, it has
been applied in the form of tar ointment by Piffard, of New York, but
only for a couple of weeks, alternately with different other remedies.
Among the varieties of tar, I give the preference to the oleum rusci cru-
dum, a product of dry distillation of the white birch. It is preferable to
other kinds, as the oil of cade and the oleum fagi, on account of its rela-
tively less offensive smell, this resembling the smell of Russia leather.
Genuine ol. rusci is very slightly soluble in fatty oil, but readily soluble
in alcohol. In private practice it is almost impossible to apply a fatty
oil, as, for instance, the linseed or almond oil, impregnated with ol. rusci
to the highest possible degree, because the smell of such a preparation is
too strong, and to many persons intolerable. The alcoholic solution of
ol. rusci, the so-called tar tincture, again, is rejected by most of the
patients, because it blackens the scalp and renders the patient incapable
of transacting business with other persons. The form which I have
chosen, after different experiments, is that of a pomatum, in which the
smell of the oleum rusci is killed by ol. rosae, the only fragrant oil capa-
ble of covering the smell of tar to a satisfactory degree.
The formula which I have employed since March, 1875, is the follow-
Ing:—
B. Olei rusci crudi, 3ss;
Ung, aquae rosae, 3iv ;
Olei rosae, gtt. X—xx.—M.
The quantity of rose oil to be added depends somewhat on the wealth
of the patient, as it is a very expensive substance. In summer time we
may unite melted wax or paraffin with equal parts of cold cream, in order
to make the pomatum more consistent. The greatest care should be
taken, on the part of the druggist, to mix the preparations named,
exactly, and for a long time, inasmuch as the smell of tar is the less
noticeable, the more carefully the union has been effected by mechanical
means. Every evening, before going to bed, the patient rubs into his
Scalp, and not into his hair only, a quantity about the size of a small
walnut; after that he has to cover his head with a tight, flannel night-
cap, in order to press the ointment somewhat into the skin, and to avoid
Soiling the bed-linen. In summer time, as the wearing of a nightcap is
unpleasant, it may suffice to protect the pillow with a suitable cover.
Next morning the remains of the pomatum have to be taken off with a
dry linen cloth, and then the patient may apply some fragrant pomatum.
Twice a week he should take a cold shower-bath of moderate force, and
about two feet in height, and as often should simply wash the scalp with
water and Castile soap. Nothing further is necessary, and especially no
internal treatment whatever is required.
The way in which the tar pomatum acts, is that after fourteen days
the falling off of the hair is stopped; in fourteen days more the sebor-
rhoea is gone ; and again, fourteen days later, a distinct new growth of
hair can be observed. After at least six weeks’ treatment, the disease is
in many instances cured. Slight relapses may occur, and are readily
dealt with by repeated applications of the tar pomatum of much shorter
S E B O R. R. H. OE A. 725
duration. In two cases of highly advanced baldness, evidently produced
by former seborrhoea, and of several years’ standing, I succeeded in pro-
ducing a remarkable new growth of hair by the application of the above-
named pomatum for two or three months. In cases of seborrhoea of the
face, the continuous application of the tar pomatum, for six or eight
weeks, will cure the disease and remove the stiffness of the skin. In
cases of seborrhoea of the nose, besides greasing with the pomatum, re-
peated emptying of the enlarged sebaceous glands by mild Squeezing
with the finger-nails is enough to cure the disease even in chlorotic
girls. As my experience embraces only twenty-eight cases of seborrhoea,
though all were treated successfully in the manner described, I do not
consider the value of the remedy as being thoroughly established. I
bring the method before the profession in order to enable every physi-
cian to try such a simple treatment, and shall be glad to learn the results
obtained by others.
7
2
6
THE TREATMENT OF SYPHILIS,
WITH
SPECIAL REFERENCE TO THE CONSTITUTIONAL REMEI) IES APPRO-
PRIATE TO ITS VARIOUS STAGES, THE DURATION OF THEIR
USE, AND THE QUESTION OF THEIR CONTINUOUS OR
INTERMITTENT EMPLOYMENT. *
BY
EDWARD L. KEYES, M.D.,
PROFESSOR OF DERMATOLOGY IN THE BELLEVUE Hospit AL MEDICAL COLLEGE, NEW YORK.
I. DOEs a mild beginning in syphilis necessarily indicate that the
malady will run a mild course, so that the duration of treat-
ment may be regulated thereby ?
TT. Is the internal use of mercury debilitating 7
III. When is mercury useful in syphilis : Has it any control over
the late symptoms ?
IV. When is iodine useful in syphilis : Can it replace mercury in
any stage of the disease ?
V. Does iodine act by liberating mercury lying latent in the tissues :
VI. Should treatment be continuous or interrupted 7
VII. General outline of a course of internal treatment.
VIII. Conclusions, negative and positive.
I. Does a mild beginning in syphilis necessarily indicate that the malady
will run a mild course so that the duration of treatment may be regulated
thereby 2—My subject restricts me to the constitutional remedies appro-
priate to the different stages of syphilis, and I shall keep as closely within
the prescribed limits as the nature of the question will allow. It is
necessary, however, to answer this first proposition before taking up the
general consideration of constitutional treatment.
I need not cite authorities to prove that syphilis, commencing mildly,
is often looked upon as a trivial, self-limited disease. Such a belief pre-
vails in the minds of many physicians to-day. It has received the sanc-
tion of high authority. Diday, of Lyons, has taught it boldly for many
years, and Lancereaux in the main supports his views. Diday divides
syphilitic patients into two classes. Of these, one class, embracing about
two-thirds of the whole number, says Diday,” contains cases beginning
mildly. The prognosis in these cases is declared to be good ; the patients
are treated mainly by expectation ; and mercury is considered unneces.
sary and even harmful. Cases commencing severely, the other class,
get mercury; but, so the teaching goes, they only get it as an evil less
bad than the severe syphilis which it is used to counteract, and the
obvious conclusion is that the remedy must be employed during only a
| Histoire naturelle de la Syphilis; Paris, 1863.
* Diday et Doyon, Thérapeutique des Maladies vénériennes et des Maladies cutanées;
Paris, 1876, p. 254,
TREATMENT OF SYPHILIS. 727
short time to overcome the symptoms, and must not be continued to
the injury of the patient. Lancereaux' is particularly strong on this
point, and I think that a similar conviction is widespread among the
profession in this country, the general notion being that mercury is bad,
and only to be used because syphilis is worse. And even if this were
not so, and if the profession should become a unit in regarding any given
case of syphilis as liable to prove serious in the end, yet it would still be
impossible to subject all cases commencing lightly to prolonged treatment.
The ordinary patient can neither convince himself, nor be convinced—after
his first alarm is over, and his trivial early eruption past—that he is likely
to suffer severely from his disease at some indefinite, future period, and
in the conviction that he will not so suffer, his physician is very apt to
encourage him.
It is certainly true that most cases of syphilis commencing mildly
continue to preserve their mild type whether treated or not, and are not
so apt to lead to serious later troubles as where the earlier lesions are
bad, the chancre, perhaps, phagedenic, and the first eruption pustular.
It is natural that this should be so. Phagedaena is a personal peculiarity,
and not a syphilitic symptom, and it is fair to assume that the quality
of constitution which allows phagedaena to occur in a given chancre,
will also cause the symptoms which follow it to be proportionally severe.
It is the same with a tendency to form pus on light provocation, either
in the elimination of an internal poison, or from external cause ; this
pyogenic tendency is a personal matter and by no means a symptom of
syphilis, and where it shows itself in the early outbreaks of the disease
by a pustular or even by a vesicular eruption, it is only natural that the
course of the future symptoms should prove severe.
That these qualities of phagedaena, pustulation, etc., are personal, and
not due to the acquisition of any especially bad type of disease, I think
is easily demonstrable. I have seen more than once two patients whose
syphilis had been derived from the same source, run a widely different
course in their symptoms. The fact seems to me to be that an individual
shows himself up physically when he is prostrated by the first onset of
syphilis. A light beginning in the disease seems to indicate that the
patient has power to rally and make a good fight. The physician, there-
fore, lulls himself into a belief that the patient can manage his disease
without much aid from medicine, and, as the remedy, mercury, is regarded
as an evil, he concludes that the patient is best off with as little of it as
possible.
This reasoning would be unimpeachable were the premises accurate,
but they are not so. First, mercury is not an evil. It is not debilitating,
but tonic, in health as well as in disease, when continuously used in
minute doses. This I think can be proved, and, if so, it becomes obvious
that even if only a small percentage of the mild cases of syphilis become
severe after a lapse of years, it is justifiable to submit all cases to such a
continuous treatment as, itself tonic and beneficial to the patient, shall
prove capable of keeping down symptoms during its use and for a con-
siderable period afterward. Second, no one can tell how many cases
commencing mildly may become severe in the end. That very many do
' Traité de la Syphilis; Paris, 1874, p. 548. “Un certain nombre de spécialistes, etc.
se croient obligés d'administrer le mercure pendant plusieurs mois, quelquefois même
pendent des années; . . . . loin de sºopposer a la marche ultérieure de la maladie,
ils conduisent le malade à l'anémie ou a l'obésité.”
728 KEYES,
change in type is certain. The journals abound in such cases, and the
experience of those who are accustomed to deal with the disease is
always rich in incidents bearing on this point. I need not go beyond
my own note-book to illustrate this.
CASE I.'—A gentleman had chancre and a faint eruption for which he took
mercury in considerable doses during a few months. After ten years of
health, he had syphilitic iritis, and a gummy destructive ulcer on the penis
which resisted eight weeks of energetic treatment (caustics, etc.) at the hands
of a surgeon, and cicatrized in three weeks under steadily increasing doses of
the iodide of potassium.
CASE II.”—A medical student had chancre and indurated inguinal glands
which were unmistakably syphilitic. He underwent treatment by small doses
of mercury at my hands. His type of disease was so mild that he had no
eruption whatever, nor any sign or symptom of disease except one indolent,
indurated, post-cervical ganglion. Therefore he concluded that I was in error,
and stopped his treatment entirely after a few months. In eighteen months
I treated him for syphilitic hemiplegia. He had had no symptom meanwhile.
CASE III.-A physician got an insignificant sore, followed by a slight papu-
lar rash. He took no mercury, but was treated by cathartics. The rash went
away, and he remained perfectly well for nine years. Then a lump appeared
upon the top of his head, and remained stationary during eleven years. But
now the patient had a fever, and, on getting up from it, the node spread,
softened, and swept away an enormous piece of his skullcap. The wound
healed kindly under the use of iodide of potassium.
CASE IV.”—A gentleman had urethral chancre. No eruption followed that he
could remember. He certainly took no mercury, and remained well for twelve
years, when he broke out with syphilitic ecthyma which disappeared after the
use of arsenic for a time. Then his brain gave out, and was declared to be
softening by one of the most noted experts in nervous disease in Europe.
Finally this got better spontaneously, and a rapidly advancing, gummy, destruc-
tive ulceration invaded his soft palate. This got well immediately, with great
improvement in his other symptoms, under the use of iodide of potassium alone.
CASE W.—A physician got chancre. A few mucous patches in the mouth
followed, but, he stated, no eruption whatever. He took mercury for a year.
Not a symptom appeared for thirty years. Then he died during a sharp
attack of intelligential and convulsive troubles which he would not treat, not
believing them to be syphilitic. The autopsy revealed a large gummy tumor
in his brain.
CASE WI.-A gentleman got chancre followed by a light eruption. This
was treated homoeopathically and disappeared. Sixteen years afterwards he
applied for treatment, being almost covered with nodes. He had ulcers in his
throat and syphilitic lung disease. Steady improvement attended the mixed
treatment.
CASE VII.—A gentleman got chancre and fell into the hands of an anti-
mercurialist who dosed him freely and continuously for a year with iodide of
potassium and Sarsaparilla. His earlier symptoms were not severe. In one
year ulcers appeared on both legs. The dose of the iodide was increased.
The ulcers progressed in depth and area, three on the right leg measuring
over one inch in diameter each. He now changed his physician. His new
adviser discontinued the iodide of potassium and ordered protiodide of mer-
cury. Improvement began at once. In two weeks the ulcers were cicatrized.
He now ceased treatment, but, after two years, a gummy ulcer destroyed a
portion of the septum of the nose; for this he consulted me.
Van Buren and Keyes, Genito-Urinary Diseases, etc.; New York, 1874, p. 537.
* Ibid., p. 650.
* Van Buren and Keyes, Clinical Contribution, etc., Archives of Dermatology, vol. i. p.
108. Cases III. IV. V. and VI. were seen by me in connection with Dr. Van Buren.
TRE AT MENT OF S Y PHILIS. 729
These cases are not very exceptional. The list could be largely in-
creased, but I restrict myself to these few cases because they sustain the
point at issue from almost every side, and because some of them bear
also upon other facts which will be used in subsequent portions of this
paper. It will be seen that all these cases had a very light syphilitic
attack in the beginning, and that they were all managed differently.
Case I. had a light eruption, and took mercury in considerable doses for
a few months. Case II. had no early eruption, and took a very little
mercury for a very short time. Case III. took no mercury, but was
treated by cathartics. Case IV. took no mercury, but was treated by
balsams, because his chancre was urethral, and his malady mistaken for
gonorrhoea. Case V. took mercury for one year, and remained well for
thirty. Case VI. was treated homoeopathically. Case VII. was treated
for one year with iodide of potasium. I have had no patient who had
been syphilized, but the seven cases cover nearly all the other methods
of treatment: that by expectation; by cathartics; by diuretics (balsam,
etc.); by mercury for a short time in large doses, for a short time in small
doses, for a year in fair doses; by homoeopathy; by iodide of potassium
from the first—and all of these, starting mildly, turned out to be severe
cases of syphilis.
It is indeed notorious how many bad cases of disease there are in which
there has been very little early eruptive trouble, and in which the pre-
vious histºry of the patient shows treatment only during a few months.
This treatment for a few months seems to be what nearly all cases get,
and although very many of them, be they light or severe at first, escape
serious subsequent trouble, yet there is no guarantee in the prevailing
modes of treatment that they will so escape, nor can a light beginning be
counted upon to signify a type of disease necessarily mild.
I have not thought it necessary to search among the array of corrobo-
rative cases which modern journals afford for material to further substan-
tiate this point, preferring to adhere to personal cases, for the history of
which I can vouch. I cannot, however, refrain from alluding to a recent
article by Fournier,' a record of forty-seven cases of cerebral syphilis,
and itself a strong argument against the too readily accepted maxim
that mild syphilis needs but little treatment. Of the forty-seven cases
only two were severe from the first, one was rather bad, thirty were
ordinary cases, and fourteen “actually benign.” One of these latter was
the case of a medical student who got what is termed “un chancre de
rien” (a mere trifle of a chancre), had a little papular rash and sore throat
only, and took mercury for a few months. After seventeen years of calm,
there came an explosion of syphilitic epilepsy, hemiplegia, hebetude,
dementia, and death in spite of all the skill and care of Fournier and
Ricord. My conclusions to this introductory section therefore are: (1)
that all syphilis is severe and treacherous, and that further efforts are
justifiable in attempting to perfect its treatment; and (2) that seemingly
light cases need as thorough a course of medication as those cases which
are apparently more severe.
II. Is the internal use of mercury necessarily debilitating?—Time would
fail me should I attempt to go into this question exhaustively, yet upon
its solution hangs the strongest possible argument for or against a con-
!, La Syphilis cérébrale, est elle plus commune dans certaines formes de la diathése, etc.,
L'Ecole de Méd., Aug. 30, 1875.
730 KEYES,
tinuous use of mercury. If mercury is an evil, if its influence is debili-
tating, then its use would only be justified by its ability to overcome
some greater evil, some more debilitating agent; and it should be dis-
pensed with in every case as quickly as possible. This indeed is the
accepted view of the mercurial question in syphilis. I think, however,
that it may be shown: (1) That mercury in minute doses is a tonic, and,
(2) That mercury in minute doses has been in use in the profession as a
tonic, in non-syphilitic cases, for very many years, and sanctioned by the
highest authority.
(1) That mercury in minute doses increases the number of the red blood
cells both in syphilitic and in healthy individuals, I think I have demon-
strated with the hámatimetre, publishing my results in the January
(1876) number of the American Journal of the Medical Sciences. . To
that paper I must refer for details. Space will not allow me to reproduce
the evidence here. I have, however, corroborated the conclusions therein
reached by repeated, new experiments, during the present year, and these
conclusions I beg leave to adduce in evidence now. They are based upon
the counting of red blood-corpuscles in over one hundred different speci-
mens of blood, which number has been greatly added to since the publi-
cation of the paper without occasioning any modification in the results
at first arrived at. These conclusions are: (a) That 5,000,000 red cor-
puscles in the cubic millimetre of blood is a full, high average for the
adult, healthy male, etc. (in New York); (b) That mercury degreases the
number of the red cells when given in excess, especially in hospitals
(this was also conclusively proved by Wilbouchewitch"); (c) That syphilis
diminishes the number of red corpuscles below the healthy standard; (d)
That mercury in small doses, continued for a short or for a long period,
in syphilis, alone or with the iodide of potassium, increases the number
of red corpuscles in the blood, and maintains a high standard of the
same; (e) That mercury in small doses acts as a tonic upon healthy
animals, increasing their weight. (Liegeois and Bennett cited.) In
larger doses it is debilitating or fatal; (f) That mercury in small doses
is a tonic” to individuals in fair health, not syphilitic. In such indi-
viduals it increases the number of the red blood-corpuscles.
I must again express regret that I cannot bring out the evidence here,
which led directly up to these conclusions in such a way that I can see
no possible escape from them, and, referring those interested to the ori-
ginal paper, I again ask to incorporate these conclusions as a part of my
present argument. This proof of the tonic action of minute doses of
mercury is scientific, but the demonstration from the clinical side is no
less positive.
(2) We are all familiar with the well-known tonic consisting of a
minute dose of corrosive sublimate in compound tincture of bark. I
first learned it from the late Valentine Mott, who was loud in its praises
as an “alterative” in the cases of strumous children. I cannot trace the
authorship of this compound. It is very favorably mentioned as having
“been long recommended both for scrofulous taint and the more declared
forms of tuberculosis,” in Copland’s Dictionary of Practical Medicine,
1858; and I find it spoken of as a preparation in common use, in a
* De l'influence des Préparations mercurielles sur la Richesse du Sang en Globules rouges
et en Globules blancs. Archives de Physiologie, 4 et 5, 1876, p. 508.
* During as long a period as the experiments were kept up. Keyes, loc. cit.
* Vol. iii. p. 760.
T R E A T M E N T OF STY PHIL IS. 731
lecture by Sir Astley Cooper, which appeared in the Lancet in 1823."
He praises it as an alterative “for the removal of chronic diseases in
children.” Modern ideas of “alterative action” are not very clear, and
in connection with this mixture I never understood how mercury
could be beneficial, until the truth flashed upon me, while counting
blood corpuscles with the hématimètre, that mercury in minute doses
was tonic in all cases in which it could be digested. I think that this
tonic action of mercury in small doses must have had much to do with
establishing the professional confidence in former days in so-called alte-
rative” medication.
This conviction of the value of minute doses of mercury as an “alte-
rative” (i.e., tonic), not in syphilis but in all chronic disease, I find to be
most deeply rooted in the minds of the older members of our profession
throughout the country. I have received many letters, from far and
near, from representative men, stating that they had inherited the faith
from their preceptors, and had been for years in the habit of using
minute doses of mercury, long-continued, as an alterative in chronic
debilitating disease; that they had used it empirically, but with good
effect. I have received similar answers from all the older men whom I
have questioned. What can be stronger evidence than this that mercury
in minute doses is tonic, increasing the vitality of the individual; and
when to this is added the scientific proof, by actual counting, that mer-
cury increases the number of the red blood-corpuscles, the chain of evi-
dence seems complete. It may be well here to mention a remedy on
which many of the profession in New York were accustomed to rely some
years ago with confidence for the cure (or certainly the relief) of Bright's
disease. It was two grains of corrosive sublimate in an ounce of tincture
of the sesquichloride of iron. The dose was ten drops (not minims), con-
taining about one-fiftieth of a grain of bichloride of mercury, a very fair
tonic dose ; and that improvement attended its use in many cases, is un-
questionable. Finally may be cited the popular sanction of minute
doses of mercury as a tonic which is found in the history of Swaim's
Panacea,” a nostrum at one time in very general use. This remedy con-
sisted of a minute quantity of corrosive sublimate in compound syrup of
Sarsaparilla. Swaim is believed to have gotten the idea from an old
book, his first business having been that of a book binder.
While then all the evidence goes to show that minute doses of mercury
are tonic, out of syphilis as well as in it, the proof is equally strong that
mercury in large doses is debilitating, if at all continued, whether in
syphilis or out of it. This is proved by history, by clinical experience,
and by actual blood counting with the hômatimètre, as has been shown
by Wilbouchewitch and by myself, in the articles already referred to.
Vol. i. p. 111.
* J. Kent Spender, of London, refers to the action of corrosive sublimate (Journal of Cuta-
neous Medicine, No. 15, 1870, p. 187), saying that it indirectly promotes the nutrition of
several tissue elements, and speaks of Dr. Billing's mention of its action as tonic. In a
letter to me, Dr. Spender says that Billing (First Principles of Medicine, 5th ed. 1849,
p. 109) states that the “tonic” action of mercury illustrates the rationale of the operation
empirically called “alterative.” He does not enlarge or explain further.
* Dr. E. R. Squibb, of Brooklyn, informs me that this nostrum, appearing about the
year 1825, was extensively advertised, and enjoyed unbounded popularity, bringing great
wealth to its inventor. In 1828, Prof. Hare, of the University of Pennsylvania, discovered
mercury in the mixture. He published the fact in the Amer. Journ. of Med. Sciences,
vol. iv., 1829, p. 530, whereupon Swaim denied that the “Panacea” contained mercury. In
fact mercury does not now seem to be one of the ingredients. Mr. Neergaerd analyzed a
specimen of Panacea for me, but failed to find any mercury.
732 KEYES,
III.--When is mercury useful in syphilis 3 Has it any control over the
late symptoms?—If it be once admitted that mercury is useful during any
stage of syphilis, the proof that it is a tonic theoretically establishes its
value during all stages of the disease; for the hômatimètre on the one
hand, and clinical observation on the other, prove conclusively that
syphilis is essentially a debilitating malady, and that it lessens the
number of the red blood-cells. Yet mercury is not alone tonic, it is anti-
dotal to syphilis; not only generally to syphilitic symptoms, but specifi-
cally when locally applied, as Koebner' has shown, particularly for con-
dylomata, referring also to Ch. Hunter and Hebra ; and as Monti” has
demonstrated by causing the local disappearance of patches of eruption
by injecting the bichloride subcutaneously into them, while other patches
at a distance remained comparatively unaltered. In a general syphilitic
eruption, the advantage of combining local with general means is strik-
ingly shown by the much more prompt disappearance of lesions which
have been subjected to the local use of mercury, than of the same lesions
elsewhere seated and not locally treated. This I have repeatedly noticed.
Every one admits the power of mercury in postponing and modifying
the earlier symptoms of syphilis, and of shortening their course when
they do appear. Even the anti-mercurialists allow this, their claim
being either that mercury prolongs the attack on the whole by post-
poning the symptoms, since the disease must run its course—or that it
suppresses the virus and causes the appearance of tertiary lesions by
debilitating the constitution, or in some other way. No statistical or
other evidence with which I am familiar has ever established either of
these assumptions,” while the almost universal advocacy of mercury in
syphilis, in one form or another, by a majority of the best minds in the
profession in all countries, goes far to show that this is the only honest
remedy for syphilis with which the profession is familiar. As for the two
points of the anti-mercurialists—that mercury used early only postpones
the symptoms, prolonging the total duration of the disease, and that
tertiary symptoms are due to mercury—if time allowed, any number of
cases might be cited in opposition to this view ; such as Cases III. and
IV. of this paper, in which, no mercury having been used, the disease
was in full force after twenty-one and fifteen years respectively, in the
most advanced tertiary type; or Case VII., in which mercury cured
! Archiv f. Derm. u. Syph., B.I., S. 628; quoted from Jahresber. d. Schles. Gesellsch. f.
waterländ. Cultur.
* Jahrbuch. f. Kinderheilkunde, 1869, S. 381. Beobachtung über die Behandlung der
Syphilis congenita et acquisita mittelst subcutaner sublimatinjectionen.
* Undoubtedly statistics exist on both sides of the question, but they fail to prove any-
thing positive. Quite recently Jullien (Gaz. Hebd., Sept. 18 and Oct. 2, 1874), in a sta-
tistical paper attempting to establish the proportion of cases of tertiary disease occurring
in those who had taken mercury for their earlier symptoms, as compared with those who
had been otherwise treated, found in 218 cases of tertiary disease that 59, more than one
quarter, had not taken mercury, while all the rest had taken it. The number of cases of
nervous syphilis he noted to be much greater proportionally in those who had taken mer-
cury. All this, however, proves nothing except that syphilis naturally runs on to tertiary
symptoms when untreated. Statistics cleverly handled are capable of proving almost any
thing in relation to syphilis, because the disease itself is so capricious. In this case the
statistics were made up from letters received from physicians in France, England, and Italy,
and undoubtedly in these countries three-quarters of the well known physicians give mer-
cury early in syphilis, and it would be but fair that three-quarters of the cases of tertiary
syphilis found should turn out to have taken this remedy. This is especially probable when
the statistics are compiled by one who is no lover of the drug, and his figures lose all value
when it is remembered that there is no record of the cases which did not become tertiary
under the mercurial and anti-mercurial courses.
TREAT M. ENT OF SY PHILIS. 733
tertiary ulcers, which failed to improve under fair doses of iodide of
potassium, in a patient who had been treated by the latter remedy
alone for a year after his chancre appeared.
That mercury retains its value late in syphilis is amply illustrated by
the well-recognized power of the mercurial, general fumigation, in many
advanced forms of syphilitic ulceration, late in the disease; by the great
value of what is known as the mixed treatment, especially in controlling
peculiarly chronic and grave symptoms of late syphilis; and by the
numerous cases of nervous syphilis found in the journals of the day, in
which the turn in the symptoms is noted as the point at which the gums
became touched. Occasionally a case is found in which the customary
forms of iodine cannot be borne late in syphilis, or in which they do not
seem to meet the requirements of the disease. Under these circum-
stances an appeal to mercury alone will often yield a victory over symp-
toms until then rebellious. Case VII. of this paper is in point, mer-
cury having succeeded where iodine had failed. While then it seems
not doubtful that mercury retains its power in every stage of syphilis,
yet it is no less true that it cannot be relied upon in emergencies in cer-
tain, especially the gummy, forms of tertiary disease. Here the differ-
ent preparations of iodine take the lead.
As a final illustration of the power of mercury over tertiary lesions
may be cited its undoubted value in inherited syphilis. Here the lesions
are grouped in a disorderly manner—tertiary, perhaps gummatous, dis-
ease of the bones, lungs, kidney, thymus gland and liver, often accom-
panying secondary symptoms on the skin and mucous membranes—yet in
these cases mercury is generally relied upon, and often proves capable
alone of routing the enemy. I conclude, therefore, that mercury is of
value during the whole treatment of syphilis, in minute doses through-
out, for its tonic and anti-syphilitic action; in larger doses, as the occa-
sion arises, to suppress outcropping symptoms, the action here being
purely anti-syphilitic, and not tonic.
IV. When is iodine useful in syphilis 2 Can it replace mercury in any stage
of the disease ?—In studying this point, I have again had recourse to the
hématimètre to watch the effect upon the red blood-corpuscles of the in-
ternal administration of the preparations of iodine. My conclusion,
based upon a considerable number of blood-counts made by myself, and
many by my friend Dr. L. A. Stimson, is that iodide of potassium is a
tonic, and increases the number of the red blood-cells. It does this in
all stages of syphilis. I have not yet tried its effect upon the healthy
individual, but notably in some experiments by Dr. Stimson this point
came out, that while iodide of potassium, given immediately after the
appearance of a chancre, increased the red blood-cells with proportion-
ally greater rapidity than did mercury given under similar conditions
(for the effect of mercury during the first depression preceding the out-
crop of the earliest eruption is often very slight), yet, in spite of this
greater increase in the number of the red blood-cells, the administration
of iodide of potassium did not retard the appearance of the secondary
symptoms to the same extent as did the use of mercury. This fact cor-
responds to the well-known results of the experiments of Grassi, who
determined that iodide of potassium increased, while mercury decreased,
the proportion of the red blood-cells to the whole mass of blood when
used in syphilis. In Grassi's day, mercury, when used at all, was
734 KEYES,
always given in excess, and his conclusions, although obtained by chemi-
cal methods mainly, are undoubtedly accurate.
These statements of Grassi have been made use of to construct a rule
of practice; namely, to give iodides and tonics early in syphilis, avoid-
ing the supposed depressing influence of mercury. But when it appears
that the iodides do not seriously interfere with the outcrop of the early
eruptions, while mercury certainly does; and when it turns out that
mercury in small doses (but large enough to greatly modify the disease)
is tonic, the rule of practice founded on Grassi’s experiments fails to
find any scientific support, and must fall to the ground. Case VII. in
this paper illustrates this point. This patient was dosed with iodide of
potassium for a year, but his early eruptions appeared none the less,
although they were undoubtedly mild, and his tertiary symptoms came
on in due time, perhaps as early as they would have come had no treat-
ment been used. Iodine doubtless has some modifying influence over
syphilis during its whole course, but not enough to make it wise to sub-
stitute this drug for its more powerful rival early in the disease.
I see no reason to believe that iodine has any eliminative power in
syphilis, and I have failed to discover any evidence to show that it tends
to prevent relapse. That it holds a place, however, in the treatment of
syphilis, is undoubted ; and a very high place it is. When tissue-infil-
trations take place; when the lesion approaches the gummatous type;
when there is considerable connective-tissue proliferation, especially if it
takes place rapidly, whether the affection is of an external or of an in-
ternal organ ; when nodes form upon the bones; when the cartilages
begin to soften ; when ulceration is spreading rapidly, then the prepara-
tions of iodine used unsparingly for the symptom are the right hand of
treatment. Here nothing can replace iodine. To its benign influence,
when well assimilated and rapidly pushed, the most formidable lesions
yield a quick response. s
In certain of the chronic lesions occurring late in syphilis, the power
of mercury is greatly enhanced by combining some preparation of iodine
with it ; but where the lesion is a gumma, mercury may be dispensed
with at once, and entirely, and iodine pushed with a lavish hand until
the symptom yields. Mercury, however, must be resumed to seal the
cure and prevent relapse, and it must be given with long patience and
scrupulous care that it is thoroughly assimilated. In syphilis, therefore,
when the lesion is gummatous, no matter where it is situated, iodine
may replace mercury with profit to the patient; but under no other cir-
cumstances can it take the place of this drug, although it may often be
advantageously combined with it. Iodine is indeed what many have
considered mercury to be, a remedy not at all curative of syphilis, but
causing the disappearance of certain of its symptoms. A curative agent
it is not, because it has little if any power of shortening the duration of
the disease, of keeping off or modifying many of its symptoms, or of pre-
venting relapse.
V. Does iodine act by liberaling mercury lying latent in the tissues 2—I
think that this question may be briefly disposed of in the negative.
That iodine taken at the same time renders a given quantity of mercury
more active, is probable, this being perhaps the secret of the success of
the mixed treatment for chronic obstinate lesions, not gunmatous. But
whatever power as an anti-syphilitic remedy iodine possesses, it probably
exercises by its merit as a tonic, increasing the number of red cells in
T R. E. A.T. M. ENT OF STY PHIL IS. 735
the blood; for this it does even early in the disease, in spite of the de-
pressing influence of the virus.
When a patient has been carrying a certain amount of mercury with-
out showing it in the mouth, the sudden administration of iodide of
potassium may call forth symptoms of salivation. Indeed, iodides given
alone, in some exceptional cases, have produced quite marked symptoms
of mild salivation. But a little positive evidence outweighs any amount
of negative testimony, and whatever power iodine may have in render-
ing mercury active, still, in its own sphere, in controlling gummy exu-
dation in any of its forms, iodine does not yield a hair's breadth to any
remedy, or demand the least assistance from mercury. An excellent
case bearing on this point was printed editorially in the Gazette des
Hôpitaux for January 28, 1860." Cases III. and IV. of this paper are
directly in point, iodine alone having cured patients who had never
taken mercury. Case VII. might be referred to as evidence on the other
side ; but, as I have already stated, some forms of tertiary disease, nota-
bly some of the ulcers, seem to demand mercury for their treatment, and
yield to it much more promptly than to iodine. In this case, also, I could
not ascertain to what extent the iodide had been pushed, and at best the
evidence is negative, while the other is positive.
The late Prof. Boeck, of Christiania, informed me, while in this coun-
try, that, when tertiary symptoms occurred in his patients who had been
treated solely by syphilization, he was in the habit of using iodide of
potassium with good effect, combined with a continuance of syphiliza-
tion. In these cases surely there was no antecedent mercury, the libera-
tion of which could do the work. And finally, in proof that the iodine
possesses the power, it is only necessary to recall that, in those frightful
cases of devastating disease which we sometimes meet with, and which
yield to the iodides, the dose must not be restricted, but pushed with
rapidity up to the point of tolerance, the amount of the dose assimilated
being in direct relation to the rapidity of cure.
VI. Should treatment be continuous or interrupted 3—The answer to this
question has already been brought out in what has been written. The
continuous use of iodine need hardly be considered, for I feel unable to
include this drug among the curative agents of syphilis. It has enor-
mous power in overcoming certain symptoms, but as these symptoms are
intermittent, the use of iodine should also be interrupted. While the
symptom lasts, and for a certain time afterwards, iodine is called for ;
but as it does not prevent relapse, or shorten the whole course of the
disease, there is no occasion for its prolonged use. Mercury, on the
other hand, has received the palm as the anti-syphilitic, at least the
symptomatic, anti-syphilitic, remedy, par excellence, from a majority of
the best medical scholars and authorities up to the present time. It is
an antidote to the poison, whatever the nature of that poison may be.
I think that the results of blood-counting by the hematimètre, used
upon the blood of syphilitic patients who had taken small doses of mer-
cury continuously for long periods (over three years).” proves that mer-
cury is not debilitating, but, indeed, a tonic, when used in minute
doses.
! Although the writer states that he thinks iodine often does not act well unless mercury
has been previously used.
* Keyes, loc. cit.
736 - KEYES,
Clinical experience also has convinced me of the value of the continued
treatment. I have employed it in all cases, light or severe, in which I
could control the patient, since the early spring of 1869. Generally I
have not commenced treatment until the post-cervical and epitrochlear,
glandular engorgement, and an eruption, have come to confirm the diag-
nosis. My observation has included nearly all the cases of my partner,
Professor Van Buren, and I have to thank him for his kindly sugges-
tions which have led to many of the steps in this investigation, an
investigation which has convinced us both more than ever of the value
of the uninterrupted use of mercury in small doses in the treatment of
syphilis. It has become a rule with us, to which we find but few excep-
tions, that patients, after acquiring syphilis, remain in as good and often
in better health while under treatment than previously. Severe cases
are the rarest of exceptions, and tertiary symptoms (in those treated
from the start) nearly unknown. Slight localized lesions, such as a
scaly spot on the palm, a cluster of a few papules here or there, appear-
ing from time to time, are, customarily, all that mark a continuance of
the disease, except the lesions of the throat and mouth. Slight ulcers
about the throat, mucous and scaly patches in the mouth and on the
tongue, are apt to persist and recur at intervals, for long periods. These
are the main, very often the only, symptoms requiring attention after
the first eruption has passed, and they respond to local measures, or to a
slight increase in the strength of the general treatment.
Usually the continuous treatment is kept up for from two and a half
to three and a half years, or even longer, and in all cases, if possible,
until six months, and sometimes a year or more, after the appearance of
the last syphilitic symptom. Many of the patients so treated are now
married and raising healthy families—themselves to all appearances
perfectly well.
Of course it is impossible to state how many of these patients are ab-
solutely exempt from any further relapse. Seven years and a half are not
sufficient to pass final judgment on any method, but against other methods
may be urged: (1) That the numerous bad cases constantly met with
have all been treated by them ; (2) That salivation is certainly harmful;
(3) That mercury, not pushed to salivation, but used in large doses, has
been proved to be debilitating by the hematimètre (Wilbouchewitch,
Keyes), by clinical experience, and by experiments upon animals (Lie-
geois, Bennett, Wilbouchewitch, and others); (4) That the intermitting
treatment is simply symptomatic, and virtually makes one confess that
he has no remedy for the disease, but can only moderate the symptoms
until such time as they may see fit to cease to reappear.
For the continued treatment with minute doses of mercury it may be
urged, on the other hand: (1) That it has given good results thus far (seven
and a half years); (2) That it is scientifically and theoretically correct to
use continuously for a given evil an antidote which can itself be proved
to be beneficial to the individual, be he sick or well; (3) That it seems
proper to use an antidote continuously against a poison which is continu-
ous, although having long periods of latency. For the poison must be
continuous and still present in the tertiary stage, although it has then
lost much of its virulence and power of transmissibility. IIow else can
we account for the undoubted fact that parents with tertiary disease may
produce children with inherited syphilis (I have notes of such cases),
and inherited syphilis is well known to be capable of transmitting itself
in full force to the nurse and other healthy persons by contact; (4)
T R F A T M E N T OF SY PHILIS. 737
That this continued treatment is only a modification of the “coup sur
coup” plan, so widely practised, for the quantity of mercury is aug-
mented upon any outcrop of symptoms, the minute, continuous dose
being maintained in the intervals. It is, indeed, not very widely dif-
ferent from the common, symptomatic, interrupted treatment, yet I can-
not but believe that it is a great improvement upon both of the Ordinary
plans.
VII. General outline of a course of treatment in a typical case.—When
the first eruption appears, or sooner if by confrontation or other sure
means the existence of syphilis is placed beyond any possible doubt, my
habit has been to put the patient upon a mercurial, and to increase the
dose, slowly if there is time, more rapidly if the eruption is pressing,
paying all possible attention to hygiene, food, surroundings, care of teeth,
etc., until slight diarrhoea with colicky pain is complained of, or until
the gums just begin to be touched. The amount required to produce
this effect is now known to be the patient’s dose, beyond which he can-
not safely go without aid from opiates, or changing the form of admin-
istering the drug, and at which, if it is maintained, the effect on the
general health will be injurious. Having found this dose, it may be
maintained, if the eruption demands it, by giving opium, bismuth, rice,
milk, etc., until the symptom yields; then it should be reduced to one
half, or a little below this point (this dose will prove tonic to the patient),
and there maintained day after day, continuously, year in and year out,
waiting for other symptoms.
Should such symptoms occur, for there may be none except mucous
patches, which local means will relieve, I think it is well to give the
patient mercurial baths, when practicable, two or three times a week or
oftener if they do not prove depressing, maintaining the same internal
dose. Instead of this, the half dose held in reserve may be immediately
or gradually added to the tonic dose, or inunction may be practised, until
the symptoms are subdued, when the tonic dose is to be again resumed
and unremittingly continued.
Later in the disease, should any of those symptoms supervene which
are known to be favorably influenced by iodine, the iodide of potassium
or sodium may be combined with the mercurial (preferably with the
biniodide of mercury), and the two continued (mixed treatment).
Should cerebral symptoms come on; or bones, or nerves, or muscles, or
viscera, or any of the tissues become involved in any of the forms of
gummatous growth (this, however, I have not yet seen in any case where
the directions have been strictly followed from the first); then the iodides
are to be used unsparingly for the symptom, it being of little importance
whether the mild mercurial is continued for the time being or not.
Many deviations from this simple course may be necessitated by vary-
ing cases, especially when the continuous treatment is only commenced
late in the disease. I think that a case treated from the first symptom
should receive mercury continuously, in small doses, for a period not less
than two and a half years, or, in any event, until at least six months
have passed after the entire disappearance of the last clearly syphilitic
symptoms. It is hardly necessary to add that all treatment may be sus-
1 Two drachms of black oxide after a few minutes of steam (not hot air), the whole bath
to last not over twenty minutes, is a fair average.
738 KEYES,
pended without ultimate disadvantage should any acute disease acci-
dentally occur within the limits of this time,
My time has expired, and it would be hopeless for me to attempt to
take up a consideration of exceptional cases, either of patients such as
those who cannot take mercury or iodine, or of peculiar forms of disease,
or surrounding circumstances, where these remedies seem powerless, and
where an appeal to change of air, or to derivation by the bowels (Zitt-
man’s decoction), or derivation by the skin (syphilization or tartarization),
seems to effect more than can be done by following the rules established
by success in the majority of cases.
I cannot consider the value of mercury locally, as a means of treatment
of the lesions, or of other local remedies; nor the relative value of iodine
used as the tincture (internally), or as the iodide of potassium, of sodium,
of ammonium, of calcium, or of amylum, or as metallic iodine with
albumen, or as iodoform ; nor of the varied use of these agents by the
stomach or rectum. My remarks have been general, and intended to
apply to the typical case, and I have endeavored to group them so as to
lead up to the following negative and positive conclusions, which I now
beg respectfully to lay before you, and on which I ask the expression of
your opinion.
Negative Conclusions. – Views for which there would seem to be no
positive foundation in fact :—
I. Syphilis commencing mildly needs but little treatment, and does
not require mercury.
II. Mercury given internally is necessarily debilitating.
III. Mercury is only useful in secondary syphilis.
IV. Todide of potassium is of considerable value in secondary syphilis.
V. Iodide of potassium is of no value unless preceded by the use of
mercury.
VI. Iodide of potassium acts by liberating mercury which has been
lying latent.
IPositive Conclusions.—Propositions which, in the present state of our
knowledge, may be affirmed :-
I. Mercury is an autidote to the syphilitic poison, and of service in
controlling all its symptoms in all (even the latest) stages of the
disease, its power over gummata being least marked, and not to
be relied upon.
TI. Mercury in minute doses is a tonic.
III. Iodine cures certain symptoms of syphilis, but does not prevent
relapse.
IV. The use of mercury, long-continued, uninterruptedly as far as prac-
ticable, in small doses, from the time of the earliest eruption, con-
stitutes the best treatment of syphilis.
DISCUSSION ON DR. KEYEs’s PAPER.
After the reading of the preceding paper, Dr. L. D. BULKLEY, of New York,
said:—Dr. Keyes's first positive proposition requires qualification, for mercury
is very injurious in gummatous cases. An exception should also be made for
certain rare cases. I had a patient who had intercourse on the fourth of July;
..a chancre appeared in due course of time, and the man came to me for treat-
T R E A T M E N T OF SY PHIL IS. 739
ment in the following September. I observed this case constantly for a year
and a half, and it developed all the symptoms possible during that period.
Yet that man could not from the first take mercury without positive injury.
Dr. KEYES said:—I myself know of a worse case, in which the patient lost
both eyes from the disease, but could not take mercury in any form. The
proposition, however, does not profess to cover every idiosyncrasy.
Dr. R. W. TAYLOR, of New York, said:—The paper gives distinctly and
clearly what many books leave in doubt, namely, the time of beginning mer-
curial treatment. I think that there are many good reasons for using mercury
before the secondary lesions begin; in cases in which the induration of the
chancre is marked, it will melt away under the influence of mercury. I have,
however, seen cases in late stages in which too much reliance had been placed
upon mercury. For the late lesions of the skin, the iodide of potassium will
be found very useful.
Dr. KEYES said:—I recall two cases in which the chancre appeared upon
the lip; in these, having no doubt that the chancres were syphilitic, I gave
mercury at once and with good effect.
Dr. BULKLEY said:—If the diagnosis is made at first, there is no reason
why mercury should not be at once administered. If I had the slightest sus-
picion that a sore was syphilitic, I should feel it my duty to give it immediately.
Dr. TAYLOR said:—In any case of doubt, however, the future of the patient
is not imperilled by waiting for the further development of the disease. I am
fully convinced of the tonic qualities of mercury, and have known it to be used
with better effect than iron or quinia in cases in which the latter are the com-
mon remedies. Pains at night, which refused to yield to morphia, I have known
to be allayed by an eighth of a grain of mercury daily; mercury is also very
efficient in controlling syphilitic fever.
Dr. WILLIAM OLDRIGHT, of Toronto, said:—I would ask Dr. Keyes to specify
the particular symptoms for which he would give iodide of potassium, and to
say whether iodide of potassium is better than other forms of iodine 7
Dr. KEYES said:—In lesions of the joints, nerves and viscera, tubercular
skin affections, etc., it is well to give the iodide. Its action is so ready and
so plain when given in large doses in such cases, that in a week or ten days
the physician can tell whether he is upon the right track, and, if he finds that
he is not, can fall back upon mercury. Other iodides may be used, but I give
the preference to the iodide of potassium because it is the most easily assimi-
lated.
Dr. BULKLEY said:—Mauriac has presented a series of cases of bone lesions
in which the iodide failed and mercury had to be resumed ; I myself, too, have
seen such a case.
Dr. KEYES said:—I have not seen many cases of bone lesion early in the
disease, but in those which I have seen I have not interrupted the mercurial
course, though I have given the iodide in connection with it. I know that there
are some tertiary lesions which do not yield to the iodide, but the rule is that
it is of benefit to them.
Dr. TAYLOR said:—Where troubles of the fibrous tissues and bone lesions
come on early, I have always used the iodide; they will not yield as well to
mercury alone as to it and the iodide combined.
Dr. CHARLES HEITZMANN, of New York, said:—I would ask Dr. Keyes
whether, having said that the iodide of potassium will not prevent a relapse,
he means to assert that mercury will prevent a relapse in syphilis 7
Dr. KEYES said:—I would not make such an assertion absolutely. I can
only speak from my own experience, and I am well satisfied with the course
of my patients under the mercurial treatment. Mercury has caused them to
have better health than they enjoyed before they contracted syphilis. I can-
not say that they will not have other symptoms, but I am convinced that the
continuous treatment with mercury is the most scientific, the most philosophi-
cal, the most harmonious, and in fact the best.
740 KEYES, TREATMENT OF SYPHILIS.
Dr. HEITZMANN said:—I have employed Dr. Keyes's method of treatment,
and have found it unable to prevent a relapse.
Dr. TAYLOR said:—Generally, after two or three years of mercurial treat-
ment, the patient is practically cured as a syphilitic, and it seems to me useless
to debate about the unimportant disorders that may subsequently occur.
Dr. HEITZMANN said:—I have seen, in Vienna, cases of mild beginning,
which have got well without any decided treatment, and others that have re-
quired the most careful management. I believe that syphilis can be cured,
but whether the cure should be attributed to the skill of the physician or to
Other causes, no one can say.
Dr. BULKLEY said:—Instead of giving mercury every day of every month,
while the treatment lasts, I generally keep my patients under constant treat-
ment for from three to six months, then let them drop one week a month, for
three months, then two weeks a month, and sometimes let them alone for a
month at a time; thus they do not take so much mercury, but keep the system
always under its influence.
Dr. TAYLOR said:—I would ask Dr. Keyes whether, after uninterrupted
treatment for two years and a half, he has not found a decrease of blood-cor-
puscles, and been forced to cease treatment, and after a while resume with in-
creased doses 7
Dr. KEYES said:—The reverse of this is the result of experiments. One-
twelfth or one-eighth of a grain of the bichloride, three times a day, is a large
dose; one-thirty-fifth to one-fiftieth of a grain is a tonic dose. Wilbouche-
witch gave large doses, and kept his patients housed in close hospitals, and of
course the number of their red corpuscles decreased. I had a patient who
after continuous treatment for two and a half or three years had six millions
of red corpuscles to the cubic millimetre, the best blood-count I have ever
known. This patient has never had any trouble since, and has become the
father of a perfectly healthy child.
Dr. TAYLOR said:—By constantly taking mercury, the patient becomes
tolerant of it, and therefore, as Fournier has said, the treatment should be
stopped for a time in order to allow the system to recover and become more
susceptible to its action when again administered. Moreover, as syphilis does
not show itself by long and continuous evolutions, it is consistent to treat it
intermittingly ; both before and since reading Fournier's paper, I have used
the intermittent treatment with excellent results.
Dr. KEYES said:—Tolerance is not established when mercury is given in
tonic doses. The intermittent treatment is nothing more than symptomatic
treatment, leaving the patient in the intervals to take care of himself; my plan
is to keep the patient in good condition by giving him the tonic dose until the
symptoms appear, and then to give him the anti-syphilitic dose.
Dr. L. A. DUHRING, of Philadelphia, said:—The only way of arriving at a
satisfactory conclusion as to the best manner of administering the drug, is by
observing series of cases treated by both methods. In my practice I use both
methods, making my selection with reference to the patient himself and the
peculiar circumstances of his case. I see advantages in both methods. I think
that the plan suggested by Dr. Taylor is practically the best, and that that
suggested by Dr. Keyes is often impracticable.
On motion, the propositions appended to Dr. Keyes's paper were adopted as
expressing the opinion of the Section.
741
THE TREATMENT OF SYPHILIS.
; BY
CHARLES R. DRYSDALE, M.D.,
SENIOR PHYSICIAN TO THE METROPOLITAN FREE HOSPITAL, PHYSICIAN TO THE
BOLSOVER STREET LOCK Hospit AL, LONDON.
[CoMMUNICATED BY THE SECRETARY.]
IT is, in my opinion, a most fortunate circumstance that the members
of the International Medical Congress at Philadelphia have determined
to discuss the treatment of Syphilis, because it cannot be said that any
clear body of doctrine has as yet been laid down as to how this should
be carried out, whilst there never has been at any time in the history of
medicine so good an opportunity for coming to a correct conclusion on
the matter.
Syphilis is now well known to have been quite a new disease in Europe,
somewhere about the end of the fifteenth century. As to whether it had
existed formerly in America and Japan, it seems to me that our historical
works do not enable us to come to any clear conclusion. At its first
outbreak, syphilis was so perfectly an unknown disease that the regular
physicians confessed that they did not know how it should be treated, and
it was handed over to a host of illiterate persons who, as usual, treated
the disease so badly that at the end of the fifteenth century it was, it
seems, a terrible and revolting spectacle.
Mercury was employed, probably in the form of inunction, in the
treatment of syphilis, as early as 1497; but Paracelsus was the first to
recommend its administration internally, about the year 1570. At first,
mercurial inunction was confined by physicians of repute to cases of true
syphilis, before the confusion-period when gonorrhoea and soft sores were
put down as belonging to syphilitic inflammation ; but, gradually, this
method of cure was applied also in cases where no true syphilis was
present; and, as salivation was caused, much misery and disease were
occasioned by the use of the drug. It was chiefly from this reason that
the period of the Peninsular War was such an important one in the
history of the treatment of the disease. In 1812, whilst that war was
going on, Dr. William Fergusson wrote a letter on the treatment of
syphilis, which was read at a meeting of the Royal Medical and Chirur-
gical Society of London. In this letter, he showed that the natives
of Spain, although entirely untreated by mercury, generally made good
recoveries from their venereal ulcers, whilst the British troops had their
sores in very many instances terribly aggravated by the careless use
of mercurial inunction. This letter of Dr. William Fergusson was fol-
lowed by a number of important experiments made by Rose, Guthrie,
Hennen, John Thompson, of Edinburgh (the teacher of James Syme),
Desruelles, and especially Fricke, of Hamburg, all of these observers
having treated both soft and hard sores without mercury. On the whole,
so great was the advantage which accrued in their experience from the
disuse of Salivation in gonorrhoea and soft sore, that most of these
742 D R Y S D A LE,
authors were strong anti-mercurialists, for a long period of their prac-
tice, at least.
About the year 1838, M. Ricord entered on his office as chef de clinique
of the Hôpital du Midi, of Paris; and from that time we may date most
of the accurate ideas we possess about venereal diseases. He made it
abundantly clear that gonorrhoea was not a syphilitic symptom, and,
hence, it was no longer treated with mercury. He next withdrew soft
Sores from mercurial treatment, and thus confined his attention to the
mercurial treatment of true syphilis. For many years, M. Ricord treated
the hard sore and its sequelae by a six months’ course of iodide of mer-
cury, in small doses; of late he has prolonged the time of treatment to
about a year. The great surgeon of Edinburgh, Mr. James Syme, and
his distinguished pupil, Professor Hughes Bennett, most vigorously pro-
tested against the long mercurial courses advised by Ricord and his fol-
lowers, and the Edinburgh School has of late years been, on this account,
On the whole, anti-mercurialist in its tendencies.
The author of this essay, in a pamphlet published in 1863, adopted
anti-mercurialistic views, and treated from 1860 to 1870, his syphilitic
patients eutirely without mercury, whether for the hard sore, or for
secondary or tertiary lesions. The result of this treatment went to show
that many cases of true syphilis were very mild indeed, the whole dis-
ease consisting in such cases in a few discrete eruptions, with occasion-
ally slight alopecia, and sore-throat, coming after indurated sore with
enlarged and indurated inguinal glands. Tertiary symptoms, however,
pretty frequently supervened after non-mercurial treatment of the early
symptoms of the disease, in the form of gummy tumor of the testicle,
sloughing sore-throat, or OZaena, with destruction of the small bones of
the nose. Hence, the lesson taught by abandoning mercury for a time
was that syphilis was not unfrequently a mild disease; but that it also
was not uncommonly a grave affair.
At the present juncture, it would seem to me, from the evidence given
in 1867 by the members of the Société de Chirurgie, of Paris–Diday,
Verneuil, Lefort, etc.—as well as by that most learned of all writers on
syphilis, M. Alfred Fournier, of Paris, taken in conjunction with the
evidence of Henry Lee, Hutchinson, De Méric, and Berkeley Hill, in
London, that mercury, when administered very carefully, and in small
enough doses, so as never to excite salivation in the slightest degree, and
for a sufficient length of time, has (what has been styled perhaps rather
sanguinely) some antidotal power in extinguishing the virus of syphilis.
Mr. Hutchinson, who is fond of hypothesis in this matter, speaks of
mercury destroying the germs of syphilis, and affirms that if mercury be
given in the period of the initial lesion, it will often nip the disease so
completely in the bud that not a trace of secondary syphilis may appear.
Hutchinson gives very small doses of mercury and chalk, not more, as I
understand him, than half a grain, twice daily; but he has never clearly
indicated for how long a time he keeps up this treatment in the primary
and secondary periods of the disease. M. Alfred Fournier is the most
strenuous of all modern defenders of mercury in the treatment of syphilis.
In his lectures, delivered at the Lourcine Hospital, of Paris, he boldly
alleges that, without doubt, of all causes for the appearance of tertiary
lesions, not one is so potent as the negative one—omission of mercurial
courses from the early treatment of this disease. He is very careful
not to advise short courses of mercury, or to lay down hesitating rules
as to the length of time it should be given. He is no believer in the
T. R. E. A. T M E N T OF SY PEIIL IS. 743
possibility of diagnosing mild from severe syphilis, as Diday thought
he could do. All hard Sores and secondary eruptions are, accordingly,
treated by Fournier for the first two years of the existence of syphilis
by means of interrupted courses of the iodide of mercury, so as to ad-
minister that medicine for some ten months in the course of the two
years. His dose is from five to ten centigrammes of the green iodide of
mercury daily, i. e., from about three-quarters of a grain to a grain and
a half of the iodide in the twenty-four hours.
Although I am not entirely persuaded of the complete truth either of
Hutchinson's germ-theory and the antidotal powers of mercury, or of
Alfred Fournier's theory of prophylaxis against tertiary symptoms, I
have been so far influenced by the views of these able syphilographers,
that I have, of late years, given rather lengthened courses of the green
iodide of mercury, or of mercury and chalk, to all my syphilitic patients
in the early periods of their disease. Commencing with two-thirds of
a grain in twenty-four hours, accompanied by two grains of extract of
hyoscyamus, in the form of a pill, I found myself constrained to lessen
the dose to one-third of a grain of the green iodide, as a usual formula.
Even with this small dose, salivation not unfrequently occurs, if the
patient be not carefully watched. This result of this treatment has not
hitherto been in any way discouraging. No accident of gravity has ever
occurred with these doses, and the patients seem to pass through the
roseolar and eruptive period (as well as through the iritis, which occa-
sionally ensues even in the midst of a mercurial course), in a very favor-
able manner. I cannot, as yet, pronounce distinctly whether these pro-
longed courses have warded off tertiary symptoms, but trust that, by
this apparently innocuous treatment, I may have in some cases prevented
the appearance of that dreaded stage of the disease.
It must not be supposed that Fournier has carried all his Parisian
medical brethren with him when he proposes this long-continued mer-
curial treatment of syphilis. I found, indeed, M. Lancereaux, in a
conversation which I had with him in the month of May last, 1876,
much opposed to Fournier's idea that long mercurial courses were
capable of preventing the occurrence of tertiaries. It will be remembered,
by those who are familiar with the literature of syphilis, that Diday, in
his work on the “Natural History of Syphilis,” published in Paris in 1863,
was of opinion that no particular cause for the appearance of tertiaries
had been shown to exist. M. Lancereaux shares, it seems, this conviction
with Dolbeau and Perrin, as declared in their speeches at the Société de
Chirurgie in 1867, and is of opinion that no mercury need be given either
for the hard sore or the secondary rash, because these may disappear of
themselves. He would reserve mercurial treatment for the tertiary period
of the disease. M. Després never administers mercury at any period of
syphilis, but trusts to iodide of potassium as a remedy for tertiary symp-
toms. M. Hardy, in common with other physicians, gives mercury con-
joined with iodide of potassium in the tertiary period; and the school
of Aix-la-Chapelle, in Prussia, seems to prescribe the inunction cure in
all periods of the disease. .
Before leaving the question of the treatment of the early periods of
syphilis, I cannot refrain from saying one word as to the confusion
which has recently been occasioned by the writings of the late Dr. Mor-
gan, of Dublin, and of Mr. Jonathan Hutchinson, as to the nature of the
soft sore, and the tendency of these doctrines to cause a revival of the
treatment of that lesion by mercury. I beg to protest with all my
*
744 D R Y S D ALE, TREATMENT OF SYPHILIS.
powers against any but local treatment of soft chancre. It is no more
requisite to administer mercury in that disease, in order to ward off
syphilis, than it is to give it in gonorrhoea. Mr. Hutchinson asserts
that mixed sores are very common, and seems to hint that it might often
be safer to administer the antidote to syphilis, on the chance that the
soft sore might be followed by the hard one; but such practice is, in
my opinion, a step backwards to the doctrines which were dominant
when Ricord and Bassereau made their great discoveries.
Supposing that we have been unable to prevent our patients from
arriving at the tertiary stage, or that they have come to us already
affected with some gummy deposit, whether in the skin, the mucous
membranes of the throat, or the viscera, what should then be our treat-
ment? For my part I have no difficulty in saying that the great remedy
for the gummy period of syphilis is the iodide of potassium ; and that
it is often most dangerous to delay in administering this drug. Mercury
is often, I am persuaded, entirely useless in the case of tertiary sore-
throat, sarcocele, tertiary epilepsy, or specific lung disease; whereas
large doses of the drug so marvellously brought into use by Wallace, of
Dublin, in 1834, will often effect a rapid and surprising cure.
The rule in practice ought to be that sloughing sore-throat, or ozaena,
ought at once to be treated by ten-grain doses of iodide of potassium,
administered three or four times daily. So, too, with ulcers of the lower
extremity and the face, and with phthisis syphilitica.
It seems to me, then, that the indications for mercury in the period
of gummy products are few ; and that it should only be used when the
iodide of potassium has been tried and found wanting. Above all, I think
we should never give mercury alone in the tertiary period, as seems
to be the fashion at Aix-la-Chapelle. By administering mercury with-
out iodide of potassium, in the tertiary period, we run the risk of seriously
compromising the health of the patient, for, whilst inert mercurial treat-
ment is being pursued, the soft or hard palate may be perforated or de-
stroyed. If, then, the practitioner be inclined to give mercury in the
period of gummy products, he should at all events combine it with the
iodide of potassium. It must be borne in mind that iodide of potassium
occasionally, though very rarely, may produce symptoms of acute poison-
ing. I have sometimes seen eruptions of a formidable nature, vesicles
filled with sero-sanguinolent fluid, caused by small doses of that great
remedy for syphilis; and once saw a case which apparently proved fatal.
In such cases, the disease may be mistaken for syphilis, and more iodide
of potassium administered.
Summing up the views contained in the previous pages, I would say at
this moment that:—
I. Mercury, in very small doses, should be given in prolonged courses
during the first eighteen months of syphilis, leaving off occasionally,
and most carefully watching the patient’s teeth, etc. This should be
done with the view of preventing the occurrence of the tertiary period.
Mercury should be given in the period of the hard sore, with the hope
of arresting the progress of the disease towards the eruptive stage.
II. When tertiary symptoms appear, they should at once be treated
by large doses of the iodide of potassium, combined, in very rare cases,
with small doses of the bichloride of mercury. In general, the iodide of
potassium is all that is needed to cure tertiary lesions, at any rate tempo-
rarily. -
MEASURES ADOPTED IN DENMARK TO PREVENT THE
SPREAD OF WENEREAL DISEASE.
BY
S. ENGELSTED, M.D.,
PHYSICIAN-IN-CHIFF TO THE COPENHAGEN H()SPITAL.
THERE existed in early times, in Denmark, a sort of control with re-
spect to loose women, but it seems to have been with a view of rendering
them more easily distinguishable from other women, partly by ordering
them to wear a certain dress, partly by assigning for them the places
they were permitted to live in. Thus, for instance, in the year 1496,
King Hans published over all the kingdom, edicts, ordering that com-
mon women and harlots should wear, as head-dress, a cap, half red and
half black, no stuff better than “Deventyrsk,” and no better linen than
what might be had at eighteen Skilling an ell."
In a law given by Christian the Second,” we find among other things:—
We will that common loose women living in towns shall not be permitted to
live in streets and lanes with other good and honest people, but there shall be
assigned to them particular quarters of the towns which they are to inhabit;
and We will that they must and shall wear good clothes, etc., such as they can
afford and procure ; they shall not, however, be permitted to wear mantuas,
that they may be distinguished from other, modest women and honest people;
and We will that they shall not be molested by blows and wounds. Whoever
does such a thing shall have his neck forfeited. If anybody should lose his
money, clothes, or other things, by rioting in the houses of such loose women,
this shall not be judged by any court. But by this is not understood such
women as are on terms only with one fellow. They may live in places conve-
nient for them, such as they please to choose in the town, not, however, in
places where there is most and greatest commercial business.
These legal provisions indicate that, in those times, a sort of control
existed with respect to public women, and are besides a proof (particu-
larly the latter of them) of a high degree of humanity in promising these
women protection against violence and molestation.
In process of time, another way was chosen, and, influenced by the fear
of venereal diseases, an attempt was made to counteract the propagation
of the same by persecuting women suffering from those diseases. This
may be seen, for instance, from a writ issued by Christian the Third in
the year 1546, from Aarhus, to all superintendents of the whole king-
dom of Denmark,” in the following terms:–
Our love to all. May it be known to all that We have learned from the
directors of the common hospitals of the kingdom, that in these hospitals are
often admitted women who formerly, when young and healthy, have lived in
| J. C. Wendt, History of the Beginning and Progress of Venereal Disease in Denmark,
1820.
* Laws given by Christian II., published by Resenius.
3 J. C. Wendt, op. cit.
7.46 ENGELSTE D,
notorious profligacy, and led an indecent life, and have thereby been spoiled
by pocks, French disease, and other complaints. We therefore beg and re-
Quest that you instruct and give orders to all parish priests, in the towns as
well as in the country, throughout the whole diocese. that they ever and again,
from the pulpit, do proclaim to the common and lower classes of the people,
that it has been resolved, that wherever there may be found such loose and
spoiled women who, in consequence of their wicked and lewd life, have been
spoiled by pocks and French disease, or other such foul and leprous disease, they
shall not, after this day, be admitted to or received at any hospital, there to
be supported and nourished, so that everybody may know this, and avoid and
abstain from such bad and loose life.
Since that time, several legal provisions and edicts have been published,
by which the propagation of venereal diseases has been partly prevented,
as far as could be done, by attempts to restrict profligacy. Thus:—
Any male who is found to come to a whore-house to commit fornication, is
to be punished ; the first time with imprisonment during a week, the second
time double the length of time. Females being in such houses, in order to
give themselves up to lechery, are to be whipped at the whipping-post, or eon-
fined in a house of correction. (Danish Law, 6–13–20.)
Pimps and bawds seducing any man's wife or daughter to live in profligacy
and lead a wicked life, are to be whipped at the whipping-post, and driven out
of the town by the hangman. (Danish Law, 6–22–1.)
They who keep whore-houses are to be punished by being whipped at the
whipping-post, and exiled from the province where they have been living, or
confined in the house of correction. (Danish Law, 6–22–5.)
The police-master shall diligently investigate that nothing is publicly done
against modesty and decency, and particularly that no whore-houses are kept;
and shall do his best that those who keep them, as well as those who frequent
them, may be seized and summoned before the police court; and that the
brothel-keeper, as well as those who have been found in such houses in order
to give themselves up to lewdness, may, after being convicted, be sentenced
and punished according to law. (Police Regulations, October 22, 1701. Post
II., Chapter 3, § 1.)
They who keep public houses in Copenhagen are forbidden to keep more
female servants than are really wanted, or to permit loose women to lodge in
their houses, if they will not be sentenced and punished for pimping. (Town-
hall placard, July 28, 1828.)
If females are found to stay in houses of bad repute, to stroll about the
streets by night, or to have subsisted by idleness, without being able to account
for their having a substance sufficient to permit them to live in idleness without
hurting anybody; or if such persons, though they have been hale and hearty,
have not for a year had any regular service, then they ought to be, the first
time, summoned before the police office, there to receive a warning, not only
to keep away from such ill-famed houses, but even to take regular service,
lawful labour, or have a legal profession ; and if, after this, they continue their
former life and conduct, he (the police-master) shall sentence and punish them,
after the laws, as vagrant persons of no use, but rather hurtful to the public,
and send them to work in the house of correction. (Instructions for the
Police-master of Copenhagen, March 24, 1741, § 9.)
Besides this, the edict of November 27, 1775, contains several special
provisions to prevent lewdness from being practised by women kept by
inn-keepers and others for that purpose, and also many directions with
regard to the behavior to be observed by such persons with respect to
their female servants, and also for the behavior of women out of work
with regard to the lower dancing houses, all to the same purpose; and
finally, $9 contains the following:—
re
V E N E R E A L DIS E A S E IN DE N M A R K. 747
Loose and idle women who have their lodgings in separate apartments and
rooms, ought, at the request of the police-master, to account for their manner
of living; and they are to be punished if complaints are brought forth with
respect to the seducing young men, or the like. As to women who trespass
against this, the police-master ought, according to circumstances and the pecu-
liarity of the case, and without appeal, to sentence them to pay a fine from
two to ten Rbd., or to be punished by detainment, with bread and water, and
exposure at the pillory, or to be punished by imprisonment in the rasping-
house or “Börnehus,” or other house of correction, from one to three months.
Towards the end of the last century a most important provision was
issued for preventing the propagation of venereal disease, viz.:-
A Royal Rescript of March 14, 1788, to the Civil Governor and Bishop of
the Diocese of Aarhus, of the following contents:—
It has been reported to the King that the venereal disease has for a number
of years been prevailing in the diocese, and that the chief cause of its con-
tinuing is supposed to be that the infected, partly from shame and partly in
order to avoid the costs of the cure, conceal the complaint, or apply to quacks,
until they suffer most severely from the disease, and spread the contagion. In
order to remedy this, it is decreed by these presents that all belonging to the
lower classes infected with venereal disease, whether wealthy or poor, shall be
favoured with completely free cure, and have the attendance of the surgeon of
the district to which they belong; and the surgeon shall have for his pains,
from each such patient, a payment of two Rdl.; and all sick persons who,
according to trustworthy information to be relied upon, are not rich enough
to pay for their being attended while sick, must be treated gratis; and all the
expenses of medicine, the doctor's fee and his conveyance, and the support of
the poor, are to be paid proportionally after the standard of the land-tax; and
the King also wills that the patients from different parishes shall, if possible,
be assembled in one town, in order to be cured in the most convenient and
shortest way; and that persons of the lower classes, who do not in due time
request to be cured, shall, after having been cured, be punished with imprison-
ment with bread and water, or other arbitrary punishment dictated by the
chief magistrate according to circumstances. In the mean time the bishops
should duly admonish the clergymen to tell the names of the sick or suspected
who are known or may become known to them.
By royal rescript of July 2, 1790, the above rescript was extended to
be a rule for the whole kingdom of Denmark. By letter from the minis-
try of home affairs of December 21, 1863, these rescripts have been
interpreted in the most liberal manner possible. This letter was issued
in consequence of an inquiry from the Direction of the Infirmary at
Aarhus, whether they were obliged to receive venereal patients arriving
from other districts, and whether the city of Aarhus was obliged to pay
the costs of their stay at the hospital, or whether the costs should be paid
by the district where those persons had their home. The jurisdiction of
the district admitted that the hospital was in duty bound to receive any
syphilitic patient who should ask for admittance, but was of opinion that
the costs in such cases, where the persons concerned had their homes in
other districts, and had only come or been sent to Aarhus to be received
in an hospital to be treated for and cured of syphilis, should be paid by the
districts or towns where the persons in question had their homesteads;
whereas the costs ought to be paid by the city of Aarhus, if the patient
had resided there even for a short time. The ministry agreed with what
the district had said, but decided that the costs for cure and support at
the hospital should be paid by the district or town where the patient had
T48 ENG E L STE D,
his homestead, only when the patient had come to Aarhus in consequence
of a summons of the competent authority, in order to be cured there;
but not if it were in consequence of his own resolution, or the summons
of private people, in which case the general rule was to be applied, that
the patient’s homestead must pay the cure.
Although prostitution has been acknowledged as a matter of fact, it
has not been thought proper, as it has been termed, to legalize it by
legal provisions; but it has been tolerated. This tolerance has been
looked upon as legal authority in consequence of the police-placard of
March 9, 1809, according to which, women belonging to the jurisdiction
of Copenhagen were summoned, if suffering from venereal disease, to
apply to the police within a fortnight. Persons conforming to this
summons were promised free cure and support, and their names kept
Secret with regard to persons not concerned, and they were free from
being accused and punished, even if their conduct had been such that,
conformably to the police regulations, they might have been accused of
lewdness and idleness; whereas they who did not apply were threatened
to be acted against with the whole severity of law. It was in order to
avoid, as much as possible, everything that might give to prostitution a
stamp of legality, that no formal concessions were given either to public
women or to their keepers, and that neither of the parties was to pay for
the tolerance shown. The position of public women was not regulated
by laws and regulations, but they were under the discretionary authority
of the police.
As early as the commencement of this century, visitation of public
women was introduced at Copenhagen. Between the years 1800 and
1807, the police-master IIaagen engaged a physician in order to inspect
the prisoners, and to examine public women. By royal rescript of
June 6, 1815, which formerly could not be published, the control in
Copenhagen was very much improved. This rescript runs as follows:–
To the Police-Director of Copenhagen : We have received a memorial in
which has been most humbly proposed to us such means as might be employed
against the spreading of syphilitic contagion in our royal residence of Copen-
hagen, and after having duly considered the matter, we by these presents
notify you that, concerning this, we most graciously have established the fol-
lowing stipulations:—
(1) You are authorized to enjoin all who may be looked upon as belonging
to the class of trading people, going under the general name of inn-keepers,
under pain of punishment according to the law of November 27, 1775, to give
up to you their names in full, and the houses they are living in, and when they
are about removing, and then at the same time what and how many female
servants or lodging females they have at their houses, when and whence they
have come, and when they leave their service, and where they are then going;
all this for the purpose of procuring for the police an exact knowledge whether
any such inn-keeper, under cover of the trade for which he has a license, may
intend keeping a whore-house.
(2) You are likewise authorized to demand from loose and idle women who,
according to the placard quoted, § 9, ought to account for their mode of
living, to let you know their lodgings, and any change of the same, on pain of
the above punishment.
(3) You must strictly take care that no women, against decency, try to
allure males by indecent gestures or words, in doors or windows, or in the
street ; and you must sentence women who thus trangress, to punishment
according to the placard of November 27, 1775.
(4) To women suspected by the police, and living alone, and to girls living
W E N E R E A L DISE ASE IN DE N M A R K. 749
in public houses that have attracted the suspicion of the police as favoring
lewd life, you are to have distributed instructions how to know the venereal
disease, which have been printed by the care of our Chancery, and you must
induce them to have always these instructions in their houses.
(5) You must order all women named under the foregoing (4) to have
themselves visited at their own houses by their own physicians (which phy-
sicians ought to be named to you and acknowledged to be skilful), or by the
police physician, in places which you must choose; you also must charge them
to procure a report from the physician, and this report ought to be delivered
at the police office the same day that it has been procured.
(6) You must superintend that the reports of the physicians are punctually
delivered, and after that you must have them arranged in such tabular form
that they may be easily inspected in order to discover immediately if anybody
has neglected to have herself visited, or to deliver her physician's report.
(7) You must give such directions that every one neglecting to deliver such
report, shall immediately be visited by the police-physician.
(8) Besides this visitation, which is to take place EVERY MONTH, you must,
after deliberation with the town-physician, and at not fixed terms, have such
women visited by the police-physician, for the purpose of having a continual
control that can be relied on.
(9) As by rescript of this day to the direction of the poor-house of Copen-
hagen, the same has been charged to have women who are found to be infected,
taken to an hospital to be cured, and also to grant to those who ask for it free
cure and support there, you are not permitted to allow any woman who is
found to be infected, to have herself cured at her house, unless you be assured
that this may be done without exposing the public to any danger.
(10) Whenever a woman who is living alone or in a suspected public house,
and who, after having received from you the above-mentioned instruction how
to know the venereal disease, is by investigation of the police found to be in-
fected to such a degree that she cannot excuse herself by pretending ignorance
of the existence of that disease, and has not then applied to be cured, and has
in the mean time neglected the visitation ordered by law, she shall not be
allowed free cure and support as otherwise given to such patients, but she her-
self, if she is living alone, or otherwise the inn-keeper at whose house she has
been living, shall be ordered to pay the costs of her cure, and in want of pay-
ment the costs are to be worked off by public labor.
(11) If any woman or man has been found to have infected a person of the
other sex, and the person thus accused is convicted of having known her or
himself to be suffering from the disease, and to have nevertheless ventured on
incautious intercourse with the other sex, the same is to be punished by the
police, with fines or corporal punishment according to circumstances.
By a writ from the Government-office of August 20, 1822, there is
repeated what the police-physician has formerly been charged with, and
among other things the visitation of public women; but at the com-
mencement of 1841, there had not yet been introduced any definite
mode of visitation. When the same was to take place, about once a
month (formerly, most likely, four times a year), the public women were
summoned, at their lodgings, by the police-officers. In March, 1841, visi-
tation was ordered to take place twice a month ; in June, 1844, it was
provided to take place once a week; at length, in July, 1853, twice a week
for each woman. This is now maintained, and the women are no longer
summoned at their lodgings to each visitation, but, on a card given to
each of them, since 1852, the days are indicated on which they are to
appear in order to be examined. Each woman is separately examined
with the speculum, and besides the inspection of the exterior genitals and
the skin of the thighs and belly, the anus and the cavity of the mouth
750 ENGELSTED,
are also examined. At every opportunity endeavors are made to detect
the persons with whom the women infected with venereal disease have
been in contact. Such persons are then, through the police, invited to
have themselves visited and duly treated.
With respect to the men of the army and the navy, there are particular
provisions with regard to venereal disease. The staff-physician of the
navy is, according to instruction of July 10, 1789, § 11, to take care that,
among the persons levied for the navy, nobody is suffering from itch,
syphilitic eacanthemata, ulcers on the legs, ruptures, etc. Whenever a
vessel is to put to sea, a visitation is ordered to take place.
With respect to the army, a writ from the ministry of war (College of
General Commissariat) dated May 5, 1804, orders that the men shall be
visited before they are sent home, in order to prevent their bringing
venereal disease to their respective communities. If they are found to
be suffering from such disease, they are detained in their garrison until
the competent chief physician can give them a certificate of health. A
circular of August 5, 1805, from the same board, provides that, at the
beginning of their time of service, an instruction shall be given to the
soldiers respecting the symptoms of the disease, that they may know the
dangers connected with their concealing or neglecting the same. All
sergeants, musicians, and soldiers are visited when beginning their time
of service, when being dismissed, and as a rule regularly twice a month.
In order to prevent, as far as possible, the propagation of syphilis in the
cities, military persons suffering from that disease are required to indicate
the probable source of their disease, so that the police may know it, and
prevent such woman from further propagating the disease.
The measures taken to prevent the propagation of venereal contagion
have been, as may be seen from the preceding notices, arbitrary, and
consequently not sufficiently to be relied on. This has been remedied by
the following:—
Law of April 10, 1874, respecting Measures to prevent the Propagation of
Venereal Disease (approved by the Parliament and by the King): —
§ 1. Persons suffering from venereal disease, whether able or not to defray
their cure, are entitled to claim medical attendance at public expense, and in
the mean time they are bound to submit to such cure if they cannot prove their
having private medical attendance; if the circumstances of the persons affected
are such that the contagion from them to other persons can be satisfactorily
prevented only by their removal, or if they do not observe the instructions
given in order to prevent contagion, they must be taken to an hospital to be
cured. Respective questions are, if necessary, to be decided by the bailiff (in
Copenhagen by the director of police) under recourse to the minister of justice;
and the observance of the obligation can be enforced by coercive fines, dictated
by the authorities. Persons who receive support through regular public alms
and are found to be suffering from venereal disease, must be taken to an hospital
to be cured. If, after the disease being cured, there is a particular reason to
fear relapse of the same in a contagious form, the physician who has attended
the patient may give her the injunction to appear before him at a fixed time,
or to produce a certificate from an authorized physician that no such relapse
has taken place. This injunction may also be enforced by coercive fines,
dictated by the above-mentioned authorities.
§ 2. A child suffering from venereal disease must not be given to be suckled
by any other woman than its own mother, nor is any nurse knowing or sup-
posing herself to be suffering from the disease, permitted to take the child of
any other mother to suckle it. Respective transgressions incur the penalty
W E N E R E A L DIS E A S E IN D E N M A R R. 751
mentioned for the crime in question, in § 181 of the General Civil Penal Law,
and in the mean time the transgressor, if the disease has been propagated, shall
be bound not only to indemnify the infected persons for the expenses connected
with their cure, but also to give indemnity for the sufferings and losses occa-
Sioned by the disease. The same duty of indemnification is incumbent on any
person who places a child at nurse, knowing that it is suffering from venereal
disease, or suspecting it to be so, or who gives a child, suspected of the disease,
to be suckled, without previously informing the foster-parents or the nurse
that the child is suffering or suspected. These legal provisions are also ap-
plicable to public authorities who place children to be fostered or suckled. A
child is to be looked upon as suspected of suffering from the above-mentioned
disease, even if no symptoms of it have been observed, if the mother is suffering
or has formerly suffered from the disease in any of its constitutional forms, and
three months have not elapsed since the birth.
§ 3. If a woman, not belonging to those who, by regulations or rules, are
submitted to the inspection of the police as belonging to prostitution, is defini-
tively suspected of subsisting by prostitution, she is to receive warnings from
the police, and to be informed of the consequences connected with the neglect
of the warnings. In the mean time, if she consents to it, or admits herself to
be leading a licentious life, she is to be examined by a physician, and, if she is
found to suffer from venereal disease, to be submitted to cure according to $ 1.
A woman duly taught and authorized can also be trusted with this examination,
and in that case the consent alluded to will not be necessary.
§ 4. § 180 of the Penal Law has been changed in such a manner that the
penalty of imprisonment mentioned in the same may, where no compulsory
workhouses exist as appointed by law for expiating punishment for vagrancies,
be changed to compulsory work for a period not exceeding ninety days. If a
woman is accused so as to be punished according to § 180 of the Penal Law,
she is to be examined by a physician, and, if she is found to be suffering from
venereal disease, is to be submitted to cure according to § 1. After having
suffered the punishment, she is again to be warned according to $ 3, and may
then be submitted to the inspection of the police, conformably to the rules
given in the following paragraphs.
§ 5. If a woman, in consequence of the preceding paragraph, is submitted to
the inspection of the police, or voluntarily submits to it, she is to be ordered
by the police to submit to medical examination at fixed periods, and to give
notice of every change of lodgings. If, when examined by a physician, she is
found to be suffering from venereal disease, she is to be submitted to cure
according to $ 1. -
§ 6. Transgressions of the injunctions given in consequence of the preceding
paragraph, are punished by imprisonment with bread and water for a period
not exceeding four days, imprisonment with the usual prison-fare not exceeding
sixteen days, or compulsory labor not exceeding twenty-four days (compare $4.)
If such woman does not present herself to be examined, and has no admissible
reason for her absence, and is afterwards found to be suffering from venereal
disease, she may, if residing at Copenhagen, or any other place having, in con-
sequence of the law of February 4, 1871, § 2, Libra C., legal provisions for the
inspection of licentious women, by the decision of the respective police masters,
be submitted to the rules and regulations of that place respecting the inspec-
tion of licentious women. But she cannot be ordered to live in public houses
unless her conduct after that time necessitates such measures.
§ 7. A woman who has already been sentenced according to § 180 of the
Penal Law (compare $4 of this law), and who is again found to have been
guilty of subsisting by prostitution, is, besides being punished in consequence
of the said rules, with the restriction mentioned in the preceding § 6, to be sub-
mitted to the regulations or rules for the inspection of licentious women, as
long as, after having suffered the punishment, she continues to sojourn at
752 ENGELSTED,
Copenhagen, or any other place for which, in consequence of the law of Febru-
ary 4, 1871, § 2, Libra C., such rules are given.
$ 8. The inspection mentioned in § 5 ceases, as far as the woman in question
has not already formerly, in consequence of §§ 6 and 7, been submitted to, or
has herself submitted to, the inspection which according to regulations and rules
is instituted in certain places for licentious women, at all events at the expira-
tion of six months. If, with respect to a woman’s situation or conduct, such
change has taken place as may be considered sufficient security with respect
to her future conduct, the police master ought to exempt her from inspection
before the expiration of the period mentioned.
§ 9. The medical examinations mentioned in this law are, if at the place in
question no local police-physician has been appointed, to be executed by the
public physician of the place, and in the locality designated by the police. For
this the physician receives an annual remuneration, fixed by the municipality
and approved by the minister of justice, or, if such remuneration has not been
fixed and approved, a payment, for each examination, of 4 Kroner (2 Rol.) for
the first person examined at the same time and at the same place, and 1 Kroner
(48 Skilling) for each following person. The remuneration is paid from the
town fund, in the country from the fund of repartition of the district, and in
Bornholm from the united fund of town and district. The physician is not
separately paid for a certificate stating whether the person examined has been
found or not found to be suffering from the disease. The medical examination
mentioned in §§ 3 and 5 may also, with the permission of the police-master,
and on condition that the particular regulations given are observed, be executed
by an authorized playsician approved by the police, with whom the woman in
question must then herself settle the matter.
§ 10. They who at public expense are taken to an hospital to be treated for
venereal disease, are not permitted to leave the hospital before they have been
dismissed by the physician of the hospital. Transgressions of this rule are
punished by imprisonment with bread and water not exceeding five days, or
simple imprisonment not exceeding one month.
§ 11. Lawsuits in consequence of $$ 4, 6, and 10 of this law are prosecuted
in the same manner as public cases, but at Copenhagen with closed doors. The
police is authorized to forbid persons, keeping public houses, to lodge women
who have received warnings according to § 3 of this law, and also to forbid
them to employ such women for the entertainment of their guests, or as servants.
If women submitted to the inspection of the police or subsisting by prosti-
tution, or persons assisting and lodging them, are guilty of transgressions or
neglect of the above prohibition with respect to regulations or rules which, in
consequence of law of February 11, 1863, § 8, or law of February 4, 1871,
§ 2, C., are given for the inspection of licentious women, the police-master is
authorized to sentence such persons to a fine not exceeding 100 Kroner (50
rix-dollars), imprisonment with bread and water not exceeding four days, or
imprisonment with the usual prison-fare not exceeding sixteen days, or com-
pulsory labor not exceeding twenty-four days.
Full effect was afterwards secured to this law by the police, through a
practical provision. It being well known that a great number of the
women who, in the capital, were comprehended in the above law came
from other jurisdictions, and that, on the other hand, women who in the
capital had received warnings according to § 180 of the Penal Law, or
who had been entered in the registers of public women, left the capital
and went to the provinces in order to continue a licentious life there, it
was attempted to bring about a control based on a regular co-operation
between the police of Copenhagen and that of the rest of the kingdom,
with respect to such women during their removal to different parts of
the country. It was stipulated by the police of Copenhagen that, when-
W E N E RE AL DISE ASE IN DE N M A. R. K. 753
ever a woman under inspection as mentioned in § 5, or at length entered
in the registers for public women, gave notice that she would leave the
town, or was known by the police to go to another part of the kingdom,
the respective police authorities should be informed of it; from such
authorities the police of Copenhagen then requested similar communica-
tions, and to be informed of every sentence passed against any woman
for transgressions after having received warnings according to § 180 of
the Penal Law. In an appendix to the Police-Intelligence, published
on the first and fifteenth of every month, and sent to all the police
authorities, informations are given partly with regard to Copenhagen,
respecting all women under inspection, or having left inspection, or
entered in the registers for public women and again crossed out, partly
with regard to the whole kingdom, respecting women who have been
sentenced for transgressions after warnings according to § 180 of the
Penal Law.
The warning mentioned in the law is by the police of Copenhagen
given to the respective women by means of a printed blank, as fol-
lows:— -
Transcript from the Registers of Warnings, kept by the Police of Copenhagen, for
licentious women.
Case No. . . .
Year 18 . ... the -> º . has been given to
the following warning :
born at º years old, and now lodging at .
having admitted herself to have incurred positive suspicion of subsisting by prostitution,
warning is given to her according to # 3 of law of April 10, 1874, and she has been given
to understand that a transgression of the warning, according to 3 180 of the Penal Law,
and & 4 of the law above mentioned, will entail upon her punishment of imprisonment or
compulsory labor.
For the correctness of the transcript:
e , Police Inspector.
Women who, according to law, are submitted to the inspection of the
police, receive a printed blank of the following contents:—
Transcript from the Registers of Warnings, kept by the Police of Copenhagen, for
lºcentious women.
Year 18 . ... the e º - - e , who, according to sentence passed
by the criminal and police court, division for public police cases, has suffered punish-
ment of . º º * . for transgression against & 180 of the Penal Law, appeared,
and received renewed warning conformably to the warning given to her the º -
and which was read to her, and she was given to understand that a transgression would
entail upon her punishment of imprisonment or compulsory labor.
It was at the same time declared to her that, according to # 4 of the law of April 10,
1874, she was submitted to the inspection of the police, and she was, therefore, given the
injunction to appear, for the purpose of medical examination, in that division every
e º º day, between . * . and . º ... o'clock in the afternoon,
and to give notice of any change of lodgings within twenty-four hours, under penalty of
punishment according to the said paragraph, if she should in any way transgress against
this injunction. -
For the correctness of the transcript:
e º g e - º , Police Inspector.
On this transcript are also printed the contents of the penal law, and
an extract from the law of April 10, 1874. Public women entered in
the registers according to the law of April 10, 1874, have been, since that
time, according to § 8 of the law of February 11, 1863, subjected to
treatment according to the following regulations:—
48
754 E N G E L STEI),
Regulations for the Inspection of the Police respecting public women in
Copenhagen.
3y whom the inspection is to be made.—$ 1. The inspection incumbent on the
police with respect to public women, is to be made conformably to § 31 of
police instructions of June 7, 1869, by the third police inspector, and under
the superintendence of the police director. The increase of medical assistance
required in consequence of the execution of the sanitary measures connected
with the said inspection, and also the distribution of the medical functions, is,
according to $ 7 of the law concerning the re-arrangement of the police of
Copenhagen, to be regulated by supplements to the police regulations of
June 12 of last year [1873], and to the police instructions of June 7, 1869.
Public Women.—$ 2. Every woman registered as a public woman is subjected
to these regulations, and to the right of punishing which the police director
has been given by the law respecting the mode of treatment of public police
cases, of February 11, 1863, § 3. (Compare law of April 10, 1874, § 12.)
§ 3. No woman can, at her own request, be registered among public women
before she has completed her eighteenth year. Exceptions, however, may be
made with regard to women who are well known to have already become ad-
dicted to a licentious life, and when all endeavors to reform them have proved
fruitless, and if they have, at the same time, completed their sixteenth year,
and are of sufficient bodily development.
§ 4. No married woman can, at her own request, be registered as a public
woman, unless she has been abandoned by her husband ; and the latter, if his
declaration in this respect is to be had, refuses to renew cohabitation.
§ 5. With regard to every woman, registered as a public woman, exact in-
formation must be produced of her name in full, place of birth, age, homestead
and last place of residence, her own personal situation and preceding life, to-
gether with her motives for this step. It is therefore the duty of the police
inspector, whenever a woman requests to be registered as a public woman,
and especially if she has not already been submitted to the inspection men-
tioned in §§ 3–7 of the law for measures to prevent the propagation of venereal
diseases, to satisfy himself that such woman fully knows the import and conse-
Quences of her intention, and by admonitions, by the assistance of her relations,
and by other means at his disposal, to try to induce her to better purposes,
and, if possible, facilitate her return to decent life.
§ 6. If, after the above injunctions having been observed, it is found that
her request ought to be granted, she is to be submitted to medical examina-
tion, in order to ascertain whether her bodily constitution should in any way
prevent her from being registered, and whether she is at the time free from
venereal contagion. She is afterwards, by the police inspector, and before the
protocol, to be acquainted with all the contents of these regulations, the need-
ful of which is to be entered in the registers, and after this read to her, in the
presence of valid witnesses, and agreed upon and signed by her. She is then
registered in the list of public women which is to be kept in schematical form,
containing, for each woman, an extract of notices concerning her person.
§ 7. When inscribed, such a woman receives, against a certain payment, a
control-book containing the paragraphs of the present regulations with regard
to her position as a public woman, as well as other rules that are to be ob-
served by her, together with rubrics for medical visitations during a whole
year. On the title-page is written her name in full, and the day when inscribed;
on the next page the days on which she is to present herself for medical exami-
nation together with subsequent changes in that respect, and on the last page
of the book her lodgings, and, if she is living in a public house, also the num-
ber of her room, together with later changes in this respect.
§ 8. Public women, with the exceptions afterwards mentioned in §§ 15 and
49, ought always to be in the possession of their books of control, in order to
be able to produce them whenever so requested by the police. It is strongly
W E N E R E A L DISE ASE IN DE N M A. R. K. 755
forbidden to pawn them, or to lend them to others. If a pubiic woman has
lost her book of control, she ought, immediately, to inform the third inspector
of it, when a new copy, marked “renewed,” is to be given to her.
§ 9. The public women are divided in two classes: (1) Women who are
living by themselves; (2) women living in public houses. To the first class
belong : (a) those inscribed in consequence of §§ 6 and 7 of the law of April
10, 1874, as long as their conduct does not necessitate their being ordered to
take lodgings in a public house ; (b) those who have special permission to live
by themselves. Such permission can be given by the police inspector, but, as
a rule, only to those women whose conduct has always been unexceptionable, and
only with the consent of the landlord of the house. This permission may be
recalled at any time, and this ought to be done with such women as are often
guilty of transgressions of these present regulations, particularly of §§ 11 and
12. All other women must live in public houses.
§ 10. Every public woman, whether living in a public house or by herself,
must have the permission of the police inspector to change her lodgings, and,
if she is herself the cause of her removing, she is only permitted to remove
twice a month.
§ 11. No public woman is permitted to have her child at her house after its
fourth year, and by no means the children of other people. She is not per-
mitted to have her sweetheart at her house. She is not permitted to receive
visits from males who are not yet adult. She is not allowed to receive any
pawn from males visiting her. She is not allowed to lodge other women.
The police has free access to inspect her rooms by day and night.
§ 12. Public women must carefully abstain from any disorder and from
any indecent behavior in streets and public places, and must strictly observe
the rules given them by the police in that respect; especially are they forbidden :
(1) To appear in any indecent or sensational dress; (2) to show any indecent
behavior; (3) to flock, to follow anybody, to accost or call anybody by words
or signs; (4) to place themselves at their windows, or to be standing in the
house-door, in the street, or on the foot-pavement before their houses; (5) to go
in company with several others, or to marshal up, or walk up and down streets,
public places, and walks; (6) to have other places in the theatres or public
places of amusement than those permitted by the police ; and (7) to be sitting
guests in coffee houses, restaurants, and similar places of entertainment. Dur-
ing the time that the street lamps are lit, the regulations given under (4) need
not be observed by public women living in the following streets: Holmensgade
between Lille Kongensgade and Wingaardstræde, Bróndstroderne, and Diderik
Badskjorsgang. Public women are never allowed to go through Amaliegaderne
and Amalienberg Plads, nor, after particular orders from the police, in the
principal streets of the city later than noon. Public women living in public
houses are not permitted to appear in the street from the time when the street-
lamps are lit, until they have been put out; the police-director is authorized
to allow exceptions from this injunction.
§ 13. Public women are strongly forbidden to apply to males who have
visited them, or to the relations of the same, in order to ask money from them,
or for other reasons. But they may request, and according to circumstances
expect, the intervention of the police.
§ 14. No public woman is permitted to go beyond the limits of the jurisdic-
tions of the northern and southern parts of the district of Copenhagen and the
jurisdiction of the island of Amager, nor to be absent more than twenty-four
hours. Before being permitted to undertake a journey, she is to be visited by
a physician.
§ 15. As soon as any public woman thinks herself infected with venereal
disease, she ought to apply immediately to the examining physician, or to
present herself at the hospital kept for that disease, and there she must deliver
her control-book, that it may be sent to the police-inspector together with
information respecting her being admitted at the hospital. Every public
756 ENGELSTED,
woman admitted at an hospital for any other complaint than venereal disease,
must also deliver her control-book at the hospital.
§ 16. Whenever a public woman is by illness prevented from coming to
the medical inspection, she must every day of the usual examination send to
the police-inspector an attestation from the physician attending her, concern-
ing the nature of her illness, and that there is no symptom of venereal disease,
or else apply for the inspector's permission to be examined at her home.
$ 17. Whenever a public woman, by certificate of marriage, has proved that
she has been legally married, she is to be immediately obliterated from the
registers of inscription.
§ 18. A public woman otherwise wishing to be obliterated from the registers
of inscription, Ought to apply to the police-inspector, whom she is to make
fully acquainted with her future profession, occupation, and lodging, and who
is then to inform the police-director of the case, and he is then to decide
whether her request can be complied with ; she must, however, if she does not
adopt a solid position of life, or may by other means come to a situation offer-
ing sufficient security as to her future conduct, continue to be under the inspec-
tion of the police, and be subjected to the right of punishing with which the
police-director is invested according to § 12 of the law of April 10, 1874, until,
after having shown an unexceptionable conduct during three months, she may
be definitively obliterated.
§ 19. Every woman obliterated from the registers of inscription, ought to
receive a warning conformably to § 180 of the Penal Law, and it ought to be
said to her that, if she again tries to subsist by prostitution, she will be prose-
cuted and punished, and submitted to the measures ordered by §§ 4–7 of the
law of April 10, 1874, and, among other things, be immediately entered in the
registers as a public woman if she has formerly been punished for licentious
life.
$ 20. Public Houses.—The police is authorized to allow the existence of
houses to afford lodgings for public women, under the inspection and responsi-
bility of a hostess living in the house. Such concession may exceptionally be
given to male persons, who are then subjected to the same regulations given,
in the following sections, for the hostess.
§ 21. Concession to keep a public house is given by the police-director. It
is always granted for an undetermined period, and preferably to old public
women whose conduct has been without grievances. When such concession is
sought for, the house must be exactly described, and it must be proved that
the house-owner's consent has been given.
§ 22. Such public houses can, without the consent of the magistracy, only be
permitted in the following streets: Lille Bróndstrode, Diderik Badskjorsgang.
Dybensgade, Faruergade, Gaasegade, Helsingorsgade, Holmensgade (between
Lille Kongensgade and Wingaardsstrode), Hummergade, Knabrostrode, Mag-
strode, St. Gertrudstode, Tornebuskegade, and Vogumagergade. A street
Once having become free from such public houses, new ones cannot be estab-
lished there without the consent of the magistracy.
§ 23. Every hostess keeping a public house, shall be submitted to the pre-
sent regulations, and the right of punishing given to the police-director by
§ 3 of the law of February 11, 1863. She must also conform to the injunctions
which the police may find it necessary to give her.
$ 24. No married woman, dependent on her husband, can be permitted to
establish a public house, without the written consent of her husband.
§ 25. In a public house no other inmates are permitted, without the per-
mission of the police-director, but only the hostess, her husband, and children
under the age of 7 years, the public women, and the necessary female servants.
All rooms for public women ought to have consecutive numbers on the out-
side and the inside of the door, written in plain figures.
§ 26. They who keep public houses are bound to observe the greatest pos-
sible cleanliness, and to procure all such things as the police-director, after
W E N E R E A L I) IS *-*
–4–4
T
K
|E
~
I N ID E N M A. R. R.
E A S & 757
having discussed the matter with the examining physician, may prescribe with
respect to health. The windows facing the streets must always have Venetian
blinds that are locked up. -
§ 27. The hostesses of public houses must be accountable for the lodging
women's coming to medical examination at the fixed hours, and in clean and
decent dress.
§ 28. They who keep public houses cannot by any means refuse to the police
officers to inspect the house, by day or by night.
§ 29. They are not permitted to give lodgings to any public woman, without
notifying it to the police. The police-inspector must ſix the number of public
women allowed to each house.
§ 30. The hostesses of public houses are bound to inform the police-inspector
of the name, age, and native place of each of their servants, and the latter can
only be engaged with the consent of the police-inspector. Hostesses who are
unmarried, or separated or divorced from their husbands, can be submitted to
medical examination as ordered by §§ 40–49 and 52–54.
§ 31. The police is authorized to fix the payment which the woman living
in public houses must pay both for room and fare in the house, and the hostess
is to conform to this injunction.
§ 32. The hostess is answerable for the observance of the injunctions given
in § 11, and she also can be rendered answerable that public women living at
her house observe the injunctions of $ 12, as far as, according to the nature of
the same, she is able to have any influence in that respect.
§ 33. When a public woman has been given notice from her hostess to
remove, both of them must, at the same time, appear before the third police-
inspector, in order to have the necessary remarks added to the registers of
inscription, and in the woman’s book. Removal may be notified from both
sides, with only twenty-four hours’ notice.
§ 34. The hostesses are subject to punishment if women are found in their
houses who have not their books of control, and have not given notice that
they have been lost, or who have not been duly announced to the police con-
formably to § 29.
§ 35. The hostesses of public houses must always have in their possession
an extract from these present regulations, containing all injunctions with
regard to them ; it must be bound like a book, and must bear the name of the
hostess and the street number of the house, and state the number of public
women permitted to live there.
§ 36. Any dissension taking place between the hostess and the public women
living at her house, concerning their situation in that quality, is to be decided
by the third police-inspector, and may only by his permission, or that of the
police-director, be brought before a tribunal.
§ 37. All sorts of games with the guests are forbidden in the public houses.
§ 38. Objects having been forgotten in such houses ought to be delivered to
the police within twenty-four hours.
§ 39. The hostesses are not permitted to leave the town for more than one
day.
Sanitary measures.—$ 40. Every public woman ought to be, as a rule, sub-
mitted to ordinary medical examination twice a week.
§ 41. Extraordinary medical examinations are to take place as often as the
police-officer thinks it necessary, and they do not exempt the public women
from the ordinary medical examinations.
§ 42. The ordinary medical examinations are made in the public localities
kept for that purpose; and there must be at least two such rooms in conve-
nient parts of the town, besides the rooms for examinations at the police
office. Medical examinations may also be allowed to take place at home,
where the localities are fit for such use. This permission is granted by the
police-director with respect to public houses, but may be given by the police-
inspector to women that have private lodgings. The police-inspector is also
7.58 ENGELSTED,
authorized to permit a woman who has private lodgings, to have her own
physician, approved by him, whose certificate that she is not suffering from
any venereal disease then replaces the medical examination. Such permissions
may be recalled at any time.
§ 43. Public women who do not appear to be medically examined, or who
are not at home in their houses at the time fixed for their examination, are to
be arrested and taken to the police Office to be examined, and are also subject
to punishment. -
§ 44. If any public woman tries to prevent the examination from being made
as exactly as the physician thinks necessary, she is looked upon as having not
appeared ; and, according to circumstances, can also be taken to an hospital
for observation.
§ 45. Whenever an ordinary or extraordinary examination has taken place,
the physician is to inscribe in the control-books of the public women, and in
registers kept for that purpose, the day when the medical examination took
place, the state of health of the woman, the nature of the complaints Observed,
and other remarks he thinks useful. All these remarks ought to be made by
the examining physician in person.
§ 46. Every public woman who by ordinary or extraordinary examination is
found to be suffering from venereal disease, is to he taken immediately to an
hospital, and have along with her a certificate declaring the nature of the com-
plaint and where it is. Persons who show dubious symptoms of this disease
are likewise taken to an hospital until it has been decided whether they are
infected or not. In consequence thereof, women who are living alone, and are
permitted to be examined at home, must appear at the hospital if they have
not been found to be sound ; and the hostesses of public houses who are
allowed to have the examinations made in their houses, are co-responsible that
persons living in their houses, and who at the medical examination are found
to be infected or are suspected of being so, are immediately sent to the hospital.
§ 47. Every conveyance of loose women between the police office and the
hospitals must be by carriage, and, as far as possible, at the cost of the respec-
tive Women.
§ 48. Any public woman who, after having been declared to be suffering from
venereal disease, removes from her lodgings, is immediately to be apprehended
and carried to the hospital, and, after being cured, is to be punished. Likewise
every public woman who is found to be suffering from the said disease without
having declared it, will be punished if, according to the declaration of the
physician, it must be supposed that, in consequence of the nature of the disease,
she cannot possibly have been ignorant of it. Every public woman who is
conscious of, or supposes herself to be afflicted with, venereal disease, and has
nevertheless sexual intercourse, will be prosecuted and punished according to
§ 181 of the Penal Law.
§ 49. Whilst public women are at the hospital, their control-books are
deposited at the police office, and are only returned to them when they have
been dismissed from the hospital after having been cured. They are also,
during the rest of their stay at the hospital, subjected to the injunctions of the
police with respect to their conduct, and submitted to the right of punishing.
§ 50. Public women are bound to observe strictly the sanitary rules given
to them by the examining physicians, or the police-inspector, or the physicians
of the respective hospitals. t
§ 51. The examining physicians are not permitted to treat public women,
their hostesses, or the servants of the hostesses, for venereal disease or any
other illness, nor to receive any fee from them or from others on their account.
Payment for medical eaſaminations, etc. — $ 52. Extraordinary medical
examinations shall not be paid for. Likewise the ordinary medical examina-
tion, in at least one of the public localities for examination, is to be made
gratis. For other ordinary examinations, when executed in the public rooms
for examination, must be paid 25 Ore, or 50 Ore for each separate examination
W E N E R E A L DIS E A SE IN L) E N M A. R. K. 7.59
after the time when they ought to have taken place; and, when executed at
home, 1 Krone if the examination is executed in a public house, and 1 Kr. 50
Ore when in private lodgings.
§ 53. The fee for examinations at home, as well as for examinations to
be paid for in public rooms for examinations, is to be paid in advance for a
fortnight to the third police-inspector, and, as to examinations in public
houses, paid by the respective hostesses or hosts, or else by the respective
women. The hostess or the woman is given a mark for each examination paid
for in advance, when the examination takes place, given to the physician and
by him to be delivered to the police-inspector.
§ 54. Every public woman who has not paid in advance, and, according to
the above rules, in due time, is in consequence thereof bound to appear at the
next medical examination (§ 7) in the rooms for examinations gratis, and at the
time fixed for such examinations. - -
§ 55. The control-books for the public women, as well as the books, etc.,
which, according to these regulations, must be found in public houses, are
furnished by the police, but are paid for by the respective women or hostesses
with a price like that which the police has paid for them. -
Divers provisions.—$ 56. Public women subjected to these regulations who,
without the precincts of the town, are guilty of transgressions against the
obligations under which they are, according to these regulations or in conse-
quence of the same, are to be punished as if the transgressions had taken place
within the precincts of the town.
§ 57. The police-director is, by § 12 of the law of April 10, 1874, authorized
to dictate punishment by fines not exceeding 100 Kr., imprisonment with
bread and water not exceeding four days, and imprisonment with the usual
prison-fare not exceeding sixteen days, or compulsory labor in the institution
for compulsory labor at Copenhagen, to public women, hostesses (and hosts)
who have a concession to keep public houses, and to the servants whom the
police-inspector has permitted the hostesses or public women to have.
§ 58. All expenses occasioned by the inspection of public women are to be
paid by the municipal fund which receives the payment fixed by § 52 for medi-
cal examinations.
Similar regulations may, according to § 2, C., of the law of February
4, 1871, be made for country towns.
No positive results of the law of April 10, 1874, can, of course, yet be
pointed out with respect to the diminution of the venereal diseases; but
such effects can be stated as will give an idea of the results that may be
hoped for.
No greater number of public women has been registered than formerly.
The respective yearly numbers were
1872 . º & ſº . .289
1873 . e tº e . 294
1874 . tº g & . 353
1875 . {} te © . 345
but before that time the numbers were as large; thus in
1862 . e ſº iº . 354
1863 . g e wº . 352
1864 . * gº . 354
and for the rest it has been between 200 and 300. But the number of
women under control, by being submitted to medical inspection without
being registered as public women, has risen to a very high degree. The
number of women suspected of a licentious life, and who have produced
attestations from private physicians, are
760 ENGELSTED, v ENE REAL DISE ASE IN DEN M A R K.
1872
1873
1874
1875
337
567
1027
1340
These numbers show that, since 1874, control has been effected with a
very great number of the sort of women who are the most dangerous
with respect to the propagation of venereal contagion."
The great im-
portance of this control may be seen from the following table, in which
the first columns refer to the women under inspection, and the others to
women not under frequent inspection, but Occasionally apprehended and
examined by the police.
Result of examinations of women
under inspection.
Result of examinations of women
not under inspection.
Number of Number found Number of Number found
examinations. diseased. examinations. diseased. Years.
|
27674 780 Or 2.8 602 173 Or 28.7 1860
27825 772 “ 2.7 551 167 “ 30.3 1861
31229 935 “ 2.9 653 192 “ 24.4 1862
30483 1056 “ 3.4 651 216 “ 33.1 1863
32020 1046 “ 3.2 642 169 “ 26.3 1864
29106 1050 “ 3.4 476 122 “ 25.6 1865
27863 990 “ 3.6 642 152 “ 23.6 1866
23.538 686 “ 2.9 888 171 “ 19.2 1867
22622 814 “ 3.6 722 230 “ 31.8 1868
23.407 800 “ 3.7 806 261 “ 32.2 1869
25,740 879 “ 3.4 602 181 “ 30.0 1870
25748 679 “ 2.6 655 182 “ 27.7 1871
261.45 823 “ 3.1 637 253 “ 39.7 1872
25547 751. “ 2.9 786 229 “ 29.1 1873
26.783 885 “ 3.3 953 300 “ 32.5 1874
291.65 907 “ 3.1 670 178 “ 22.2 1875
| Among special affections I will only mention mucous patches, which have been found
nine times as often in women not under control as in those registered and regularly in-
spected.
SECTION ON OBSTETRICS.
P R E S I D F N T OF T H E S E C T I O N .
ROBERT BARNES, M.D.,
OF LONDON.
W I C E - P R E S I D E N T S .
ALEXANDER. R. SIMPSON, M.D., WILLIAM H. BYFORD, M.D.,
OF EDINBU R G H . of CHICAGo.
S E C R. E. T. A. R. Y.
WILLIAM GOODELL, M.D.,
OF PHILADELPH H A.
On taking the chair, Dr. BARNES said:—
I do not know how I can express my thanks for the very unexpected honor
of being called upon to preside over this Section—one of the most important
connected with this Congress. In England we recognize the value of this
branch of study, but there is no country that can claim superiority over Ame-
rica in the development of the science of Obstetrics. Your writers are acknowl-
edged as authorities, and, as you are in the lead, it is incumbent upon you to
cultivate and improve your discoveries. It is incumbent upon us all to culti-
vate the practice of obstetrics, for it lies at the very root of the human race.
I have been asked why I did not attend a congress in St. Petersburg, which
may be called a great medical centre. I preferred to come here, and yet it
seems singular to leave the centre and come to what we might call the outside.
It is no slight task to spend three weeks of one's holiday on the stormy ocean,
but our assembly to-day is an event—it might be called an epoch--in the His-
tory of Medicine. I cannot sufficiently express my sense of the honor con-
ferred upon me. I hope to hear some interesting discussions upon the topics
brought before us, and have no doubt that I shall go back to my home wiser
than when I came.
762
THE CAUSES AND TREATMENT OF NON-PUERPERAL
HEMORRFIAGES OF THE WOMB.
BY
WILLIAM. H. BY FORD, M.D.,
PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN IN THE CHICAGO MEDICAL COLLEGE.
THE short time at my disposal makes it impossible for me to give any-
thing more than a brief outline of the etiology and therapeutics of
uterine hemorrhage, and I shall, therefore, confine myself to a succinct
expression of the views which may be fairly sustained by our present
knowledge of the subject.
Without stopping to discuss at length the meaning of the terms ap-
plied to uterine hemorrhages, I may say that I shall use the words
“uterine hemorrhage” and “metrorrhagia” in the same sense, and shall
apply them to such losses of blood as occur between the menstrual
periods, or in unusual amounts at the time of the periods themselves.
An excessive, or too long-continued, flow of blood at a menstrual period
is practically neither more nor less than metrorrhagia, Originating in like
causes, and amenable to the same treatment.
CAUSES OF METRORREIAGIA.
Non-puerperal hemorrhage is properly regarded as a symptom, and the
consideration of its causes brings to our attention a great variety of local
and general pathological conditions. Exceptional cases of metrorrhagia
sometimes result from direct violence to the uterus, or from sudden and
severe shocks to the system, which apparently act upon the uterus in
common with other organs, and cause it to bleed because of its inherent
tendency to do so. The pathological causes which induce uterine hemor-
rhage do not always—perhaps do not generally—act singly, but two or
more of them are found associated in most cases, some being essential,
and others merely auxiliary. The uterus, by virtue of the conditions
upon which menstruation depends, is naturally a hemorrhagic organ ;
and it is in consequence of its anatomical and physiological peculiarities
that the ordinary and frequently acting causes of uterine hemorrhage
are rendered so potent and effective. -
The more obvious phenomena of menstruation are doubtless the result
of a definite reflex nervous influence exerted by the ovaries upon the
uterus. Although this influence is more distinctly manifested in the
great hyperaemia which precedes the occurrence of the catamenial dis-
charge, and the changes in the utricular glands and mucous membrane
of the womb, yet it is unquestionably constant in its action and parallel
in this respect to that which presides over the motions of the heart, the
arteries, and the alimentary canal. Generated in the nervous apparatus
of the ovaries, and contemporaneous with the changes called ovulation
in those organs, this influence is probably conveyed by afferent nerves to
the genito-spinal centre (the existence of which was first established by
N ON - PU E R P E R A L H E M O R R H A G E S OF T H E W O M B. 763
T}udge, of Greifswalde'), or to some other reflecting ganglion, whence it is
Sent back to the uterus, giving rise to a wonderful series of tissue-changes
during the month. Some of these changes have been lucidly described
by Dr. John Williams, in the Obstetrical Journal of Great Britain and
Ireland, and by our own talented young countryman, Dr. Engelman, in
his recent essay upon the subject, published in the American Journal of
Obstetrics. These changes are aptly termed by Aveling, nidation and
denidation.
A few days before the menstrual flow makes its appearance, the whole
uterus, and especially its mucous membrane, becomes greatly hyper-
trophied and very vascular; when the discharge begins, the membrane
is invaded by fatty degeneration. This process is so rapid that, in four
or five days, the entire mucous membrane disappears, leaving the mus-
cular structure of the inside of the uterus exposed, while some remnants
of the utricular glands are left, and found entangled among the denuded
fibres. As soon as the monthly flow ceases, a reproduction of the mem-
brane is commenced, and it continues to grow until at the end of twenty-
eight days its menstrual maturity is attained. Accompanying these
changes in the cavity of the uterus are others equally remarkable, affect-
ing all the other tissues of the organ. The blood vessels become enlarged,
and circulate an increased amount of blood ; the fibrous tissue is devel-
oped beyond its inter-menstrual condition ; while hyperaesthesia indicates
extraordinary nervous endowment. In fact a true hypertrophy of the
uterus occurs. During the discharge, the process of involution reduces
the organ to its smallest dimensions, and the hemorrhage ceases. The
culmination of this hypertrophy in the discharge of biood from the
uterus is doubtless not merely an accompaniment, but a consequence of
the breach of capillaries in the mucous membrane. These of course are
physiological phenomena, but I desire to imvite attention to the fact that
they strongly resemble pathological conditions, and would be so considered
in any other organ in the human economy. Moreover the dividing line
between health and disease in uterine hemorrhage is as difficult to trace
as that between sanity and lunacy.
It is not difficult to understand that an exaggeration of the hyperaemia,
or an unusually rapid disintegration of the uterine mucous membrane,
would cause more than a normal amount of flow ; nor that a want of
accordance in time might be followed by the same result. Indeed most
cases of uterine hemorrhage are traceable to conditions which disturb
the equilibrium of these phenomena. The causes which thus act are
varied and numerous.
Morbid nervous influences which increase the discharge of blood from
the uterus, sometimes emanate from the nervous centres, and hence may
be properly termed centrie ; much more frequently, however, they are
reflected through the nervous centres from other and sometimes distant
organs, and these last are entitled to the denomination of reflec or eccentric
nervous influences.
Mental and emotional excitement emanating directly from the brain,
and cerebral and spinal excitement originating in inflammation or func-
tional exhaustion of the brain or spinal cord, are examples of centric
etiological influences. Many years ago I witnessed the ravages of an
Ueber das Centrum genito-spinales des N. sympatheticus. Virchow's Archiv f. Path.
Anat, und Klin. Med., Band XV., S. 115–126, and Chicago Journal of Nervous and Mental
Diseases.
764 BYF OR D,
epidemic of cerebro-spinal inflammation, in which uterine hemorrhage
was of almost universal occurrence among those adult females who fell
under its influence.
Morbid reflea nervous influences afford a more numerous class of causes.
First among them, both in frequency and importance, are those arising
from abnormal conditions of the ovaries, such as congestion, inflammation,
displacement, and erotic excitement. Next to the influence of these
bodies is that exerted by the mammary glands. Menstruation is generally
more profuse when it occurs during lactation. The effect of mammary
irritation in causing congestion of the uterus, and thus promoting hemor-
rhage from it, is well illustrated by the familiar fact that sinapisms or
blisters applied to the breasts will often cause metrorrhagia. Vesical
irritation or inflammation, which gives rise to tenesmus; rectal irritation,
as from the presence of hemorrhoids, or ascarides; and dysenteric inflam-
mation, through the reflex influence which they exert upon the uterus,
are generally recognized causes of uterine hemorrhage. Among other
reflex causes may be mentioned certain forms of indigestion, hepatic
congestion and inflammation, and some of the disturbances of the small
intestines, as may also strong impressions upon the cutaneous surface, as
from cold, or from the long-continued application of heat in warm
climates and seasons.
All of these last-mentioned causes I think act through the reflex
system of spinal nerves, and perhaps also through the agency of the
sympathetic ganglia which perform a reflex.function between the viscera.
The morbid effects of the various reflex nervous impressions are rendered
more effective and intense by the presence of such uterine diseases as
predispose to hemorrhage by increasing the vascularity of the uterus.
Many pathological conditions which conduce to the production of uterine
hemorrhage, independently of direct nervous influence, act by increasing
the hyperaemia of the uterus. When the mucous membrane is granulated,
or is the seat of inflammation, of fibrous polypus, or of malignant fungus,
the circulation of the uterus is increased, and harmony in the process of
midation disturbed ; and these conditions will be accompanied by an
unusual and long-continued flow of blood. Subinvolution, congestion
and inflammation, hyperplasia, tuberculosis, cancerous and fibrous deposits
in the muscular structure, and chronic and acute endometritis, in addition
to preventing the normal deciduous changes in the mucous membrane of
the uterus, maintain a permanent hyperaemia, and thus render the womb
prone to large losses at each return of the menstrual period. We have
in fact abundant reasons for assuming that chronic hyperaemia, no matter
how produced, will, by virtue of the malnutrition connected with it,
prevent menstrual changes from being effected in an orderly manner, and
thus render the mucous membrane more frail in organization, and con-
sequently incapable of resisting the force of vascular pressure to which
it is periodically subjected.
Besides the causes of uterine hyperaemia last alluded to, and existing
within the tissues of the womb, there are many other outside pathological
conditions acting in a different way. Some of these cause venous hyper-
aemia by mechanical retardation of the circulation, while others give rise
to both arterial and venous hyperaemia by nutritional attraction, and
others again cause arterial hyperaemia alone, by forcing unusual amounts
of blood into the organ. Among the most frequent and important causes
of venous retardation are displacements and flexions of the uterus—pro-
cidentia, retroversion and retroflexion—the former by stretching the
N ON - P U E R P E R A L H E M O R R H A G E S OF T H E W O M B. 765
veins and rendering their course more tortuous, the latter by twisting
them and thus lessening their calibre; exudations into the cellular tissue
and peritoneal pouch, from cellulitis and local peritonitis, and effusions
of blood in the cul-de-sac of Douglas, in retro-uterine hematocele, by
pressing upon the veins, prevent a free return of blood from the uterus,
and thus cause venous hyperaemia. Retardation of movement in the
uterine veins may also be caused by obstruction to the venous circulation
quite remote from the womb, as by the pressure of a tumor upon the
ascending vena cava, by a loaded condition of the large intestines, by
dislocation or enlargement of the liver, by obstruction to the free passage
of blood through the heart from valvular disease, and even by certain
pulmonary affections.
In the class of causes giving rise to both arterial and venous hyperaemia,
may be mentioned fibrous, fibrocystic, polypoid and fungous growths of
the fibrous structure of the uterus. These all increase the flow of blood
to and through the vessels of the uterus, both arteries and veins are
increased in capacity, and to these changes is added general hypertrophy.
In these cases, the hyperaemia of all the tissues is sometimes enormously
great, and the losses of blood are proportionally large and dangerous; the
hemorrhage, unlike that from venous obstruction, is not checked by the
emptying of the vessels, but continues until the arterial and cardiac vis-
a-tergo is weakened by approaching syncope.
Causes producing arterial hyperaemia alone, are hypertrophy of the
heart, general plethora, febrile excitement, and violent exercise. The
uterine hyperaemia in these cases is caused by unusual arterial and cardiac
pressure alone. When not attended by local pathological conditions, the
hemorrhage in these cases is not apt to be serious. -
Other not uncommon causes of hemorrhage from the womb are various
diseases of the blood. Among these may be mentioned scurvy, leucocy-
thamia, chlorosis, albuminuria and syphilis. It is not likely that the
vice in the composition of the blood is the sole causative influence
operating in the above-named conditions. In Scurvy, for instance, we
know that the solid tissues—whether as a primary condition or as an
effect of the blood-changes—are diseased, the capillaries more fragile than
natural, and consequently less capable of resisting the cardiac impulse.
As evidence that the vicious condition of both blood and solid tissues is
the cause of uterine hemorrhage in scurvy, the well-known fact may be
added that bleeding is very easily provoked in other mucous membranes.
It is the more likely to take place from the mucous membrane of the
uterus, because of the great normal fluctuations in the circulation of that
Organ, and also because the vitiated state of the blood would naturally
cause disturbance in other conditions attendant upon menstruation,
especially the decidual changes. It will be seen therefore that the pecu-
liarity in the operation of this variety of cause, is not due to the presence
of local or general hyperaemia from retardation of the venous circulation,
or from arterial and cardiac pressure, but is due to the tendency of the
blood to escape through the walls of the vessels, and to the inability of
the capillary tubes to resist the circulatory force ordinarily applied to
them.
As another cause of hemorrhage from the womb, must be mentioned
the well-known law of the human system to continue a long-established
habit, after the original cause is removed. This is probably the only
rational explanation of those rare uterine losses which are sometimes
observed in pregnancy, and in cases where both ovaries have been re-
766 BY FORD,
moved. The habit of bleeding continues after the ovarian, reflex, nervous
influence has been withdrawn from the uterus.
Still another rare, yet very dangerous, cause of uterime hemorrhage, is
that known to surgeons as the hemorrhagic diathesis. The writer has seen
one case in which he believes that the bleeding was clearly attributable
to this mysterious condition, and which proved fatal. It was that of a
young girl who died with her second menstrual flow.
The wide range of causative conditions found connected with uterine
hemorrhage is but an inverse exhibition of the sympathetic relations of
the uterus. When diseased, it exercises an almost universal pathological
influence upon other organs, and as a consequence it is susceptible of being
impressed to the same degree by certain morbid conditions of all import-
ant viscera. In this assembly of intelligent practitioners it will not be
regarded as making an undue claim to say, that the practice of gynaeco-
logy requires a more thorough theoretical and practical familiarity with
the details of all the branches of medicine than any other of the so-called
specialties. We are not prepared to treat the most common of female
diseases without being able to scan with scientific scrutiny every organ
and function of the body. Nor until we can compete successfully with
the general practitioner, the surgeon, the alienist, and the neurologist, in
the therapeutic processes of their respective departments, may we hope
to exercise in the highest sense the office of the gynaecologist. These
remarks apply with force to the comprehension of the causes and treat-
ment of hemorrhages of the unimpregnated and non-puerperal uterus.
TREATMENT OF METRORRIIAGIA.
I find it quite impossible to satisfy myself as to the best order in which
to bring forward the various measures proposed for treating uterine
hemorrhage. Those which have for their object the removal of the caus-
ing conditions, properly fall under the head of curative means; while those
which we employ to stop the bleeding temporarily, until the remedies
of the first order have accomplished their purpose, seem as naturally to
belong to the category of palliative measures. We find in each of these
divisions, however, remedies which act in both ways, and the palliative
means are often radical and energetic. Notwithstanding the many
obvious deficiencies in this arrangement, it seems to me to be the best
that I can adopt.
Palliative Treatment.—Before entering into a detailed description of the
more essential, remedial methods of curing the various forms of hemor-
rhage, it will be profitable to consider some of the important, minor
measures which are applicable in almost all instances. As the great
majority of hemorrhages occur at the menstrual periods, we often have
opportunities of adopting measures in anticipation of them. These
measures are sometimes calculated to entirely prevent an exaggerated
flow, and at others to very much modify it; and in all to greatly promote
the action of more direct remedies. The patient should abstain from all
causes of local or general, vascular or nervous excitement. Among these
causes are mental and bodily fatigue, emotional excitement arising from
certain social relations, sensational books, and the contemplation of erotic
objects. The patient should also abstain from stimulating drinks and
highly seasoned food; her clothing should be loose and cool, so that no
N O N - PU E R P E R A L H E M O R. R. H. A. G E S OF T H E W O M B. 767
part of the body may be constricted, and the genital organs should not
be too warmly covered. Her bowels ought to be kept regular, or rather
free. The secretions from the skin, liver, and kidneys should be main-
tained as nearly as possible in a normal condition, and tonics, such as
arsenic, strychnia, and quinia, with digestible, nourishing and unstimu-
lating diet, should be given in quantities sufficient to keep the health up
to the normal standard. Other things which will contribute very
greatly to good results, are plenty of pure air, night and day, and
moderate, muscular exercise. Many other general directions will sug-
gest themselves, which I cannot stop now to mention.
When the time for the paroxysm has arrived, and the hemorrhage has
commenced, isolation, quietude, and recumbency are very important pre-
cautions to be enjoined. Position indeed may be made to do much
good of itself. If the hemorrhage is not severe, mere recumbency will
be sufficient; but if it is protracted, the hips should be elevated, and some-
times it will be beneficial to raise them so high as to cause the blood to
gravitate to the fundus uteri, and to fill the whole genital canal before
any of it passes out. To a considerable extent this may be made to act
as a tampon. The position chosen to effect this object may be on the
back, or upon the knees and chest. If the latter position can be com-
manded, it is much the best, as the reversal of gravitation is more com-
plete. Cold and acid drinks, cold applications to the hypogastric and
Sacral regions, hips and vulva, and in the vagina, are also among the
remedies applicable to almost all cases.
Many practitioners value astringents, administered internally, in
uterine hemorrhage, but I have found so little benefit from them when
not given with opium or belladonna, that I seldom resort to them.
Where there is much pain in the pelvis, and a dry state of the skin,
opium and ipecacuanha are often very servicable. Dobelia, gelsemium,
digitalis, aconite, and veratrum viride, may also be mentioned as very
frequently applicable where there is vascular and nervous excitement.
Perhaps the medicine most generally applicable in paroxysms of uterine
hemorrhage, is ergot. In all cases of local arterial hyperaemia, as in
tumors, hyperinvolution, etc., we may expect good from its employment.
But it will generally fail to be useful when the uterine hyperaemia is
venous, as in retroversion, pelvic infarction from periuterine effusion,
abdominal tumors, etc. It will not act efficiently in cases of carcinoma-
tous deposit, granulations of the mucous membrane, or tuberculous
degeneration of the fibrous texture of the uterus.
In the more dangerous instances of hemorrhage, these moderate pal-
liative measures are not sufficient. In some, the amount of loss is so
great, and occurs so suddenly, as to threaten the life of the patient. Or,
if life is not in danger, the discharge may be sufficient to lead to other
very serious, remote consequences. These emergencies are to be met by
such means as will promptly arrest the flow, and keep it in check until
curative processes can be instituted. Fortunately this may be done with
great certainty by mechanical and chemical appliances generally at our
command. The genital canal, practically closed at its upper extremity,
and conveniently open at its lower termination, admits of being impacted
to an impermeable degree, and allows of topical applications to its whole
extent. In using either form of these topical measures, the effort should
be made to apply the remedy as near to the bleeding loint as possible.
When practicable, we may secure the best effects by employing the
mechanical and chemical means conjointly. The mechanical means em-
768 - BYF ORD,
brace the different forms of the tampon. Plugging arrests the hemor-
rhage by forcibly opposing the evacuation of the blood, and by thus
imprisoning it in the smallest cavity. The blood so confined, coagu-
lates, and fills the space between the tampon and the bleeding sur-
face with a fibrinous clot which also closes the mouths of the vessels.
When plugging is skilfully performed, the relief is temporarily perfect,
and gives us valuable time for other treatment, or allows the cyclical
period to pass, when the hyperaemia subsides. The chemical means con-
sist in the use of powerful haemostatics. By their chemical action upon
the solid constituents of the blood, they produce a much firmer coagulum
than results from mere stasis, and, if applied to the ruptured vessels, Seal
them up with coagulated plastic material, while if further away the
coagulum forms a chemical tampon which opposes the flow toward the
vulva. Used with the mechanical tampon they may be made to fill the
interstices of the material of which it is formed, and thus solidify the
whole mass. -
In the greater number of dangerous cases of the kind of uterine hem-
orrhage treated of in this paper, the mouth of the womb is sufficiently
patent to permit the introduction of the plugging material saturated
with a haemostatic preparation into the cavity of the uterus. Dr. Sims's
method of preparing the material and performing the operation of plug-
ging the womb is admirable in its simplicity and efficiency. The sub-
stance used is the finest article of cotton-wool, Saturated with a liquid
composed of one part of the strong solution of the subsulphate of iron.
and two of water. After the cotton has been perfectly saturated, it is
deprived of the major part of its fluid by pressure, and is then allowed
to dry until ready for use. The application is made by wrapping a suffi-
cient quantity of the dried iron-cotton around a long, small piece of
whalebone, and introducing it into the cavity of the uterus, when the
cotton is detached and left there. If the hemorrhage is comparatively
moderate, one of these pieces may be sufficient; if severe, it will be
necessary to stuff the uterine cavity full. This can be best accomplished
by having the patient placed on her side, and the uterus exposed by
Sims's speculum. To facilitate the removal of this ferruginous tam-
pon, the suggestion of Dr. J. R. Chadwick, of Boston, is, I think, a
valuable one, viz., to wrap strong thread loosely around the cotton as it
surrounds the whalebone. I prefer this method of using the haemostatic
to its injection, because the shock from the application is much less.
If the mouth and cervical cavity of the womb are not sufficiently
open to permit of the introduction of this haemostatic preparation, we
may plug the cervix with prepared sponge. The first sponge should be
pushed through the cervix into the cavity, and up to the fundus uteri,
so that when it expands its upper end may possibly reach and press upon
the bleeding point. If large enough, the cervical cavity will be com-
pletely filled and the bleeding effectually checked. The sponge should
be carbolized, and well secured, before it is introduced, by passing a
strong piece of twine through it, from one end to the other. Neither
the cotton nor sponge should be allowed to remain longer than twenty-
four hours, and half of that time is usually long enough. After removal,
the vagina may be cleansed, and the application repeated if necessary.
I have sometimes been obliged to renew the sponge tampon several times
in the same case, though this is not usually required. -
If these means are not at hand, or if the case is not sufficiently urgent
to require plugging of the uterus, we may resort to the vaginal tampon.
N ON - PU E R P E H A L H E M O R H H A G E S OF T H E W O M B. 769
This may be made of cotton, of which pieces as large as pullets' eggs may
be used, rolled somewhat solidly, and each secured with thread and
lubricated with oil or lard. A sufficient number to perfectly fill the
vagina should be prepared. The patient should be placed on her left
side, with the limbs flexed, and the upper one thrown forward over the
other. The operator, standing at the back of the patient, inserts into
the vagina two fingers of the left hand, with which he draws the peri-
neum well backward. This will open the canal so that the clots may be
easily removed with the fingers, when, with the right hand, the cotton
may be placed with great facility in the vagina. At first several on the
Os, and around it, and then the whole vagina may be packed solidly under
the eye of the operator. If Sims's speculum be at hand, it should be
used instead of the two fingers to hold back the perineum. Or we may
vary this according to the process described by Dr. Thomas, in the Ame-
rican Journal of the Medical Sciences for July, 1876, page 147. After
dilating the vagina, “pieces of cotton, soaked in water, pressed and flat-
tened out by the fingers, each about the size of a very small biscuit, are
pressed into the vaginal cul-de-sac by means of forceps till this is filled.
Then other pieces are packed firmly around the cervix until only the os
is visible—a smaller pad is then pressed firmly against or introduced
within the cervical canal, and the whole vagina is then filled to its lowest
portion.”. An ordinary surgeon's roller answers admirably for a plug,
and may be introduced by first inserting one end, and then passing it up
in short folds until enough has been placed in the vaginal cavity to fill
it up compactly. In most cases where we desire to leave the patient, the
tampon should be retained by a compress and “T” bandage.
When we have reason to anticipate a sudden occurrence of severe
hemorrhage in our absence, we may instruct the patient or nurse how to
make and apply a very safe vaginal plug. A sponge, large enough to
fill the vagina closely, may be prepared by wetting it in a strong solution
of alum, or in a weak solution of subsulphate of iron, passing a piece of
strong twine or tape through the centre, and then wrapping it with tape
in an elongated shape to its smallest dimensions. It may then be laid
aside to dry. When the necessity for its use arises the tape is removed,
and the sponge thus compressed may be passed without any resistance
entirely into the vagina. It is soon expanded by the blood, and the
vaginal cavity thoroughly filled. A few of these sponges prepared ready
for instant use will enable the patient to prevent any material loss until
the practitioner arrives. The plug may be removed by the tape or twine
whenever desired. The plug may be allowed to remain from eighteen to
twenty-four hours, when it should be withdrawn, and, the vagina having
been thoroughly cleansed with carbolized water, replaced if necessary.
Curative Treatment.—The central nervous disorders which cause ute-
rine hemorrhage will, when recognized, require the treatment set forth
in the various wºrks upon these subjects. I need rot. “herefore, dwell here
upon the mauagement of the spinal and cerebral inflammations and irri-
tations, nor upon the numerous forms of emotional excitement which
lead to metrorrhagia. The treatment of the reflex, morbid, nervous in-
fluences, belongs more particularly to gynaecology, and will call for all
the ingenuity and varied knowledge taught in that branch of practical
medicine. The ovarian derangements, being the more obvious and com-
mon of these, may be noticed first. Our means for replacing and retain-
ing in position displaced ovaries are very meagre. The patient must be
770 BY FOR D,
confined to the horizontal position, with the pelvis elevated as much as
practicable. The knee-chest position is the best, and may often be main-
tained for a considerable part of the twenty-four hours. Generally the
displacement is accompanied by congestion or inflammation of the ovary,
which increases its size and weight. When this is the case, the treatment,
in addition to position and quietude, recommended during the inter-
menstrual period, will consist in the use of counter-irritants, hip-baths,
hot water vaginal injections, and alteratives, administered internally, or
applied externally in the form of ointments, or per vaginam as supposi-
tories, injections, etc. Among the alteratives, the muriate of ammonia
will be found very valuable. When there is much debility, the bichlo-
ride of mercury, dissolved in the compound tincture of cinchona, is
among the very best. Iodine, iodide of potassium, and iodide of iron
should also be named as efficient alteratives in these conditions of the
ovaries. One derivative measure which I desire to mention as especially
beneficial in these cases is dry cupping over the sacrum, often repeated.
To be effectual the cups should be large, and allowed to remain for a long
time, say an hour or more. When there is much pain in the ovarian
regions, suppositories of the extract of belladonna and ergot, once or twice
daily, will not only relieve the pain, but will do much towards allaying
the inflammation.
When hemorrhage occurs in a nursing woman, if it is of sufficient
gravity, the child should be weaned. At the time of the paroxysm, if
the breasts are tumid and tender, cold may be applied to them to relieve
both the uterine hemorrhage and the mammary congestion. These pa-
tients require invigorating measures in connection with the local treat-
ment of the breasts.
The vesical or rectal tenesmus which gives rise to hemorrhage must
be treated by the remedies found necessary after investigating the cause.
So, also, with diseases of the stomach, bowels, and liver, as well as with
the effect of cold or of long-continued heat.
Subinvolution and chronic congestion of the whole uterus require to
be treated very much alike, by the application of such remedies as con-
dense the uterine tissues—ergot, belladonna, quinia, electricity, cold in-
jections, compresses and sitz-baths. When there is no tenderness, ergot
will be found a very efficient remedy, if administered for a sufficient
length of time—several months for instance. If there is considerable
tenderness and pain, belladonna and quinia will be best adapted to the
case. Ergot in some instances induces sensitiveness and heat in the pelvic
organs, and then it should be used very cautiously. This effect of ergot
is especially noticeable when there is chronic local peritonitis or cellulitis.
If there is a high degree of sensitiveness, a mercurial alterative may very
properly be given in connection with the belladonna and quinia, and a
good form for administering it is the bichloride of mercury dissolved in
the compound tincture of cinchona; or we may use mercurial inunction,
or mercury in suppositories. I have not been able to do much good in
these cases with iodine in any form. If given with iron, as the iodide
of iron, it has occasionally a good tonic and alterative influence. These
conditions of the uterus are very obstinate, and require a continuous
treatment, oftentinues for many months.
The treatment of endo-metritis is too well described by systematic
writers on gynaecology to require more than a very brief notice. It
consists mainly in a persevering continuance of stimulating applications
to the diseased mucous luein brane. I do not like the term caustic, for
N ON - PU E R P E R A L H E M O R. R. II A G E S OF T H E W O M B . 771
even the strongest remedies used for this purpose are applied so sparingly
that their effects are little more than strongly stimulative. In the light
of our present knowledge of the processes of menstruation, these remedies,
as suggested by Dr. Atthill, should be resorted to immediately after the
monthly flow has ceased. By common consent of the profession, in this
country, the treatment of granulations of the uterine mucous membrane
consists in scraping them off, and the teaching of Sims and others has
made the process sufficiently familiar not to require description here.
Although not curative, the same treatment may be mentioned as most
efficacious in arresting the hemorrhages resulting from cancerous granu-
lations. In a discussion of Dr. Hanks’s recent paper, Dr. Peaslee gives
the very judicious advice not to cut into the sound tissue in the process.
In cases of malignant fungus, we may often arrest the tendency to hemor-
rhage by injecting alcohol, by means of a hypodermic syringe, deeply
into the substance of the part. This process frequently repeated some-
times retards the growth very materially. The tincture of the chloride
of iron, similarly used, will often have the same effect.
The various conditions which give rise to retardation of the venous
circulation, require to be treated according to the improved methods
now so well understood by the profession. The displacements of the
uterus which are arranged among these conditions, must be corrected by
the various ingenious appliances designed for this purpose. And this
may be done during the time of the preternatural flow with the expecta-
tion of moderating it at once.
Dr. T. D. Fitch, of Chicago, has recently proven this last assertion in
the management of a case occurring in a patient who had just passed the
menopause. The uterus was retroverted, and all the means resorted to
did not even moderate the metrorrhagia until the organ was elevated
and retained in position by an appropriate pessary, when in a short time
the bleeding ceased. After the subsidence of the flow, the patient re-
moved the instrument, on account of some slight inconvenience which it
gave her, but the flooding began again in a very few hours, and contin-
ued, notwithstanding repeated efforts to arrest it, until the pessary was
once more introduced, when the hemorrhage again subsided, and has
not returned. The patient was still wearing the pessary when I heard
of her case.
The subject of the treatment, and especially the surgical treatment, of
tumors of the uterus which cause arterial hyperaemia and uterine hem-
orrhage, is too extensive to be entered into in this paper ; and I refrain
from considering it the more willingly because it will no doubt be ex-
haustively and ably discussed by Dr. W. L. Atlee in the paper which he
is to read before the Section. I cannot, however, forego the duty of
making some suggestions as to the method of treating these growths
with internal remedies.
The extreme danger from hemorrhage, connected with fibrous tumors
of the uterus, is not so often encountered since the profession has become
acquainted with the great influence exerted upon certain conditions of
the unimpregnated uterus by ergot. It is now understood that fully
seventy-five per cent. Of hemorrhagic cases of fibrous tumour of the ute-
rus may be rendered free from danger, as far as the hemorrhage is con-
cerned, by an intelligent and persevering use of ergot, and that in twenty
per cent., the tumors may be removed. In using ergot, in these cases,
the mode of administering it cannot be uniform. Some patients cannot
take it in any sufficient doses to answer the purpose; some cannot take
772 BY FOR D,
it in the form of fluid extract, or wine, but can take the solid extract in
the form of pills; others can take it in any form. When the stomach
will not tolerate the ergot, it may be given hypodermically, or per rec-
tum in suppositories, and I believe that it can be made to act efficiently
when given in any of these ways.
Whatever method or form we may adopt in the administration of
ergot, we should give it in sufficient quantities to produce a sensible
effect by causing contractions and pain, and there is no better rule to
guide us, as far as I can judge, than to give it in increasing doses until
that result follows. Twenty minims of the fluid extract, three times a
day, will sometimes be sufficient, while some patients, on the other hand,
will require twice or three times as much to produce the effect.
The length of time required to obtain the ultimate effects of the ergot
in these doses, varies as much as the quantity required. The tumor will
sometimes diminish very rapidly, but generally the decrease in size is
quite slow. From one month to over a year may be required to accom-
plish a cure when it can be accomplished at all. Ergot is sometimes
very violent in its action, but by withdrawing it temporarily, lessening
the dose, or combining and alternating it with anodynes, it may be
safely managed. Although I have given it extensively, and for a long
time together, I have not seen anything worse than inconvenience aris-
ing from its use.
It will not, of course, be expected that I should enter into a considera-
tion of the treatment of scurvy, leucocythaemia, albuminuria, or syphilis,
as general conditions causing uterine hemorrhage, both for want of time
and because they are subjects well treated of in works on the general
practice of medicine. Our ignorance of the last of the causes mentioned
in the first part of this paper, viz., the hemorrhagic diathesis, will also
excuse me from dwelling upon the treatment of that mysterious condi-
tion which afflicts some unfortunate individuals belonging to our race.
DISCUSSION ON DR. DYFORD’s PAPER.
After the reading of the preceding paper, Dr. WILLIAM GooDELL, of Phila-
delphia, said:—I did not wish to begin the discussion, but as others are back-
ward I will try to start the ball. I was not able to hear all that Dr. Byford
said, but some of the points made by him are of extreme interest. I wish
to refer to the almost absolute inertness of astringents when given by the
mouth in cases of uterine hemorrhage. The text-books laud them, but I have
found most of them useless. In my opinion, the canonical pill of acetate of
lead and opium would be inert, save for the opium in it, the latter being a
valuable has mostatic. A pure astringent which I have found of much value is
gallic acid—not administered in the ordinary dose of five grains, but in doses
of from twenty to thirty grains every two hours, or more according to the
urgency of the case. I have discovered no bad effects resulting from its use,
although I have given half an ounce in the course of a day. It is a bulky and
disagree.v.)ie remedy, but I mix it with some table-syrup or with molasses, and
have found it the only astringent of any efficacy in stopping these hemorrhages.
Ergot acts well, especially when used hypodermically, but I know of cases where
it has increased the hemorrhage; I do not now refer to cases of fibroid tumor
in which it will sometimes so act, but to other cases of metrorrhagia in which I
have found it to increase the discharge from the uterus in a way that is inexpli-
cable to me. Free dilatation of the cervix by tents will alone often cure
hemorrhage. The causes of uterine hemorrhage are sometimes obscure, and I
N ON - P U E R P E R A L H E M O R R H A G E S OF THE WO M. B. 773
have sometimes been humiliated by not discovering them. I have dilated the
cervical canal, passed my finger into the uterine cavity, made careful examina-
tion, and yet have found no tangible cause. There are other causes beside
granular conditions of the lining membrane, which may be so minute as to
elude an examination by the finger. When I could find no explainable cause
for such hemorrhages, I have treated them empirically, by introducing into the
cavity pure nitric acid. I refer particularly to the case of an unmarried lady,
in which the hemorrhage lasted for weeks at a time. I fully expected to find
a polypus, but did not. The flow was arrested by nitric acid, but it shortly
began again ; I then used intra-uterine injections of iodine, but the benefit was
only temporary. At my request Dr. A. H. Smith also examined the patient,
but failed to discover any cause. The hemorrhage finally yielded to ergot,
which in the first instance had failed. To this day I am ignorant of the cause
of this hemorrhage. I have found the tincture of iodine of use, though it is
not infallible. In using it, I first stretch open the OS with a dilator, and then
inject about a fluidrachm. It has the great advantage of not forming hard clots.
There is a plain, homely remedy, which I have successfully used in menorrhagia
when others have failed—cinnamon tea, or cinnamon boiled in milk. Heat
applied to the spine has also proved of benefit, though not invariably. I am
pleased to find that the bichloride of mercury has been referred to by Dr. By-
ford in high terms. This is a favorite remedy of mine, not only as an alterative,
but for its property of increasing the number of red blood-corpuscles. When
given for two or three weeks, but not longer, in cases where much flooding has
taken place, it renews the blood rapidly, fattens up the patient, and is in my
opinion a fine tonic, especially when combined with iron and arsenic.
Dr. J. W. RosBBRUGH, of Hamilton, Canada, said:—I think that Dr. Goodell
has failed with the acetate of lead because his doses have been much too small.
Dr. Workman, of Canada, has given half a drachm at a dose, and claims that
with large doses he can stop any hemorrhage at once. I do not, myself, like
the remedy, but in cases of extremity it may be effectual.
Dr. EDWARD M. HoDDER, of Toronto, said:—The subject is limited to cases
of non-puerperal uterine hemorrhage only. Ibut such doses of acetate of lead
as are referred to by Dr. Rosebrugh are only to be used in cases of post-partum
hemorrhage. I have employed the tincture of cinnamon largely, and have
also used the tincture of cimicifuga, as well as sulphuric acid, but always in
conjunction with local treatment. I have injected the perchloride of iron into
the uterus until the acid has passed through the Fallopian tubes into the peri-
toneal cavity, but with only temporary inconvenience. I have also used the
persulphate of iron in relaxed and flabby conditions of the uterus. I think
that if astringents were used, and the uterus were kept in place, cases of hem-
orrhage would be more amenable to treatment than is generally supposed.
Dr. ALEXANDER. R. SIMPSON, of Edinburgh, said:—The subject is an im-
portant and practical one. It appears, from what I have heard, that uterine
cases are much the same on both sides of the Atlantic, and that no one treat-
ment will suit all cases. I have a general impression as to the in utility of
astringents, and yet there are cases in which I would use any of them. While
agreeing with Dr. Goodell as to the efficiency of gallic acid (which I prefer above
all others), and in some cases of sulphuric acid, I wish to mention another
agent which often acts admirably as an astringent, and that is the oxide of
zinc. I know of cases which have been carried over by one or two-grain doses
thrice daily. It is a truth, however, that physicians are often left in the lurch,
and have to resort to direct local treatment. The first direct application should
be in the shape of vaginal plugging, although I have but little faith in the
value of the tampon per se. For instance, in some cases the hemorrhagic
habit is kept up by the terror and dread of the patient, but the use of the plug
by stopping the flow gives her confidence, and there is a corresponding lessen-
ing of the menorrhagia. It is difficult at times to apply the tampon so as to
make it effective, and I therefore think that plugging the cervical canal i
774 BY FOR D,
the better plan, especially as it opens the way for subsequent exploration and
treatment. As to direct applications to the uterus, nitric acid is good in some
cases, but where a hemorrhage is in progress, I do not find it so effective as
the perchloride of iron. In cases of enlargement and of thickening of the
mucous lining, it would be important to scrape off the redundant portions by
the curette, as recommended by Récamier and Sir J. Y. Simpson. In one case,
I simply scraped off the thickened membrane, and, contraction of the womb
being kept up by ergot, the patient recovered. The blood at times also gets
into such a watery condition as to tend to the continuance of hemorrhage, and
then special constitutional treatment is required.
Dr. THOMAS W. GoRDON, of Georgetown, Ohio, said:—I think very highly of
the value of quinia in cases of non-puerperal hemorrhage occurring in mala-
rious districts, Or in broken-down constitutions, and think that in such cases
it should never be omitted.
Dr. J. A. CAMPBELL, of Grafton, West Virginia, said:—I believe with Dr.
Gordon in such a thing as an intermittent uterine hemorrhage, and know that
in malarious sections of the country we could not treat hemorrhage without
quinia. In most cases, however, the hemorrhage is dependent upon conges-
tion of a displaced womb. The circulation of the blood being prevented by pro-
lapsus, congestion arises, engorgement follows, and then there is a hemorrhage
at every recurrence of the menstrual period. I have in my practice insisted
upon nightly replacement of the Organ by the patient herself, for no physician
could attend to this, unless he had but the one case ; I consider replacement
the chief prophylactic for engorgement and the consequent hemorrhage. This
replacement can be effected by the woman herself, by first assuming the knee-
breast position, and then by either separating the labia with two fingers, or by
introducing a short glass tube into the vagina. I have used iced water also
with advantage, but of course not during the menstrual period. Or a gallon
of water may be injected every four or five hours, not letting the tempera-
ture be much below 60°. In the water I sometimes dissolve sixty grains of
the sulphate of iron. The fluid extract of ergot I often give hypodermically,
or internally in doses of thirty or forty drops. Dilute sulphuric acid is a
favorite remedy with me; I have known women, who from continued hemor-
rhage have become debilitated, and whose menstrual flow has been so length-
ened in duration that the interval between each period has been reduced to a
very few days. In these patients, by examination with the speculum, I have
found polypoid granulations; but a few applications of nitrate of silver have
changed the entire aspect of the case.
Dr. THOMAS F. Roch ESTER, of Buffalo, said:—Quinia should be used in all
cases of chronic hemorrhage, whether under malarious influences or not, but I
am not in favor of full doses ; quinia acts upon the capillaries, and thus exerts
a good effect. I do not therefore think that its use should be confined to cases
of malarious hemorrhage alone.
Dr. EDWARD H. TRENHOLME, of Montreal, said:—There are two modes of
treatment, the local and the constitutional. The former is adapted to check
the actual flow when the patient is in imminent danger. I employ “Sims’s”
iron cotton, prepared in proper-sized plugs. As a constitutional remedy, where
it was difficult to find the cause, I have found oxide of silver, in combination
with opium, very efficient.
Dr. B. F. SHERMAN, of Ogdensburgh, N. Y., said:—I can also recommend
the styptic cotton for use as a tampon, and, in granulations, a saturated solu-
tion of permanganate of potassium. In obscure cases I give internally one
grain of the oxide of silver thrice daily, combined with one-quarter of a grain
of Opium. -
Dr. CHARLEs SHEPARD, of Grand Rapids, Michigan, said:—While I am a
warm advocate of the use of quinia, I desire to laud a mode of local treatment
which I employ. I use an elastic rubber bag into which I inject iced water.
N ON - PU E R P E R A L H E M O R. R. H. A. G E S OF T H E W O M B. 775
This is capried up through the cervix, and it applies itself so closely to the
bleeding surface as to be very efficient in stopping the hemorrhage.
Dr. H. D. WoSBURGH, of Lyons, N. Y., said:—Gallic acid is, I think, the
only astringent from which much benefit can be derived in uterine hemorrhage.
All physicians have pet remedies, and pet plans of applying them. I have
found the ordinary solution of persulphate of iron effective; I inject it into the
uterine cavity by means of a glass tube with a rubber bag at one end, and can-
not recall a case of non-puerperal hemorrhage which has not yielded to this
remedy.
Dr. ROBERT BURNs, of Philadelphia, said:—In an experience of forty years,
I have seen many cases of this character. In my early practice, when the
speculum was hardly known, my dependence was upon large doses of astrin-
gents, which often disappointed me. But since the discovery of the speculum
I have much less trouble. My system is a simple one, and varies but little.
I first attend to the state of the constitution—if the patient is weak, giving her
tincture of chloride of iron, quinia, and aromatic sulphuric acid. I then use a
combination of a drachm each of tannic acid and sulphate of zinc, in an ounce
of glycerine, which I apply to the interior of the uterus, through the previously
dilated cervical canal, using cottom saturated with the mixture. I repeat this
several times, and brush the cervix with the same, putting the patient on
gentle purgative treatment. There are cases of extreme hemorrhage where
Ordinary methods fail, but most of them are amenable to this mode of treat-
ment.
Dr. THEOPHILUs PARVIN, of Indianapolis, said:—We must all agree, from
the discussion and from the number of remedies that have been suggested, that
the uterus is an organ which can be abused with impunity. It has been said
that we must find the cause of the hemorrhage : true, but in the mean time one's
patient may bleed to death. Stop the hemorrhage first, and find out the cause
afterwards. There is one method which has not been referred to, and that is
vaginal injections of hot water. This is a first-class remedy. Hot water
rubber bags, applied to the back, have also been found efficacious. The diffi-
culty of local treatment is often due to the fact that the physician shrinks from
the examination of an unmarried woman ; but desperate cases require modesty
and shame to be put aside. The remedies spoken of may be empirical, but
they are the best in such cases. As to local treatment, there is often some
disorder with the parts. Some practitioners use the curette, while others say
that it is murder to do so. Mucous polypi in the cervical canal are irritants,
but are not the source of the hemorrhage. They cause an increased flow of
blood to the parts that are irritated by their presence, and there is a solution
of continuity as the result. Remove these polypi, and then apply tincture of
iron. I thought that I had made a discovery when I used a small forceps
instead of the curette for the purpose of pinching off small granulations, but I
have found that others had used them before me. The hemorrhage is not an
entity in itself, but merely the expression of something else. We cannot cure
the patient without finding out the cause, which, in doubtful cases, I believe is
often an inflammation of the lining membrane of the uterus.
Dr. S. S. ToDD, of Kansas City, Mo., said:—I wish to remove the subsul-
phate of iron from the list of injurious remedies. I used it shortly after its
introduction by Dr. Barnes, and have reported eight cases, in all of which it
was successful, though the hemorrhages were all dangerous. I believe that
many lives have been saved by its use. I desire to reiterate that the subsul-
phate of iron is absolutely innocuous.
The President, Dr. Robert BARNES, of London, said :—I have been much
impressed with the great advantage of these meetings; the members of the
Section have heard a variety of expressions from all parts of this great conti-
nent, and every expression of individual opinion has embodied much that is
valuable. I have received several new ideas while the discussion on this in-
teresting question has been going on. In London, we know but little of
776 BY FORD, NoN-PUER PERAL HE MORR H A GE's of THE WOMB.
malarial hemorrhages; but we have found quinia a valuable means of control-
ling bleeding, as it contracts the uterus, and is otherwise of service to the
system. I always use it in cases of hemorrhage from subinvolution, and do
not think a merely local treatment all that is needful in such a condition. I
have noticed the law of habit mentioned by Dr. Simpson, for hemorrhages
will sometimes take place when the uterus is apparently healthy, not only in-
dependently of ovulation, but often after the climacteric period. These hemor-
rhages are largely attributable to regional attraction of blood to the uterus,
for that Organ is liable to regional hemorrhage, even when there is no disease
of a local character. The treatment must be local or general, and sometimes
it is necessary to resort to both. Topically, the best plan is to dilate the cer-
vix and inject the perchloride of iron. A stringents by the mouth are of use
at times, and, of these, I think with Dr. Goodell that gallic acid is the best.
The heart-action often has an effect on the hemorrhage, and by using aconite
and other remedies to reduce cardiac action, there will be a corresponding
reduction in the flow of blood. In some cases in which the cause of hem-
orrhage could not be ascertained, I have used, with excellent results, the
witch-hazel, which I believe to be a native of this country. Although the
curette has undoubtedly been of service in many cases, yet I condemn its use,
for it is often followed by furious bleeding, and the growth of small malignant
excrescences is more rapid after using it. Besides, it is, at best, a dangerous
instrument, and requires to be handled with the greatest care. In one year I
lost two patients from its use.
Dr. BYFoRD, in reply, said:—Quinia is only second to ergot in causing
uterine contractions, and is an admirable remedy. I have known of miasmatic
conditions producing hemorrhage in non-puerperal cases. Quinia is of use in
these cases, especially in causing condensation of the uterus. In the vast
majority of cases, hemorrhage from a non-puerperal womb is owing to one of
two conditions, either hyperamia or a vitiated state of the uterine mucous
lining, from inflammation or from growths. For the former condition I use
ergot and local remedies, such as the tincture of iodine, but not as intra-uterine
injections. In my experience, uterine hyperaemia and hypertrophy need the
application of a strong astringent to the neck of the womb alone, for the body
of the uterus can be made to contract by applications to the external and in-
ternal surfaces of the cervix. Local remedies can be applied in many different
ways. The other common cause of hemorrhage is a disorganization of the
lining membrane of the uterus. Hemorrhage becomes more easy when this
mucous coat is not firm, because it gives way more readily. Topical treatment
is here indispensable. When bleeding has occurred after the menopause from
a determination of blood to the womb, I have been able to do more with large
doses of quinia and iron than with ergot or with anything else. I do not
consider ergot particularly valuable in such cases. The vaginal plug is of
great use when used properly and thoroughly. It should not simply be pressed
against the os, but firmly packed in front and behind the cervix, in order to
compress it. I have, in my own practice, been rather timid in regard to inject-
ing fluids into the womb, probably too much so, but I avoid such treatment
wherever it is possible to do so.
777
THE MECHANISM OF NATURAL AND OF ARTIFICIAL
LABOR IN NARROW PELVES.
BY
WILLIAM GOODELL, A.M., M.D.,
CLINICAL PROFESSOR OF THE DISEASES OF WOMEN AND OF CHILDREN IN THE
UNIVERSITY OF PEN NSYLVANIA.
“Opinionum commenta delet dies, naturae judicia confirmat.”
CICERO, De Naturá Deorum.
IN studying the mechanism of natural and of artificial labor in narrow
pelves, let us first inquire what is meant by a narrow pelvis, and what
are its kinds.
A pelvis with a true conjugate (conjugata vera) measuring less than four
inches constitutes a narrow pelvis. For, although the biparietal diameter
of the average foetal head at term measures less than four inches, the
working space between the promontory of the sacrum and the symphysis
of the pubis is lessened by double the thickness of the uterine wall, and
by double that of the vesical wall. While, therefore, the actual conju-
gate is ample for an average head to pass, the virtual conjugate may be
too small. Thus, according to our best authorities, a standard head in a
pelvis measuring in its conjugate 3.75 inches—viz., half an inch less than
that of the average-sized pelvis—constitutes a difficult labor.
A spontaneous delivery is not impossible under such circumstances,
but the forceps will usually be needed ; sometimes, indeed, craniotomy.
Every line below this measurement greatly increases the difficulties of
parturition. For instance, Out of thirteen vertex presentations in pelves
measuring at the least 3.75 inches, Dubois had three cases of craniotomy
or of cephalotripsy. In conjugate diameters between 3.75 and 3.1 inches,
he had ten presentations at term of the vertex, and one of the face. Of
these, two ended spontaneously, two were delivered by the forceps with
the death of one child, and seven needed the cephalotribe." Baudelocque
contends that out of five hundred children at term and of average size,
hardly one will be delivered alive through a pelvis of three inches. To
this, Dezeimeris” adds that one of 3.25 inches does not give much better
results, and that one of 3.5 inches also offers to the child a very dangerous
passage. Joseph Clarke gives,” as the result of an experience of 14,077
cases of labor, that “three and a half inches is the least diameter” through
1 Management of Labor in Contracted Pelves. By Wm. H. Jones. This author, it is
true, makes these cases occur respectively in pelves whose conjugates measured “Over 3.5,”
and “between 3.5 and 3 inches.” But since he has adopted the classification of Dubois,
these figures seem to me incorrect. For Dubois's first and second categories of deformed
pelves are those in which the conjugates measure respectively, at the least, 3.75 inches
(au moins 9.5 centimetres), and between 3.75 and 3.1 inches (au plus 9.5 centimetres et 8
centimetres au moins). This information I get second-hand from Cazeaux, and not from
Dubois, whose thesis is beyond my reach.
* Dictionnaire en 30; Art. Accouchements Prématurées, p. 427.
3 Contributions to Midwifery; by T. E. Beatty, p. 23.
77.8 GOOD ELL,
which he has known “a full-grown foetus to pass entire.” Chailly-Honoré
says, “The forceps will frequently extract a living child through a con-
jugate of over nine centimetres (3.54 inches), sometimes, indeed—although
this is very rare—under this size.” From these facts, the broad rule may
be laid down that, when the short diameter of the brim does not exceed
the biparietal diameter of the child's head, the unaided efforts of the
mother will in general be inadequate to effect a safe delivery, and that
even with instrumental aid the life of the child will be greatly imperilled.
The most common kinds of narrow pelvis are three in number:—
(1) The simple, flat pelvis, or conjugate narrowing with correlative
transverse widening. -
(2) The generally and uniformly narrowed pelvis, in which all the
pelvic diameters are symmetrically shortened.
(3) The generally narrowed, flat pelvis, which combines the bone-lesions
of the other two, but in varying proportions.
Of these three varieties, the one most commonly met with is the
simple, flat pelvis, in which the lesion is limited mainly to the brim and
to its posterior half. Practically the obstruction is a marginal one, and
is confined to the sacral pole of the conjugate diameter. In the second
variety—or the generally and uniformly narrowed pelvis—the obstruction
is not a marginal One, nor of limited area, but diffused over every plane
of the pelvic canal. In the third variety, the obstruction depends upon
the preponderance of conjugate or of transverse narrowing, and is, there-
fore, either mainly at the brim and marginal, or mainly in the pelvic
canal and diffused.
Since “Art is the imitation of Nature, and those will best succeed in
any science who closest watch her operations,” let us next note the
mechanism of an unaided head-first labor in these different kinds of
narrow pelvis.
In the generally and uniformly narrowed pelvis, the mechanism is very
analogous to that which takes place in the standard pelvis, but is of course
attended with more delay. The head enters the brim synclitically and
with the normal Solay rés obliquity—that is to say it engages in one of the
oblique diameters of the brim, but without lateral (Naegele's) obliquity. It
will also be strongly flexed (Roederer's obliquity), because the resistance at
the brim is equal on all sides, and the shorter hind-arm of the head-lever
must therefore descend. The head also begins to flex at a higher plane
of the pelvic cavity than in the standard pelvis. For flexion in the latter
is chiefly brought about by the resistance of the os uteri; in the former
by the more highly situated brim. During the descent of the head, the
synclitic movement is preserved except in so far as vertical or lateral
shearing interferes with it. Since the absolute conjugate narrowing is
rarely great, and the general narrowing is symmetrical in all directions,
the furrows or the fractures of the cranium are by no means so common
as in the other varieties of deformed pelvis. But, when present, they
usually start from the boss of the parietal bone and run more or less
parallel to the Sagittal suture, as in cases of fracture reported by Lizé
and D'Outrepont," and one of depression of the skull by Danyau.” It
must, however, be borne in mind that, while the bone-furrow always
| Accouchements; Paris, 1867, p. 649.
2 The Present State of Midwifery in Paris; by A. Tolver, 1770, p. 22.
3 Union Médicale, Fév. 1860, p. 295.
* Journal de Chirurgie, par Malgaigne, 1843, p. 41. * Ibid., p. 49.
L. A B O R IN N A R R O W P E L V E S = 779
indicates the transit-line, the fractures do not, as they may radiate from
it in every direction.
When left to the unaided efforts of nature, the typical mechanism of
a head-first labor in the flat pelvis, or in one whose brim is narrowed
mainly in its conjugate diameter, is as follows:—The hind-head offers
its biparietal diameter at the conjugate, but cannot enter. The resist-
ance being nearer to the occipital end of the head causes extension, and
the fore-head dips. As the fore-head descends, the Sagittal suture,
losing its Solay rés and Roederer obliquities, becomes transverse in two
senses—viz., it lies in the transverse diameter of the brim, and with the
two fontanelles on the same plane. The shorter and more compressible
bitemporal diameter—that is to say, the upper or vault portion of each
temporal region near the coronal suture—reaches the conjugate, and is
driven into it, by the changed direction of the propelling force, which,
acting through the vertebral column, is now thrown out of its perpen-
dicularity to the base of the skull, and so bears at an angle directed to
the forehead. Thus the head is nipped, bent in on its sacral side, and
moulded to the promontory. Sometimes it is the bicoronal (the bifronto-
temporal) diameter which is nipped. Hence the frequency of face-pre-
sentations in narrow pelves—a frequency, according to Michaelis, eight
times greater than in normal pelves." Hence, also, the ease with which
the anterior fontanelle is reached, and the corresponding difficulty with
which the finger touches the posterior fontanelle.
The resistance is now at a point nearer to the fore-head than to the
hind-head, and the latter, therefore, begins to descend, but with the
biparietal diameter to one side of the conjugate diameter. But the
resistance of the iliac margin of the brim to the descent of the hind-head
causes that portion of the cranium to expand and to mould itself to the
corresponding Sacro-iliac space. It also tends to shove the whole head
over to the forehead side of the pelvis. In a generally narrowed, flat
pelvis with absolute transverse shortening, this displacement in the
direction of the occipito-frontal diameter may go on until stopped by
the impact of the forehead on the opposite ilium. The head, therefore,
passes the conjugate, not vertically in the bicoronal or the bitemporal
diameter which first engaged, but along a transit-furrow running some-
what obliquely from that portion of the vault near the coronal suture to
the base posteriorly, that is to say, in the resultant of three forces—
flexion, uterine propulsion, and occipito-frontal displacement in the
transverse (bisiliac) diameter of the brim. In proportion as the head
descends, it becomes more and more flexed, and the biparietal diameter,
which passed the brim to one side of the conjugate, will, at a later stage
of labor, be found almost directly under the promontory. It must, how-
ever, be remembered that, since all the transverse diameters of the pelvic
cavity are also lengthened out, the head usually descends to the floor of
the pelvis with less flexion than in the normal pelvis, and anterior
rotation of the vertex is proportionally delayed.
Thus, from the mechanism of natural labor in this kind of pelvis, it
will be seen that the head enters the brim in a state of partial extension,
or at least in a state midway between flexion and extension, and passes
the short pelvic diameter by a short and most compressible cranial
diameter. Further, the head usually passes the brim with also a lateral
obliquity. Before the engagement of the head, the Sagittal suture in a
| Clinical Lectures by German Authors, New Sydenham Society, 1876, p. 302.
780 G O O DE LL;
typical case will be found very close to the promontory. To engage, the
head must cant over the edge of the promontory; and during the first
stage of descent this suture approaches the pubis. Later on, it begins to
return towards the sacrum. This last movement is owing partly to the
moulding of the posterior side of the head, and partly to the greater
resistance to descent at the sacro-vertebral angle, while the pubic margin
of the brim offers a smooth and glib surface. The head, therefore, pivots
on the promontory as a centre of motion, and, as it were, rolls over into
the pelvic cavity. It “doubles the promontory,” as our honored Presi-
dent, Dr. Barnes, so happily expresses it.
After such an unaided delivery, or after an artificial delivery in which
the application of the forceps is delayed until the head has been driven
past the brim, the cranium exhibits two very characteristic shears. In
the one, there is a bending in of the sacral side of the head, and a bulging
out of the pubic side—it is kidney-shaped. In the other, an equitation
of one parietal bone over its fellow—usually the anterior over the pos-
terior. The site of the pressure-furrow, or of the bone-lesion, varies with
the size and the position of the head, and with the shape of the pelvis.
It is not found at one of the poles of the biparietal diameter, and more
or less, parallel to the sagittal suture, as in the uniformly narrowed
pelvis in which the vertex dips ab initio, but at the forepart of one
Jarietal bone, close to and more or less parallel to the coronal suture.
Often it lies directly over this suture, overlapping both frontal and
parietal bones, and sometimes on the frontal bone alone.
When the disproportion between the size of the head and that of the
brim is relatively great, or when the conjugate is short and the head
unduly ossified or bullet-shaped, engagement is often delayed. Under
such conditions the head does not at once become fixed by the preliminary
dip of the anterior fontanelle, but it coys at the brink of the brim without
entering. Perched on the sacral shelf, it swings backward and forward,
and see-saws with every foetal movement. The finger will find the sagit-
tal suture usually close to the sacrum, and the posterior fontanelle now
in front and now behind the transverse diameter of the brim; now dip-
ping into the inlet, anon tilting up out of it. It is momentarily fixed
by each uterine contraction, and then is the time to take the position.
This cranial play usually ends before long, and that by the adjustment
and moulding of the bicoronal region to the conjugate, and by its conse-
quent engagement and descent. And this may be hastened, as the late
Edward Martin has shown, by turning the woman over on to the side
towards which the forehead looks. The breech of the child then sags
Over to the same side, the hind-head is lifted out of the brim by the
leverage of the spinal column, and the fore-head sinks in more deeply.
Whenever this dipping of the fore-head does not happen, delivery without
artificial aid will be indefinitely delayed.
In the foregoing description I do not pretend to have labelled all the
natural processes involved, nor to have codified every law which governs
the cranial movements in narrow pelves. Nor do I contend that the
anterior fontanelle always dips, for the head may be a small one, or the
cranium a yielding one, or other disturbing elements may intervene.
But from a study of the writings of Schroeder, Spiegelberg, Martin, and
Otto de Haselberg, and also from patient bedside observation, I believe
that the above mechanism is in the main correct—it certainly best ex-
| Prager Vierteljahrsschrift, 1868, Band ii., Analect, S. 76.
L A B O R IN N A R R O W P E L W E S. 781
plains the behavior of the head. Since, however, the truth is not always
truthlike, and since the flexion of the head with the dip of the hind-
head has hitherto been taught as the mode of engagement, a few more
words on this point are needful. &
If, in a pelvis narrowed mainly in its conjugate diameter, the hind-
head always dips, and the vertex first enters the brim, as contended by
Hodge and by many others, what explanation can be offered for the
indisputable fact that the anterior fontanelle, at the outset of labor, is
so commonly on the same plane with the posterior fontanelle, or even on
a lower plane? How interpret the well-known frequency of face pre-
sentations in narrow pelves? Again, if it can be shown, that, after such
unaided labors the pressure-marks or other coarse cranial lesions are found,
not at one of the poles of the biparietal diameter, which is alleged to be
the implicated diameter, but, as I have asserted, at the fore part of the
head somewhere near the coronal suture, then the burden of reconciling
this fact to theory must rest on those who hold to the initial dip of the
posterior fontanelle.
Let me summon to the stand impartial witnesses, such as had no pet
theories to which their facts were trimmed. And, in these forceps days,
I own to some difficulty in finding cases of labor in narrow pelves which
were either neglected, as we should now call it, or left entirely to the
unaided efforts of nature. Nor are the following examples noting the
pressure-mark, selected ones; but the only ones which I have been able
to collect within a short and busy time.
In describing a natural labor in a pelvis whose conjugate measured
about three inches and a quarter, Mlle. Anna Puéjac, midwife in chief
of the Maternité at Montpellier, says' that “At the anterior angle of the
left parietal bone, there was a very considerable depression, sufficient to
admit the half of an ordinary egg. It was the exact cast of the promon-
tory.” Smellie writes” that in a case of narrow pelvis he waited until
the head was “squeezed down to the lower part of the pelvis”—that is,
had passed the brim. The pains failing, he then applied the forceps
along the sides of the pelvis, and caught the head, which was still trans-
verse, over the face and occiput. “The child’s head was squeezed into a
longitudinal form, flattened on the sides, with a deep impression on the
cranium above the ear.” Again he tells us that, after a woman, who was
“very much distorted,” “had been in strong labor for four-and-twenty
hours,” he found “ the head down to the lower part of the pelvis,” viz.,
past the brim, and applied the forceps first over the face and the
occiput, and then, when the perinaeum began to bulge, over the sides of
the head. “The head was of a lengthened form, and contorted to one
side, and there was a deep impression above the ear.”
Lachapelle contends, as the result of close observation, that “the head
of the foetus, driven through a narrow and solid pelvis, is fractured and
indented near one of the frontal bones. This accident is not uncommon,
and we shall cite many examples of it.” Again, she writes. “I have
remarked with Smellie (tome ii. p. 533) that, in cases of navural labors
in pelves considerally distorted, the depression is no longer found on the
frontal region (sur le front), but near the temporai region.” Out of a
number of cases reported by her I select the following: Case I. Occiput
1 Gazette Obstétricale, Juin 20, 1876, p. 179.
* Collection of Cases, 1773, Collection xxvii., No. 2, Cases iii. and iv.
* Eleventh Memoir, p. 423. * Ibid., p. 429,
782 G O O DE LL,
to the left ; the anterior fontanelle was easier to reach than usual. A dead
child was born naturally ; it had the frontal boss indented and broken."
In another case,” the occiput was to the right; conjugate 3.25 English
inches; a dead child was born naturally after a long labor. “The right
frontal bone, although without fracture, offered a very marked depression
which was undoubtedly due to the jutting promontory.” In a third case
the conjugate measured 3.25 English inches; position of the child's head
not known ; after six and twenty hours of labor the forceps was applied
along the sides of the pelvis; “extraction prompt and easy.” The left
frontal and parietal bones were found fractured.” A fourth case" was a
primipara, with a conjugate of about 3.5 English inches, and with a
second position of the vertex. The forceps was applied to the sides of
the head, but failed to extract; the blades were, therefore, withdrawn
and applied in each ilium. There was now no further delay in delivery.
The child weighed five pounds, and died twelve hours after birth. “The
right frontal was depressed and fractured by the sacral promontory.” In
a fifth case,” the conjugate measured 3.25 English inches. The occiput
looked to the left ilium ; the sagittal suture lay transversely and on the
sacro-vertebral angle, with the right parietal affronting the inlet.
Siebold describes a typical case of unaided labor in a pelvis of 3.5
inches." At the first labor, a dead child was delivered by the forceps.
At the second labor, the head presented transversely, with the occiput
to the right ilium. By means of ergot a dead child was expelled. It
had lesions and furrows at both temporal regions. At the third labor,
the head presented transversely “with the small fontanelle to the left
and the large to the right.” “It was also greatly extended to the right,”
viz., the forehead dipped. After many hours of hard labor, the head
was driven past the promontory, and then the vertex rotated anteriorly
to the first position. Thereafter the child was soon delivered. It
weighed seven pounds, was dead, and had the left temple denuded of its
cuticle, at a point on a level with the small anterior inferior fontanelle
(Casserius's fontanelle). At the autopsy, four fissures were found ; one
on the left side of the coronal suture (on the frontal bone), and three on
the parietal bone. In the same journal, Carus reports an analogous case,
in which there was a furrow of the parietal and a fracture of the frontal
bone. Schöller, of Berlin,’ relates a unique case of labor in a primipara
with a narrow pelvis. At the end of three days the woman was delivered
of a living child. “In the middle of the left parietal, and in the neigh-
borhood of the left temple, the skin was abraded and the bone depressed.”
“The bone beneath died, and a portion as large as a sixpence of the whole
thickness of the parietal bone exfoliated, leaving the dura mater exposed.
The destruction of the frontal bone was less considerable.” The Transac-
tions of the Medical Society of Erlangen contain the history of a case of
spontaneous delivery in a narrow pelvis, reported by W. J. Schmidt.”
The child was still ; its skull had a fracture and a depression on the left
frontal region. In the same paper analogous examples are given by II. A.
IIirt and Jörg. Another case of natural labor, in a pelvis measuring
| Fourth Memoir, p. 154. * Eighth Memoir, p. 189.
* Eleventh Memoir, p. 475. * Ibid., p. 469.
* Ibid., No. i. p. 463.
* Revue Médicale, 1833, tome i. p. 301; from Siebold's Journal für Geburtshilfe, B. xi.
S. 404.
7 Berlin. Medicinische Zeitung, September, 1841.
* Jörg, Schriften zur Kentniss des Weibes, Bd. ii. S. 123, 130.
LA B O R IN N A R R O W P E L V E S. 783
about three inches, is given by Osiander." After the most violent expul-
sive pains a dead child, weighing six and a half pounds, was born, with
fracture of the left parietal and frontal bones. Danyau, whose excellent
paper” has furnished me with some of these references, gives the following
remarkable history of a woman whose pelvis was found after death to
measure 2.75 French inches: Her first child was delivered dead by the
forceps. In five succeeding labors each child offered by the breech, and
one was born alive. In her seventh and eighth labors the head presented,
and the children were born without aid, but dead. In her ninth labor
she was brought to the Maternité. The head came first, and for four
hours stayed locked at the brim. Its sacral side was then felt suddenly
to bend in, and the same pain drove it down to the vulva. The child
was dead. Its skull had a deep depression overlapping the left coronal
suture, and shelving obliquely backward to the boss. The death of the
mother on the fourth day permitted a careful measurement of the pelvic
diameters.
Levretº writes of a natural labor in a narrow pelvis in which the “face-
half” of the head was obliquely furrowed. Antoine Dugés contends,”
that “The bones of the skull are often fractured with depression by the
sacro-vertebral angle of the mother. It is one of the frontal, or, indeed,
one of the temporal regions, which is the most ordinary site of these
lesions.” As a voucher for this statement, he gives an example of a
living child born spontaneously, after a labor of thirty-six hours, through
a pelvis measuring 3.25 English inches. The occiput presented to the
right, and the right temple showed a red and contused furrow.” In
another case, the left frontal bone was so depressed as to push the corre-
sponding eye nearly out of its socket. Velpeau declares," that “the
depression of the parietal or of the frontal, with or without fracture, has
been observed at the Maternité of Paris.” Budin, a most careful observer,
met with a case of spontaneous delivery in a flat pelvis measuring about
3.4 English inches in its conjugate." The occiput presented to the left,
and a small living child was born twenty hours after the rupture of the
membranes. On the left frontal region it had a deep furrow, which
started from the coronal suture at the anterior fontanelle, and ran
obliquely backward toward the base of the skull. Chailly-Honoré holds’
that “The depressions of the skull have their site ordinarily on the
frontal or the parietal bones,” and are often the result of natural labor
in a reniform pelvis. Casper, after giving a list of writers on this subject,
whose works are unfortunately beyond my reach, says that the skull-
fractures caused by unaided labor are commonly on the parietal bone
“ and usually transversely to the sagittal suture.” Sometimes they are
found “stretching from the frontal bone more or less parallel to the Sa-
gittal suture.” From these citations, it follows that the site of the bone-
lesions caused by a natural head first labor in a flat pelvis, is found, not
at one of the poles of the biparietal diameter, but either directly over the
| Handbuch der Entbindungskunst, Bd. ii. Abth. 2, S. 206.
* Journal de Chirurgie, par Malgaigne, Janvier, 1843, p. 42.
* Accouchements Laborieux, Paris, 1762, p. 119.
* Manuel d’Obstétrique. Montpellier, 1840, part v. sect. i. p. 306.
* These, No. 64, 1821, pp. 51, 54.
* Accouchements, Paris, 1835, tome ii. p. 588.
7 De la Tête du Foetus, Paris, 1876, p. 58.
* Accouchements, Paris, 1867, p. 950.
* Forensic Medicine, New Sydenham Society, vol. iii. p. 118.
784 G O O DEL L.,
track of the coronal suture, or on either side of it, and generally parallel
to it, and at right angles to the sagittal suture."
After turning in a flat pelvis, or in one narrowed mainly in its conju-
gate diameter, a very analogous cranial mechanism takes place. The
partial extension of the wedge-shaped head throws the biparietal diameter
to One side of the promontory, and places in the conjugate of the brim
the small bisauricular (bimastoid) diameter—viz., that portion of each
temporal region lying directly in front of the ear. Now, upon traction,
if the Occipito-frontal diameter of the head be short, or the occipital
portion of the pelvis roomy, the head will pass in the transverse (bis-
iliac) diameter of the brim, and in a state midway between flexion and
extension, while the transit-furrow will be vertical, running directly
upward from the smaller bisauricular diameter to the larger bitemporal
diameter, close to and parallel to the coronal suture. If the head be
large or the brim shortened in its transverse diameter, the resistance to
the descent of the hind-head tends to bring about two movements; the
one of flexion, and the other of occipito-frontal displacement towards the
forehead side of the pelvis. The head should, therefore, pass in the
resultant of these forces and of traction ; viz., in a line running some-
what obliquely from the front of the ear, or from the anterior inferior
angle of the parietal bone, to the vault posteriorly. But this transit-line
is more vertical than in the given case of unaided head-first labor, being
very generally found very near and almost parallel to the coronal suture,
sometimes indeed in the very gutter of this suture-track. For the sacral
side of the head being, under traction and propulsion, quickly bent in
and fixed by the promontory, resists occipito-frontal displacement; while
free lateral bulging at uncompressed points prevents any exaggerated
lengthening Out of the Occipito-frontal diameter. Furthermore, supra-
pubic propulsion together with two movements of unremitting traction,
first in the axis of the outlet and then in that of the inlet, cants the base
of the skull over the edge of the promontory, causes its sacral side to be
nipped high up, and makes its pubic side revolve around the promontory
as a centre of motion, and descend over the glib under-surface of the
pubis; in other words the head is, as I have elsewhere expressed it,
warped around the promontory.”
Now, since this mechanism of a head-last labor in a narrow pelvis is
yet mooted, I shall try to prove it by such clinical histories as note the
site of the pressure-furrow. Smellie,” after turning in a narrow pelvis,
and making traction on the child’s body “with all my strength,” delivered
a living child, which did well, although it had “a depression of the
temporal bone before the ear, and the frontal and parietal bones pushed
outwards.” Madame Lachapelle' advises turning in narrow pelves in
| In order to facilitate the work of others in this direction, I append the following refer-
ences to papers on fractures of the foetal cranium, which I have not been able to consult:
Procès verbal de la distribution des prix, June 20, p. 64, et seq.; London Medical and
Surgical Journal, March, 1834, p. 145; Charles West, in Medico-Chirurgical Transactions,
2d series, vol. x. 1845, p. 404; Siebold's Journal für Geburtshūlfe, 1825, B. v. S. 224, B.
xi. S. 400; C. F. Hedinger, tiber die Knochenverletzungen bei Neugebornen in Med.-
gericht Hinsicht, Leipzig, 1833. The following authors have also written on the same
subject: Chaussier, Meissner, Siegel, Ollivier, D'Angers, Viardel, Haller, Bosc, Berchols,
Deventer, Dionis, Roederer, Baudelocque, and Stein.
* Philadelphia Medical Times, March 20, 1875, p. 386.
* Cases in Midwifery, Collect. xxxiv., No. ii., Case ii., p. 237.
* Pratique des Accouchements, Paris, 1825, Eleventh Memoir, p. 429.
T, A B O R IN N A R R O W P E L V E S , 785
order to make the head descend midway between flexion and extension,
so as to get the “temporo-auricular diameter” in the conjugate. From
several cases of head-last labor in narrow pelves, which she narrates, I
select the following: Case I. Primipara; conjugate 2.75 French inches;
vertex presentation ; forceps slipped ; prolapse of the cord; version ; head
extracted with difficulty and with a sudden jerk (secousse brusque). A
large girl was born alive, but did not live long. The head had a deep de-
pression on the left frontal bone. Case II.” Second position of breech; con-
jugate 2.5 French inches; child weighed five pounds and had been dead
for some time. The head had “a deep depression of the right parietal in
its anterior portion and near the temple, caused by the sacral promontory.”
Case III.3 First position of breech ; “For more than ten minutes the
head resisted the most violent tractions” (aur efforts les plus violens).
Child did well for twenty-four hours and then died in convulsions, from
the cranial lesions. An autopsy revealed the separation of the right
parietal bone from the temporal along its whole inferior border.
J. J. Phillips' reports three cases of successful version in contracted
pelves after failure with the forceps. In one of them the child had a
“marked depression on the left parietal and frontal bones.” Here the
transit-line followed the course of the coronal suture. Carl Ruge” gives
six cases of fracture of the frontal bone, and one along the temporo-
parietal suture, after version. In the seven of my own cases" in which
the pressure-furrow is noted, the site was near or on the coronal suture.
The late Prof. E. Martin, of Berlin, says" that, after version, “These
impressions or depressions of the respective parietal bone are always to be
found upon its anterior portion, more or less near the coronal suture.”
Dr. R. Barnes avers" that “The mark of pressure or indentation against
the jutting promontory is always seen at one end of this short diameter:”
viz., the bitemporo-frontal. Dr. I. E. Taylor, of New York, in describing
a case of labor in a pelvis measuring 2.5 inches in its conjugate diameter,
states that “By version and propulsion from above the pubes, the head
was flattened or indented at the junction of the parietal and frontal bones,
which is the usual place.” Many other examples could be cited, but
further evidence is needless.
From this mechanism it is clear that version closely imitates the pro-
cesses of nature, for by it the head enters and passes the conjugate by
its shortest diameter, where four yielding bones meet; where four wide
sutures converge; where the fontanelle is large and always open ; where
overlapping is most free, and where compressibility is greatest. Since
the resistance is limited mainly to the margin of the brim, that once
passed (and generally with a well-marked jerk), there is usually no fur-
ther obstacle to the descent of the head. It is now brought into relation
with new pelvic diameters, and the greater friction of the broader and
harder surface of the hind-head brings about the needful movements of
flexion and of rotation. To effect this the line of traction must be
changed to that of Carus's curve, and finally to one at right angles to
the mother's body.
Op. cit., Eleventh Memoir, p. 481. * Ibid., p. 486.
3 Ibid., Fourth Memoir, p. 157. * Lancet, March, 1871, p. 404.
5 Bulletin Général de Thérap., Août 15, 1875, p. 130.
* Anerican Journal of Obstetrics, August, 1875, p. 197.
7 Richmond and Louisville Medical Journal, April, 1870, p. 421.
* Obstetric Operations, London, 1871, chap. xvi., p. 237.
Transactions of the New York Academy of Medicine, September, ls, 3.
9
50 -
786 G O O DE L L ,
I3ut there are mechanical advantages which turning lossesses over a
cephalic presentation in a narrow pelvis. Outside help, that of traction
and of propulsion, can be invoked without in the slightest degree inter-
fering with th natural mechanism. Again—and this must not be
overlooked—by turning, the head enters the brim by the very short bis-
auricular (bimastoid) diameter of its base, and passes the conjugate by
the larger but more compressible bitemporal diameter of its vault; that
is to say, the small end of the wedge is first nipped. In the correspond-
ing head-first labor, the reverse to this takes place; for the head enters
the conjugate by its bitemporal, or the vault portion of its bicoronal
diameter. From repeated measurements taken shortly after birth, I find
that the average length of the bisauricular diameter is 2.6 inclies, and
that of the bitemporal diameter 3 inclies—a difference of nearly half an
inch.
From this description of the cranial movements, it follows that turning
should be limited to cases of antero-posterior shortening of the brim. For.
in other kinds of narrowing, the previously described mechanism, so essen-
tial to success, could not take place. In the generally and uniformly mar-
rowed pelvis, the transverse (bisiliac) diameter of the brim would probably
be too short to permit the after-coming head to pass in a state midway
between flexion and extension ; while, on the other hand, if the head
were forcibly flexed, a longer diameter than the bitemporal would be
jammed into the short diameter of the brim. Again, from the marrow-
ing of all the diameters of the whole pelvis—brim, bony canal, and out-
let—the after-coming head would be detained at every stage of its
descent, and could not, therefore, be delivered soon enough to avert
fatal asphyxia. To save the life of the child, then, the forceps, and not
turning, is here needed. As a corollary to this, less power and time are
needed after version to deliver an average head in a flat pelvis, than a
large head in an average pelvis; for, in the former, the resistance is mar-
ginal, and limited to a single Osseous point; in the latter, diffused more
or less, not only over the whole bony brim, but over the pelvic canal and
outlet.
How to tell a uniformly narrowed pelvis from one narrowed mainly
in its short diameter, becomes, then, an important question. Apart from
careful digital examinations, much may be learned from measuring the
distance between the anterior-superior spinous processes and that between
the crests of the ilia. In a standard pelvis these distances average re-
spectively 25 cent. (9.8 inches) and 28 cent. (11 inches).' But what should
mostly be relied on is the position of the head. When conjugate narrow-
ing alone exists, or when it preponderates, the occipito-frontal diameter
lies parallel to the transverse diameter of the brim, with the anterior
fontanelle low down. A head so situated implies conjugate narrowing
and transverse amplitude of the brim. When the pelvis is uniformly
narrowed, or when transverse (bisiliac) narrowing preponderates, the
head will be found high up and very strongly flexed. This happens
because the resistance at the brim is equal on all sides, and the shorter
arm of the occipito-frontal lever must therefore descend. The sagittal
suture, for the same reason as in a standard pelvis, will be found running
more obliquely than transversely. Such cranial conditions show that
the transverse diameter of the brim is too short to admit the occipito-
| Carl Martin, Monats. für Geburtsk., Dec. 1867.
LA B O R IN N A R R O W P E L V E S. 7S7
frontal diameter of the head, and that version is consequently inadmis-
sible.
Turn now to the mechanism of labor when the forceps is used at the
brim of a flat pelvis. If the blades are applied to the fronto-Occipital, or
to the fronto-mastoid diameter, the head, which is lying midway between
flexion and extension, is—unless firmly nipped in the conjugate—forcibly
flexed, and either the biparietal diameter, or some diameter longer than
the bitemporal, is made to enter the short diameter of the brim. Again,
the fronto-occipital compression to which the head is subjected, not only
prevents the natural lengthening out of the long diameters, but it causes
bulging of all the cross diameters. This is, of course, a mechanical dis-
advantage, one which increases the difficulty of the head’s transit, and
which can be overcome simply by a brute tractile force—such as puts
foetal life in jeopardy. In addition, the fronto-mastoid application tends,
to force a premature anterior rotation of the hind-head. Also, the line
of traction on the forceps-handles will invariably be at an angle to the
axis of the superior strait, and the brunt of the traction is wasted on the
pubis. Finally, such an application, by flexing the head or by shortening
its fronto-occipital diameter, so widens the iliac spaces that prolapse of
the cord is very liable to occur. “Statistics show that out of five appli-
cations of the forceps above the superior strait, no fewer than two are
complicated by a prolapse of the cord. I,” continues Chailly-Honoré,
“have met with it in the ratio of twice in three cases.”
On the other hand, when the blades are applied along the sides of a
head at the brim of a narrow pelvis and lying in its transverse (bisiliac)
diameter, flexion is inevitable.” So essential, indeed, is this movement
for the accurate adjustment of the blades, that some practitioners try
| Accouchements, 1867, p. 643.
* The statement often appears in foreign medical works, that this application is imprac-
ticable whenever the head lies in the transverse diameter of the brim. This is a mistake;
for, although the long curved forceps then becomes virtually a straight one in so far as the
pelvic curve is concerned, this application can be very generally made with a properly con-
structed instrument, provided the head be not locked. With the Hodge or the Davis for.
ceps I have frequently made this application, and have repeatedly seen others make it.
Hodge and Meigs, it is true, condemned it; but they denied, not its practicability but, its
advisability. Baudelocque, Capuron, and Gardien, warmly advocated it, and it is now the
habitual practice of some of the best obstetricians of Philadelphia. It possesses the great
merits of securing the firmest grip, of compressing the head in its least vulnerable diameter,
and of lessening the pressure on the bladder. Since the mode of making this application is
peculiar, a description of it may not come amiss. If the occiput look directly to the left
ilium—and this is the most common cephalic position in the simple flat pelvis—the woman
is turned over on her back, and her coccyx made to project over the edge of the bed. The
right (female) branch is first introduced in the right side of the pelvis, with the convex sur-
face of its blade looking obliquely to the sacrum. By a rapid downward sweep and a spiral
twist of its handle, together with upward pressure on the convex edge of its blade by the
fingers in the vagina, it is rotated very nearly half of a circle over the forehead to the side
of the child's head under the pubis. The left (male) branch is now so held at its lower
convex edge by the tips of the fingers of the right hand, that its handle hangs down.
While held in this position, the blade is introduced, as far as it can be made to go, in the
right side also of the pelvis' over the child’s left temple but under the shank of the female
blade. The right hand is next carried to the still pendent handle, which it raises, and upon
which it makes upward pressure. This movement, combined with a guiding pressure from
the ſingers of the left hand in the vagina, makes the blade glide up over the Sacral side of
the head. When the branches are united, the lock should press firmly on the tuberosity of
the left ischium. Should the occiput look to the right ilium, the same general rules are to
be observed. But now both blades are to be introduced in the left side of the pelvis—the
left (male) blade first, and under the pubis; the right (female) with its handle pendent.
The lock should now press firmly on the tuberosity of the right ischium.
788 - G O O DE L L,
first to flex the head, either by the hand, by the vectis, or by one blade
of the forceps. In my own experience, however, the act of locking and
that of grasping the handles, usually bring about the needful amount of
flexion ; for success in such an application of the forceps presupposes a
certain amount of mobility of the head, which insures its flexion.
Hence the large biparietal diameter, or one of its congeners, must
inevitably pass directly through the narrow conjugate. But, apart from
its width, the hind-head is the least compressible portion of the cranium.
The parietal bosses, being projections, as their name indicates, and being
also the centres of Ossification, are the most unyielding points of the vault.
They are in fact eburnaceous when compared with other portions of the
parietal'bones. The posterior fontanelle is small, not open, and not infre-
quently Ossified. The sutures are narrow. Only three bones meet there,
the Occipital and the two parietals. But the occipital bone goes to form
the hard cranial base, and is incompressible. The compressibility of the
hind-head is therefore limited to the equitation of the parietal bones.
But being shored up and buttressed by the unyielding occipital bone
underneath them, they cannot readily overlap or bend in. Hence the
tedious traction needed for forceps-deliveries, when compared with that
required after turning. Transit-furrows are rare, but, when present,
they run anteriorly from the boss either obliquely toward the cranial
base, or parallel to the Sagittal suture. In a recent case of forceps-
delivery this was very strikingly shown. The diagonal conjugate, mea-
sured by the rule and finger, gave a length of four inches. The Sagittal
suture ran transversely to the left ilium, with the large fontanelle dipping
down so low as to make it almost the presenting part. The blades of the
forceps were applied to the sides of the head, which flexed on bringing
the handles together. After strong traction of about two hours’ duration,
made alternately by the attending physician and myself, the head was
finally delivered. It was much flattened, and presented on its sacral side
the well-marked furrow of a fracture running from the parietal bone
obliquely to the mastoid process behind the ear. The child was still ; the
mother died four days afterwards from peritonitis, and I now regret not
to have turned. Dugés' also describes such a fracture of the parietal boss
in one of his forceps cases. Fractures and furrows at this site would far
more frequently happen in instrumental labor, were it not that the hard
boss so resists the direct pressure upon it as either to flatten the whole
parietal bone, or to cause lesions of it at weaker, although unimplicated,
points.
Dut there are mechanical objections still stronger against the forceps
when compared with version. The base of the skull being unyielding,
the head cannot be compressed so readily by catching the vault with the
forceps. For the effect is then to direct the compressive power toward
the unyielding base. But by turning, the compressive power is directed
toward the yielding vault. Further, from the peculiarity of construction
of the forceps, the compression exerted by it is necessarily diffused over
the whole surface covered by the blades. Now, in a bilateral application,
the tips of the blades cover the bones of the cheeks, which are incompres-
sible and so narrow as to need no compression whatever, Hence, not
only is this amount of compressive power misapplied and sheer waste,
but it detracts by so much from that applied to the Offending diameter—
the biparietal. Thus the surface covered by the blades not only involves
| Manuel d’Obstétrique; Montpellier, 1840, part v. sect. i. art. i. p. 306.
I, A B O R IN N A R R O W P E L V E S. 789
unimplicated diameters, but it is too broad to be very materially reduced
by compression. Even when the handles are lashed, but little more is
gained, and that little at the expense of a prolonged, disorganizing pres-
sure upon the brain. Baudelocque's exceptionally powerful forceps were,
with lashed handles, found by their inventor barely to reduce the bi-
parietal diameter as much as four lines, although the force applied was
So great and so prolonged as to spoil the three instruments used. It fol-
lows, therefore, that the Hodge or the Davis forceps, which are much fee-
bler instruments than the French one, cannot compress the biparietal
diameter as much as three lines, and the operator is therefore compelled
in narrow pelves to make the anterior portion of the brim and the pro-
montory of the sacrum do most of the compressing work; and that by
sheer and prolonged dragging force, which, as in the case just narrated,
threatens injury to the mother and death to the child.
Again, the forceps-blades being of equal length and breadth, and being
also applied to corresponding surfaces of the child's head, make equal
compression upon the pubic and the sacral side of the head. But from
the limitation of the bone-lesion in these pelves to the posterior half of
the brim, the pubic side of the head needs no compression ; for its con-
vexity naturally adapts itself to the smooth concavity of the anterior half
of the brim. Therefore just one-half of the effective compressive power
is absolutely thrown away. For granting that, in a given case of conju-
gate narrowing, the forceps reduces the biparietal diameter by three lines,
this diminution does not facilitate to the same extent the passage of the
head ; for supposing that it actually reduces the width of the head by
three lines, yet it does not virtually so reduce it. This is evident from
the fact that the pubic side of the head needs, not compression, but adap-
tation, and the bulging tissues around the periphery of the blades will
at points separated by their width still impinge on the pubic concavity
of the brim, making the clamped portion of the head subtend the sym-
physis pubis like the chord of an arc. In all the narrow pelves belong-
ing to the museum of the Philadelphia Obstetrical Society, and one of
them is under two inches in its conjugate diameter, the pubic side is con-
cave and smooth. After a careful examination of the distorted pelves.in
the museum of the University of Pennsylvania, I find that the same con-
dition obtains in all that were not affected by Osteomalacia. Turn now
to the sacral blade of the forceps; it is the posterior half of the brim
which is distorted; and to its irregular configuration must the sacral side
alone of the head be moulded. Since also the distortion is mainly owing
to the descent of the sacrum as a whole, and to the anterior projection
of its promontory, the portion of the head needing moulding is a small
area of surface corresponding with the Sacro-vertebral angle. In other
words, it is, when flexion is forced by the forceps, the biparietal dia-
meter alone that needs shortening, and that by the indentation of its
sacral pole. But the very width and length of the Sacral blade thwarts
this indication. This blade flattens the whole sacral surface of the head,
but does not mould it. The whole head and included brain are in fact
flattened out by the two blades. And this excessive bilateral compression
so unnecessarily lengthens out ail the other diameters of the head, that
every physician has seen forehead bulging out, eyeballs starting from
their sockets, and life destroyed by the violent and prolonged compression
to which the whole brain has been subjected. In one word, by the bi-
lateral compression of the forceps the pubic blade interferes with the pro-
cess of adaptation ; the sacral blade prevents the utilization of the roomy
790 G O O DELL,
concavities on each side of the promontory, and the whole brain is, there-
fore, subjected to an unnecessary amount of compression.
The catch-word “moulding,” which is so much used to designate the
action of the forceps, is a misnomer. Moulding here means an outline
conformity of the cranium to the kidney-shaped configuration of the
brim. To attain this end, it is needful for the pubic side of the head to
adapt itself to the smooth concavity of that portion of the pelvis, for
the occipito-frontal diameter to be moderately lengthened out, for a
limited area of the sacral side of the head to be bent in by the promon-
tory, and for lateral bulging to take place around it in the very roomy
sacro-iliac spaces. No moulding of the head, in its true obstetric sense,
can possibly occur, unless, as in natural labors or by version, the pelvis
itself acts the part of the moulder. Look at a head in the grasp of the
forceps applied bilaterally. How is it possible for this steel-ribbed head
to alter its shape to that of the brim ; How can any bending-in take
place within the fenestra of the sacral blade, whose iron rim, by firm
pressure, acts as an abutment to the included parietal boss? How can
the pubic side of the head adapt itself to the anterior portion of the pel-
vis? How can the head bulge out at points clamped by iron The
forceps, thus applied, indeed moulds the head, but to its own shape, and
not to that of the brim. For how can bow-shaped blades mould a head
to a kidney-shaped brim : The thing is an impossibility. Who ever
saw a head kidney-shaped which had been delivered in such a manner
through a narrow brinº. The truth is that the head then passes the
brim by being flattened out, and not by being moulded ; and, what is
worse, since the blades do not exert the needful compressive power, the
promontory itself is made to do most of this unnatural work—the work
of flattening and not of moulding. When the head is squeezed suffi-
ciently flat, it is delivered by being dragged straight past the promon-
tory, without revolving around it as it does in natural or in version
CàSeS.
So true is this that, when a head has been delivered through a small
conjugate by the forceps applied bilaterally, never will it exhibit a cast
of the promontory by a spoon-shaped depression, and only once have I seen
a slight furrow. The whole head is flattened, the bones are separated at
the sutures, sometimes so much so as to seem loose in a scalp-bag, but no
lesion of limited area is found by a surface examination. Post-mortem
examination will, however, reveal fissures and fractures radiating from
the base of the parietal boss.
It follows that the hackneyed term of “wire-drawing” the head by
the forceps, is also a misnomer. In “wire-drawing,” the pincers which
seize the end of the wire do not pass through the graduated holes in the
draw-plate, but work outside of them. But when the head is seized by
the forceps, the pincers, so to speak, must also pass through the bony
draw-plate itself. So great a disadvantage is this, that there are on
record far more remarkable cases of successful natural delivery in very
small pelves, than there are by this use of the forceps. For it stands to
reason that when a forceps, whose blades lie from two and three-quarters
to three inches apart, is applied to the sides of a head at the brim of a
pelvis with a conjugate of less width, the blades will need wire-drawing
as much as the head, before they can be made to pass.
So far the use of the forceps. Mark now what happens when the
child is turned in a flat pelvis. The wedge-shaped and semiflexed head
enters the conjugate by its small bisauricular diameter, and passes it by
L AIR O R IN N A R R O W P E L V E S. 791
its very compressible bitemporal diameter. The very cause of the conju-
gate deficiency—the jutting promontory—becomes itself the moulder,
and the plastic head, unhampered, unclamped, unribbed by bars of steel,
being also drawn upon by outside traction, accurately moulds itself to the
shape of this small bony barrier. Meantime the pubic side of the head,
already presenting its convexity to a concavity, is made by lateral pres-
sure to fit snugly the anterior half of the brim. Bulging takes place at
all the uncompressed points, and the whole head becomes concavo-
convex, being rapidly moulded to the kidney-shaped configuration of
the whole brim, while backward traction and supra-pubic propulsion
cause the pubic side to revolve around the promontory as a centre of
motion. To my mind nothing can be plainer. How, otherwise, is the
absence of vesical disturbance, after version, explainable? How the fact
that, as I have seen and others attest, it will take as many minutes, less
minutes indeed, to deliver the head by version, as it has taken hours of
unsuccessful traction with the forceps? Even without these facts and
without a cloud of witnesses to sustain them, an d priori reasoning would
compel me logically to the inevitable conclusion that version possesses
great mechanical advantages over the forceps.
One word in regard to the obliquely ovate pelvis. If the hind-head
present in the less roomy side, by turning, the soft and voluminous breech
is very likely to adapt itself and pass through the more roomy side. This
tendency, together with a knowledge of the fact that the foot drawn on
usually rotates to the pubic arch, ought, very generally, to enable the
practitioner to place the occiput in the larger half. Yet so great an
advantage is it to turn, that Barnes and Strassmann declare that they
have saved the children, even when they had failed by this operation to
effect the desired change of position.
The use of the vectis, or tractor, in narrow pelves has been so highly
lauded by Boddaert, of Brussels, Raffaele, of Naples, Fabbri, of Bologna,
Marchant, Herbiniaux, Coppée, Beytter, Frayes, and other Dutch, Bel-
gian, and Italian writers,” that a few words in regard to the action of
this instrument are needed.
When the head is transverse, this instrument should be passed over the
pubic mastoid region ; when oblique and anterior, over the pubic side of
the occiput; and when oblique and posterior, over the pubic fronto-
temporal region. At first it is used as a lever of the “first kind,” the
left hand on the shank representing the fulcrum, and the right hand be-
coming the power by raising the handle toward the pubes. In other
words, each hand acts in opposite directions—the left one mainly to pro-
tect the pubis from pressure. As soon as the handle is raised high enough
for the blade to secure a good hold, the right hand is kept at rest to be-
come the fulcrum of a lever of the “third kind,” while the left acts as
the power. This compound action of traction and leverage, peculiar
alone to the vectis, here meets several important indications. As a lever,
this instrument compresses the head from before backward in its lateral
diameter, and aids the moulding of its free sacral surface to the posterior
distortion of the brim. By its action as a tractor, it hooks down the
pubic side of the head, making it revolve around the promontory of the
sacrum as a centre of motion, and roll over into the pelvic cavity.
Obstetric Operations: by R. Barnes, 1871, chapter xvi. p. 241. -
2 Cazeaux, edited by Tarnier, 1874, p. 998; Congrés Médical de France, 1865, pp. 554,
589: Traité des Accouch... par Hyernaux : Bruxelles, 1st;6, p. 699 ; New Sydenham So-
ciety's Biennial Retrospect. IS69–1870, p. 409.
792 Goo DE LI,
From the close resemblance of this mechanism to that of an unaided
head-first labor, and to that of an aided head-last labor, I am led to think
that the vectis, in skilled hands, will be found more efficient than the
forceps in dislodging a head from the brim of a pelvis narrowed mainly
in its conjugate diameter. Below the brim, and in the generally narrowed
pelvis, it cannot of course compete with the forceps excepting in certain
anomalous positions and presentations. But in selected cases this neglected
single-bladed instrument is, in my opinion, destined to take rank over its
double-bladed fellow. For instance, in 1863, the late lamented Fabbri,
of the University of Bologna, quickly delivered with the vectis, through
an artificial pelvis, a head which S. Tarnier, although using all his
strength, was not able to budge with the forceps. The head was then
replaced, and the forceps re-applied, but with the same want of success.
Professor Tarnier, who is the narrator, then resorted to the lever, and,
much to his surprise, delivered the head “with astonishing ease” (avec
une étommante facilité). This experiment was repeated, and invariably
with the same result.
To sum up then the mechanism of natural and of artificial labor in a
flat pelvis:–Nature makes the first-coming and the after-coming head
enter the brim by extension ; the forceps by flexion. With the former
the head engages in the short conjugate by its shortest and most com-
pressible diameter; with the latter by its largest and most unyielding
diameter. By nature and by version the head revolves around the pro-
montory as a centre of motion; by the forceps it is dragged straight
past, over this Osseous point. By the former the head is moulded to the
outline configuration of the brim ; by the latter, when applied to the
biparietal diameter, it is moulded more to the shape of the blades than
to that of the brim. By the one the brain lesion is local and limited to
the area bent in by the promontory; by the other the area of undue com-
pression is increased. By nature and by version the compression is that
which is needed and no more ; by the forceps it is more than is needed.
Regarding then alone the mechanism of labor in narrow pelves, to
which the scope of this paper is strictly limited, the following conclu-
sions are reached :-
I. The unaided first-coming head and the aided after-coming head
observe in a flat pelvis precisely the same general laws of engagement
and of descent. Hence, version here means art plus nature.
II. The forceps, however applied in a flat pelvis, antagonizes more or
less with the natural mechanism of labor. Hence, the forceps here means
art we?"SºlS nature. -
III. The aided and the unaided first-coming head observe in a uni-
formly narrowed pelvis precisely the same laws of engagement and of
descent. But version violates these laws. Hence, the forceps here
means art plus nature ; version, art versus nature.
IV. At or above the brim of a flat pelvis, the fronto-mastoid or even
the fronto-occipital application of the forceps interferes less with the
moulding of the head, and violates less the natural mechanism of labor,
than the biparietal application.
V. In the flat pelvis, the vectis aids the natural mechanism of labor,
and, therefore, meets the indications better than the forceps.
| Cazeaux's Obstetrics, 1874, p. 996.
LA B O R IN N A R R O W P E L W E S.
7
9
3
DISCUSSION ON DR GOODELL’s PAPER.
After the reading of the preceding paper, the President, Dr. ROBERT BARNEs,
of London, said:——The paper is now open for discussion. I desire, however,
first to say that it is the ablest paper that I have ever heard or read upon the
subject. I am aware of the difficulty in treating this question, for the passage
of the foetus through the pelvis, and the obstructions to its progress from de-
formities, are not only to be studied clinically, but, as the conditions are me-
chanical, by a priori reasoning. Yet, after all, experience is the best guide,
whether the method proposed is clinical or empirical. I shall be glad to hear
from the members of the Section, and may suggest as heads for the discussion
(1) the mechanism of labor when unaided, and (2) its mechanism when aided
by art. I am glad to see in the room Prof. Barker, who has possibly more
special knowledge on this subject than any one I know of.
Dr. FoEDycE BARKER, of New York, said:—I believe that Obstetrics has
begun to make itself an exact science, and I am sure that investigation and
the presentation of papers such as we have heard will have a tendency to make
it more and more exact. I am sorry that I did not hear the first part of the
paper, for I should feel like studying it carefully before commenting upon it.
I think that the vectis in certain cases of contracted pelves is preferable to the
forceps, and I am pleased to find that Dr. Goodell agrees with me upon this
point.
Dr. WILLIAM H. By FoRD, of Chicago, said:——I have greatly enjoyed the
reading of Dr. Goodell's paper, but as to criticism, I think mine would be
valueless. I have in my writings advised the use of the vectis in cases of the
after-coming head, where it has not entered the pelvis; but I use the forceps
where the head is fully in the pelvis. Since hearing Dr. Goodell's paper, I feel
disposed, in the case of kidney-shaped pelves, not only to turn, but to use the
vectis instead of other instruments. Obstetrics is a science that is almost en-
tirely mechanical, and for that reason I think, with Dr. Barker, that it will ere
long become an exact science. I regret very much that I have not had the time
or the opportunity to study the valuable paper which has been presented, and
the subjects treated of in it.
The President, Dr. BARNES, said:—It must be apparent that in certain cases
of narrow pelves one must resort to the induction of premature labor; but
that point has not been referred to. The value of this operation has been
called in question of late years, and it may be well to inquire how does the
mechanism of labor bear upon those cases in which lives are thus saved 7 I
should like to have the experience of those familiar with cases in which the
child has lived after the induction of labor.
Dr. WILLIAM LUsk, of New York, said:—In the main I agree with the con-
clusions of Dr. Goodell. I have, however, applied the forceps along the sides
of the pelvis, and have, in some cases, dragged the head down to the floor of
the pelvis, without flexing it, both fontanelles being nearly on a level. It has
always been my habit, after the conjugate diameter has been passed, to wait for
the head to flex and the occiput to rotate, before renewing traction and com-
pleting the delivery. If continuous traction be kept up, then all the statements
of the paper are justified; but if occipito-frontal compression be applied at the
brim, and traction made only during the pains, the child’s head will generally
pass without being flexed, and delivery will be effected in accordance with the
mechanism described by Dr. Goodell. When the head is fixed in the brim, I
would use the forceps with no apprehension of flexing it.
Dr. GOODELL, in reply to a question, said:—I have no experience with the
instrument of Chassagny. But all the distinguished obstetricians in France
are leaning in the very questionable direction of importing the labor-saving
instruments, the straps, pulleys, and capstans, of veterinary obstetrics, into
human obstetrics. In 1872, Chassagny bore off the Montyon prize for his
794 G O O DELL,
appareils de traction soulenue, and since then many others have been invented.
It is a significant fact that these instruments have originated in France, where
version is bitterly opposed. It is also a significant fact that the only eminent
French obstetricians who oppose them are Blot, who practises version to save
the life of the child in narrow pelves, and Pajot, who turns in order to crush
the base of the skull by his cephalotribe.
Dr. A LEXANDER. R. SIMPson, of Edinburgh, said : —The flat pelvis presents
peculiar advantages for version. One would expect the greatest advantage
when the base of the skull, which is the narrowest part, comes in relation to the
narrowest part of the pelvis. I have seen this, in my own practice, again and
again. Reference has been made to Budin and his series of mechanical experi-
ments on the comparative force needed by version and by the forceps in drag-
ging the child through the pelvis. These experiments have somewhat stag-
gered me. In some of them the long diameters were shortened, and in others
they were elongated. In Dr. Goodell’s conclusions I see allusions made to
the application of the forceps to the sides of the head at the brim. But it is an
impossibility for the forceps to grasp the sides of the head in the case of a
flattened pelvis; for there is no room, and the operation is simply impracticable.
It might be possible for one blade of the forceps passed over the occiput and the
Other over the forehead to so grasp the head as to produce elongation and thus
cause the head to pass through a narrow brim, but version is preferable in
these cases. .
The President, Dr. BARNES, said:—I have practised version for twenty
years in preference to using the forceps, and am becoming more partial to it
the more I practise it. From the forceps there can be but little benefit except
in minor contractions, but in great contractions, where there is any chance of
saving the child, I should use all means in preference to the forceps. As to the
mechanism of labor in a “head-first presentation,” it has been well explained
in the paper of Dr. Goodell. I can only add force to those deductions by
referring to the frequency of occipito-posterior positions in contracted pelves,
a frequency which enforces Dr. Goodell’s arguments. Under such circumstances
version is the best mode of delivery, but there are occipito-posterior presenta-
tions in which, the head having passed through the narrow brim, and the woman
being exhausted, the forceps will finish the labor. I have delivered one lady
five times, all with the same difficulty of occipito-posterior presentation. In
another case in which there was a slight contraction of the pelvis, the child was
lost by the use of the forceps, but on two occasions when I turned, the child
was saved. It requires practice in these cases of version in a narrow pelvis,
and the mechanism, in head-last presentation, will be much better understood
by careful study. In turning, there is the danger from dragging on the child's
neck, and from the traction on the medulla oblongata, or in some cases from
the injury to the brain pulp. I have seen a child's head pulled off by injudi-
cious traction. There is in these cases often a misdirection of force on the
part of the physician which jeopardizes the child's life.
[Dr. Barnes explained by a diagram on the blackboard the method of getting the head
around the sacral promontory by backward traction.]
The force needed can be augmented, and the mechanism facilitated if some
one pushes from above while the physician pulls from below, as this will take
off a great deal of the strain on the neck, and the propelling hand can guide
the child’s head in its rotation around the promontory. I lay great stress on
supra-pubic propulsion by the hands of an assistant. The use of forceps on
the fore-coming head in contracted pelves, is not based upon sound mechanical
principles. In cases of minor contraction, it aids delivery by elongating the
head. The direction of thought in obstetrics is now tending to a greater pre-
cision in this question of the mechanism of delivery. Sometimes it is found
impossible by any mode of delivery to save the child alive; sometimes the
woman is too much exhausted for an attempt at version to be made. In these
L. A B O R IN N A R R O W P E L W E S. 795
cases, after perforation and the escape of a few ounces of brain, the forceps can
be used for breaking the skull from behind, and it will be found to collapse at
Once. It cannot be said under such circumstances that the child has been
sacrificed, but that all endeavors to save the life of the mother have been used,
and that the child has been abandoned only when it has become absolutely
necessary. As to the vectis, I deem it of service only in cases of minor con-
traction ; but it has been greatly lauded by some provincial practitioners, who
prefer it to the forceps.
Dr. GooDELL, in reply, said :-I was glad to hear Prof. Simpson refer to
M. Budin's paper. Its conclusions in favor of the forceps at first staggered
me also, but, upon an examination of the experiments, three sources of fallacy
became manifest. In the first place, the pelvis used by M. Budin was not
an originally flat one, but an iron cast of what was supposed to be a normal
pelvis. To narrow the conjugate of this metallic pelvis, Budin had a movable,
false promontory so constructed that a sacral screw forced it towards the
pubis. Hence the conjugate diameter of the brim was shortened without
a proportional lengthening out of the transverse diameter, and every turn
of the screw converted the pelvis into a uniformly narrowed, flat pelvis, and
not into a simple, flat one. Thus, as his experiments abundantly showed, there
was not room enough in the transverse diameter of the brim to admit the
occipito-frontal diameter of the head. But when he experimented with chil-
dren born before term, and consequently with a shorter occipito-frontal dia-
meter, far less tractive-force was needed to deliver them by turning, than by
the use of the forceps. Again, this movable and metallic, false promontory
was cast from a mould taken from the broad, blunt, and rounded promontory
of a normal pelvis, and not from the narrow, sharp, and jutting promontory
of a flat pelvis. Hence the needful indentation of the head was gained by
this broad and blunt knob of a promontory with very great difficulty. In the
third place, Budin’s iron pelvis was placed on a table and near its edge, to
represent the dorsal decubitus of a woman when artificially delivered, while
the tackle used by him for these experiments was fastened to a staple driven,
not into the floor near the legs of the table, but into the wall. Consequently,
not only no backward traction could be made on the legs of the child, but the
traction was so directed as to cause the head to revolve around the pubis, and
not around the promontory, as the centre of motion. In reply to Dr. Lusk I
would say that, if the head be well nipped in the conjugate, the fronto-mastoid
or the fronto-occipital application of the forceps will not ordinarily flex it. Iłut
in other cases it commonly flexes the head, and always tends to do so. When
the blades are applied to the sides of the head, the vertex always dips, and
the biparietal diameter enters the conjugate, because such an application could
not be made if the head were tightly nipped. I wish finally not to be mis-
understood as recommending version to the exclusion of the forceps. The
forceps is for obvious reasons generally my first choice ; besides, version can-
not always be made; in some cases, indeed, should not be attempted. But in
the paper which I have read, I have avoided all such side-issues, and have
approached the subject from a purely mechanical stand-point.
7
9
6
THE MANAGEMENT OF CONVULSIONS, IN CHILDREN,
DEPENDING UPON A HIGH TEMPERATURE
OF THE BODY.
T}Y
T. K. HOLMES, M.D.,
OF CHATH AM, ONTARIO, CANADA.
GENTI.EMEN:
I purpose, in this short paper, to ask your attention to the manage-
ment of convulsions, in children, depending upon a high temperature of
the body. The subject will not be thought unworthy of consideration
by any one who has seen this complication resist various plans of treat-
ment, and prove fatal after hours of intense anxiety on the part of all
concerned. The great frequency and fatality of convulsions, in children,
should be a strong incentive to all physicians to avail themselves of
every mode of reducing the mortality. In this city during the five
years from 1844 to 1848 inclusive, 1729 children, under fifteen years of
age, died of convulsions; a higher mortality than attended either cholera
infantum, marasmus, pneumonia, or hydrocephalus, during the same
years. It is neither possible nor desirable in this paper to enter into a
lengthened discussion of all the phenomena connected with this subject.
This has been done by most modern authors, and by none more lucidly
or ably than by your distinguished countrymen, Meigs and l’epper.
It is admitted by all that eclampsia is a frequent complication in
many febrile diseases, as Scarlatina, measles, pneumonia, malarious
fevers, etc., and by nearly all writers great prominence is given to the
particular poisoning of the blood in these affections, as the chief factor
in the causation of the convulsive fits which so often complicate them.
While admitting that certain septicæmic conditions may not be without
influence in producing the convulsive attacks, I believe that the simple
elevation of temperature, accompanying these diseases, is sufficient, in
most cases, to account for them. In this connection it is worthy of note
that those febrile diseases in which convulsions are common, are those
usually marked by a high degree of temperature, although the specific
poison in each may be quite different ; and that in other diseases, as
smallpox, syphilis, and diphtheria, in which the blood-poisoning is very
virulent, but the temperature not very high, convulsive seizures are
comparatively rare. The experiments of Dr. Brunton prove that heat
acts as a direct excitant to the heart, causing it to beat more frequently,
directly as the elevation of temperature, and that cold has the opposite
effect. These results are due to the influence of heat and cold upon the
'ardiac nerves, and from the extreme nervous irritability accompanying
fever, as evinced by restlessness and liability to convulsions, it is fair
to conclude that heat and cold act similarly on the cerebro-spinal sys-
tem. While an elevated temperature causes increased frequency in the
heart’s action, it weakens the force of its contractions, a fact that should
not be overlooked in the administration of some therapeutic agents
which, however useful under other circumstances, become highly dan-
C O N V U L S I O N S IN C H II, I) RE N. 797
gerous when the heart has become weakened from any cause. This is
especially true of aconite, veratrum viride, chloral hydrate, and bromide
of potassium.
From observations upon thirty cases, of which I have preserved notes,
the following propositions may be deduced : (1) That the nervous sus-
ceptibility of children under ten years of age strongly predisposes them
to convulsions; (2) that in children of that age a temperature of 103°
Fahr., and upwards, is very liable to excite an attack; (3) that the
severity of the attack bears a direct ratio to the intensity of the fever;
(4) that convulsions are more liable to occur during the first few hours
of the pyrexial seizure, than at any subsequent period of its course ; and
(5) that whatever reduces the temperature, modifies or arrests the con-
vulsions.
Regarding the first four propositions, few will differ, but while the
fifth may be generally admitted, there is great diversity of opinion as
to the best manner of accomplishing the reduction of temperature. The
means at our disposal may be classed as internal remedies and external
applications; the former including veratrum viride, aconite, digitalis,
quinine, and salicine, with probably some others not as much used nor
as well understood, and the latter consisting of cold applications to the
surface of the body. Most of the remedies of the first class exercise a
very depressing influence on the heart, and so are not applicable to these
cases, quinine being almost the only one upon which any reliance can be
safely placed. It generally happens, moreover, that in all severe cases of
convulsions the child cannot swallow, and then remedies of the first
class must be dispensed with altogether unless we resort to their adminis-
tration hypodermically, a proceeding not warranted by the results ob-
tained.
For the antipyrexial action of quinine, veratrum viride, aconite, and
digitalis, I would refer to the experiments of Dr. Roberts Bartholow, of
Cincinnati, which have been published in one of a series of clinical lectures
edited by Dr. Seguin, of New York. From a study of the physiological
action and therapeutic influence of these remedies, it is plain that their
modus operandi, in reducing the temperature, is quite different from
that of cold applied to the surface of the body. In the former, the re-
sult is accomplished by interrupting the conditions which render rapid
chemico-vital change in the capillary system possible; in the latter, it is
accomplished by the simple abstraction of heat already generated. By
the former, it is accomplished slowly, imperfectly, and with great risk
to the patient ; by the latter, the same is done rapidly, perfectly, and, in
at least the great majority of cases, without risk. It is chiefly with the
view of illustrating the curative influence of remedies of the second class
that I have ventured to ask your attention even for a few minutes.
For this purpose I have transcribed from my case book the following
CàSéS : —
CASE I.—July 3, 1876. M. Arnold, two years of age, strong and well devel-
oped, was taken suddenly ill last evening with dysentery and high fever which
lasted all night, and at seven o'clock this morning had a pretty severe convul-
sion. At eight I saw him for the first time, and found the temperature 103?
F., and the child restless. I gave a large dose of castor oil, and also one-third
of a drop of tincture of aconite, to be repeated every hour while fever lasted.
Another convulsion occurred at ten o'clock, and a third at half-past ten, when
I arrived in time to check its violence with chloroform. At noon, the castor
oil had operated well. At 2 P. M., convulsions returned, and continued for
798 HOLMES,
two hours with no intermission, although the patient was partially under the
influence of chloroform during the time. At 4 P.M. they were as violent as
possible, the temperature was 105° F., the pulse 150 and very weak, and death
seemed imminent. I now put the child into a tepid bath, and rapidly cooled
it to 50° F. by the addition of ice and iced water. At the end of ten minutes
the breathing became easier, in fifteen minutes the temperature was 103° F.,
and in twenty minutes it had fallen to 999 F., and the pulse to 110 beats per
minute. I then dried the child and wrapped him in a blanket. He was very
much better, but the breathing was still somewhat noisy and labored, and there
were two slight fits during the first half hour succeeding the bath ; the tempe-
rature also began to rise again, and had reached 101° when I again put him
into the same cold water for five minutes. The temperature now fell to 98%2,
and the pulse in the same time to 100 beats per minute. The child slept
Inaturally for half an hour, and awoke apparently quite well. There was no
return of fever, and no further treatment was required.
One can scarcely avoid the conclusion that the convulsions in this case
were caused by a high temperature alone. The previously healthy state
of the child, the freedom of the alimentary canal from anything irritating,
for the castor oil had acted thoroughly two hours before the most violent
attack came on, the absence of any other appreciable, centric, exciting
cause, and the almost instantaneous cessation of the convulsions when
the temperature had fallen below 99°, all support this conclusion.
CASE II.-Sept. 26, 1872. P. T., aet. 8 years, was never ill until noon to-day,
when he had a chill for a few minutes, followed by fever and convulsions, which
still continued when I arrived at one P. M. His temperature was 1069, and
his pulse 140, full, and regular. The attendants had just removed him from a
warm bath and wrapped him in a blanket. It was impossible to get him to
swallow anything. I at once applied cold to the head, administered an enema,
and put him under the influence of chloroform. This modified the violence of
the spasms, but they returned immediately when the effects of the anaesthetic
were allowed to pass off. The enema acted well, and the chloroform was con-
tinued, but the temperature was unchanged, the pulse became gradually weaker
and more frequent, and after three hours the patient died. As this boy had
been well until now, and as no other exciting cause could be traced, it is not
unreasonable to conclude that the high temperature led to the fatal result.
CASE III.-July 12, 1876, 10 A.M. C. S., a well-nourished male child, five
months old, has had diarrhoea for three days, and the mother thinks fever also,
but was not very ill until yesterday afternoon, since which time he has neither
nursed nor slept, but has constantly uttered half suppressed cries. The child
is pale, the hands and feet quite cool, and the skin dry. Gave a purgative dose
of rhubarb and soda.
3 P. M. The rhubarb has acted on the bowels three times, the last evacuation
having been quite natural in color. The hands, feet, and legs are quite cold :
the pulse almost imperceptible; the pupils not larger than pins' heads; the
thumbs contracted; the face pinched, and of a leaden hue ; and the thirst most
intense. The axillary temperature, to my surprise, was 105° F., for I had been
deceived by the coldness of the extremities and the general appearance of the
patient, and did not expect to find the temperature so high. I now gave the
child half a drachm of brandy, and placed it in a tepid bath, adding water froln
the well until the whole was quite cold. In ten minutes the temperature fell to
1039, and the child went to sleep for the first time in thirty hours. When the
temperature had fallen to 100°, I wrapped the child in a blanket, and he con-
tinued to sleep most of the afternoon and was not thirsty. As the temperature
fell, the pulse became slower and fuller, and the pupils larger.
8 P. M. Temperature 103°, pupils natural; the child sleeps well and looks
placid. Bath repeated, and temperature reduced in five minutes to 999.
C O N W U L S I O N S IN C H II, D R E N. 799
13th, 10 A. M. Child rested well all night; nurses; temperature 103°. As
he appeared quite easy, I merely ordered a dose of castor oil.
11 A. M. Child has had two severe convulsions in the last ten minutes, and
is insensible, and the temperature has risen to 105}*. Repeated the cold bath,
and reduced temperature to 98%", when the child became quiet and slept. After
this the temperature never rose above 101°, the bath was not repeated, and in
a few days the child was well.
The coldness of the extremities and the weakness of the pulse in this
case made me hesitate before resorting to the cold bath, but as death
seemed imminent, and as the axillary temperature was so high, I con-
cluded that any other means would fail, and that some risk was justi-
fiable. It is remarkable that during the hour preceding the convulsions,
the temperature rose from 103° to 105}*. I could cite a number of cases
resembling the three here detailed, half of which would go to show the
superiority of the treatment by cold baths over every other, when the
temperature is high ; and my friend and co-delegate here, Dr. Murphy,
informs me that his experience with this plan of treatment entirely
coincides with mine.
Where other indications for treatment exist, as malaria, teething,
offensive accumulation in the alimentary canal, etc., it of course becomes
necessary to attend to these also. In pursuing the plan I here recom-
niend, I have always been guided by the thermometer, never resorting to
the bath when the temperature has been below 100°, and always removing
the patient from the water when the axillary temperature has fallen to
nearly the normal standard of health.
It is much better to have the water tepid at first, on account of the
excitement and alarm produced by sudden cold. I have not ventured
to use the cold bath in convulsions complicating pneumonia, my expe-
rience being chiefly confined to those occurring in connection with
dysentery, diarrhoea, cholera infantum, and malarious fevers. In these
diseases, when the fever is high, although there be no convulsion, I
have found no remedy that approaches the cold bath in its power of
allaying nervous irritation and procuring quiet rest, and I am fully
persuaded that all who resort to this mode of treatment once, will do so
agall).
DISCUSSION ON DR. Holm Es’s PAPER.
After the reading of the preceding paper, the President, Dr. ROBERT BARNES,
of London, said:—Where there is an increased temperature in children, there
is always some trouble with the blood, poisoning, or something else, which
leads to convulsions. The question is, what develops convulsion ? what is the
first cause 2 It has been found that as the temperature rises, there is an
increased liability to convulsions, and that as the temperature sinks, there is a
decrease in this liability. Do we find that high temperatures always produce
convulsions? In children, there is an exalted nervous irritabilty like that in
pregnant women. Do they always have an increase of temperature ? I have
watched cases in which there has been no rise whatever—in uraemic convulsions
after scarlet fever, for instance. In simple pyrexia I believe that cold water
can be used to reduce the temperature; I have wiped the surface of the body
with it, and found it to act well. The cold water acts by evaporation, and
consequently reduces the temperature. The cold bath is a powerful remedy;
its use by the Germans is a revival of a remedy first employed by Dr. Currie.
Dr. THOMAS F. Roch ESTER, of Buffalo, N. Y., said:—I have paid consider-
800 HOLMES, CONV ULSIONS IN CHILDREN.
able attention to infantile disorders, and think I can corroborate the views
advanced by Dr. Holmes in many respects. The subject is one which requires
more attention than is paid to it. The reduction of the temperature by water,
I regard as more safe than by the use of drugs. In my own city there have
been many children lost, during the hot season, from what is called summer-
complaint, which is ascribed wholly to the elevation of the temperature, but
this I deem an error. The thermometer rises to 90° or 100°, the sky is blue
and the Sun bright, and yet the mortality is not as great as it is when the
atmosphere cools off. Some years ago we had, in my city, a hot, dry spell,
with but little sickness among the children ; a hail storm came without any
bremonition, and at once infantile disorders set in. The diminution in the
heat had caused the whole trouble. I have not examined the temperature
before and after such atmospheric changes, but to me it seems conclusive
that the fall in the temperature produces more diseases of children than the
rise. I speak of convulsions as associated with the diseases of children, and
make my remarks only in that connection.
Dr. HOLMES, in reply, said:—I have lost a good many children from high
temperature; and now think it well to reduce the frequency of the heart beats,
for, as they become slower, the exhaustion lessens, and the beat becomes more
forcible. My views are embodied in the short paper presented, and are based
upon experience gleaned from my own practice.
801
OVARIOTOMY BY ENUCLEATION.
BY
JULIUS F. MINER, M.D.,
PROFESSOR OF SPECIAL AND CLINICAL SU RGERY IN TEIF MEDICAJ, DEPARTMENT OF THE
UNIVERSITY OF BUFFALO.
IT is now about seven years since I announced to the profession that
ovarian tumors could be removed by enucleation, and invited my profes-
sional friends to make trial of the proposed plan, describing, as well as
I could, what I had done and the conclusions I had formed." The idea
that a tumor having such large arterial supply, could be removed without
clamp, ligature, or cautery, though at first startling, received considerate
attention, and, both in this country and in Europe, its successful results
have led some of the most distinguished Operators, not only to make
trial of it, but to speak of it in high terms of commendation.
From the numerous reports and papers upon the subject, I discover
that the exact manner of enucleation is not yet distinctly understood;
some have spoken of a clamp after enucleation, others have spoken of
cutting, the very thing that is to be avoided, while others still have
limited the detachment of the pedicle to two or three inches above its
base, thus showing me that I have never been fully understood as to the
method of removing ovarian tumors by enucleation, a plan which, my
experience convinces me, if properly understood and executed, possesses .
advantages over all others, and is of almost universal application.
It is well known that the ovarian tumor is surrounded by a peritoneal
covering; that the pedicle, proper, usually divides into three or four parts,
passing up over the walls of the tumor in bands of variable width, which
contain vessels, often of large size, and which gradually diminish in
thickness and in the size of the contained vessels, until finally they are
lost in simple thickened portions of peritoneal covering. The peritoneal
investment is not closely attached to the cyst, but separates readily, just
as the peritoneum separates elsewhere in the pelvic cavity, being imme-
diately lined by the subserous cellular tissue; thus no vessels of any con-
siderable size enter the cyst. The tumor separates from its attachments
with remarkable readiness, So much so that, in several instances, it is
reported to have escaped the grasp of the operator and fallen spontane-
ously from the pedicle, accident thus plainly indicating the natural and
proper method of removal.” The capillary vessels thus broken do not
bleed, for the band contracts, and corrugates the larger trunks, while the
broken-off capillaries ooze a little for only a minute or two, and a dry
napkin, applied for a short time, is all that is required. The fear of
hemorrhage is wholly unfounded, and I now say, without hesitation, that
the danger of bleeding after this mode of proceeding is vastly less than
the danger of slipping of clamp or ligature, in other methods in which
| Buffalo Medical and Surgical Journal, June, 1869.
* British Medical Journal, Nov. 26, 1870, p. 577; Braithwaite's Retrospect, July, 1871,
p. 212.
51
802 MIN E R ,
the vessels are divided in their trunks. In this they are separated only
in their extreme branches, and cannot give troublesome hemorrhage; it
is seldom that any vessels are torn large enough to be seen as vessels or
points of hemorrhage, and torsion is all that can be required in almost
any case. If care is taken not to wound the vessels with either trocar,
knife, or scissors, there will be no bleeding.
The tumor being removed, the operation is completed ; there is no
clamp to be used, for there is nothing to clamp; the pedicle requires no
attention except to be carefully handled, and to be restored, as nearly as
possible, to its original place; if the usual conditions are present, no
drainage is necessary; and the incision may be closed as accurately as
possible.
The bands referred to are to be grasped where they commence to
diverge, raised from the cyst, and traced out to their terminations, often
nearly around to the opposite side; the cyst is thus separated from its
vascular supply, which is contained in these bands, other attachments
being separated in the usual manner. Care must be taken not to wound
or divide the vessels in their trunks, and, although the attachments will
be found at points very strong, they can be forced off, or even with care
a small piece of the cyst may be left attached to the pedicle, and no
harm result, for it has a vascular supply, and is living tissue like the
pedicle itself. -
The method of enucleation has the further advantage that if upon
trial it is for any reason thought impracticable, a clamp may be still
applied, or the pedicle may be cauterized or tied with a ligature just as
well as if enucleation had not been attempted. Few rules in surgery
have no exceptions, and, though I believe that all ovarian tumors can
be, and should be, removed by this simple method, supplemented when
necessary by torsion or ligature to small vessels which bleed, still, to
provide for all possible contingencies, I would assure the operator that a
trial of enucleation is no hinderance to the subsequent adoption of any
other plan that may be preferred, so that, while everything may thus be
gained, nothing can be lost.
The accompanying cut, from a drawing by Dr. Edward N. Brush, who
has several times assisted me in operating, will give a very fair idea of
the procedure. The fingers of the operator are represented beneath a
vascular portion of the pedicle, separating it from the walls of the tumor.
This separation, as has before been observed, is to be carefully made, until
the vessels are traced to their termination. To make the illustration
plainer, the tumor is represented as raised from the abdominal cavity
and supported by the hand of an assistant, but, of course, where extensive
adhesions are present, this is impossible, and the risks of removal are
greatly augmented. Formerly the operation in such cases was abandoned.
When adhesions exist, they are to be separated, and the process continued
to the pedicle. ge
There is no need to point out the advantages of this plan. Those who
have studied the history of ovariotomy, and who are familiar with the
difficulties and objections which may fairly be urged against the ordinary
methods of procedure, will at once perceive that, if enucleation is success-
ful, there is no pedicle to keep open the lower angle of the wound or to
drag upon the parts—no unfavorable adhesions of the pedicle, no wires
to be discharged by suppuration, and no crusts of burned tissue to be
provided for. The abdominal cavity has simply been opened, and the
diseased part removed ; all that is left behind is capable of life.
O V A. R.I.O TO MY BY E N U C L E A TI O N. 803
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It has been supposed that enucleation was designed exclusively for
cases of extensive adhesion or short pedicle, in which no other plan could
be adopted, thus lessening the number of incompleted operations. Cer-
tainly the method is adapted to such cases, but, instead of being reserved
as a last resource, it should be chosen first, and the case regarded as most
favorable in which it can be successfully accomplished. My surgical
friends who have seen the operation, unite in regarding it as the most
natural surgical procedure possible. To see it, is to be convinced of its
entire feasibility and Safety, while its advantages are too apparent to
require a moment's consideration.
The following case first attracted my attention to this mode of treatment.
I was invited to remove an immense tumor from the person of Mrs. Foster, of
Cattaraugas County, N. Y. It was of many years' standing, and had been
repeatedly tapped, but at length its contents became too thick to be drawn
through the largest sized canula, and the patient’s distress too great for en-
durance. The tumor was multilocular and very large, weighing, as nearly as
could be ascertained, almost one hundred pounds. It was attached, through-
out its entire circumference, to the omentum, intestines, walls of the abdomen,
and all other parts with which it came in contact. These attachments were
not so firm but that they could be broken up, and, with great care, the tumor
was separated from the surrounding parts until the pedicle was reached. The
process of enucleation had been carried on so extensively and successfully that
encouragement was afforded for its continued trial ; the pedicle was large, and
extended over a wide surface, but by gentle and patient effort it was separated
from its entire attachment to the tumor, and the immense growth removed
without the use of a single ligature. The terminal branches of the vessels of











804 MINER,
the pedicle gave out no more blood than issued from the vessels of the adhe-
sions, and none of them required ligation. All hemorrhage soon ceased, and
the incision was closed by the interrupted suture. The success of this proce-
dure was complete, and the patient for nearly two weeks did not present a
single untoward symptom, so that her recovery was considered almost certain.
But she then began to lose her relish for food, grew weak and desponding,
and died on the twentieth or twenty-first day after the operation. The fatal
termination of this case detracts nothing from the success of this mode of treat-
ing the pedicle ; indeed, so remarkable were the size and attachments of the
tumor, that any attempt at recovery was surprising, and yet the feeble, emaci-
ated, exhausted patient, continued to improve long enough to show that the
manner of treating the pedicle was, at least in her case, unobjectionable.
On the fourth of June, 1873, I was called, in consultation with Dr. Mixer,
of Buffalo, to see a patient, aged twenty-three, in whom he had diagnosed an
ovarian tumor. After careful examination, Dr. Mixer's diagnosis was con-
firmed, and an operation was decided upon. The patient had suffered from
pain in the right iliac region for about a year, but had menstruated quite
regularly, though not to the usual amount, and had not noticed any enlarge-
ment of the abdomen until about six months previous to my seeing her, since
which time the tumor had grown quite rapidly; she had never been tapped.
On Monday, June 17, I operated, assisted by Drs. S. F. Mixer, C. C. Wyckoff
and son, E. R. Barnes, and E. N. Brush. Dr. Mixer administered chloroform,
which was afterwards replaced by ether. An incision about four inclies in
length was made in the abdominal wall, when the tumor was found adherent
to the anterior surface of the abdominal cavity for a circumference of about
nine inches. The attachments were carefully separated, but the walls of the
tumor in this locality were so thin that it was accidentally ruptured, and some
of its contained fluid escaped, whereupon a large trocar was immediately
plunged in, and the contents of the cyst evacuated. The mass was now lifted
from the abdominal cavity, and the pedicle brought into view. It was found
to be of medium length, and its vessels were spread out over the tumor. I next
introduced my finger beneath the central portion of the pedicle, at its least
vascular part, between it and the sac, and by gentle manipulation separated it
from the cyst. Two vessels only bled sufficiently to attract attention, and
these were easily controlled by torsion. All further hemorrhage soon ceased
on exposure of the part to the air, and, the cavity of the abdomen having been
sponged out, the pedicle was returned without the application of a single liga-
ture or other mechanical means to prevent bleeding. The slight oozing of
blood caused by the separation of the adhesions from the abdominal wall ceased
spontaneously. The wound was closed with the interrupted silver suture, sup-
ported by adhesive plaster, and warm flannel cloths were applied with bandages
over the abdomen. The tumor was multilocular, and weighed eighteen pounds.
On recovering from the anaesthesia, the patient complained of nausea, and
vomited frequently. One-fourth of a grain of morphia was administered by
hypodermic injection, and repeated once in four hours, and the patient was
also given brandy and beef-tea. The following is a report of her condition as
I found it on seeing her occasionally with Dr. Mixer. The temperature was
not taken.
June 17, evening; pulse 120.
June 18, morning; pulse 108; vomiting at night.
June 19, morning ; pulse 108; less vomiting.
June 20, morning; pulse 98; no vomiting; slept well ; urinated without the
use of the catheter ; no swelling nor tympanites; wound was healing rapidly.
June 21; pulse 94; no symptoms of constitutional disturbance; slept and
ate well.
June 24; pulse 84.
June 27 ; stitches removed ; patient well.
During the whole course of recovery the patient declared that, with the ex-
O W A RIO TO MY BY E N U C L E A TI O N . 805
ception of the nausea experienced during the first two or three days after the
Operation, she felt better than at any time just previous. -
The pedicle in this case was of medium length, but too short to admit
of its being brought out of the wound and secured by a clamp, without
dragging upon the uterus, especially if any portion of it had been taken
away with the tumor, as is the case when it is severed by the knife in
the ordinary mode of performing ovariotomy. The vessels of the pedicle
were large, and could be felt to pulsate plainly ; and it is doubtful whether
severing these with the cautery would have controlled the hemorrhage.
Silk and metal ligatures have been employed successfully in many cases,
and have been left in the cavity of the abſlomen without producing any
ill effects. Their employment, however, leaves within the peritoneum
a foreign substance, which in most cases cannot but produce more or
less inflammation, and any method which will allow the return of the
pedicle to the abdomen, free from sources of irritation, must meet with
approval. The question has been asked: “Can the pedicle be easily
separated from the tumor?” In the case just narrated, the separation
was accomplished with as great facility as attends the separation of cys-
tic growths from surrounding parts in other portions of the body, and
was easier, in fact, than was the detachment of the adhesions from the
abdominal walls.
Prof. Logan, of the Medical Department of the University of Loui-
siana, in a private letter, speaking of an operation which he had per-
formed for the removal of an ovarian tumor, the solid portion of which
weighed sixteen and a half pounds, says:—“I was surprised at the
facility with which the enucleation was effected ; not a single vessel of
sufficient size to throw a jet of blood presented itself, and no ligatures
were, of course, required.” In this case also, there was a rapid conva-
lescence, with not a single bad symptom.
Upon these and similar facts is based the suggestion that the pedicle
can, in ovariotomy, in some cases at least, be separated without ligature
or cautery, thus avoiding many of its dangers. At first, this proposition
may appear startling, and surgeons who have tied large vessels in the
operation, or who have witnessed the fearful hemorrhage which some-
times takes place from the slipping of the clamp or ligatures, may regard
it with some surprise, and may perhaps, without trial, look upon it as
wholly impracticable ; I should myself, probably, hold such an opinion,
had I not had the opportunity of demonstrating to myself its entire
feasibility.
An ovarian tumor is generally composed of a firm dense cyst, contain-
ing fluid of varied color and composition. It may, or may not, have a
solid portion, but usually it does have more or less of a body, the rem-
nant of an enlarged or degenerated gland. Upon the surface of this
cyst is spread out the vascular, fibrous, cellular, and other tissues which
compose the pedicle, but only the terminal branches of the vessels enter
the cyst wall; the vessels may be quite large at their origin, but soon
they are numerously divided, and enter the cyst, if at all, only when of
capillary size. The attachment of the pedicle to the cyst is more easily
broken than any one would imagine who had not tried the experiment
in the manner described, and I am confident that the same efforts which
are made to break up the adhesions to the peritoneum, Omentum, and
other parts, would, if extended to the pedicle, many times be equally
successful.
806 MIN E R ,
If this method can be adopted without hemorrhage or other difficulty,
its advantages are apparent. The pedicle can then be returned to the
abdominal cavity without any of the objections which have been urged
against this procedure. There is no ligature to be discharged by ulcera-
tive process, or to become encysted, or to induce inflammation. There
are no purulent or inflammatory products to be in any way removed or
provided for ; the pedicle is wholly living tissue, and has no irritative
qualities which render its return to the abdominal cavity objectionable.
My object will have been wholly accomplished if the feasibility of
enucleation in ovariotomy has been shown with sufficient clearness to
insure a trial of the method by other surgeons.
DISCUSSION ON DR. MINER's PAPER.
After the reading of the preceding paper, the President, Dr. Rob ERT
BARNES, of London, said:—I am glad to hear the paper, as I was the first to
introduce the method of enucleation into England. I think it a good method,
but it cannot wholly supersede other modes of dealing with the pedicle. In
some cases, enucleation is the Only mode of removal practicable ; but these
are exceptions to the rule. I must say that I do not share Dr. Miner’s
dread of leaving silk and silver ligatures in the peritoneal cavity, for I have
frequently seen them left there without mischief. I have also seen the per-
chloride of iron used to sponge bleeding points left after the sundering of
strong adhesions, and without any of those formidable results which some
writers attribute to its passage through the Fallopian tubes after intra-uterine
injections. In ovariotomy, the great thing is security against hemorrhage;
and that, I think, is best gained by the use of the clamp or the ligature. The
operation of ovariotomy demands still more study than has been given to it,
and I congratulate Dr. Miner upon having very materially added to the stock
of knowledge regarding it.
Dr. JAMES P. WHITE, of Buffalo, said:—I am cognizant of twenty or thirty
cases in which enucleation has been used. It is not a very difficult operation,
but in some cases it is impossible—for instance, where the growth of the
tumor has been rapid and the pedicle is short and large. In these cases, the
cyst cannot be safely enucleated. I have no doubt, however, that enucleation
is often the best method of treating ovarian tumors, but the subject merits a
great deal of study and consideration, and the cautery, the clamp, the ligature,
and enucleation, all deserve attention, and should be severally used according
to the special indications of individual cases.
Dr. E. R. PEASLEE, of New York, said:—We should not confine ourselves
to any one method of treatment in the removal of ovarian cysts. Nor is
enucleation always feasible. In some cases, short and large vessels enter into
the cyst directly from the pelvis, and do not become capillary. In these,
enucleation will not answer, because it cannot arrest the hemorrhage. Such
an instance I have met with, and the patient bled to death. Again, owing to
the thinness and the friability of the cyst-wall, it will sometimes break down
before the adhesions can be broken up. But I feel under great obligations to
Dr. Miner for introducing this method, for I have removed tumors by enucle-
tion, which I am confident could have been removed in no other way. In
most cases the ligature can be used, and I then see no particular advantage to
be gained by enucleation. But I would adopt it in cases of cysts adherent to
the liver. I am myself inclined to the use of the ligature, which I generally
cut close. As I have only once seen the pedicle slough, I do not share Dr.
Miner’s fears on that score.
Dr. G. KIMBALL, of Lowell, Mass., said:—I have tried enucleation but once,
but believe that I might have saved some lives had I known of this method
O W A RIO TO MY BY E N U C L E A TI O N . 807
earlier in my practice. I feel very much indebted to Dr. Miner for his sug-
gestions on this subject. Dr. Keith's great success has been obtained with
the cautery, and I think that the profession is still at sea as to the proper
method of dealing with the pedicle. I myself generally use the clamp, but I
adapt the treatment to the particular case.
Dr. WHITE said:—As a rule, I prefer cauterization, because it leaves fewer
foreign bodies in the cavity of the abdomen; and I am sure that, in my
practice, I have seen as many children born from women who have lost one
ovary as I have lost cases of ovariotomy. I think that the treatment of these
tumors should be eclectic, and that each case should be separately studied with
a view to its treatment.
Dr. ALExANDER. R. SIMPSON, of Edinburgh, said:—In regard to the applica-
tion of the cautery, Dr. Keith has used it very successfully; personally, I am
ready to use any method that the case may demand. The great strength of
Dr. Keith lies in the thorough preparation of his cases, and in the care which
he takes with them. There is always a difference in operators, and Dr. Keith
does not consider minutes wasted that will prevent hemorrhage into the peri-
toneal cavity.
Dr. THEOPHILUs PARVIN, of Indianapolis, said:—Enucleation is of use
when the pedicle is too short for the clamp. I have had two cases: one
complicated with pregnancy was attended by considerable hemorrhage. This
I checked by the application of flannels dipped in hot water. In such cases I
can recommend hot water, and I referred to the same agent in the discussiºn
of yesterday on uterine hemorrhage. I think, contrary to Dr. Miner's state-
ment, that it is settled that there is no peritoneal coat to an Ovarian tumor, as
there is no peritoneal covering to the ovary itself. Enucleation is of value
where there are peritoneal adhesions, but I believe that it can be very often
dispensed with by the use of hot water. I recognize its advantages, but do
not think that it is the only treatment for ovarian tumors.
Dr. MINER, in reply, said:—I agree that possibly in some cases enucleation
may not be of service, and that torsion, the ligature, and even the cautery may
have to be used. But in ordinary cases of ovarian tumor, I deem it to be a
plain piece of surgery; and I have myself never seen a case in which the cyst
could not have been removed by enucleation. Where there is bleeding, I resort
to torsion ; but enucleation does not interdict the subsequent use of the clamp,
the ligature, or the hot iron.
808
THE TREATMENT OF FIBROID TUMIORS OF THE UTERUS.
BY
WASHINGTON L. ATLEE, M.D.,
OF PHILADELPHIA.
IN opening the discussion on The Treatment of Fibroid Tumors of the
Uterus, a question that has for many years engaged my attention, it will
be imposssible to present the subject properly in the short space of time
allotted to me; and I must, therefore, ask your indulgence if, in adhering
closely to the text and compressing my material, I should fail in satis-
factorily elucidating the several points in this paper.
I beg, also, to premise that, in bringing this subject before the Section
on Obstetrics, I shall not go into the detail of every method of treatinent.
This I think would be out of place before an assembly of such enlight-
ened men, who are already familiar with its written history. I shall
merely refer to my own experience. Every gentleman, who will engage
in this discussion, has an experience of his own, and if each one will
bring his personal contributions, able architects of our profession will
rear a structure out of these materials which no individual could erect
from his own observations, and which will stand as a lasting memorial
of this day’s work. In this way we will be likely to arrive at the best
practical results for the benefit of Science, Art, and IIumanity.
My methods of treatment have been surgical and medicinal. In the
use of medicine I have principally confined myself to iodine, ergot, and
muriate of ammonia. Many years ago I lost faith in iodine, and now
seldom use it, and only as a local application. As early as 1845, I intro-
duced the use of ergot in the treatment of uterine fibroids, and have ever
since employed it. In proof of this I may refer to my essay on Fibrous
Tumors of the Uterus, published in the Transactions of the American
Medical Association for the year 1853. Ergot, no doubt, acts in two
ways in influencing the nutrition of fibroids of the uterus: (1) on the
muscular tissue of that organ, and (2) on the capillary circulation of the
tumor itself by contracting its smaller vessels. Notwithstanding this
action of the medicine, I have never been so fortunate as to see a fibroid
quietly disappear under its sole influence, although in many cases the
size has been diminished, while in others no effect has been produced.
The reason of its variability in action may be explained in the course of
this paper. Recently, Hildebrandt has introduced the hypodermic use
of ergot, and with results, in his hands, quite extraordinary. I cannot,
however, conceive how this agent can accomplish more by its subcutane-
ous employment than by its administration by the natural passages. It
certainly acts more promptly through the cellular tissue. Dut it is ques-
tionable whether this increased speed of action is a sufficient compensa-
tion for certain inconveniences to the patient from this mode of its
application, as well as for the greater tax on the time, convenience, and
patience of the medical attendant.
In the consideration of the treatment of uterine fibroids, it must also
be kept in mind that spontaneous cures may result in consequence of
FIB R O II) T U M O R S OF T H E U T E R U S. 809
fatty degeneration; that diminution in the size of the tumors is often
observed in advancing age, through senile atrophy of the muscular fibres;
that fibrous induration sometimes occurs, the muscular tissue becoming
Scarcer as the connective tissue hardens, and that this induration is fol-
lowed by calcification and an arrest of growth.
With these preliminary remarks, I will proceed to discuss the subject
of treatment more definitely. In doing so understandingly, it will be
necessary to keep in view the relative position of the tumor with the
uterus. IIence I will make the somewhat arbitrary division into the
following heads:–
I. Tumors usually accompanied with hemorrrhage, embracing (1)
fibroids occupying the vaginal canal; (2) fibroids within the cavity of
the uterus; (3) interstitial, submucous fibroids; (4) interstitial fibroids
proper; (5) recurrent fibroids.
II. Tumors usually not accompanied with hemorrhage, including (1)
interstitial, subperitoneal fibroids; (2) sessile, peritoneal fibroids; (3)
pedunculated, peritoneal fibroids; (4) interstitial, cervical fibroids; (5)
myomatous degeneration of the uterus; (6) fibro-cysts of the uterus.
I. TUM0Rs USUALLY ACCOMPANIED WITH IIEMORRIIAGE.
(1) Fibroids expelled from the Cavity of the Uterus, or occupying the
Vaginal Canal.—The treatment of these tumors will vary according to
their size. When small, with a slender helicle, the tumor may be
grasped as high as possible on its neck by means of Luer's polypus for-
ceps, or a similar instrument, and twisted off, or, in other words, removed
by torsion. -
When larger, with a pedicle not thicker than a finger, it may be seized
and brought down with some force so as to stretch the pedicle, which
may then be severed at as high a point as possible with Cooper's hernia
bistoury, or a probe-lpointed bistoury properly wrapped and protected.
When quite large, distending the vagina or filling up the pelvis like
the head of a child, a small obstetric forcel's may be applied to it, and
then placing the patient under the influence of an anaesthetic, with the
assistance of supra-pullic pressure, the tumor may be gradually brought
through the os externum. IIaving accomplished this, one of several
plans may be adoptel for the purpºse of detaching it: (a) J35 means of
the bistoury the proper coat of the tumor may be severed all around, about
an inch or so beyond the insortion of the pedicle, and then the upper end
of the tumor enucleated from its peduncular attachment; (b) the sub-
stance of the pedicle may be directly severed by the knife; (c) the
pedicle may be divided by the écraseur. I have used all these methods,
and it is best to be prepared for either operation, as the surgeon must be
governed by the circumstances of each case. When it can be accom-
plished, I prefer the first method, or that by enucleation of the leluncu-
lated end of the tumor.
Immediately after the removal of these large tumors we should use a
tampon, charged with persulphate of iron or other efficient haemostatic
and antiseptic, adapting it well against the amputated stump, and allow-
ing it to remain from twenty-four to forty-eight hours. The raw and,
usually, inflamed surfaces should afterwards be treated through the
810 A T L E E ,
speculum by suitable applications until they are brought into a normal
condition.
It may be noticed that I have not referred to the ligature as one of the
methods. I have long since abandoned this plan, preferring immediate
ablation of the tumor.
(2) Fibroids entirely within the Cavity of the Uterus.-The treatment of
fibroids inclosed within the cavity of the uterus must depend somewhat
on their size and locality. When large and of long duration, having dis-
tended the body of the uterus and dilated the cervix as does the head of
a child in the last months of gestation, an examination by the finger
will discover a mere uterine ring, through which by firm pressure, par-
ticularly when counteracted by supra-pubic support, a tumor within may
be detected. This no doubt is the condition precedent to the first form of
fibroid which we have considered, and the lapse of time in all probability,
if the patient should hold out, would accomplish the same state of things.
It is, however, not always safe to wait, but safer to facilitate measures by
imitating the processes of nature. To make the tumor more accessible,
the OS uteri should be dilated by the usual means, and at the same time
ergot administered to excite and maintain the contraction of the expul-
sive fibres of the organ, and in this way also aid in opening the uterus.
Or, instead of using dilators to open the os uteri, the action of ergot may
first be established, and afterwards the tense edges of the os may be
nicked with a bistoury, thus successively dividing the circular fibres, and
accomplishing the object in much less time. As soon as the mouth of
the womb is sufficiently expanded, a small obstetric forceps may be intro-
duced and applied to the tumor in the same way as it is to the head of a
child. Traction should now be made on the tumor under the influence
of an anaesthetic, and if the circular fibres, as will probably be the case,
should resist its escape, the bistoury must be employed until all resist-
ance is overcome, and the tumor is brought into the cavity of the vagina.
It is now in the position described under the first head of our subject,
and may be managed accordingly.
There is, however, a very important difference between a tumor pass-
ing from the uterus into the vagina spontaneously and one brought
there by violence, and that difference involves a very grave practical
point. This will be at once apparent when it is stated that in the former
case the tumor alone occupies the vagina, and that in the latter it is very
apt to be accompanied by an inverted uterus. This is particularly liable
to occur when the pedicle is attached to the fundus. Usually too, in vagi-
mal fibroids, we find a moulded and elongated pedicle which is readily
and safely managed, but in the tumors under consideration the pedicle is
usually sessile, and affords but small space for any surgical appliance.
Hence, the inverted fundus uteri is in great danger of injury and muti-
lation, and unusual care is required in amputating the tumor. I believe
the safest mode is to enucleate the upper portion of the tumor from its
proper coat, and thus free it from its uterine connections. Of course, after
this is done, the inverted uterus should be at once replaced after proper
styptics have been applied to the raw surface, and the case treated upon
general principles.
These fibroids, however, are not always as simple and as easily
managed as has been just described. From some cause or other the tumor
may have formed adhesions to the surface of the uterus, independent of
its original, peduncular attachment. These adhesions may be so situated
as to interfere materially with the dilatation of the OS uteri, or with the
FIB R O II) TU M O RS OF T H E U T E R U S. 811
introduction and application of the forceps. It is necessary, under these
circumstances, as soon as they are recognized by the finger, to sever them
with the bistoury until the surface of the tumor is free. If, in conse-
quence of such adhesions, or of a lateral origin of the pedicle, the ordi-
nary forceps cannot be applied, Museux's forceps, or appropriate hooks,
may be substituted to seize and bring down the tumor after the OS uteri
is sufficiently dilated. -
Besides the fibroids referred to, there are other tumors in the cavity of
the uterus which are entirely concealed, and, either from their diminutive
size or a very adipose abdomen, cannot be detected. The cervix uteri
may be intact, and there may be no bulging of the uterine wall recog-
nizable by the finger in the vagina. Yet the symptoms may be so diag-
nostic of their presence that we are bound to be governed by them alone.
In such cases we must dilate the cervical canal by sea-tangle, sponge
tents, etc., until we are able to pass the index-finger and explore the in-
terior of the uterus, and get access to the tumor. The dilatation must
now be carried further, so as to admit, in addition to the finger, the
necessary instruments for the removal of the growth. These are usually
a strong, slender forceps, or hook, and a long-handled, probe-pointed bis-
toury, or a probe-pointed, semicircular knife. A small wire écraseur,
passed above the forceps, will answer the same purpose. If the tumor
have a small pedicle, it may be removed by torsion.
(3) Interstitial Submucous Fibroids.—These are tumors which, originating
in the wall of the uterus, develop mainly towards the mucous surface.
Like the two preceding forms, they more urgently demand the surgeon’s
attention in consequence of inducing uterine hemorrhage. When the
cervix is not implicated in this class of tumors, and the body of the
uterus alone is involved, it is best not to be too precipitate in resorting
to surgical means for relief. As long as hemorrhage can be controlled,
and blood saved to the patient, it is best to depend upon the judicious
employment of ergot and other remedies, rather than to resort to a hazard-
ous use of the knife. A tumor thus situated, with muscular walls on
one side of it and a mere mucous covering on the other, will be in a
favorable condition for ergot to gradually expel it from its muscular bed,
and force it into the uterine cavity, and, in proportion as this is accom-
plished, we secure the aid of all the longitudinal fibres of the uterine
walls in propelling the growth against the circular fibres of the cervix,
and in causing a gradual opening of the OS uteri—thus finally reducing
this form of tumor to the second variety before considered.
If, however, exhausting hemorrhages cannot be controlled, and fatal
consequences threaten, other and more decided measures must be adopted.
The Os and cervix should be well dilated, so as to get free access to the
interior of the uterus, and to be able to command the surface of the
tumor. As soon as this is done, efficient doses of ergot must be adminis-
tered, and, when its action is established, a long, probe-pointed bistoury,
guided by the index finger of the left hand, should be passed up flat-
wise into the uterus, as in using a sound, and carried over the face of the
tumor until it reaches its upper border. An assistant should now grasp
the lower part of the abdomen and steady the uterus. The bistoury is
then turned with its edge against the tumor, and boldly pressed into it
and drawn downwards through its dense tissue, so as to slit open both
its mucous covering and its proper coat, burying the knife well in the
fibrous mass, and carrying it downwards until it makes its exit at the
lower border of the tumor. As the knife passes through the dense tissue,
812 A T LEE,
a decided grating is perceptible. It is a remarkable and interesting fact
that, if hemorrhage have existed before this incision, it will cease after it
has been made, and it will sometimes be found that when nothing else
will arrest hemorrhage, a free use of the knife will accomplish it. Im-
mediately after the section, an attempt should be made to enucleate the
tumor from its bed, which can often be accomplished if the tumor be
not too massive. Should it not be removed at once, it is apt soon to
become disorganized and dead, throwing off a very offensive, dirty,
watery discharge, and endangering septicæmia. Ergot must be con-
tinued, to maintain the contraction of the uterime tissue, antiseptics
administered by mouth, lungs, and vagina, and the patient sustained
until the tumor is removed by the surgeon, or is discharged in a soft-
ened mass resembling wet tow. The danger to be apprehended after
this operation is blood-poisoning from dead matter. This is very much
diminished when the tumor is removed by one operation, but, even then,
the extent of raw surface remaining after the tumor is taken away, some-
times causes toxaemic symptoms.
(4) Interstitial Fibroids Proper.—These are tumors which originate
deeply in the substance of the uterine wall, and during their growth and
development are surrounded by a pretty uniform coat of uterine or mus-
cular tissue, neither impinging on the mucous lining on the one side nor
on the peritoneal covering of the organ on the other. As a general rule,
the demand for active treatment in these cases is not as great as in the
submucous varieties. These intra-mural tumors, however, are the very
ones most amenable to the mode of treatment that has recently claimed
the attention of the profession, viz., the hypodermic use of ergot. I can
understand how the tonic contraction induced by ergot can impede nutri-
tion in a tumor so located, but I cannot conceive how absorption could
be promoted under a similar amount of compression obstructing the
absorbent vessels. In the treatment of interstitial fibroids I think it
best to use ergot periodically and not constantly; employing it in anti-
cipation of and during the menstrual periods, and associating with it the
continuous use of an alterative sorbefacient, such as muriate of ammo-
nia. If ergot acts mechanically in destroying the life of a tumor, then,
when that is accomplished, the stress or pressure should be removed, so
that this dead matter may be absorbed. As long as this dead material
is hermetically encased in living tissue, unaffected by atmospherie influ-
ences, it is not likely to become offensive or toxic, and may be carried off
by the absorbents like other molecules of dead matter in the regular pro-
cesses of repair, without infecting the general system. As there is a
tendency for fibroids to increase in size before each menstrual period, in
consequence of the greater determination of blood to the organs of gene-
ration, so there is a diminution in their size after menstruation subsides.
Hence ergot is calculated to act beneficially, when given in time, in
arresting this supply of blood to the tumor; and yet we must not always
attribute the diminution in size, which usually follows menstruation, to
the influence of ergot, as it is a natural physiological sequence.
These interstitial fibroids often assume a great size, and in doing so
stretch the cavity of the uterus to an unusual length, increase the vascu-
larity of the organ and the size of the vessels pervading the correspond-
ing mucous covering, and, during the menstrual period, these unsupported
vessels are rendered turgid and congested, and, giving way, produce copious
and dangerous hemorrhages. When this is the case, and danger cannot be
averted by medication, Surgical means are demanded. A bold, free inci-
FIB R O I D TU M O RS OF TH E U T E R U S. 813
sion through the muco-muscular envelope of the tumor, and through its
proper coat, burying the knife into the fibroid substance, will be attended
by an arrest of the bleeding. This may be followed by an enucleation
of the tumor—the several steps of the subsequent operation being the
same as detailed under the head of Interstitial Submucous Fibroids.
Sometimes the interstitial fibroid, even when very small, may produce
the most violent symptoms, both local and reflex, leading even to death;
and may be so situated that, under certain circumstances, its existence
may not be suspected, and that, even if correctly diagnosticated, it could
not be removed by any ordinary operation. This is particularly the case
when the tumor originates in the lateral part of the fundus uteri and
becomes intra-ligamentous. Such cases, fortunately, are extremely rare,
and I will endeavor to illustrate them by the detail of one which recently
proved fatal:—
Mrs. D. G. S., aged 34 years, was brought from the interior of the State to
Philadelphia, and placed under my care. She was small in stature, but exces-
sively corpulent, particularly in the abdominal wall. For a long time she had
suffered the greatest agony and distress, and had had frequent and most violent
convulsions. All the symptoms were distinctly traceable to the uterus. There
was decided endo-metritis, and the slightest touch of the sound would cause
terrific spasms. There was also extreme tenderness confined to a small spot
in the hypogastric region, on the right of the linea alba, so that she could not
tolerate the most gentle pressure. The treatment during the winter of 1874–75
relieved the endo-metritis and several of the reflex symptoms, and, although
she had not fully convalesced, she went home with the expectation of gradually
regaining her health. Iłut she again became worse, and her husband, an intel-
ligent physician, conducted the treatment, but without controlling the symp-
toms. I visited her several times during the winter of 1875–76, and I never
saw a greater sufferer. The spot in the hypogastrium was the point of trouble.
She had not been able to lie down for months, and the right thigh was kept
flexed all the time. Her suffering was so constant and intense that both she
and her husband begged me to open her and remove the womb. She required
the constant use of the most powerful anodynes to afford the least comfort.
Finally symptoms of cerebral congestion supervened, and in a few days after,
on the twenty-third of March last, death came to her relief. In exposing the
abdominal cavity after death, about four inches in thickness of adipose tissue
had to be penetrated. The uterus was enlarged and highly congested. Its
cavity was three and a half inclies long. The lining membrane was normal.
In the right wall of the fundus was an interstitial fibroid, not over two inches
in diameter, surrounded by a dense wall of uterine tissue, and so closely adhe-
rent to its capsule that it could not be shelled out or enucleated. The capsule
had evidently been in a state of inflammation, and this was thought to be the
cause of the intense and fatal suffering. Both openings of the Fallopian tubes
were obliterated.
In reference to this interesting case I wish to state that I had ap-
pointed the very day on which I witnessed the post-mortem examination
to visit the patient to decide upon the feasibility of extirpating the
uterus. In consequence of the extreme amount of abdominal fat, as shown
by the examination, this would have been very difficult, if not impracti-
cable. For the same reason it was impossible to make a correct diag-
nosis of the case, and the fibroid discovered after death was not at all
suspected to exist before. Of course the case might possibly have been
made out by the barbarous practice of exploring with the hand through
the rectum. If such an extreme case were again to present itself to me,
814 ATI, EE,
particularly in a thin patient, I should think it my duty to remove the
diseased organ.
(5) Recurrent Fibroids.-The recurrent fibroid is polypoidal in charac-
ter, and is supposed to be reproduced, after its removal, from the same
pedicle. These cases are very troublesome, because, after one tumor is
removed, there may be repeated recurrences of others, resembling in
this respect, and in this only, the several forms of malignant disease.
The operation for their removal is the same as for that of the ordinary
uterine polypus, but, as this is a much more grave trouble, I wish to
submit to the Section a proposition embracing more extensive surgical
interference. This proposition is based upon the treatment of two cases
of very great interest, which I beg permission to relate.
In the first case I removed eleven successive tumors, after which the
patient recovered and had no return.
On December 27, 1860, I visited Mrs. T. W. S., aged 31 years. Menstrua-
tion for the first four years was small in quantity and free from pain, but after-
wards was accompanied with extreme agony during the first day. She married
at the age of 24 years, in one year after gave birth to a child, and had a mis-
carriage afterwards. The menses were regular, having only missed the last
period. In April, 1858, she first discovered something wrong in not being able
to pass water. A large quantity was drawn away by the catheter, which Opera-
tion had to be repeated. Several physicians saw her, and diagnosticated mal-
position of the womb, and very violent efforts were made to restore it to its
normal position, but without effect. June, 1860, she had a sudden attack of
severe pain, which so entirely disabled her that she could not walk for several
weeks, suffering much of the time with the most dreadful bearing-down pains.
After a period of intermission the expulsive pains again returned with extreme
violence, and, on November 28, 1860, while using the catheter, she felt a
tumor in the vagina which she supposed to be the womb. The pain now dimin-
ished, but the size of the tumor gradually increased, and it finally protruded
through the os externum. During the above period she had copious discharges
from the vagina of bloody clots and a greenish, slimy, and offensive fluid,
changing usually about twenty-five napkins in a day.
When I saw the patient she was perfectly blanched and anaemic, with a small
thread-like pulse, and evidently in a state of toxicohaemia. A tumor, as large
as a small adult head, protruded from the vagina, and was lying between the
thighs. It was in a gangrenous condition, and gave off a most offensive odor.
The index finger, passed into the vagina in front, came against the anterior lip
of the os uteri about two inches up. It was stretched across the front face of
the tumor, which was continued into the uterus as far as the finger could reach.
The sound struck the fundus uteri one inch above the anterior lip. The vagina
behind the tumor was also explored. A cul-de-sac was reached at the distance
of one and a half or two inches, formed apparently by the inverted vagina
coalescing with the tumor. The growth had clearly been developed in the pos-
terior wall, and had been extruded by the uterine efforts from the cavity of
the organ. The circulation was still maintained in the posterior portion of
the mass. The pedicle was about two inches thick. With the assistance of
Drs. Drysdale and Burpee, I removed the mass by means of the écraseur.
Although much decomposed, its weight was one and a quarter pounds. For
several weeks the patient continued to be very ill with septicaemic fever, but
finally fully recovered.
April 17, 1862, the patient consulted me again, stating that she had remained
well until three months before, when she had had a copious puruloid discharge,
and that one week before seeing me another tumor had begun to protrude. On
examination, I found that the relative positions of the tumor and uterus were
now different. The former, instead of being behind the ostincae, was anterior to
it, and the expanded posterior lip could be distinguished in the hollow of the
FIB R O ID TU M O RS OF T H E U TIE R U S. 815
sacrum. This second tumor increased to a considerable size, and was removed
in the same way. At the same time a hard tumor was felt occupying the hy-
pogastric region. A few weeks after the removal of the second tumor it was
followed by a third, which was also taken away. A mass still occupied the
hypogastric region.
The following December she was taken with excessive hemorrhage, requiring
the use of the tampon. Subsequently quite a large tumor was expelled from
the vagina, and at the same time the supra-pubic tumor disappeared. This,
the fourth tumor, was removed by the écraseur on the 9th of January, 1863, and
the operation was followed by a rapid recovery. June 1, 1863, another large
tumor, the fifth, was removed in the same way. January 21, 1864, the sixth
tumor, less in size, was removed. I could plainly trace this one into the cavity
of the uterus, and the anterior lip of the os stretched over it, the sound en-
tering anterior to the mass two and a half inches. At the same time I recog-
nized a hard tumor in the right inguinal region. August 24, the same year,
the seventh tumor was removed. The eighth, ninth, and tenth were subse-
quently removed up to the 20th of May, 1866. The eleventh tumor was taken
away on the 18th of August, 1867, with the assistance of Dr. J. Nicolaysen, of
Christiania, Norway, now Professor of Surgery in the University of Norway.
After this no tumor could be detected anywhere.
After the eleventh operation there was no return, and the patient regained
her health, at least for two or three years, after which I lost sight of her.
In reviewing the above case—its extraordinary features, its long dura-
tion, its imminent perils, and its almost endless recurrence—the question
has often presented itself to me: Would not extirpation of the uterus at
an early period have been not only justifiable but preferable :
A question also of great interest—the pathology of the so-called Recur-
rent Fibroids—might be discussed with profit, but this is not compatible
with our present subject. Both questions will be in a measure involved in
the detail of another case, which I think would have exhibited the same
features as that above narrated, but which was terminated quickly and
happily by a different mode of treatment:—
On May 15, 1874, Mrs. C. T. was brought from the interior of Pennsylvania
for treatment. She was 30 years of age, had first menstruated at the age of 14
years, and had continued to be regular until her marriage in 1870. Two years be-
fore marriage she began to suffer from a burning sensation in the pelvic region,
and from bearing-down pains, which gradually grew worse. Soon after mar-
riage menstruation became more copious, and, eighteen months after, she was
seized with great pain, accompanied with excessive flooding. Subsequently
she was confined almost constantly to bed by copious hemorrhage, intense suf-
fering, and constant nausea and vomiting. She had never conceived. Pros-
tration, emaciation, and anaemia were very strongly marked.
The uterus was enlarged to the size of a four-months’ pregnancy, the cervix
fully expanded, and the os, round and ring-like, merely admitted the point of
the index finger. A hard, smooth tumor could be felt within. I immediately
put her on the use of iron and ergot, but, notwithstanding, she had an over-
whelming attack of flooding and pain. By the 22d of June the condition of
the patient and of the os uteri was such as to warrant me to proceed with an
operation. Assisted by my son, Dr. W. Lemuel Atlee, I introduced a forceps
into the cavity of the uterus, and, grasping the tumor, made traction while the
patient was under the influence of an anaesthetic. As the os was not suffi-
ciently open to allow the tumor to escape, it was nicked by the bistoury as
it tightened over the descending mass, which finally was delivered into the
vagina with a sudden slip, and afterwards through the os externum. The
écraseur was now applied, but, proving to be faulty, was removed, and the
pedicle was severed by the bistoury. While preparing for this part of the
816 ATLEE,
operation, I was struck with what appeared to be an unusual elongation of
the pedicle, which was dotted over with several molluscum-like bodies. Ap-
prehending that this might be the uterus itself inverted, I was careful to make
the section close to the tumor. Immediately afterwards I tamponed the vagina
with strips of muslin wet with Monsel's solution of iron.
The operation was followed by intense pain, and in the course of two or
three hours by hemorrhage, which was controlled by removing the first tampon
and substituting small sponges. There were also incessant sickness and vomit-
ing, which, the patient said, always followed the loss of blood or the use of
anaesthetics. These symptoms were sublued by opiates in the course of twenty-
four hours. The pulse increased in frequency, and the case looked rather
alarming. Next day the sponges were removed, an examination was made, and
a rough, irregular, tumor-like mass still occupied the vagina. I could not livest
myself of the apprehension of its being an inverted uterus. The parts were
SO very tender that a satisfactory examination could not be made. This sore-
ness continued for eight or ten days.
The regular menstrual period came on the first week in July, accompanied
with very little pain and a moderate discharge. On the 13th I repeated the
examination, and found the same state of things. The os grasped the tumor,
and a sound passed up entered the uterine cavity the normal distance of two
and a half inches. From this examination I inferred that there was no inver-
sion, and that there still remained a portion of the original tumor. Pressure
Over the pubes did not enlighten me. Perhaps a ſinger in the rectum would
have disclosed the true state of the case. I seized the body with a strong
double tenaculum, brought it partially through the os externum, applied the
écraseur, and on working the instrument found the tissue unusually resisting,
requiring much force and time in getting through it, and indeed having to finish
the Operation with the knife. On examining the mass, after its removal, I was
surprised to find it to be the body of the uterus.
[The specimen was then exhibited. The mucous surface was dotted over with several
small tumors in different stages of development.]
Great pain and sickness of the stomach succeeded the operation as before,
but did not last so long. Much less bleeding accompanied the amputation,
and none followed it. The patient had a rapid and excellent recovery, grew
fat and hearty, and, with the exception of slight coccy.odynia, has been in the
continued enjoyment of perfect health. Menstruation has not occurred since.
The speculum reveals a perfect os tincae, and the sound enters only one inch.
Although the treatment of the above case was ultimately conducted
on an error of diagnosis, does it not teach a valuable practical lesson : If
the history detailed to you this day explains and illustrates the patho-
logy of the so-called recurrent fibroid of the uterus, and if each abnormal
body on the surface of the womb is liable to be successively developed
into a life-endangering tumor, will not the amputation of the body or the
entire removal of such a diseased organ be the best mode of treatment,
keeping in view the comfort and life of the patient 7
II. TUMQRS USUALLY NOT AccompasTED WITH IIEMORRHAGE.
(1) Interstitial Subperitoneal Fibroids.-These are tumors having the
same relation to the Serous coat of the uterus as the interstitial submu-
cous fibroids have to the mucous coat. They are imbedded in uterine
tissue except where they present towards the abdominal cavity, and there
they are covered only by peritoneum. Their locality renders them much
less serious in their consequences to the patient, and does not call so
FIB R O II) TU M O R S OF TII E U TE R U S. 817
imperatively on the surgeon for interference. Still, circumstances might
arise in which relief would be demanded. Treatment in these cases will
accomplish a great deal, either with or without reference to an ultimate
surgical operation. I have just hinted at the action of ergot in the sub-
mucous fibroids. It is the same, in an opposite direction, in the sub-
peritoneal tumor. The tendency of any foreign body, when acted upon
by the contractile efforts of uterine tissue, will be towards the point of
least resistance. Hence ergot, acting forcibly on the muscular substance
of the uterus, in which the fibroid is deposited as in a closely-fitting nest
covered merely by a delicate serous membrane, must, as a necessary re-
Sult, gradually diminish the bed of the tumor, and as gradually cause the
mass to encroach upon the abdominal cavity. I have no doubt that nature
herself sometimes converts this kind of tumor into a sessile or even pe-
dunculated fibroid. And hence, by following her teachings, by means of
ergot we are able greatly to aid her in accomplishing such results. Sup-
posing, however, that this result has been reached, the tumor has not
been destroyed nor diminished, but only changed in its locality, for I
very much doubt whether ergot has influenced its growth in this situa-
tion. Still, our patient has been benefited by relieving a very sensitive
and irritable organ of a troublesome tenant, and by placing the tumor in
a position more accessible to the resources of surgery if the case should
ever demand it.
In interstitial subperitoneal fibroids, it would be extremely hazardous
to invade them by the knife from the interior of the uterus, and in this
way attempt their enucleation or even disorganization and devitalization,
as their thin serous coating would not be a sufficient barrier to protect
the abdominal cavity from being entered, which would necessarily cause
fatal results. It would be much safer, after the administration of ergot,
to open the cavity of the abdomen, expose the surface of the tumor,
divide its peritoneal coat with the knife, and enucleate the mass from its
muscular bed. Should bleeding occur, the vessels could readily be secured
as they are in ovariotomy, and to guard against Oozing and accumula-
tions in the abdominal cavity a siphon-drain could be carefully placed
and brought out of the lower angle of the wound. At the same time,
if deemed necessary, a communication between the bed of the tumor and
the cavity of the uterus could be made, and thence through the cervical
canal with the vagina, and a siphon introduced so as to assist in carry-
ing off fluids also in that direction. These precautions would go very
far in preventing septicæmia and fatal inflammation.
(2) Sessile Pritoneal Fibroids.-These are tumors which present bodily
into the abdominal cavity, but are closely seated on the exterior surface
of the uterus, and have a broad base. They do not sink deeply into the
uterine tissue itself, and do not elongate the uterine cavity. They may
be removed in the same way as the subperitoneal variety, but the same
precautions need not be exercised with regard to the uterine bed which
receives the tumor. Indeed, in both varieties, a peculiarly formed tube
of silver, glass, or hard rubber, around which the detached coats of the
tumor could be fastened or ligated, might be secured with one end in the
bed of the tumor, while the other could be carried out of the lower end,
of the abdominal wound, thus acting as a siphon in drawing off the fluids,
or as a conductor for the introduction of antiseptic washes from with-
out. By the time the ligatures should have become loosened, the drain-
age tube could be removed, and a fistulous track would remain to fill up
and heal by granulation and cicatrization.
52
818 ATLEE,
In cases of ovariotomy, when complicated with small sessile fibroids,
I have not hesitated to enucleate them before closing the incision, being
careful, if there were any oozing, to carry a tent from the raw surface to
the lower angle of the wound.
(3) Pedunculated Peritoneal Fibroids.-These are fibroids having a dis-
tinct pedicle, either membranous or myomatous, attached to the exterior
surface of the uterus, and contained within the cavity of the abdomen.
These tumors, being beyond the limits of uterine action, are not usually
influenced by the use of ergot, but do sometimes yield to the sorbefacient
action of muriate of ammonia uninterruptedly maintained for a long
time. If they fail to yield to medical treatment, and induce such severe
symptoms as to destroy personal comfort or jeopard life, they may be
removed, as are ovarian tumors, by abdominal section, and the pediele
secured by the clamp or ligature. The operation need not be described.
I may, however, remark that, in proportion to the size of the tumor, the
incision through the walls of the abdomen must necessarily be larger
than that required by ovariotomy, and that the pedicle will need more
careful attention. Should the pedicle be short, we can add to its length
by incising the proper coat of the tumor around its base, two or three
inches beyond the stem, and shelling it off and making it part of the
pedicle. I have several times removed these tumors in this way.
(4) Interstitial Cervical Fibroids.-These tumors occupy the vagina, but
are not ejected from the cavity of the uterus, and consequently are not
pedunculated, and are not capable of being treated in the same way as
uterine polypi. They are surrounded by the tissue of the cervix, and are
imbedded within it. When small, resembling a bullet submerged in the
cervical structure, a simple incision carried through the tumor, so as to
bisect it, will often be sufficient to lead to its decay and destruction. To
make its disorganization more certain, the surfaces of the cut fibroid may
be touched through the speculum with a pencil of vegetable caustic or of
potassa-cum-calce ; or, better, the small mass may be entirely enucleated by
the point of the finger after opening its capsule. When the tumor is large,
swelling out a portion of the cervix to the size of a walnut or an orange,
it will be necessary to make a free slit in its envelope and enucleate the
mass at once. These tumors are so accessible to the finger that this pro-
cedure can readily be accomplished, provided their capsule has never
undergone inflammation. In all of these cases the vagina should after-
wards be kept carefully cleansed by antiseptic washes, and the inflamma-
tion of the cervical mucous membrane, which usually accompanies these
tumors, should receive proper treatment.
(5) Myomalous Degeneration of the Uterus.-The uterus sometimes seems
to be overwhelmed with fibroids filling up the interstices everywhere, and
even to harbor at the same time every variety of tumor heretofore con-
sidered. When such a condition exists, it is not to be expected that
medicinal means alone will be of much use, nor can the surgical treat-
ment of each, individual, diseased mass be contemplated, but if anything
is to be done, it must be the entire extirpation of the affected organ. As
these cases cannot always be clearly diagnosticated, the surgeon must be
..prepared to vary his original course of action during the progress of an
operation. He may commence with the expectation of removing only a
pedunculated fibroid, or even an ovarian tumor, but will sometimes end
by extirpating the entire uterus and its appendages. I will relate the
following case:—
FIB R O II) TU M O RS OF THE U T E R U S. 819
On August 8, 1875, I visited, with Dr. Kurtz, Mrs. J. A. D., of Reading, Pa.
She was 44 years old, had menstruated at 15 years of age, and had always been
regular. When 27 years old she had married, and had had two children, and
one miscarriage between them. In 1872 menstruation had become more free,
and in the summer of 1874 she had had two or three attacks of bleeding during
the menstrual intervals. In 1872 she had first noticed a tumor in the right
groin. It was hard and movable, and fell over on turning her body. For
two years its increase in size had been gradual, but during the last twelve
months very rapid. As the tumor enlarged, her general health failed, and she
rapidly emaciated.
At the time of my visit, the abdominal enlargement was equal to that of an
eight-months’ pregnancy. It was irregular in shape. There appeared to be two
tumors, or one with a deep sulcus dividing it. The mass was hard, but slightly
elastic, and upon the left side of its fundus there was a harder knob the size of a
walnut. The two lobes were movable on each other. The uterus occupied the
back part of the pelvis, admitted the sound two-and-a-half inches, and was not
much influenced by manipulating the abdominal growth. While the sound was
in the uterus, I discovered still another and much harder mass in the superior
strait of the pelvis, which I diagnosticated as an intra-mural fibroid, but had
some doubts in consequence of the abdominal enlargement having masked the
examination. The diagnosis was obscure, but I inclined to the opinion that
the abdominal tumor was pedunculated, and hence rather favored an Operation.
The patient's health continuing to fail, she solicited relief. September 1,
1875, I visited Reading, and met Drs. Kurtz, Brooke, Ulrick, Dundor, Kuhn,
Coblentz, Cleaver, Weidman, Brodhead, and student Ellis Kurtz. The divi-
sion of the tumor had now disappeared, and the mass was more consolidated.
An incision seven or eight inches long was made below the umbilicus through
a very attenuated abdominal wall. On exposing the tumor, the characteristic
mahogany color at once disclosed its uterine nature, and further examination
developed its real character: fibroid degeneration of the body of the uterus.
There being no adhesions, the whole mass was easily rolled from the cavity of
the abdomen. The body of the uterus was now found to be occupied by intra-
mural fibroids, while the cervix was normal. Both ovaries were seated on the
lower portion of the enlarged uterus; the right one being healthy, and the left
cystic, and as large as a walnut. A strong needle was now armed with a double
ligature of strong plaited English silk cord, and with it the cervix uteri was
transfixed just above the insertion of the vagina and below the Ovaries. Each
ligature was securely tied on its respective half of the cervix, and each
was again made to encircle the whole cervix and firmly secured. The tumor,
consisting of the uterus and both ovaries, was now cut away, leaving a large
button beyond the ligature. To make it doubly safe the stump was embraced
in Atlee's clamp, and maintained outside. The cervical canal was plainly seen
on the face of the cut pedicle, into which a probe was passed about three-eighths
of an inch, and a finger introduced into the vagina entered the ostincae and
felt the grasp of the clamp. The return circulation of the tumor, which
escaped on excising it, was prevented from entering the abdominal cavity by
protecting sponges. The wound was closed with iron-wire sutures. The patient
made an excellent recovery, and now enjoys good health.
In considering the propriety of extirpating the uterus by abdominal
section, we must judge each case by itself. The condition of the pelvis,
vagina, and cervix uteri, is of primary importance. If the cellular tis-
sue is indurated in consequence of inflammation or other cause, or the
ragina shortened and rigid, or the cervix occupied by fibroid deposits, it
will not be a case favorable for Operation. If, however, the pelvis is free
from morbid deposits, the vagina long or extensible, and the cervix in a
normal state, the chances of life may be considered almost equal to those
of ovariotomy.
820 A T LEE,
(6) Fibro-cystic Tumors of the Uterus.-The fibro-cystic tumors of the
uterus, as far as my observations go, are developed upon the exterior sur-
face of the organ, and are usually pedunculated. They are constituted
of fibrous tissue, and are more or less cancellated in structure, and in
consequence of their greater impressibility are called soft fibroids in con-
tradistinction to the hard tumors heretofore considered. They grow some-
times to an enormous size. These tumors, in my opinion, are entirely
beyond the influence of ergot, while they seem at times to be controlled
in their growth by muriate of ammonia. I have had no experience in
the treatment of uterine fibroids by means of galvanism, but I should sup-
pose that this would be the kind of tumor most amenable to such an agent.
There are, however, surgical means, both palliative and radical, which I
have employed with benefit. The palliative treatment consists in pene-
trating the abdominal wall with a long, large-sized trocar and canula, thrust
into the centre of the tumor, withdrawing the trocar and passing a strong
sound through the canula, and with it breaking up the interior, cancellated
structure in every direction, and drawing off all the fluid possible. Usually
after such a proceeding the tumor will diminish in size to a considerable
extent. The operation, at proper intervals, may be repeated. As this
treatment is original with myself, I must ask permission to illustrate it
With a case:—
On April 22, 1863, I was consulted by Mrs. A. E. S., of Washington City,
D. C. She was 42 years old, had commenced menstruating at 14 years of age,
and had been married at the age of 17. She had had three children, the
youngest then 18 years old. About four weeks before seeing me, she had been
seized with very acute pain in the right groin, which lasted for twenty hours, and
was only relieved by strong opiates. This was followed by an enlargement of
the right side. She was a fine, healthy-looking lady, disposed to corpulency,
and exhibited no unusual abdominal prominence. An elastic, cyst-like, smooth
tumor was detected Occupying the hypogastric and right inguinal regions, and
rising above the umbilicus. It was at that time diagnosticated to be an ova-
rian tumor, and she was advised to let it alone.
September 24, 1868, she consulted me again. The abdomen then was very
much larger than that of a woman at the full period of pregnancy. It was
smooth, elastic, compressible, semi-fluctuating, and of uniform shape. The
uterus was normal in size, and movable, independently of the mass. In com-
pany with Dr. David 13urpee, I passed the large trocar into the tumor below
the umbilicus, but no fluid escaped. The sound was then introduced through
the canula, and passed round in several directions. It was very evident that in
manipulating with the sound many fragile septi were broken up, which proved
to be the walls of cells containing fluid. Two or three gallons of fluid, stained
with blood, were removed in this way, and it coagulated on exposure to air.
The operation was followed by no unpleasant symptoms, and afforded great
relief. Up to this time the case is reported in detail in my work on the Diag-
nosis of Ovarian Tumors, page 285. Subsequently the tumor was invaded in
the same way at distant intervals three times, and each time with beneficial
results—the last being in March, 1871. I saw the patient in November, 1872,
when her general health was good, and her size very much diminished, although
the tumor was still there. During all this time she had used the muriate of
ammonia internally, and the combined treatment had had a very happy effect on
her condition. Letters from her assure me that she still remains in comforta-
ble health, that the size of the tumor is not nearly so great, and that its fur-
ther development is probably arrested.
I have treated other cases of fibro-cystic tumor of the uterus in the
same way with similar results, but have never entirely cured them by
FIB R O I D TU M OF S OF THE U T E R U S. 821
these means. In one case, I cut up the interior structure with a small
knife introduced through the large canula, and afterwards injected acetic
acid. This was followed also by a decided diminution of the tumor, and
by no unpleasant consequences.
The only radical cure for these tumors I believe to be extirpation. In
their removal, the surgeon must keep in mind their peculiar pathological
relations with the uterus and with the peritoneum, as these differ mate-
rially from those of ovarian tumors. As far as my observations have
gone, the fibro-cystic tumor originates from the wall of the uterus at the
junction of the cervix with the body, at or just below the point where
the peritoneum is reflected from the uterus to form the recto-vaginal
cul-de-sac. As the tumor enlarges it raises the pelvic peritoneum above
it, and, dissecting it from its natural attachments, elevates it into the
abdominal cavity far above the pelvis, so that a real peritoneal cul-de-sac
almost surrounds the enlarged tumor between the umbilicus and pubes.
The tumor now is covered by a peritoneal coat above, while its pelvic
portion is free from peritoneum. The reflected peritoneum, therefore,
acts like a coronary ligament in binding the lower portion of the tumor
in the pelvis. To illustrate the operation, I will relate the case of Miss
E. E., aged 57 years. The same case is detailed for another purpose in
the work referred to above, page 279, but the manner of operating is
omitted:—
On June 5, 1868, in the presence of Drs. Mitchell, Brinton, Thompson, and
Reen, and assisted by Drs. Drysdale and Burpee, an incision seven inches in
length was made through the linea alba down to the tumor. Passing my hand
through the incision, I found the tumor to be adherent to the abdominal wall;
but these adhesions were readily broken up. I now particularly explored the
interior of the left side, in the previously ascertained locality of the elevated
uterus, but soon encountered an additional tumor, resembling an hypertrophied
spleen and filling up the whole left side from the hypochondrium down into
the iliac fossa. In carrying on the investigation downwards, over the large
tumor, my hand was interrupted in its descent by a cul-de-sac of reflected
peritoneum, extending around the tumor midway between the umbilicus and
pubes, and firmly fixing it in position. It was, therefore, plain that the fundus
of the tumor was covered by a coat of peritoneum which had been lifted from
the pelvis by its development upwards. The membrane was vascular and thick-
ened. I next cut boldly into the tumor, in the line and to the extent of the ex-
ternal incision, and, passing my hand into the gap thus made, broke up the
whole interior of the mass, freeing it of one or two gallons of yellowish fluid,
which coagulated on exposure to air. After thus reducing the size of the
tumor, I succeeded in shelling off the whole peritoneal coat, to which were at-
tached several folds of intestines, and by this means relieved it of all points of
attachment in the abdominal cavity. The entire mass was now readily dis-
located and turned out of its bed. It was found to be attached by a fibrous
pedicle, an inch to an inch and a half thick, to the uterus on the right side, at
a point between the insertion of the vagina and that of the uterine peritoneum.
The pedicle was short, almost sessile. It was transfixed by a strong double
ligature, which was tied both ways and also encircled the whole pedicle. The
tumor was then excised, so as to allow a large button beyond the ligature.
The remaining tumor now presented itself at the opening. It sprang from
the posterior surface of the left broad ligament just where it joins the posterior
part of the uterus. The Fallopian tube coursed along in front of the pedicle,
was wrapped around it, and its fimbriated extremity rose up on the tumor, and
was attached to it. Several adhesions to the walls of the abdomen were
broken up, and the tumor was turned out. The pedicle was very short, but
was clamped, the Fallopian tube being included, and the tumor was removed.
822 . . ATLEE,
The abdomen was afterwards carefully cleansed with soft sponges, as well as the
pelvis, which was nothing but a raw surface having no peritoneal lining. The
right ovary was found to be healthy, the left being absent and evidently in-
volved in the small tumor. A large amount of loose peritoneum, which had
been removed from the large tumor, now occupied the lower portion of the
abdominal cavity. It had contracted very much, and appeared more thickened.
It was allowed to arrange itself. The uterus was enlarged to more than twice
ts normal size. On its anterior wall was a small sessile subperitoneal fibroid.
I opened its capsule, enucleated, and removed it.
The clamp was arranged across the middle of the wound, the ligated pedicle
in the lower end, and five wire sutures were introduced above and five below the
clamp ; the fundus uteri occupying a position against the interior surface of the
wound between both pedicles. Several ounces of blood were lost, but not suffi-
cient to affect the pulse. One vessel was controlled by torsion, and one by silk
ligature, cut short and dropped in. The large tumor was fibro-cystic, weighing
thirty-five pounds. The small one was an ovarian fibroid, and weighed over
five pounds. The patient made an excellent and rapid recovery, and is now in
the enjoyment of perfect health.
In presenting this subject for discussion, I am aware that I am open
to criticism for having made such an arbitrary subdivision of fibroid
tumors of the uterus. It is, however, apparent that this has been done
for practical reasons. A much simpler classification would have been
into subserous and submucous, or eartra-muscular, and interstitial or
intra-muscular. But as the question to be considered was the treatment
of fibroids, I preferred arranging these tumors as we find them in
patients, so as to make the paper purely clinical and practical. In
making the above division, it must not be inferred that each case can
be classified under one or other head, for several or even all forms of
fibroids may be present at the same time. According to my observation,
however, the intra-muscular tumor is most likely to be solitary, while
the extra-muscular is more frequently multiple.
As a consequence of the limited time allotted to this paper, and which
has already been exceeded, I have viewed this subject only from a per-
sonal stand-point. In omitting to mention the various modes of treat-
ment of which I have no experience, I mean no disrespect or disparage-
ment to any of my medical brethren, who, perhaps, may have had better
success than myself. These methods, it is hoped, will be stated by their
advocates. With regard to the use of one agent, which has recently
been extensively used, I may be excused for repeating that I commenced
the use of ergot in 1845 in the treatment of fibroid tumors, and have
continued to employ it beneficially ever since. I have, also, for many
years, used muriate of ammonia alone, and in connection with ergot,
and with such results as have satisfied me of its value. The dose is ten
grains three times a day. A solution of one drachm to one pint of
water is used twice a day as a wash to the abdomen and to the vagina,
and an apron of silk oil-cloth is worn next to the skin. Neither patient
nor physician should tire in its use, using it for months and even years,
if the tumor does not disappear. I am satisfied that it often arrests the
growth ; so does ergot. It sometimes causes its entire disappearance;
I have yet to see this result from ergot alone, except in mechanically ex-
pelling polypi. It sometimes fails to produce any appreciable results; so
does ergot. I attribute the influence of muriate of ammonia to its altera-
tive, resolvent, and sorbefacient power, as well as to its alkaline properties.
I am well aware that the remedial power of muriate of ammonia has been
FIB R O ID T U M O R S OF T H E U T E R U S. 823
denied on the ground that inflammatory or plastic deposits have been
mistaken for fibroids. I do not pretend to possess any more diagnostic
tact than others, but the same remark will apply to all other remedies
and to all other persons. Even if it accomplishes so much under an
error of diagnosis, it certainly is a great boon to suffering humanity.
I now present the following propositions, which will throw the whole
subject of treatment open to discussion:-
I. Fibroid tumors of the uterus, although frequently unaffected by
treatment, are sometimes cured, and often controlled in their growth, by
medicinal and other agents. -
II. Fibroid tumors of the uterus which are entirely harmless to the
patient, should never receive surgical treatment involving the least
danger.
III. Extra-muscular, submucous tumors usually demand surgical
treatment.
IV. Hemorrhage, caused by a fibroid, uncontrollable by other means,
may be, and should be, arrested by the knife.
V. In the surgical removal of fibroids, it is of the greatest importance
to extirpate the living tumor.
VI. When the living tumor cannot be removed, as is usually the case
when the capsule has undergone inflammation, antiseptics must be dili-
gently employed.
VII. Extra-muscular tumors of the subperitoneal variety, when involv-
ing health and life, should be removed by abdominal section.
VIII. In cases of recurrent fibroids, it is justifiable, under certain cir-
cumstances, to amputate the inverted uterus, or to remove the organ by
abdominal section.
IX. In exceptional cases of uterine fibroids, extirpation of the uterus
by abdominal section is warranted.
N. As a general rule, in all cases of fibroids which destroy the com-
fort of a patient, or hazard life, and are not amenable to other treatment,
surgical interference is to be commended.
DISCUSSION ON DR. ATLEE’s PAPER.
After the reading of the preceding paper, the President, Dr. RoberT BARNEs,
of London, said:—This is a very important subject, and one upon which we
need all the light possible to get. We need not care so much about the suc-
cessful cases as about the failures, and also the reasons for the failures. We
should not rush into an operation when there is no hope of benefit. From the
distinguished physicians present, I think that some ideas may be developed
in a surgical way that will be of use to humanity.
Dr. Jo HN L. ATLEE, of Lancaster, said:—I believe that abdominal section for
the removal of fibroid tumors has been decided upon as a necessity in some
cases. I Once met with a case in which the enlargement of the abdomen was
equal to that of an eight months' pregnancy, and was hard on the right side.
I diagnosed an ovarian tumor. Two days afterwards the operation was per-
formed. On Opening the abdomen I encountered a dark-brown cyst, such as
I had never noticed in cases of the kind. I drew off six pounds of fluid,
which looked like an infusion of coffee-grounds, and succeeded, with some dif-
ficulty, in surrounding the pedicle with a clamp. On examining the tumor,
I found it to be of unusual character, and uterine. It weighed, in addition to
the six pounds of fluid drawn off, about as many pounds of a solid mass.
Hemorrhage had occurred in the tumor on one side, and had bent it over the
824 A T L E E ,
uterus until it was of a half-moon shape. I confess that I was disappointed
in my diagnosis, but the patient did well. If through an error in diagnosis
I was successful in removing such a tumor, I do not see why it is not a legiti-
mate operation to perform abdominal section for fibroid tumors, as well as
in ovariotomy. In another case there was an ovarian cyst on the right side,
and a subperitoneal uterine fibroid weighing six pounds on the left. Both
pedicles were included in the same clamp, and the woman did well.
Dr. ALEXANDER DUNLAP, of Springfield, Ohio, said:—The treatment of fibroid
tumors is now on trial before the profession. I have been watching the ques-
tion for thirty years, and my experience does not entirely coincide with that
of the author of the paper which has been read. Many tumors require no
operation at all, for after attaining a certain size some disappear, while others
stop growing, and give us no further trouble. I think that if the mind be
withdrawn from the diseased organ, in nine cases out of ten the tumor will
remain quiescent and give no annoyance. I have known of cases in which the
tumor was as large as a uterus at full term, without giving much inconve-
nience. Fibroids often cause hemorrhage, a thing to be guarded against.
I have found that ergot contracts the muscular coat, and cuts off the source of
blood from the tumor. I differ also as to methods of operation. Dr. Atlee
uses the knife to remove the tumor; I prefer the écraseur, because it prevents
hemorrhage. In some cases enucleation is effective, but I have lost two cases
from want of proper drainage, septic inflammation having supervened. I
would propose a new method of dealing with the pedicle in cases requiring
the removal of the uterine tumor. This consists in dissecting the peritoneum
off of the lower half of the tumor, and in removing the latter by the écrase wr
very close to the os internum. Strong silk threads are then passed at various
points through the edge of this cup-shaped peritoneal covering. Next the
cervical canal of the uterine stump is dilated, and a small speculum introduced
per vaginam. Through this the ends of the silk threads are passed, and the
peritoneal coat is drawn by them through the uterine canal into the vagina.
Thus no raw surface can remain within the abdominal cavity, for the stump is
covered by peritoneum, and all discharges become external. In some cases of
hemorrhage I have found it of advantage to lay the patient on an inclined
plane, with the head low down, so that the tumor can be pressed from the
pelvic into the abdominal cavity; the proceeding is very easy in these cases.
I have never been able to stop the growth of a tumor by ergot, but it is of
use in checking hemorrhage.
Dr. G. KIMBALL, of Lowell, Mass., said:—I concur in the opinion of Dr.
Dunlap, that these tumors should be let alone, except when it is absolutely
necessary to use the knife. They sometimes disappear spontaneously, and it
requires good judgment to tell what cases need operation. Such as do not
involve the vagina or the neck of the uterus are the only ones that can be
operated upon. A surgeon would be almost guilty of homicide who should
attempt an operation in some cases in which the fibroid fills the vagina and
invades the cervix, and in which hemorrhage would inevitably result, for there
would then be no pedicle which could be ligated. In one case I removed the
womb on account of a sessile subperitoneal fibroid, and secured the pedicle
with a silk ligature the ends of which were brought out externally. For
eighteen months the ligature ends remained in situ, and then disappeared in-
ternally, as the patient averred. Instead of the ligature I now use the wire
écraseur, which I fasten externally by adhesive straps, after searing the stump
with the hot iron. In this manner I am able to control all hemorrhage with-
out having much of a pedicle left. Very few cases authorize extirpation of
the uterus. I have seen good results from ergot, but none from the muriate of
ammonia in subperitoneal fibroids. But one of my cases got entirely well
after using for a year intra-uterine injections of a solution of eight grains of
iodide of potassium in an ounce of water.
Dr. E. R. PEASLEE, of New York, said:—Fibrous tumors should be consi-
FIB R O I D TU M O RS OF THE UTE R U S. 825
dered apart from other tumors. They either produce hemorrhage or they do
not, and this depends greatly on their site. When there is no hemorrhage I do
not consider that we have any right to interfere. In the treatment of these
growths, I have used the muriate of ammonia with good effect, but I do not
think that we can expect much from ergot, except in cases of interstitial tumor.
It might possibly affect the uterine muscles, and cut off the nutrition of a sub-
peritoneal fibroid, but I have little faith in most of the ways suggested for its use.
I would reject the use of ergot entirely except in cases in which contraction
was an absolute necessity. There is no hemorrhage so great that it cannot be
Stopped for a time, and this time is important, as it gives a chance to think
whether the case really needs a surgical operation. Women very rarely die
from hemorrhage in these cases, but more frequently from septicaemia. In
ordinary cases of hemorrhage I give ergot in combination with the tincture of
the ferric chloride. In severe cases I introduce a tent into the cervix, and keep
it in Situ by means of a vaginal tampon. When septic symptoms show them-
Selves, I consider repeated, intra-uterine, disinfectant injections as of para-
mount importance. I regard it as a safe rule not to interfere with fibroids.
In regard to cutting into a fibroid, I have found that an incision through its
mucous capsule is valuable in arresting hemorrhage, but I have never used
enucleation because I am afraid of subsequent bleeding. In such cases I use
the ligature and antiseptic washes. I would suggest to Dr. Atlee instead of
the term “recurrent fibroid,” which he has used in his paper, that of “multi-
ple fibroid.” In the discussion of this subject, fibro-cysts should be separated
from fibroids proper; the former generally spring from the posterior wall
of the uterus, and drag the organ upward, elongate it, and bend it forward;
this does not occur in cases of simple fibroma, and constitutes a diagnostic
point. I do not think that we are justified in removing a fibroid unless the
patient is in such a condition that she will die without the operation. With
fibro-cysts, the operation is often necessary, and if, in a case of ordinary
fibroid, life were threatened, I should not hesitate to extirpate the uterus.
Dr. H. LENOx Hopg|E, of Philadelphia, said:—No reference has been made
to what I consider very important, namely, accurate statistics of operations
for the removal of these tumors by abdominal section. It would be of great
value if each surgeon would state how many times he had operated, in how
many cases the operation had been successful, and in how many it had been
fatal. This has been done in regard to ovariotomy, and the same reasons
apply for doing it in this case. Dr. Péan, of Paris, has published such statis-
tics. His results are very favorable. They as yet stand alone. No one else
has approached the success which he reports. I have myself, as yet, never
Operated in a case of this kind, and have never met with a case which seemed
to require it. On the other hand, it would also be of value to know the his-
tory of cases which have not been operated upon. I have seen many of these
tumors of the uterus, and have the record of some of my father’s cases, dating
back many years, which are still under my observation. In my experience,
the number of deaths resulting from such tumors when let alone is very small;
and, as the patient approaches the age of fifty years, the tumors often begin to
diminish. In some of my cases, no trace of the old tumors can now be
detected. One of the dangers, dreaded by some, is inflammation, resulting in
septicaemia; this I remember to have seen in only a single case. Another dan-
ger is hemorrhage; this I have always been able to control. I have seen very
good results follow the use of hypodermic injections and suppositories of
ergot. The ergot, according to my observation, acts well in all the varieties
of these tumors, including the subperitoneal. I believe that it acts by con-
tracting the blood vessels, rather than the muscular tissue, of the uterus. There
is a remedy, however, which is far superior to ergot. It is a surgical one, and
consists in pushing up the tumors out of the cavity of the pelvis, and maintain-
ing them, by proper pessaries if need be, above the brim of the pelvis. This
relieves the dysuria and tenesmus so common from pressure of the tumor on
826 ATLE E, FIBROID TU M ORS OF THE U TE RU S.
the bladder and the rectum ; but more than this, it lessens in a most remark-
able manner, or arrests, the hemorrhage. The cause of this haemostatic effect
is somewhat obscure and diflicult to explain. It seems probable, however,
that there being no longer pressure from the firm pelvic walls, the circula-
tion becomes unembarrassed, and, the blood returning by the veins, the con-
gestion of the uterus is diminished.
The President, Dr. ROBERT BARNES, of London, said:—We must have ade-
quate reasons for these operations. The question is, whether we should allow
patients to die, or use all the means at Our command to save life. This discus-
sion will be a help to all of us. In my own practice I last year lost three
patients from a sort of necrosis which supervened upon the incision of the
capsule of submucous tumors, and an attempt to enucleate them. This un-
fortunate experience has made me very shy of undertaking any such procedure
unless the whole tumor can be removed at One operation. If the tumor were
too large to be approached by the vagina, I should advocate gastrotomy as
soon as the woman’s life was threatened.
Dr. ATLEE, in reply, said:—I beg to return thanks for the attention given
to my paper. All of the points which I have advanced have been sustained
by the very distinguished gentlemen who have taken part in the discussion.
Physicians are bound to aid a patient when in extremity, and should employ
the means which they know to be of use ; we have no right to let a disease
alone; our business is to relieve the patient.
827
THE THREE MOST IMPORTANT OBSTETRICAL
INSTRUMENTS.
BY
T. LAZAREWITCH, M.D.,
PROFESSOR OF CLINICAL MIDWIFERY AND DISEASES OF WOMEN, AND DIRECTOR OF THE
GYNAECOLOGICAL CLINIQUE, IN KHARKOFF, RUSSIA.
[COMMUNICATED BY THE SECRETARY.]
A BLUNT hook,' a parallel forceps, and an embryotome, devised by Prof.
Tazarewitch, and presented by him to the Congress, under this title, are
offered to the Section on Obstetrics.
The Blunt Hook is bent at both ends in the same direction, and has
a hole drilled in one end, and two holes in the other. Apart from the
uses to which the ordinary, obstetric, blunt hook is devoted, this one pos-
sesses the important advantage of enabling the practitioner to replace a
prolapsed funis, and to carry a fillet around the thigh of the child, or a
noose around its ankle.
The Parallel Forceps weighs only one pound, has narrow blades, is but
eleven inches in length, and when closed gives a divergence of two and
a half inches at the hollow of the blades. The handles lie parallel to one
another, and are locked by lateral contact. The lock, consisting of a
tenon and mortise, is so loose as to permit freedom of movement to the
child’s head. Dy the shortness of its handles, this instrument cannot
exert much compressive or extractive power. To compensate for this
deficiency, a strong silk loop is attached, either just above the lock when
compression is needed, or at the ends of the handles when merely power-
ful traction is called for. By this loop, traction can be made also in any
direction, and the forceps converted into a lever whose fulcrum is repre-
sented by the hand at the handles. The inventor attributes the following
advantages to his parallel forceps:—
“Either half may be introduced first with equal facilities for locking.
“After the first blade is introduced, the way is not obstructed against the
second, as it is with the crossing forceps, which is especially important in cases
in which the head is high up in the pelvis, and the vagina imperfectly dilated.
“The locking is effected with perfect ease, and without risk of pinching the
soft parts of the mother, which are quite clear of the lock.
“Whatever force of traction may be applied, in all cases immediate pressure
of the head with the blades may be avoided on account of this possibility of
accommodating themselves to the head and the mother's parts. This cannot
be so perfectly effected by any other forceps.”
The Embryotome consists of a hollow shaft, armed with a steel beak
at one end, and with a screw at the other, which opens and closes the
beak. The instrument is introduced closed. The beak is then opened
! [An abstract, only, of Professor Lazarewitch's paper is here inserted. The original
manuscript, with elaborate illustrations and samples of the instruments described, is deposited
in the Museum of the Obstetrical Society of Philadelphia.-EDITOR.]
828 LAZAREWITCH, OBSTETRICAL INSTRUMENTS.
and made to bite into the cranium. By turning the shaft on its longi-
tudinal axis a portion of the skull is them torn off. By repetitions of
this process the whole vault is broken up. For this instrument, Prof.
Lazarewitch claims not only the property of lessening the bulk of the
head, but that of acting as an efficient tractor, and of being available for
severing the neck, or any portion of the body, in a difficult cross-labor.
829
ON THE NATURE, ORIGIN, AND PREVENTION OF
PUERPERAL FEVER,
BY
W. T. LUSIK, M.D.,
PROFESSOR OF OBSTETRICS AND DISEASES OF CHILDREN IN THE BEI,LEVUE HOSPITAL MEDICAL
COLLEGE, NEW YORK.
THE total number of deaths in the city of New York for the nine
years from 1868 to 1875, inclusive, was 248,533. Of these, 3342 were
deaths either from diseases complicating pregnancy, from the accidents
of child-bearing, or from diseases of the puerperal state; or, in other
words, very nearly one in seventy-five of all the deaths occurring during
that period, was the result of the performance of what we are in the
habit of regarding as a physiological function.
A careful study of the records preserved by the Health Department of
the city has enabled me to classify these 3342 deaths into :—
(1) Those due to child-birth proper, under which head I would place
deaths from shock, from protracted and unusually severe labor, from
convulsions, from flooding, from rupture of the uterus, and, for the
sake of convenience, those from extra-uterine pregnancies;
(2) Deaths from eruptive diseases, from phthisis, and from the various
non-puerperal, inflammatory disorders complicating child-birth. A few
cases recorded as typhus, typhoid, and intermittent, I have included
under puerperal fever, on account of certain inherent difficulties in the
differential diagnosis. Should exception be taken to this action, I have
only to state that the entire number thus recorded is much too small to
palpably affect any conclusions which this report may contain ;
(3) Deaths from a variety of diseases, occurring during pregnancy, in
which the pregnant state was, in all probability, an active cause of the
unfavorable result; -
(4) Deaths from miscarriage (I use the term as I find it employed by
the majority of physicians, in their reports, to designate all cases of inter-
rupted pregnancy during the first six months), in which either intercur-
rent affections, the lack of proper medical assistance, actual want, or
criminal malpractice, have been the chief factors in determining the fatal
issue. To be sure, in many of these instances, death is due to the super-
vention of peritoneal complications, septicaemia, and pyaemia, assimilating
them closely to cases of puerperal fever. I do not, however, include them
under puerperal fever, because their origin is not involved in mystery.
Two words tell the whole story, viz., neglect and violence. The explan-
atory term, retained placenta, testifies to the one, and the certificate of
the coroner to the other. We all know how common fatal cases of metria
are, in large hospitals, after delivery at full term. After abortions, on the
contrary, they are rare. Thus the uterine wards of the Bellevue Hospital
have always contained a large complement of women, who have entered
the hospital in a very low state induced by some of the sequelae of abor-
tion. Of these, in nine years, two only have died. Dr. George K. Johnston
830 LU S K,
reports in seven years, in the Rotunda Hospital in Dublin, but one death
in 234 cases of abortion, and that the result of mitral disease of the
heart. I have, for the sake of convenience, exhibited the precise propor-
tion of deaths due to each of these several causes in tabular form. Collec-
tively they will be seen to have numbered 1395 eases, or about 42 per
cent. of the entire number.
TABLE I.—Deaths occurring during pregnancy, confinement, and the puerperal
State, in New York, between the years 1867 and 1875, inclusive, eaccluding
those from metria.
1867. 1868. 1869. 1870. 1871. 1872. 1873. 1874. 1875. Total ==
£75
Childbirth * º o . 18 13 20 20 | 37 38 22 19 16 203
Convulsions . te º . 55 36 || 47 || 46 54 || 62 || 30 || 51 | 27 | 408
Uraemia” . º º . . . . . . . 4 || 8 || 3 || 5 || 5 || 7 || 29 || 22 || 83
Flooding . - e o . 16 || 35 | 13 25 | 20 24 20 25 26 || 204
Placenta praevia . e . . . . . . 4 || 10 || 5 || 11 || 9 || 14 | 11 | 18 82
Protracted & instrumental labors || 4 || 5 || 4 || 2 | . . . 7 || 10 20 || 52
Rupture of uterus tº & 4 || 4 || 3 || 4 || 5 || 5 || 6 || 5 || 11 || 47
Extra-uterine pregnancy . º 1 || 1 | . . . 5 || 3 | . . . | 1 || 4 | . . . . 15
Miscarriage” . e * . 13 || 10 | 12 19 || 36 27 24 30 26 || 197
Pregnancy" . 4 || 2 || 4 || 1 || 5 || 5 || 3 || 2 || 5 || 31
Phthisis . º 3 || 2 || 1 || 2 || 6 || 8 || 8 || 4 || 5 || 39
Smallpox . 1 || 9 || 2 | . . . 7 || 19
Scarlatina 2 || 4 || 1 || 4 || 2 | 13
Erysipelas l l 2
Total . - e . 118 116 |122 |132 |185 |196 ||146 |194 186 1395|3342
1 Under childbirth are included deaths from shock, from intercurrent non-puerperal diseases, from complica-
tions, such as tumors, can cer, disease of the heart, and the like, and all cases reported under childbirth which
proved fatal within twenty-four hours of delivery, not elsewhere mentioned. -
2 A large number of deaths from wraemia are reported, in which it is not stated whether convulsions existed
Or not.
3 Under miscarriage are reported all cases in which pregnancy was interrupted previous to the seventh
month. -
* Under pregnancy are given deaths, from non-puerperal causes, in which pregnancy existed and probably
contributed to the fatal issue. The number of deaths from phthisis is specifically given in the report, as are
those from smallpox, Scarlatina, and erysipelas, subsequent to 1870.
(5) There thus remain 1947 cases which, variously reported as puerperal
fever, puerperal peritonitis, metritis, metro-peritonitis, phlebitis, phleg-
masia dolens, pyamia, and septicæmia, furnish the subject for special
inquiry in this paper. All these varieties we will term briefly puerperal
fever, attaching to the term, however, no special significance. The diag-
nosis of anatomical lesions from clinical symptoms alone, unverified by
post-mortem examination, is, in the most experienced hands, only approxi-
mative. As usually reported by the practitioner, these lesions reflect for
the most part his individual theory, or early training. As a matter of
convenience then we propose to employ the name puerperal fever as a
general term to cover all the febrile conditions peculiar to the puerperal
State.
In the 1947 cases of puerperal fever, I have included cases of patients
reported to have died of puerperal mania, the non-febrile form rarely
proving speedily fatal. That this rule is not universal, I readily admit.
Thus, I remember a case occurring in the Bellevue Hospital, in which the
PU E R P E R A. L. F E W E R . 831
maniacal patient was confined in one of the cells of the hospital. T)uring
the night, she got out of bed and broke the windows. The night was
bitterly cold. The patient sat up in her night-dress with the cold air
streaming in upon her. On the next morning she was seized with pneu-
monia, and died. A few cases of death, too, reported from insane asylums
do not belong in this category. Giving to the term, puerperal fever,
then, this broad significance, we find that in nine years it was the cause
of nearly one one-hundred-and-twenty-seventh of all the deaths occurring
in the city. It is to be regretted that the returns of births in the city are
imperfectly rendered. The actual number of births during the last nine
years may, however, be roughly set down at 284,000. This estimate is
based upon the assumption that the natural birth-rate is thirty-three to
the thousand, an estimate which errs upon the side of liberality. The
total number of deaths then to the entire number of confinements would
be at least in the proportion of one to eighty-five, or, from puerperal fever
alone, in the proportion of one to one hundred and forty-six. These
figures proclaim more eloquently than any words can do, the necessity of
frequently reviewing the state of our knowledge as to the nature of puer-
peral fever, and of inquiring as to how far it is due to causes which are
amenable to human control.
At the outset, it is proper to recall that, as the various names applied
to puerperal fever indicate, it is, with rare exceptions, associated at some
period of its progress with certain inflammatory processes which have
their starting-point in the generative apparatus. The lesions most com-
monly found in post-mortem examinations consist of catarrhal inflamma-
tions of the mucous membrane lining the vagina and uterus, with simple
ulcerations, or those presenting a diphtheritic character, inflammation
in the pelvic cellular tissue, metritis, local and general peritonitis, inflam-
mation of the lymphatics and veins, thrombosis, pleuritis, pericarditis,
valvular affections of the heart, abscesses, and other destructive processes
in the parenchymatous organs, and purulent collections in the joints. As
a rule, the occurrence of one or other of these inflammatory processes is
synchronous with the first outbreak of fever.
When we come to analyze our cases of puerperal fever, we find two
general groups, the one infectious, the other non-infectious.
I. The Non-infectious Group.–Every one who has seen much of hospital
practice, has of necessity observed instances of puerperal inflammations
and febrile conditions, often of a severe type, which have possessed this
distinctive peculiarity, that they have in no wise visibly affected the
health of puerperal patients in their vicinity. They possess this feature
in common, viz., that in them the symptoms of blood-poisoning are
absent, or are present only to a subordinate extent, and as a late feature
of the disease. The nature of cases belonging to this group may be best
expressed by an examination of the known causes which call them into
existence. I give the following from a vast number of recorded cases,
without pretending, however, that they exhaust the list:-
(1) Inflammations may arise from traumatic injuries, such as rupture
of the cervix uteri during labor, those resulting from unskilfully per-
formed operations, and from the bruising or crushing of the soft parts of
the mother in long labors, especially in cases of moderate pelvic deformity.
The census for 1870 gives to New York a population of 942,292. The average of
annual increase from 1860 to 1870, was 15,000. I have taken 15,000 as the probable aver-
age increase since 1870. The inaccuracy in this calculation is not considerable enough to
materially affect the proportions.
832 LU S K,
(2) The imprudence of patients or their nurses. Thus I have frequently
been able to trace, in hospital practice during the winter season, severe
cases of cellulitis, pelvic peritomitis and general peritonitis, to the pa-
tient’s getting out of bed, dripping with perspiration and clad only in
a night-dress, and going thus bare-footed over a cold uncarpeted floor to
the water-closet. Even in private practice, like instances of wilfulness
are not unknown ; nurses too, especially those who are reputed by the
fair sex to know more than any doctor, are fertile sources of trouble.
(3) Moral causes are frequently effective in producing serious disturb-
ance. In studying the records of Bellevue IIospital for the year 1873, I
was greatly impressed by the fact that in 240 deliveries in married women
there were but two deaths from puerperal fever, while in 209 in non-
married women there were thirteen deaths. From the Bureau of Vital
Statistics I learn that one-eighth of the deaths from puerperal causes
occur among unmarried mothers. Dr. Johnston dwells much upon a
similar state of affairs existing during his mastership at the Dublin
Rotunda IIospital. In a paper on “The Genesis of Puerperal Fever,”
I reported an instance in which five women were confined in the same
ward, by the same attendants, and under absolutely the same conditions,
with the exception that one chanced to witness the sudden death of a
patient from rupture of the uterus. While the other four women did
well, this one, after a period of great mental agitation, developed peri-
tonitis and died. It has been suggested that such cases occur only in
the records of hospital practice. This is not so. During the past
summer I saw in consultation, in a remote and very healthy rural dis-
trict in which puerperal diseases were unknown, a case of severe fever,
lasting eight days, which was traceable to the mother's anxiety and fret
over the illness of one of her children. Dr. Alfred Wiltshire, of London,
after writing to me an account of a poor woman who died in less than
twenty-four hours in collapse, brought on by a rough remark from her
husband, adds, “I have seen many other similar though less severe
cases, and I confess that my sympathies are deeply touched whenever I
have to attend women who have cause for depression during labor.”
(4) I have, in a number of cases, had occasion to notice the influence
of old adhesions existing between the serous coverings of the pelvic
Organs, due to a by-gone peritonitis, upon the pregnant and puerperal
states. The two following instances will serve as illustrations:—
The first was that of a young wife, who, a few months after her marriage,
had a miscarriage. Unfortunately a portion of the ovum remained in the
uterus, where it became the source of protracted hemorrhage and some felprile
disturbance. A couple of months later, however, the offending body was
removed, after preliminary dilatation of the os, by a distinguished physician
who was summoned in consultation. A sharp attack of pelvic peritonitis fol-
lowed, from which, however, the patient so far recovered as to enjoy a period
of reasonable health. Then she became āgain pregnant. In the sixth month
of gestation she began to lose flesh rapidly, and had repeated chills, with pro-
fuse perspirations, and a continuously high temperature with evening exacer-
bations. Living at the time, however, in a New Jersey rural district, her
symptoms were attributed to malarial influences. I was consulted concerning
the case in the eighth month, and on hearing the history predicted an inflam-
mation of the kind under consideration ; and found, as I had anticipated, on
examination, a large and distinct tumor reaching from the left iliac fossa to
the upper margin of the kidney, which was evidently the product of chronic
| American Journal of Obstetrics, vol. viii., Nov. 1875, p. 371.
PU E R P E R A. L. F. E. W. E. R. 833
cellulitis and peritonitis. Soon after, she gave birth to a premature but living
child. In a few days subsequent to her confinement, the lady died. Every
Circumstance in the clinical history pointed to the connection between the
slowly developing inflammation during pregnancy and the earlier acute attack
Of peritonitis.
In the second case I was called to see a patient suffering from puerperal
convulsions, in whom gestation was complicated by a large fibro-cystic tumor
of the uterus. After administering chloroform, I dilated the os, and delivered
the child by version. Hemorrhage followed, which was, however, promptly
arrested. The three days following, my patient had no bad symptoms. On
the fourth, she complained of pain on the left side, which gradually extended
Over the abdomen. Meantime the temperature rose, the pulse became rapid,
and on the following day she died. The post-mortem examination showed no
lesions of either the uterine cavity, the cervix, or the vagina, which were all
normal in appearance. That portion of the uterus, however, which had under-
gone fibro-cystic degeneration, and which was found to weigh between six and
seven pounds, was covered with fibrinous flakes. Everywhere the tumor was
glued to the adjacent serous surfaces by adhesions of long standing, and
strong, organized bands, many of them the size of a goose-quill, connected it
with neighboring organs. There could be no doubt, on examining these ap-
pearances, that the peritonitis had been caused by the dragging of the heavy
tumor upon these adhesions, after the evacuation of the uterus and the loss of
the support of the abdominal walls.
(5) It is proper to take into consideration the vulnerability of indi-
viduals. All puerperal women are said to tremble in the balance between
a physiological and a pathological condition, and it is no unfounded as-
sertion to say that trivial causes which would be inoperative in many
cases will turn the scale in others. We see this exemplified in first
births, and in women who have borne children in excess. In this con-
nection, the question started by Dr. Nathan Allen, of Lowell, as to what
is “The Normal Standard of Woman for Propagation,” becomes of real
interest.
(6) It is to be borne in mind that the zymotic fevers, not peculiar to
child-bed, may provoke in the puerperal woman the same inflammatory
lesions that are commonly associated with puerperal fever.” This is in
conformity with the well-known surgical experience that a febrile
paroxysm from any cause exerts an unfavorable influence upon a
wounded surface. Olshausen” has, however, recently shown that pelvic
inflammations and peritonitis are somewhat rare in cases of Scarlatina
complicating the puerperal state. He likewise adds affirmative evidence
to the view advanced by Braxton Hicks,” that scarlatina, after a long
period of latency or incubation during pregnancy, can make its appear-
ance two or three days after delivery, and, as a rule, with slight throat
symptoms. The discussion in the London Obstetrical Society” has done
much to draw attention anew to the effects of infective diseases upon the
puerperal state. I should prefer, however, to exclude well-defined cases
of typhus, typhoid, and scarlatina, complicating child-bed, from the
1 Amer. Journ. of Obstetrics, April, 1876, p. 1.
2 Vide Hervieux, Traité Clinique et Pratique des Maladies Puerpérales; Art. Mala-
dies Accidentales, pp. 1073 et seq.
3 Untersuchungen ueber die "Complication des Puerperium mit Scharlach und die
sogenannte “Scarlatina Puerperalis;” Archiv für Gynaekologie, Bd. ix. Heft 2, 1876.
# Contribution to our Knowledge of Puerperal Diseases; Obstetrical Transactions, vol.
xii. p. 44.
* Obstetrical Transactions, London, vol. xvii.
53
834 LU S K,
category of puerperal fever, unless coexistent local lesions should involve
the pathogeny in doubt."
Now as regards the foregoing dangers to the puerperal woman, it is
rare that the physician is enabled to employ preventive measures; and
these are necessarily not general, but those suggested by his tact, skill,
and wisdom, for indel endent application to each case.
II. The Infectious Group.–The infectious form of puerperal fever is
characterized by blood-poisoning. The poison is of a septic nature.
The usual points of introduction of the poison are the lesions of the par-
turient canal. This does not, however, exclude other points of entry,
and clinical experience renders it highly probable that, under certain
conditions, the poison may be primarily introduced into the blood
through the respiratory and digestive organs. This form is contagious,
but all cases of infection are not contagious in an equal degree. It is
customary for many to limit the term puerperal fever to the members of
this group ; as, however, there is as yet no common understanding of
authors among themselves, or among practitioners in general, as to the
precise limitation of the term ; as, indeed, hardly any two physicians
mean precisely the same thing when they speak of puerperal fever, I shall
endeavor to avoid confusion by not using the term in a specific sense.
That the infectious diseases of child-birth are of septic origin, there is
now abundant evidence. The question of the identity of puerperal fever
and septicaemia is largely one of definition. It is a matter of ordinary
experience that the retention of a small bit of the membranes within the
uterus will produce fetid lochia; and, as the result of infection, a febrile
condition, which, as a rule, subsides with the expulsion of the offending
body and the use of disinfectant washes. A virulent form of fever is not
unfrequently occasioned by retained coagula, or placental débris, which
have undergone decomposition. I was once sent to see a puerperal
patient, suffering from fever, on the fourth day following her confine-
ment. On entering the room I found the stench intolerable ; turning
down the sheets, I discovered that the patient was lying in a decomposing
mass, and learned that her doctor had forbidden, after the birth of her
child, the removal of the soiled linen and blankets. The patient died in
the third week from pyaemia multiplex.
Haussmann” reported a case of auto-infection in the rabbit, which ter-
minated fatally. A portion of the membrane, retained in the left cornu,
led to diphtheritic losses of substance in the lower portion of the vagina,
to hemorrhagic enteritis, and to peritonitis. The same author produced
death from septicaemia by injecting into the gravid uterus of the rabbit
serum from the abdomen of a rabbit which had died from infection.
The post-mortem examination showed the muscles filled with granules,
and the peritoneum injected, but no fibrino-purulent exudation. Injec-
tions into the uterus of pus from the abdomen of a woman dying from
infectious puerperal disease, produced no effect upon rabbits two weeks
gravid, while in the second half of pregnancy premature delivery and
| There does not appear to be any very good reason why a well-marked case of scarla-
tina occurring in a puerperal patient should be termed puerperal fever, more than one of
smallpox. Dr. George K. Johnston informs me that the cases of Scarlatina occurring in
the Rotunda Hospital of Dublin have never started epidemics of puerperal fever among
the lying-in patients. I remember but one case of the kind in the Bellevue Hospital, and
this did not affect unfavorably patients in the vicinity.
2 Entstehung der übertragbaren Krankheiten des Wochenbettes; Beiträge zur Geburts
hülfe und Gynaekologie, Bd. iii., Heft 3, S. 345.
P U E R P E R A L FE V E R . 835
death occurred, in one case in one and a half, in another in two and a
half days. In the animal which died in thirty-six hours there was com-
mencing perimetritis and peritonitis, while in the one dying after the
lapse of sixty hours the abdomen was found to contain fibrin and pus."
D’Espine injected into the uterus of a rabbit, which had just produced her
young, pus from the abdomen of a woman who had died from puerperal
disease two days before. This was subsequently followed by other injec-
tions of fetid fluids during the four days following. On the twelfth day
the animal died. The autopsy revealed peritonitis, most marked in the
pelvic cavity, inflammatory alterations in the vagina, uterus, and tubes,
small abscesses in the body of the uterus, softened clots in the veins of
the broad ligaments, and infarctions of the liver.” Schüller found that
subcutaneous injections of septic material in female animals, during
pregnancy, produced a diphtheritic, ulcerative process on the uterine
surface, which determined the separation of the placenta; diphtheritic
patches, likewise, were found in the cornua of the uterus.”
Thus we find that in the human subject, and in experiments made
upon animals, septic poisons introduced into the system following or near
delivery produce lesions similar to those found in puerperal fever. As a
further coincidence, we notice that, as in puerperal fever, the lesions
from direct, septic poisoning have nothing characteristic about them,
producing in one case pyaemia, in another partial peritonitis, in another
general peritonitis, in another diphtheritis, while in others the lesions
are comparatively trivial—these differences being due to differences in
conditions which are but imperfectly understood.
My friend, Prof. Barker, in his magnificent work on “The Puerperal
IDiseases,” which is, as every one knows, a masterpiece in the way of
clinical observation, mentions, as a distinction between septicaemia and
puerperal fever, that, while puerperal fever is contagious, septicaemia is a
non-contagious affection. I have the record of the following case which
militates against this theory. A physician in New York delivered a
woman of a putrid foetus. The woman died of Septicaemia. Two days
after attendance upon the first case, he attended a second patient, who
likewise died of septicæmia. Dr. Barker states that by inquiry among
surgeons he cannot learn that septicaemia follows in their wake as does
puerperal fever in that of the obstetrician, and yet Sir James Simpson
asserts it to have been the case in his younger days.” The vital statis-
tics of New York, for the last nine years, show that a sequence of deaths
following confinement in the practice of individuals has become very
rare, and, let us hope, that if the enlightenment of these later days has
enabled the surgeon to avoid such a misfortune, in the end the same
profit may accrue to the practitioner of midwifery.
But it is to be remembered that the conditions in a puerperal patient,
and in one upon whom a surgical operation has been performed, are not
identical. Samuel, in speaking of immunities and dispositions to
septic poisoning, says:—“The statistical frequency of septic, puerperal
! Ibid., p. 394. e’
* Contribution à l'Etude de la Septicémie Puerpérale; Paris, 1873, p. 28.
* Experimentelle Beiträge zum Studium der septischen Infection ; Deustche Zeitschrift
für Chirurgie, Bd. vi. S. 141. -
* “I have repeatedly heard of instances of a rapid succession of Surgical fever cases and
disasters in the practice of the same surgeon, while the other surgeons in the same locality
had their patients recovering as usual.” On the analogy between Surgical and Puerperal
Fever; Simpson's Obstetric works, edited by Priestley and Storer, vol. ii. p. 19.
886 LU S K,
diseases is due to the length of the parturient canal, to the fact that
through this long passage there must pass all the pathological and phy-
siological excretions, and to the soiling of these parts with fingers, instru-
ments, and secretions, which have become the bearers of sepsis.” He
found, on the other hand, that it was extremely difficult to produce a
progressive ichorous condition by daily painting an open stump with a
septic fluid,” though the same was readily obtained when an infinitesimal
quantity of septic fluid was injected underneath a fascia. Dr. Barker
is, however, much too keen an observer to ever go far astray, and it is
true, as will be mentioned hereafter, that there is a form of septicaemia
which is not contagious. The only question to be raised is as to whether
it is allowable to restrict the term to this form. As usual in all questions
concerning puerperal fever, there is practical agreement as to facts, with
divergence of opinions concerning definitions.
Until very recently the whole subject of septicæmia has been in a state
of wellnigh hopeless confusion. From Gaspard and Panum, through a
long list of experimenters, hardly any two have arrived at precisely
similar results. Something like an approach to order has, however, been
produced since it has begun to be understood that the effects produced
by septic fluids vary with the quality of the poison and the method of
experimentation, and that to obtain identity in the result, there must be
identity in all the conditions. Thus Samuel has shown that the same
organic substance produces different effects at different stages of decom-
position; again that the enteritis which is commonly quoted as character-
istic of septic poisoning, occurs, as a rule, in animals, when the septic
fluid is injected directly into the blood, and is rare when it finds its
way into the circulation through the lymphatics, as is the case usually
in clinical experiences.” There is one experimental point of extreme
practical importance too in connection with puerperal septicæmia, viz.,
that if the injection of a septic fluid be made directly into a vessel, toxic
effects speedily follow, but are transitory, unless the amount of the fluid
be large, or its virulence exceptional, or the animal very young,”
whereas very small amounts injected subcutaneously, by developing
rapidly spreading phlegmonous inflammation, resembling malignant ery-
sipelas in man, are capable, after a period of incubation, of producing
fatal results; or they may, if injected into a shut cavity or underneath
a fascia, lead to the development of an inflammation of an ichorous char-
acter. In other words, the eliminating organs suffice, under ordinary
conditions, to remove from the blood the same amount of Septic fluid
which would prove fatal if injected into the tissues." To produce simi-
lar results the injections into the blood need to be repeated at intervals.
This experience leads us to the conclusion that, in the tissues, septic
poison possesses the capacity of self-multiplication, and that, in the local
inflammation set up, a reservoir is formed from which poison is con-
tinuously poured into the circulation.
This capacity of self-multiplication, which septic fluids possess, has
| Ueber die Wirkung des Fatilniss Process auf den lebenden Organismus; Arch. f.
exp. Pathologie, Bd. i. S. 343.
* Loc. cit., p. 339. * Loc. cit., p. 349.
* Traube und Gscheidlen, Versiiche ueber Faillniss und den Widerstand des lebenden
Organismus. Schles. Ges. f. waterländische Cultur, Febr. 13, 1874.
* In some instances in which absorption from the tissues is very rapid, the effects of sub-
cutaneous injections may be similar to those produced by injections made directly into the
circulation, and the local lesion be insignificant.
PU E R P E R A L FE W E R . 837
recently been found to be coincident with the presence of certain organic
bodies, termed variously micrococci, microspores, or sometimes, less spe-
cifically, bacteria. All carefully made experiments serve to show that, if
a septic fluid be deprived of these organic bodies by boiling, or filtration,
while it continues capable of producing inflammation, the inflammation
is usually of diminished intensity, and remains local in its character;"
whereas the microspores, retained upon the filter, possess all the virulent
properties of the original fluid.” This does not alone necessarily prove
that the virus resides in the microspores, for it does not exclude the pos-
sibility that both the virus and the microspores remain upon the filter.
So far, attempts at isolating the microspores and cultivating them
separately in vehicles, composed of water holding in solution certain
inorganic constituents necessary for their healthy nutrition, have been
only partially successful in proving them to be the sole source of infec-
tion. Some experiments of Tiegel and Klebs” were attended with positive
results, but Hiller arrived at different conclusions. He found that bac-
teria washed in pure water were innocuous.” But pure water had long
before been proven by observers to be inimical to the well-being of the
organisms in question. Schüller says that IIiller's experiments prove
apparently that while a putrid fluid may be in the highest degree poison-
ous, its component parts, viz., either the fluid or the bacteria singly, are
neither deadly nor poisonous.” The fact is that all isolation experiments
are subject to what seems an unavoidable source of error. As Davaine
noted, early in his observations, the physiological action of bacteria is
very dependent on the constitution of the medium in which they are
developed, which is in entire harmony with what is known of organisms
much higher in the scale. “Many plants,” says Burdon Sanderson,”
“containing active principles, become inert when transplanted from an
appropriate soil.” Bucholtz, in a series of experiments designed to test
the influence of antiseptics upon the vitality of bacteria, found not only a
difference between those taken directly from the infusion and those cul-
tivated in artificial fluids, but between bacteria derived from the same
source and cultivated in modifications of the nutrient medium.” Under
these circumstances, all evidence of a positive character is to be regarded
as of more value than that which is purely negative.
It is, however, from the constant presence of the round bacteria in
infected wounds, and their distribution through the tissues, that the argu-
ment in favor of connecting septic symptoms with the bacteria has been
mainly deduced. Here the ground is sufficiently solid, and, judged by
ordinary laws of scientific evidence, the pathological importance of the
microspores may be regarded as established. To be sure, we find them
| In filtration through porous earthenware cylinders, the filtrate possesses no phlogo-
genic properties.
* Tiegel, Correspondenzblatt für Schweizer Aertze, 1871, S. 1275. Klebs, Archiv für
exp. Pathol. und Pharmakol., Bd. i. Heft 1, S. 35.
* Klebs, Archiv für exp. Pathologie und Pharmakologie; Beiträge zur Kenntniss der
pathogenen Schistomycetin : Band iv., Heft 3, S. 241 und ff. Tiegel, loc. cit.
* Exp. Beiträge zur Lehre von der organisirte Natur der Contagion und von der
Fatihiſſiss; Archiv für khinische Chirurgie, Bd. xvii. Heft 4, S. 669 u. ff.
* Exp. Beiträge zum Studium der septischen Infection; Deutsche Zeitschrift für Chi-
rurgie. Bd. vi. S. 162.
* Lectures on “ The relations of bacteria to disease;” British Med. Journal, March 27,
1875. See, also, Klebs, Beiträge zur Kenntniss der pathogenen Schistomycetin; Arch.
für Pathol. und Pharmak ol. Bd. iii. S. 321.
7 Antiseptica und Bacterien; Arch. f. exp. Pathol. und Pharmakol., Bd. iv., Heft 1
und 2.
838 LU S K,
in tongue-scrapings of healthy individuals, but tongue-scrapings are
poisonous if injected into the tissues. That they do not ordinarily prove
so in the mouth, is no more singular than that woorara can be swallowed
with impunity. Tiegel has endeavored to show that the round bacteria
are found normally in the internal organs of the body.' If his experi-
ments should in fact stand the test of criticism, they would only show
that a few bacteria may be found in health in the liver and in the pan-
creas, but never in anything like the same numbers or the same general
distribution, nor with the same characteristic groupings, that have been
proven for a number of infectious diseases.” It is stated that they are
sometimes absent from the blood taken during life in septic diseases.
As, however, their constant presence has been confirmed in the vessels
and glomeruli of the kidney, it is fair to assume that they are filtered
out by those organs when the conditions favorable to their development
do not exist in the blood. Again it is an open question, which awaits
confirmation, whether it be not true, as Hueter claims, that the micro-
spores do not disappear, but are taken up by the blood-globules, rendering
the latter adhesive, and predisposing the blood to the stases character-
istic of inflammation." Zahn has shown that the inflammation in the
mesentery of the frog, in the Conheim experiment, does not take place if
the air is first filtered through diluted carbolic acid."
As to the exact manner in which these minute bodies exercise their
pernicious influence, whether they operate mechanically, or whether they
produce a virus in the process of nutritive activity, or whether, as is
probable, both suppositions are correct, we may safely leave as questions
to be decided by subsequent investigations. It is enough for us to note
that the connection between sepsis and the round bacteria is intimate and
vital. Panum, who is often quoted as opposed to what is known as the
Bacteria theory, admits as probable that the microsporom septicum is inocu-
lable, appears in the blood during life, multiplies in the tissues, and, in part
by production of a special poison, perhaps, and in part by mechanically
irritating the tissues, excites inflammation, suppuration, and fever." Berg-
mann, who once thought that he had found the secret of sepsis in a crys-
tallizable substance derivable from putrid fluids, which he termed sepsin,"
now squarely accepts the modern doctrine. Virchow has so far given in
his adhesion to the new school as to say: “Especially in this connection
are to be mentioned the diphtheritic process and the erysipelatous,
especially erysipelas malignum. The granular deposit in diphtherically
affected tissues, of which I formerly spoke, has more and more proven to
be of a parasitic character. What we formerly regarded as simple, organic
granules, as infiltration, or exudation, has since proven to be a dense
aggregation of micro-organisms which penetrate into the tissues and cells
to compass their destruction.” Even Billroth, who contends that what
he terms a zymoid ferment is the first thing developed in the line of cau-
! Virchow's Archiv, Bol. lx. S. 453.
* Klebs., Arch. für Path. und Pharmakol. Bd. iii. S. 319.
* Allgemeine Chirurgie, Cap. xvii.; Der fielberhafte Process. So, too, Schüller, loc. cit.
pp. 168, et seq. Birch-Hirschfeld likewise found bacteria in the white globules of pya.
mia ; Schmidt’s Jahrbücher, 130. 166, No. 5, S. 187.
* Arbeiten an der Berner pathol. Institut., 1871.
* Das putride Gift, die Bacterien, die putride Infection und Intoxication, und die Septi.
camie ; Virchow's Archiv, Ba. lx. S. 348.
* I have not been able to obtain access to Bergmann's original paper, but make this
statement on the authority of Hueter, Allgemeine Chirurgie, S. 543.
7 Die Fortschritte der Krieg's Heilkunde; Berlin, 1874.
PU E R P E R A. I. F. E. W. E. R. 839
sation, and that the bacteria are a sort of epiphenomenon, concedes that
the organisms, by their migrations, may become the carriers of the virus
into the interstices of the tissues.' I mention the less willing witnesses
to the importance of bacteria in disease: I need not recapitulate the
names of a host of active advocates of the germ theory.
I have been thus explicit regarding the evidence concerning bacteria
in septic diseases, because it places the question of the infectious group
of puerperal fever-cases in the following position :- Experiences occur-
ring clinically, as well as those produced upon animals, teach us that
certain lesions and symptoms, similar to those we are accustomed to re-
gard as characteristic of puerperal fever, result from Septic poisoning. In
a large class of cases, however, the connection between child-bed fever
and sepsis has been deduced rather from analogy than direct proof. For
those who chose to regard such as due to a specific poison peculiar to
the puerperal state, there was really no objection. If, however, round
bacteria are characteristic of septic poisoning, the question presents itself
in a different light, and we have to inquire whether, in the less obvious
cases, bacteria are present in puerperal fever in the proportions and
groupings that we find them in other diseases due to putrid infection.
Now it is precisely proof of this nature that has recently been abundantly
rendered.
Waldeyer,” Orth,” Heiberg, and Von Recklinghausen, found the
tissues and lymphatics of the parametria filled with pus-like masses,
which consisted, in addition to pus-cells, chiefly of bacteria. Bacteria
swarmed in the fluid of the peritoneal cavity. In one case examined by
Waldeyer, six hours after death, while the body was still warm, the
peritoneal exudation was like an emulsion, and furnished an abundant
deposit which consisted almost entirely of bacteria. Orth injected ten
minims of peritoneal fluid from a woman dead of puerperal fever into
the abdomen of a rabbit. As the animal was dying he broke up the
medulla oblongata, and found in the peritoneal fluid enormous quantities
of these organisms. In puerperal fever, round bacteria have been like-
wise found, though in less quantities, in the lymphatics of the dia-
phragm, and in the fluids of the pleura, the pericardium, and the ventri-
cles of the brain. In post-mortem examinations of fresh subjects, the
serous fluids, withdrawn under proper precautions, do not contain round
bacteria except in cases of septic infection.” Orth found in the purulent
contents of the vessels of the funis, in children who died of sepsis, pre-
cisely the same formations as existed in the exudations of the mother.
The presence of these germs in puerperal fever serves not only to fix
cases hitherto considered doubtful in the category of septic diseases, but
it affords the best explanation of the protean phenomena of puerperal
fever itself. Steurer, formerly interme at the Bellevue Hospital, where
he witnessed the epidemic which prevailed in that institution in the
year 1874, afterwards made, under the guidance of Prof. Von Reckling-
hausen, a special investigation of the pathological changes in a similar'
| Untersuchungen über die vegetaliens Formen von Coccobacteria septica; Berlin,
1874, S. 200.
* Ueber das Verkommen von Bacterien bei der diphtheritischen Form des puerperal Fie-
bers; Archiv für Gynaekologie, Bd. iii. S. 293.
3 Untersuchungen ueber puerperal Fieber; Virchow's Archiv, Bd. lviii. S. 437.
4 Die puerperalen und pyaemischen Processe ; Leipzig, 1873.
* Klebs. Beiträge zur Kenntniss der pathogenen Schistomycetin; Archiv für exp. Pa-
thol. und Pharmakol., Bd. iv. S. 441 u. ff.
840 LU S K,
epidemic which occurred in Strasbourg. From a written communication
received by me from Dr. Steurer, many of the following facts concerning
the pathogeny of the disease have been derived. These facts, I may add,
are fully supported by the investigations of others, and form a most
valuable contribution to our knowledge of puerperal fever.
Steurer's cases all presented diphtheritic patches about the vulva, or
upon the mucous membrane of the vagina and uterus. These patches
were always associated with a loss of substance, and were composed of
disintegrated fibrin, white and red blood-corpuscles, and colonies of round
bacteria in great abundance. From the patches, the bacteria could be
traced between the muscular fibres, and deep down into the canalicular
spaces of the connective tissue, where their presence gave rise to cellu-
litis. From the canalicular spaces they entered the lymphatics, with
resulting lymphangitis. In many cases the lymphatics could be traced
along the broad ligaments to the Ovaries (puerperal ovaritis), and into
the subperitoneal tissue of the lumbar region. Dy perforation of the
walls of the lymphatics which directly underlie the peritoneum, they
made their way into the peritoneal cavity and excited pyaemic peritonitis,
an affection which differs from traumatic peritonitis, and for which the
claim has been set up that it is peculiar to puerperal fever. The wide
stomata upon the abdominal surface of the diaphragm allowed the facile
entrance of the organisms into its lymphatics. Waldeyer found in dia-
phragmitis the lymphatics of the diaphragm filled with bacteria. And
thus following the lymphatic system, if we only admit that the round
bacteria are the carriers of sepsis, a fact which hardly admits of dispute,
the frequency, in severe types of puerperal fever, of inflammations of the
serous membranes—Of the peritoneum, the pleurae, the pericardium, and
the joints—finds an easy explanation. We can understand, too, how it
is not always altogether accident which determines in different cases
the precise serous membranes which are affected.
The ductus thoracicus is the principal channel through which the poi-
son enters the blood. Bacteria are not usually found in the blood during
life. A few hours after death they swarm in that fluid. Possibly the
rapidity of the blood-currents during life does not favor the multiplica-
tion of bacteria. That the bacteria do, however, enter the general cir-
culation during life, is incontestable. Steurer writes, “As the kidneys
are the great filters of the human system, I never neglected to examine
them, and almost invariably found the glomeruli and arterioli filled with
micrococci (round bacteria).” This is in correspondence with what oc-
curs in other septic diseases, and accounts for the albuminuria and inter-
stitial nephritis which often supervene in the advanced stages. We
have seen already that, in consequence of septic poisoning, the white
blood-globules have a tendency to adhere to the walls of the vessels.
This leads to stases in the capillaries, to congestion of the deep-seated
organs, and to an increase of blood in the large veins of the trunk.
Finally death takes place from apnoea, partly from the inability of the
blood-corpuscles to carry oxygen to the tissues, and partly from paralysis
of the respiratory nerve centres." Sometimes the bacteria pass directly
into the veins, where they give rise to phlebitis. Prof. Von Reckling-
hausen recognizes three ways in which this may take place : (1) Through
a thrombus; and here let me call to mind that it is very common in
| Wide Schüller, Exp. Beiträge zur Studium der septischen Infection. Deutsche Zeit-
schrift für Chirurgie, Bd. vi. Heft. 1 und 2, S. 149 u. ff.
PU E R P E R A L FE V E R . 841
uterine phlebitis to find the uterus large, and the vessels at the placental
site filled with soft thrombi; (2) through direct perforation of the
venous walls; (3) by being taken up by white corpuscles and by them
conveyed into the vessels in the manner described by Cohnheim.
When the bacteria enter directly into the circulation, they sometimes,
in passing through the heart, adhere to the endocardium and the valves,
causing exudation, ulceration, and decomposition, and thus give rise to
the so-called endocarditis ulcerosa puerperalis." In the cases studied by
Waldeyer and Steurer, there were diphtheritic patches, serving as the
starting points of the puerperal processes. Whether these so-called
diphtheritic patches are identical with those which appear in the throat,
is an open question. Morphologically, they are so, but, in hospitals,
epidemics of puerperal diphtheritis are not associated with throat diph-
theritis.
To avoid misapprehension, let me distinctly state that diphtheritic
patches are not necessary to the infectious form of puerperal fever. They
indicate an unwholesome atmospheric condition, and are somewhat rare
outside of public institutions. Orth and Heiberg noticed the same,
general, post-mortem changes in those cases in which the patches were
absent, as in those in which they were present. My own observations
show that they are rarely developed in the early stages of a hospital
epidemic of puerperal fever, nor are they to be found in all cases when
such an epidemic is at its height. In some of the lying-in hospitals in
Europe, puerperal diphtheritis appears, however, to be endemic.
The question as to the extent to which erysipelas and puerperal fever
are cognate diseases, is in a fair way to be solved by recent investigation.
Orth took the contents of a vesicle, from an erysipelatous patient, which
contained bacteria in great abundance, and employed the same for injec-
tions under the skin of rabbits. In this way he succeeded in producing
in these animals a species of erysipelas malignum. In the subcutaneous
Oedema, and affected portions of the skin, he found enormous masses of
bacteria, so far exceeding in quantity the amount introduced as to prove
an abundant new production.” Samuel produced similar results by the
injection of ordinary putrid fluids containing round bacteria. An affec-
tion resembling simple erysipelas he obtained most frequently by the
application of fluid to a wound torn open after the second or third day.”
Lukowski found that erysipelas could be produced by fluid containing
micrococci even when putrefaction did not exist. The contents of erysi-
pelatous vesicles containing no micrococci, excited no morbid manifesta-
tions. Where the erysipelatous process was fresh and progressing, micro-
cocci were found in great abundance in the lymphatics and canalicular
spaces. Where the process was retrogressive, there were no micrococci
to be found, even in cases in which inflammation existed to an intense
degree.* Virchow's testimony we have already given.
Thus we find in surgical fever, in puerperal fever, in diphtheria, and
in erysipelas, the presence of a common element which links them
together, and which establishes the relationship which has long been
recognized as existing between these various processes. Experiments
made by competent men, with care and intelligence, serve continually
| Heiberg, Die puerperalen und pyacmischen Processe; Leipzig, 1873, S. 22 und 34.
Gives references to cases reported by Wirge and Eberth.
* Untersuchungen über Erysipel. ; Arch. für exp. Pathol, und Pharmakol., Bd. i. S. 81.
3 Arch. für exp. Path. und Pharmak., Bd. i. S. 335 u. ff.
* Untersuchungen über Erysipel. ; Virchow's Archiv, Bd. lx. S. 430.
*
842 LU S K,
to increase the probability that the bacteria are no chance products, but
that they have a vital connection with the diseases designated. Whether
these organisms are identical in the different infectious diseases in which
they have been recognized, is another question. Billroth complains of
the monotonous appearance of always the same forms." When we bear
in mind, however, that our best instruments fail to enable us to distin-
guish the ovum which is to produce a mouse from one that will produce
a tiger, though the ovum is at least one hundred times larger than the
micrococcus, the argument loses something of its value. Whether iden-
tical or not, they all possess the common property of penetrating the
tissues, under favorable conditions, of multiplying, and of producing, by
their migrations, local inflammations and general infection.
I cannot refrain, in conclusion, from quoting entire the following state-
ment of Panum, which appears to reconcile certain differences in the
definitions of the term septicæmia by different authors:—
“The putrid poison may, during life, enter the blood with or without bacteria,
especially from wounds, and occasion all the symptoms of Septic poisoning,
whereas, however, the bacterium termo does not appear to occur in the blood
during life. This simple putrid infection does not appear to be inoculable.
Another, as it appears, distinct, specific, pathogenic fungus, the microsporon
septicum of Klebs, developed especially in pus (and blood 7), perhaps under
the predisposing influence of the putrid poison, when the air (as in overcrowded
hospitals) contains the latter, or when it is transferred by inoculation, seems
on the other hand during life to increase in the blood and tissues, and, in part
perhaps, by production of a special poison, in part, perhaps, in a more
mechanical way, by penetration, and, under circumstances by its irritative
action on the tissues, excites inflammation, purulence, and fever.”
CAUSEs OF PUERPERAL FEVER.
The Atmosphere.—The effect of a poisoned state of the atmosphere
is best observed in the so-called nosocomial malaria of hospitals. At
Bellevue I have had frequent occasion to witness febrile outbreaks among
the patients in the lying-in service, which were instantaneously arrested
by closing the tainted ward and transferring the inmates to a healthy
locality. As at these times the nurses, the bedding, and the utensils,
remained unchanged, it is fair to assume that the previous, unhealthy
condition was not due to the transfer of a poison from patient to patient
by the attendants, but to something residing in the air of the vacated
apartment. In the inquiry as to the production of this condition, it can
be assumed that it is not caused by aggregation alone. The medical
wards of Bellevue, always crowded, have been in time of need safe recep-
tacles for lying-in patients. It certainly is not due to the presence in
excess of what are generally regarded as the ordinary constituents of the
atmosphere. We must, therefore, look for some additional element
capable of unfavorably affecting the economy. When the disturbance
produced by nosocomial malaria is not arrested by change of locality, and
the golden moment is allowed to slip by, the secretions of the patients
affected become inoculable. Under such circumstances the epidemic
spreads rapidly, and assumes continuously a more and more severe type.
| Untersuchungen über die Coccobacteria septica, S. 3.
* Das putride Gift., etc., Virchow's Archiv, Band lx. S. 349. I have translated literally.
The meaning of the sentences, in spite of the involved construction, is sufficiently clear.
PU E R P E R A I, FE V F. R. 843
If, during such an epidemic, the external genitals be carefully watched,
diphtheritic patches may now and then be observed. At first these
patches may not be of any special clinical importance. It is possible that
they may rapidly clear off, and thus come to be regarded as of little con-
sequence. When, at length, the epidemic has assumed a pestilential
form, these patches, which may make their appearance in isolated cases
at any time in a hospital, are rarely absent. I have already dwelt upon
the composition of these patches, not because I believe that they are
essential to puerperal fever, but because their presence tells the tale of
what it is in the atmosphere which accomplishes the charnel-house work.
Conditions have been present in the air to favor the multiplication of
bacteria, and have fitted them to become the active producers of disease.
Can we doubt this? First, the epidemic was mild. If a patient, how-
ever, died, her tissues and secretions were filled with bacteria, as has
been described. Then the epidemic became viruleut, and the lesions of
the generative apparatus, especially of the external organs which were
most exposed to the air, became covered with patches which were found
to swarm with micrococci. I cannot, under the conditions named, but
consider it more in accordance with ordinary scientific reasoning to con-
clude that the micrococci played an important part in the production of
puerperal fever, than that the puerperal fever produced the micrococci.
To be sure, bacteria or their spores are always present in the atmosphere,
and it may be fairly asked how patients are ever spared from their per-
verse industry. The answer is that they are not always equally active
for evil. Bucholz found that the same bacteria, developed in Cohn's
fluid, offered more resistance to carbolic and salicylic acids than those
cultivated in an analogous fluid which he had adopted. Distilled water
renders the action of bacteria extremely feeble. In experiments upon
animals, the results obtained with septic fluids depend in no ordinary
degree upon the age of the fluid, the material from which it is formed,
and the conditions under which it is generated. Micrococci multiply in
hospitals when organic materials favorable to their growth are present in
sufficient quantities. Robin and others have demonstrated the existence
of albuminoid matters in water condensed upon vessels containing freezing
mixtures, and placed in overcrowded wards of hospitals. When the
results of crowding become manifest, these albuminoid matters not only
impart a peculiar fetid odor and putrefy with great rapidity, but rapidly
impart putrefaction to normal blood and healthy muscle with which they
are brought in contact." Micrococci both cause putrefaction, and serve
as the carriers of septic virus. IIueter found putrid blood a most favor-
able fluid for septic experiments. It was noticeable in Bellevue Hospital
that febrile outbreaks always arose in, and were usually confined to, the
ward in the hospital which, by a bad arrangement, was assigned to
patients for the first four or five days following confinement, i. e., during
the period of the lochia cruenta. As puerperal fever is rare after the
fifth day, this at first sight would seem natural. But if a patient was
transferred directly after confinement, during one of these unhealthy
periods, to the ward containing the patients who had passed the first five
days, but had not completed the ten days, she would escape the fever.
It was always the same ward that required to be disinfected. In a com-
municating apartment all the confinements took place ; and at all times,
therefore, the conditions were present for loading the atmosphere with
* Leçons sur les Humeurs; Paris, 1867, p. 195.
84.4 LU S K,
the products of decomposing blood. In the summer months, as long as
the windows were open all the time, the patients enjoyed immunity from
nosocomial malaria. In the early fall, as soon as it became necessary to
close the windows partially on account of the cool nights, it was not
uncommon for the more trivial disturbances, such as so-called milk-fever,
the hospital pulse, and catarrhal affections of the genitalia, to manifest
themselves. Through the months of February, March, and April, the
mortality was usually greatest. During the winter months there was,
as a rule, crowding of patients, insufficient ventilation, the saturation of
the air with albuminoid materials chiefly derived from blood, which,
under the furthering influence of the heat requisite to make the wards
comfortable, entered readily into decomposition. That the latter winter
months should prove the most perilous, is in accordance not only with
the theory of continuous accumulation, but with the experimental fact
that weeks sometimes elapse before a decomposing substance acquires the
highest degree of virulence.
Apart from the nosocomial malaria of hospitals, there is reason to be-
lieve in the influence at times of certain general wide-spread atmospheric
states which affect the entire community. In the year 1871, the mor-
tality from child-bed in New York was 399; in 1872, 503; in 1873, 431;
in 1874, 439, and in 1875, 420. Now the excess in the deaths for 1872
was due wholly to an increase in the cases of metria, those from ordi-
nary accidents remaining nearly the same as in the preceding years. The
disease certainly did not extend into the city from the hospitals serving
as foci, for the mortality that year at Bellevue Hospital was hardly more
than half the usual average. There was no especial mortality that year
from either diphtheria, erysipelas, or scarlatina, but the aggregate mor-
tality was the largest known in the history of the city. There are no
positive data connecting the civil deaths from puerperal fever in 1872
with parasiticism, but the prevalence of epizootics, of epidemic catarrhal
affections, of peculiarly fatal forms of pneumonia, and other diseases
which are now attributed to the presence of minute organisms in the
atmosphere, renders such a source highly probable.
It is proper to say here that, though the argument is very strong in
favor of regarding the genitalia of puerperal women as the exclusive
point of entry into the system of infectious materials, it seems impossible
at the present time to make all the facts coincide with such a theory.
I have the records of a number of cases occurring during an epidemic of
puerperal fever, in which patients were either attacked with fever pre-
vious to parturition, or in whose cases the unusual length of labor, the
frequency of post-partum hemorrhage, and the imperfect contraction of
the uterus, immediately after confinement, were signs of some abnormal
influence exercised upon the economy at an early period of labor, pre-
vious to the existence of traumatism. That deleterious materials may
find other channels for entering the system than a wounded surface, is
evidenced by the cachectic condition not unfrequently produced in phy-
sicians by too assiduous attendance in dissecting-rooms and places in
which post-mortem examinations are conducted. One severe and rapidly
fatal case of puerperal fever, which occurred in Bellevue Hospital, I find
it impossible to attribute to any other cause than that the woman, for
five months previous to her confinement, served as a helper in a lying.in
ward. The post-mortem examination disclosed no special local lesions,
but her symptoms were those of intense septicæmia. It does not yet
seem quite time to give up the idea that, under exceptional circum-
PU E R P E R A L FE V E R . 845
stances, the respiratory, and probably the digestive, tracts, may allow
the passage of materials of a septic character.
Inoculation.—r Another and frequent source of puerperal fever is by
direct inoculation. Any material of a septic character, introduced into
the genital passages of a woman during or after confinement, may pro-
duce a general infection of the system. But the point upon which I
wish especially to dwell is that it is possible to trace epidemics of puer-
peral fever directly to carrying puerperal poison from patient to patient,
through the medium of attendants. In such cases, changes in wards
and the most rigid sanitary precautions avail but little, as long as the
affected personnel is continued in charge. Unless this fact is fully
recognized, all the cleverest devices in hospital construction will fail to
prevent the occurrence of disasters. In epidemics this source of danger is
especially to be guarded against, as septic poison is increased in intensity
by successive inoculations. Davaine' showed that when a number of
animals were poisoned, the one from the other, while from ten to fifteen
drops of putrid blood were required to produce death in the first animal,
one ten-trillionth part of a drop was sufficient in the twenty-fifth animal
of the series, and in puerperal fever epidemics a similar augmentation in
the deadliness of the poisons generated by patients is observed.
The nurses in hospitals and in private practice are usually the carriers
of contagion. In studying the records of New York City for nine
years, I find, however, that the occurrence of two deaths from puerperal
disease, following one another so closely as to lead to the suspicion of
inoculation, occurred to thirty physicians; a sequence of three cases oc-
curred in the practice of three physicians; one physician lost three cases,
and afterwards two, in succession ; one physician had once two deaths,
once three deaths, and twice four deaths following one another; finally,
a physician reported once a loss of two cases near together, then of six
patients in six months, and then of six patients in six weeks. Thus in
the practice of more than 1200 physicians, in nine years, I find, exclud-
ing cases occurring in hospitals, that the experience of thirty-six only
lends color to the idea that puerperal fever is due to criminal neglect on
the part of the medical profession. Undoubtedly in many of these cases,
too, the responsibility is only apparent, as when a practitioner has, for
example, had the misfortune to lose in one week a woman from puerpe-
ral convulsions, and another in the following week from placental hem-
orrhage. Singularly enough, not one of the sequences mentioned oc-
curred in the practice of a physician connected with a lying-in hospital.
In face of the charge that the physicians holding obstetrical appoint-
ments in public institutions are active disseminators of puerperal fever
through populous communities, I find that the total loss from all puer-
peral causes occurring in the private practice of ten physicians intimately
associated with such institutions, numbered, during the nine years, but
twenty-one cases. Of these, thirteen were the result of ordinary accidents,
and only eight cases of metria proper, of which one was developed before
the physician was called in attendance; whereas a single physician, hold-
ing no hospital appointment, lost during the same time twenty-seven
cases, of which twenty-one were cases of metria.
I have been interested in endeavoring to ascertain how far experience
corresponds with Semelweiss's theory that puerperal fever owes its origin
to poisonous materials obtained from dissecting-rooms, and introduced into
* Report before the Académie de Médecine, Sept. 17, 1872.
846 LU S K,
the genital canal by the hands of physicians attending cases of labor.
With this view I have made personal application to a number of gentle-
men who have engaged in midwifery, practice while performing the
functions of demonstrators of anatomy in our medical schools. Dr. H.
T}. Sands, of the College of Physicians and Surgeons, reports that in the
five years during which he held the office of demonstrator, he attended
about sixty cases of labor. All did well. IIe lost his first patient, from
child-bed, a short time after he had resigned his position in the dissect-
ing-room. Dr. J. W. Wright, the present Professor of Obstetries in the
Medical Department of the New York University, who held for one year
the position of Demonstrator in the Woman’s College, writes me that “dur-
ing the year, I attended one hundred and four cases, including twenty-two
forceps cases, two of craniotomy, two of podalic version, and four of
breech presentation. Of this number I lost two cases, one from phleg-
masia dolens complicating uraemia, from both of which troubles the
patient had suffered during her previous labor, and one from double pneu-
monia, the result of unusual exposure following confinement. Out of
these one hundred and four cases, I can recall but three or four cases of
metritis, and those of a mild character; I have never thought they had
any special connection with my duties in the dissecting-room. I may
add that for ten years I have attended a pretty large number of confine-
ments each year, and that during the whole of this time I have been in
the habit of making autopsies as occasion has offered, and of handling
and examining pathological specimens both in and out of the dissecting-
room, notwithstanding which, my death record among this class of cases
has been unusually low.” Dr. Samuel B. Ward, formerly Demonstrator
at the Woman’s College, at present Professor of Surgery in the Medical
School at Albany, writes: “While I was daily in the dissecting-room,
during the winter sessions of the school from 1868 to 1872, I attended
thirty-two confinements of which I have notes. All of the patients
recovered, nor did any of them suffer from any complication that could
be traced to infection.” It is familiarly known that after Semelweiss had
introduced the practice, among the physicians attending patients at the
large lying-in hospital in Vienna, of washing the hands in a solution
of chloride of lime, there was a great diminution in the mortality
which prevailed, notwithstanding which, G. Braun reports, however, that
in 1857, in the month of July, in two hundred and forty-five deliveries
there were seventeen deaths. The following month, Prof. Klein gave
orders to suspend the use of disinfectants. By chance, in August there
were only six deaths out of two hundred and fifty confinements, and in
September, of two hundred and seventy-five patients, none died. From
1857 to 1860, the mortality was slight, though disinfectants were not
used, while during the three following years, in spite of the systematic
and persistent employment of these agents, the death-rate once more
assumed formidable proportions."
Of course I do not wish to underrate the importance of Semelweiss's
lai)ors. There is no question but that it is a perilous experiment to pass
from the dissecting-room to a patient in labor, without employing rigor-
ous measures to disinfect the hands and all parts of the person brought
into contact with the dead body. But it is well to call attention to the
fact that puerperal fever is not due to any single, simple cause, nor is to
! Rückblicke auf die Gesundheits Verhältnisse unter den Wöchnerinnen, u. s. W., S. 32,
33. -
PU E R P E R A L FE W E R . 847
be effectually guarded against by a single precaution ; and again that
cadaveric poison does not of necessity exist in every cadaver examined.
Haussmann found that injections into the vagina of gravid rabbits, in
the latter half of pregnancy, of serum from the corpse of a person not
dying of septicæmia, produced no fatal results, while rapid death resulted
from injections, under the same conditions, of pus from the abdomen
of a woman dying from puerperal infectious disease."
TABLE II – Deaths occurring in New York, between the years 1867 and 1875,
inclusive, from metria, eaccluding other causes, which proved fatal during
the puerperal period.
Total || Tota.1
deaths from
Year. Jan. Feb. Mar. April May. |June. July. Aug. Sept.' Oct. Nov. Dec frolin all
| . metria. I causes.
- -
––––––––– -----
1867 15 10: 14 16 12 || 5 || 6 || 8 || 5 || 5 || 9 || | 120 || 238
1868 |}} 14 27 16 18 || 9 || 12 8 || 7 || 3 || 8 || 12 151 267
1869 25 25 18 10 | 15 14 | 12 15 || 8 || 12 16 19 190 || 312
187 () 12 17 37 27 20 10 | 12 | 16 || 10 | 12 11 17 | 201 || 333
1871 21 30 22 25 26 17 | | | | 13 || 7 || 7 | 12 23 214 || 399
1872 26 37 41 40 27 21 14 24 || 13 14 18 32 307 || 503
1873 . . . 33 40 32 39 29 22 | 16 15 13 || 1 | 23 2 | #35 | #3.
1874 . . . . 19 32 24 33 34 21 18 15 10 || 7 || 7 25 | 245 || 439
1875 28 28 40 30 22 17 10 10 || 5 | 11 14 19 234 420
––––––––––––
|
Total 19, 21, 2% ºf 208 136 || | | | 124 78 tº his is 1947 || 3342
Season of Year.—I have in a special table (Table II.) classified all the
deaths from metria in New York, during nine years, according to the
months in which they occurred, and from this it appears that more than
twice as many deaths took place between the six months from December
to May inclusive, as between the six months from June to November
inclusive. The greatest mortality occurred in February and March,
amounting to 499 cases, or rather more than one-fourth of the entire
number. The smallest death-rate occurred in September and October, in
which months but 150 deaths, or one-thirteenth of the entire number,
took place.
| Untersuchungen und versuche tiber die Entstehung der übertragbaren Krankheiten
des Wochenbettes; Beiträge zur Geburtshilfe und Gynākologie, Bd. iii, Heft 3, S. 374,
u. ff.
848 LU S K,
TABLE III.-Deaths from puerperal causes in the different city wards
of New York.

i | | y | -
| I. II. III IV. v. vſ. VII. VIII. Ix. X. XI. XII. XIII.
~. i –––––––––– –
1S67 4 () () } () 6 3 7 17 4 15 2 13 2
1S6S 4 1 1 12 3 4 9 II. 9 S 8 2S 7
1869 7 0 () O 4- 5 20 24 S 19 || 13 20 16
1870 4 () J. 5 6 5 6 20 4 19 13 21 16
1S7] . | 6 || 2 || 4 4 S 3 || 17 | 17 | 11 21 21 27 1()
| | | .
1 S72 6 1 4 5 4 11 13 19 I () 26 14 47 11
|
1S73 S () 2 5 4 12 12 19 S 20 14 40 14
1S74 7 () I 7 7 14 14 26 S 23 11 24 13
1S75 9 2 2 3 4 7 | 17 | 14 | 13 | 17 20 25 is
Total . . . 55 6 15 56 44 64 || 115 167 75 16s 116 245 107
|
Estilnated number of |
births" . . . . 4284 387 1089 7053 5049 6237 |12,85510,395 14,137|12,325||18,975 |14,107, 980s
—
Ratio of deaths to |
births - • - | : 7S 1 : 64.5 1 : 72 || 1 : 126 1 : 115; 1: 97.5|1 : 112 1 : 62 1 : 1 SS| 1 : 73|1:163.5| 1 : * 1 : {}2
| ! , i -
XIV. XV. XVI, XVII. XVIII. XIX. XX, XXI. XXII. XXIII, XXIV. Total.
t i |
1S67 . . . . 9 9 || 8 3S 15 22 1S 24 12 ... 23S
|
1S68 . . . 7 5 6 32 18 17 21 35 2] 267
|
1S69 . . . 10 4 9 33 21 || 37 ! 22 27 10 - ! 312
i
1S70 . . . . 2 5 9 41 2S | 34 19 53 22 . | 333
1871 S 6 B S 4t 21 38 37 54 2.5 395
1872 . . . ; 14 11 23 45 24 i sã 45 43 42 .... . .... 503
- | .
1S73 & 5 7 | 14 40 24 51 40 54 3S ... 431
1S74 7 6 20 36 S 56 39 66 34 12 4:39
1S75 T 4 || 12 IS 51 27 53 19 30 39 5 | 1 || 420
| | | |
Total . . . . 76 65 125 357 is8 393 260 386 243 17 I 3342
| | – -
i --
Estimated number of | | | i
births" . . . . 7850 S197 14,363. 28,323 17,701 25,542 22,394 16,840 21,191
—— –––– --

Ratio of deaths to
births * . 1 : 103 1: 1261 : 113 1: 79
i |
}
1 The twelfth ward includes Ward's Island Hospital and the Colored Home, which furnished together 102
deaths ; died ucting these the ratio would be 1 : 99.
2 The nineteenth ward contains the Nursery and Child’s Hospital and the Charity Hospital, which furnished
together S3 deaths; deducting these the ratio would become 1 : S2.
3 Includes 189 cases from Bellevue Hospital, deducting which the ratio would become 1 : S5.
* The number of births in each ward is roughly estimated by assuming the population of 1870 to be the
average of the nine years, and then allowing 33 births to the thousand. This method makes no pretence to
accuracy, but it is not likely that exact returns would materially alter the relative proportions given. It
furnish is a total of 279,000, or 5000 less than that obtained by assuming an annual increase of 15,000 to the
entire population of the city.
1 : 95
1 : 65 1 : S6 (1:45.6 1 : S7
l | t - |
Influence of Locality.—I have likewise prepared a table showing the
number of deaths from puerperal causes occurring in each year in the
several wards into which the city is divided, and the ratio of deaths to
PU E R P E R A T, FIE W E R . 849
the estimated number of births in each ward. The average ratio is, as
has been already stated, about 1 to 85. In the 9th Ward, however, it
was 1 to 188; in the 11th Ward, 1 to 163.5 ; and in the 15th Ward, 1 to
126. These wards make the most favorable showing in the city. Dy
reference to the map, they are all found to occupy the same territorial zone.
In the 17th Ward, situated between the 11th and 15th Wards, the ratio
of deaths to births, it is true, was 1 to 79; but the 17th Ward is the
most densely populated section of the city. As neither the 9th nor the
11th Wards are otherwise especially favored, both containing a large and
crowded tenement-house population, it is.hard to understand their rela-
tive immunity from deaths due to puerperal diseases, unless upon the as-
Sumption that local causes, probably superior drainage, render them
exceptionally free from endemic sources of disease.
TABLE IV.- Deaths from puerperal causes in the 18th, 19th, and 21st wards,
with the relative proportion of deaths, not occurring in Hospitals, among the
population east and west of Third Avenue.
| Deaths upon Deaths upon | Relative proportion of
Died in the west side the east side deaths on west au (1 east
Year. | Total. hospital. of Third of Third side, expressed in
| Avenue. A well lit. pºrce II tag es.
1867 e & - 6]. 20 8 33 24 per cent.
1868 * º 7() 28 8 34 23.5 4 *
1869 | 85 23 12 5() 24 * {
1870 . . . . 115 34 9 72 12.5 “
1871 * º . 113 32 15 66 22.7 § {
187 - e e 173 43 10 120 8.3 & 4
| S73 º º º | 29 37 | 5 77 19.5 4 &
1874 - iſe - 130 45 14 71 19.7 { {
1875 -> g - 110 15 8 87 9.2 { {
Aggregate . - 986 277 | 99 610 16.2 & 8
Social State.—I have, too, sought to ascertain whether the wealthy and
well-to-do classes enjoy special immunities from puerperal disease. The
district bounded by Fourth and Sixth Avenues, and Twelfth and Fifty-
ninth Streets, contains the great proportion of those who make up the
privileged classes. In this portion of the city, the proportion of deaths
from puerperal causes to the deaths from the same sources throughout
the city, is as 1 to 43. The precise population of the district I cannot
obtain, but it is safe to say that it contains at least one-thirtieth of the
entire population of the city.
The eighteenth, nineteenth, and twenty-first wards, included between
Sixth Avenue and the East River, and extending from Fourteenth to
Bighty-sixth Streets, contain in a marked degree the two extremes of
wealth and poverty. Third Avenue separates the territory into two
equal parts, and forms a fair dividing line between the upper and the
lower social strata. The population upon the west side of Third Ave-
nue is, it is true, less than that upon the east side,' possibly not more
than half as great, but the mortality of nine years from puerperal causes
was in this favored region less than one-sixth, even after deducting
i I am informed by politicians that the vote in the ward mentioned is about 50 per cent.
larger on the east side of Third Avenue.
54
850
LU S K,
deaths occurring in hospitals, which for the most part lie upon the east
side. In 1872, the fatal year, the propoltion was one to twelve.
TABLE V.—Deaths from scarlatina, diphtheria, and erysipelas, and from all
causes, by quarters, compared with deaths from metria, for the mine years
ending December 31, 1875.
1S67. I S6S. 1869.
| - ~ ------sº
. | g * i
# 3
('a uses of , ºf ! = | i º -
death. # : s — # & 3 3 . £ 3 & 3 -
| = | # # | | | | | | | | |
# | = | 7 | > || “. -->
| *- CŞı tº -* * r— | CN * + | t- r—t CŞı co ~H t-
scarlatina 264 194 so 103 || 650 31s 351 102 90 SG | 200 2S5 159 223 966
| | |
Diphtherial 79 56 53 63 || 251 92 si 43 55 277 | S7 | S9 66 S6 || 32S
Erysipelas 40 32 20 22 || 114 || 31 45 13 || 13 102 || 54 55 | 1.4 29 152
All causes 5197 512 1516 5325 |23,15, 5953 5523 S65s 4755 24,ssol 5919 6065 7300 5793 25,167
| |
Metrº … … º 120 tº e º 'º gº è º e 151 … 10
1 S70. I S71. IS72
– ... . . | | |
3. : 3. 25 |
Causes of † º º
death. | g *º s: * * , à | * S: s: te : J. s: & .
} == | º: > º * ! º:
| + | | 3 | + | e +: | º
| f ci cº + É * CŞı cry *H E- #. st cº *H H
. . . —- —— ------> : ------- I -------------- ---------- - , --— --——
| | } | :
Scarlatina 41S 258 105 193 975 274 196 || 137 ISA 791 301 367 132 180 990
I) inh therial 94 | 69 67 || 7S 30S S9 49 || 46 54 || 23S | 93 S6 S7 1S0 4.46
Erysipelas 50 42 4 25 | 2] 54 | }{} 1S 23 145 64 73 23 25 lS5
tº, | | - |
All causes 65.17 6293 $416 5949 27,175 0622 6621 7833 5000 26,976, 7406 $737 º 6479 32,647
t | } - | i ; *
Metria . . . . . . . . . . . . . . & ... . . . . . . . . . 2i + j . . . . … . . . . . ºf
| ! | t | |
| I S73 1ST 4 1S75.
} } - - - - - -
-- | | | | | | | | = | | | |
('a uses of + } ; : +. | }
death. : . §: * . . ; 3 : & & — à J. l * –
| | | | | | | | | | | | | | : #
→ C +: º +:
# cºl e-N + E- f ci sº + = à CŞı cºy + É
--- - - -------> ----------- --- | -------- ! —
| |
! .
Scarlatina | 242 275 202 326 1045 322 230 166 152 S79 1S6 161 63 104 514
i i | i | |
Diphtheria. 169 184 || 316 4S2 1151 334 314 320 697 1665 60s 549 || 489 683 2329
* | | |
Bºº S3 60 || 30 31 | 204 || 49 62 25 33 169 | 66 51 21 2.) 167
All causes GS15 6583 sos3 0703'29,0sq 032s 654s sooo 7342 2s, 27 isł0 | 7065 9257 6547 30,709
| a - | { - :
Metria, . . . . . . . . . . . . . . . 2S5 . . . . . . . . . . . | . . . . 245 º . . . . . 234
Relations to Zymotic Diseases.—I prepared, some time ago, tables to
answer the inquiry as to whether there was any relation between the fre-
quency of cases of scarlatina, diphtheria, and erysipelas, and those from
metria proper.
Previous to their publication, however, I was anticipated
in my deductions by a paper upon the same subject by Dr. Matthews
Duncan."
I therefore simply submit the tables with the comment that
1 On the alleged Occasional Epidemic Prevalence of Puerperal Pya-mia, or Puerperal
Fever, and Erysipelas; Edinburgh Medical Journal, March, 1876, p. 774.
PU E R P E R A L F E W E R . 851
they show no relation to exist between the statistical frequency of puer-
peral fever and the zymotic diseases mentioned. The tables do not, how-
ever, invalidate any direct testimony which goes to show that, in indi-
vidual instances, a real connection between puerperal fever and the
Zymotic diseases may exist.
PREVENTION OF PUERPERAL FEVER.
Of the 3342 deaths from puerperal causes, 420 died in hospital, or one-
eighth of the entire number. Of the 1947 cases of metria, about 300, or not
quite one-sixth, were contributed by the hospitals. Upon such a showing
the first impulse would be to cry out loudly for the suppression of materni-
ties. But a wiser policy suggests the inquiry whether the large mortality
in hospitals is an evil necessity. To this the answer is “ No.” It is pos-
sible, in the present state of our scientific knowledge, to so control the
conditions that favor the generation of puerperal diseases in large hos-
pitals, as to make them safe asylums for the needy.
Thus in the Charity Hospital, Dr. Kitching reports the number of con-
finements between July 1, 1874, and May 1, 1876, at 1149; of which
20 ended in death, or 1 in 57. But only six were cases of metria, or 1
in 191 deliveries, a better record than that afforded by the average of the
city at large. In the Nursery and Child’s Hospital, there was but one
death from metria in 1874, and one in 1875. In 1872, the number of
confinements was 205. I regret that a request for the number of confine-
ments in the succeeding years has been refused me. The Marion Street
Lying-in Asylum, an excellent institution for married women, reports
two deaths from metria in nine years. Dr. Goodell reports that, at the
Preston Retreat, in 756 cases of labor there have been but two deaths from
Septic disease; Winckel,' of the Lying-in Institution in Dresden, reported,
in 1873, eighteen deaths from metria, or 1.8 per cent., but from the 10th
of January to the 7th of July, in 570 deliveries there was but one case of
septic disease; in the year 1872 the death-rate exceeded 5 per cent. The
reduction in the in Ortality was no fortuitous circumstance, but was due to
rigid measures for the prevention of disease.” Stadfeldt reduced the mor-
tality from puerperal fever, in the Maternity Hospital of Copenhagen, from
1 in 37, the proportion between the years 1865 and 1869, to 1 in 87, between
the years 1870 and 1874.” Dr. Johnston reports in the Rotunda Hospital
of Dublin, during seven years, 7860 deliveries (I have excluded the cases
of abortion) with 169 deaths, of which 85, or 1 in 91, were from metria.”
I’rof. J. J. Bischoff reports that in the Maternity of Basel, between the
years 1862 and 1867 inclusive, in 514 confinements there were 33 deaths,
or in about the proportion of one to sixteen. In 1868, of 75 patients
confined, there died three, or one in twenty-five. In 1869, of 86 patients
confined, seven died, or one in twelve. In 1870 effective measures of
prevention were introduced, and, that year, in 80 confinements there were
no deaths.” In 1871, two out of 124 patients died, or one in sixty-two.
In 1872, in 153 confinements there were four deaths, a proportion of one
| On the Means employed at the Preston Retreat for the Prevention and Treatment of
Puerperal Diseases, p. 13.
* Berichte und Studien, u. s. W., Leipzig, 1874. S. 183.
* Les Maternités, leur Organisation et Administration; Copenhague, 1876.
* Series of Clinical Reports, from 1870 to 1876 inclusive.
* J. J. Bischoff, Zur Prophylaxis des puerperal Fiebers; Basel, 1876, S. 12, 13.
852 LU S K,
to nearly forty. The next year, 1873, strict measures were again put
in force, and in 184 labors there were two deaths, or one in ninety-two.
In 1874, in 214 labors there were three deaths, one to seventy-one, but
one of the patients entered the hospital with endocarditis, of which
affection she died. In 1875, in 204 confinements there were two deaths,
one from hemorrhage, and one from pyelitis which existed at the time
the patient entered the hospital.
Surely these figures do not support the idea that it is better for a
woman to be confined in a street gutter than to enter the portals of a
lying-in asylum. Dr. Goodell’s experience shows that a hospital for re-
spectable married women may be so conducted that its inmates may
enjoy absolutely a greater degree of safety than do women in their homes,
surrounded by all the aids that wealth can command. Equally good
results are not to be obtained in hospitals which are open to unfortunates
of every class. But there is much misapprehension and confusion of
ideas respecting the fate of these women, when no charitable provision
is made for them. In Copenhagen, the Maternity IIospital is closed for
from six to eight weeks in the summer time. During this period, un-
married, parturient women receive pecuniary assistance from the hospital
to enable them to obtain a place in which to be confined. Now Stadfeldt
reports a larger mortality among this class than among those delivered
in the hospital. Yet they are confined at a favorable season of the year,
without any communication with the furniture, the sage:femmes, or the
physicians of the hospital. As they fortunately receive nothing but
money, that can hardly be suspected of communicating contagion.
What their fate would be in New York City, perhaps, may be judged
from the following facts: Excluding cases confined in hospitals, nearly
one-thirtieth of all the deaths and one-twenty-fourth of the cases of
metria are reported by four practitioners. Ten practitioners out of 1200
signed the death certificates of one-fifteenth of the women dying from
puerperal causes, and one-tenth of the cases of metria. But it is not to
be supposed that these deaths were all the result of malpractice and in-
competence. The true history of most of them probably was that the
doctor was engaged to attend the case of confinement for a small fee,
with the understanding that he should make no calls subsequently, unless
specially summoned by the friends of the patient. The latter, left to
ignorant care, or perhaps without any assistance whatever, and exposed
to all the pernicious influences bred by poverty, when illness supervened
probably did not call the physician to her aid until the time for help had
passed, so that in the end his professional functions were confined to pro-
curing the requisite permit for burial.
Humanity demands that charity should furnish places of refuge in
which poor outcasts can receive assistance during the perils of child-
bearing. If we must then have maternities, we should make them safe,
and this can be in great measure accomplished by remembering the two-
fold source of danger arising from a poisoned atmosphere and direct inocu-
lation. A hospital must be clean, spacious, and well ventilated, or its
atmosphere will become charged with decomposing albuminoid sub-
stances, and produce nosocomial malaria. But the experience of the
Hôpital Cochin,' a costly, palace-like structure, with every appliance of
art, proves that fresh air alone does not protect patients from the conse-
quences of inoculation. On the other hand, the most rigid sanitary pre-
| Billet, Réforme des Maternités, p. 75.
Pl] E R P E R A. L. F. E. W. E. R. - 853
cautions observed by the attendants will not prevent a badly ventilated
ward from becoming unhealthy, unless unoccupied wards are kept to
which patients can be transferred upon the first admonition of danger.
At the Charity Hospital, the service consists of two large wards, occu-
pied for three weeks at a time alternately. Dr. Goodell states that at
the Preston Retreat the wards are used invariably in rotation. In con-
nection with the Maternity at Copenhagen, there are a number of small
supplementary hospitals scattered through the city, which serve as safety-
valves for the central institution. Artificial methods of ventilation
render the task of keeping the wards healthy, comparatively easy. They
do not need, however, to be complicated and expensive. The good re-
pute of the Rotunda Hospital, it seems to me, is in large measure due to
the natural ventilation afforded by open fireplaces.
The testimony is very general to the advantages of frequently washing
the wards with carbolic acid. At the Charity IIospital, in addition, the
wards are fumigated three times a week by burning a mixture of carbolic
acid, chloride of lime, and sulphur. During parturition, Stadfeldt ex-
poses the woman to a fine spray of carbolic acid. If, after confinement,
vaginal washes of carbolic acid should be used, every woman should be
supplied with her own nozzle, which can be made of glass tubing, and
attached in turn to the irrigator. When not in use, these should be
kept in solutions of carbolic acid.
A liberal supply of metallic catheters should be always kept on hand
and, when not in use, placed in a disinfectant fluid. Sponges, in a hospi-
tal, are an abomination. Oakum, lint, or old cloths should be employed
to receive the discharges, and, when removed, should be placed at once
in a vessel containing disinfectants, and then, instead of going into the
washtub, should be burned. As regards all prophylactic measures, cheap-
ness is not to be consulted.
As puerperal patients require much attention, lying-in wards should
possess a sufficiency of attendants, best, perhaps, by making them training
Schools for nurses. Nurses should be intelligent enough not only to com-
prehend their duties, but their responsibility. Physicians should wash
their hands with disinfectants before and after making examinations,
and nurses should do the same whenever their hands are brought into
contact with vaginal secretions. D’Espine has shown that the lochia of
the third day of a healthy patient will poison a rabbit." A nurse employed
in the puerperal wards ought not to have access to cases of labor. A
patient attacked with fever should be immediately removed to another
part of the building, and the nurse in attendance should go with her.
Special wards for the recently confined should never be established. As
enforcement of details is essential to success, a lying-in hospital should
have a resident medical head with plenary power to enforce the most
rigorous discipline. The adoption of Lister's principles in maternity
hospitals has, when carried out with the requisite discipline, served to
dissipate the well-founded objections to their existence. It makes no
difference whether they are old hospitals or new, cottages or pavilions.
All that is required is space, light, air, intelligent nursing, an active
head, and generosity in needed supplies, to keep them as free from infec-
tious diseases as are the homes of the better classes. I have already
shown, in another paper, how, through limited room, ignorant nurses,
* Contributions à l'Étude de la Septicémie Puerpérale, p. 1S.
854 LU S K,
lax discipline, and niggardly management, an epidemic, costly in life,
could be generated.
So far from tearing down the maternity hospitals now in existence,
new maternities of small size, for married women, modelled after the
Preston Retreat, are urgently called for to meet the present waste of life
among the very poor. I cannot but hope that such institutions, intelli-
gently constructed, ordered, and maintained, may yet be the outcome
of private charity. A small maternity has the advantage over a large
one that, when a dangerous element is introduced, repressive measures
can be more rapidly and effectively carried into execution. I have already
taken up so much time that I will not dwell upon the duties of the phy-
sician toward his private patients: how he should avoid conveying to
them zymotic diseases, or septic poisons; how he should understand
that the proper management of labor involves a normal puerperal state ;
how he should guard lest the antecedents of his patients should unfavor-
ably affect the period of parturition and child-bed. I have only to add
that, among the wealthy and refined, there is an annual sacrifice of lovely
women, due, not to want of skill or care, not to infection, but to the
fact that the enervating influences of civilization and the pressure of
social life, have apparently unfitted them for offering effective resistance
to any form of traumatism. Dr. E. H. Clarke's little work entitled “Sex
in Education,” strikes the key note of a subject requiring on the part of
obstetricians the profoundest consideration.
In closing this paper, I beg to offer the following conclusions:—
I. There is no specific, puerperal fever, and, as long as, when the term
is limited, each physician uses it in some sense personal to himself, it is
best to employ it as a general term for all the febrile affections peculiar
to the puerperal state.
II. Puerperal fever, the term being used as above, may be either a
non-infectious or an infectious disease.
III. The non-infectious form is due to traumatic inflammations of a
simple character, to Old peritoneal adhesions, to moral causes, and to the
vulnerability of the patient.
TV. The infectious form, on the other hand, is a septic disease, inti-
mately associated with the existence in the tissues of minute organisms
which form the connecting link between puerperal fever and erysipelas
and diphtheria.
V. Its causes are certain atmospheric conditions (nosocomial malaria
of hospitals), and infection from septic materials. It prevails most in
certain winter months, and finds its victims chiefly among the very poor.
VI. Prevention is best accomplished in hospitals by the adoption of
Lister's principles." Maternity hospitals are no longer necessarily foci
| The following regulations, enforced by Bischoff, in Basel, will serve as an example:–
Removal from the genitalia, after confinement, of débris capable of undergoing putrefac-
tion. Protection of the wounded surfaces from all air not impregnated with carbolic acid.
Hands of attendants, and all instruments used in labor, to be disinfected with carbolic acid.
A full bath to be given upon the advent of labor, and the vagina to be washed out with a
two per cent. Solution of carbolic acid. In cases of premature rupture of membranes, of
protracted labor, artificially induced premature labor, and of dead foetus, a repetition of
the injection every two hours. Hands and instruments to be lubricated when necessary
with a ten per cent. preparation of carbolized glycerine. In cases of version, of artificial
removal of the placenta, of putrid foetus, of post-partum hemorrhage with relaxation of the
uterus, employment of intra-uterine injections of two to three per cent. solutions of carbolic
acid. After the end of labor, the external genitalia to be inspected, and a ten per cent.
P U E R P E R A L FE V E R . 855
of disease. Small maternities, if well managed, meet a need among the
very poor, and their establishment by the charitable should be encour-
aged. In private practice the physician should never, and need never,
be the carrier of contagion. The antecedents of nurses should be investi-
gated. Auto-infection should be very rare in cases properly managed
during the period of labor.
VII. The question of personal responsibility cannot be too strongly
impressed upon the medical profession.
DISCUSSION ON DR. LUSK's PAPER.
After the reading of the preceding paper, Dr. H. P. YEOMANs, of Mount
Forest, Ontario, Canada, said:—With regard to Dr. Lusk's statement that
bacteria in puerperal fever cause endocarditis, I would say that the presence
of lactic acid in the blood may produce precisely the same cardiac conditions,
and that when injected into the veins of animals, it has developed endocarditis,
and caused deposits of fibrin on the valves. Now it is a significant fact that,
in cases of puerperal fever, lactic acid is one of the morbid constituents of the
blood. In such cases it is not necessary, therefore, to invoke the presence of
bacteria as the cause of the endocarditis.
Dr. WILLIAM GooDELL, of Philadelphia, said:—I have listened with much
pleasure to the admirable paper just read. There are points in it on which I
should like to dwell; but, as the time for discussion is very limited, I shall
confine my remarks to the prevention of puerperal disorders. I contend that
no statistics are trustworthy, excepting those of hospitals and of other public
institutions, for physicians very naturally shrink from reporting their fatal
cases of puerperal fever as such. In evidence of this, I may adduce the fact
that at one time I was cognizant of fourteen deaths in two weeks from puer-
peral fever. Yet the weekly mortuary returns of the Board of Health gave
for that time but twelve deaths in the whole city from that disease. With re-
gard to the prevention of fever in the inmates of the lying-in institution of
which I am in charge, I am governed by four golden rules: Cleanliness, Venti-
lation, Rotation, and Isolation. And I am the more satisfied with them since,
among 1021 hospital patients who have passed under my care, I have not had
a single case of phlegmasia dolens, and but one of pelvic abscess, while I have
lost only three from fever. Each one of these rules is a generic term embrac-
ing many specifications, but since the first three explain themselves, I shall
dwell on the last only. By isolation I mean the imitation of the home-environ-
ment—in other words, the putting a hospital patient in a condition as like as
possible to that which she would have at home. While this ideal cannot be
wholly reached in a hospital, yet it should be approached as closely as possible.
If the same sponge, the same chamber-pot, or the same syringe, be used by
several patients, this law of home-environment is violated ; for every woman
delivered at home has her own sponge, her own syringe, and her own vessel.
Hence in place of sponges I use finely picked oakum, with which every
woman—and not the nurse—washes her own person. Hence every bed is
provided with its own vessel, and hence every woman's person is sweetened,
carbolized oil to be applied to all lesions. Rupture of the perineum to be closed with
carbolized silk or catgut sutures. The parts to be washed clean, and picked lint soaked in
carbolized oil (ten per cent.) to be laid upon the vulva. Yaginal injections of a two per
cent, solution of carbolic acid to be used twice a day—or, in cases of difficult labor, putrid
foetus, or retained portions of ovum, to be repeated every two hours. In cases of retained
portions of placenta, hindering the contraction of the uterus, intra-uterine injections of a
two or three per cent. solution of carbolic acid in water twice a day. The nurse to wash
at each visit the genitalia and inner surface of the thighs, with a lukewarm solution of
carbolic acid. I have already given the results of this treatment.
856 LU S K,
not by detergent vaginal or intra-uterine injections, but by the upright position,
by making her get out of bed and slip into a chair several times a day. Since
the same ward holds, and the same nurse attends, a number of women at the
same time, this is a flagrant violation of the law of home-environment, but
one which cannot be avoided in hospital practice. As a make-weight, however,
I put but few women in the same ward, and make the nurse use a nail-brush,
take frequent baths, and wear such clothing as can be washed. As soon as
the women are out of bed for good, the nurse is relieved from duty; she takes
a carbolized soap-bath, and goes into a clean ward, which has lain fallow for
some two weeks or more, and usually gets a week of rest before a new batch
of patients falls to her care. I myself always wash my hands with carbolized
soap, before making an examination, and, to make assurance doubly sure, I
keep an obstetric and a gynaecological hand. With my left hand I make all my
office and dispensary vaginal examinations; my right hand I reserve as much
as possible for Obstetric work. Since moist heat forms the condition under
which poison-germs best germinate, after a ward is once occupied, the floor
should not be washed. An accidental stain may be wiped up, but nothing
more. I have been led to this practice from observing that the cleanest ward-
floor, when drying, emits a bad smell, and from finding, some hours after such
a floor-washing, that the body temperature of my patients often shows a sharp
curve-peak. From the cloud of epidermic scales, and of other human and
consequently septic débris, raised by the broom, I am also opposed to sweep-
ing a ward, and especially while any patient is in it who has not yet got her
milk—that is to say, whose labor-lesions have not yet become protected by a
covering of granulations. But, since such a mode of enforcing cleanliness,
although a wide departure from our ideal of the home-environment, cannot be
well dispensed with, I would suggest the plan devised by my friend, Dr. Addi-
nell Hewson, viz., to strew the sawdust of some terebinthinate wood, such as
cedar or pitch-pine, Over the floor of the ward before it is swept. The saw-
dust of any ordinary wood would do, if sprinkled with turpentine, which,
while being antiseptic, would give the needful amount of dampness without
moistening the floors. Since fatty degeneration of the heart as well as of the
other viscera is one of the most common lesions of child-bed fever, to avert
this tendency large doses should be given of such antiseptics and antipyretics
as quinia and alcohol, combined with opium enough to allay all pain. And
such a heart-tonic as digitalis should be given instead of a pure depressant
like veratrum viride.
Dr. W. II. ISYFORD, of Chicago, said:—I believe with Dr. Lusk that puer-
peral fever is produced by many different causes, and assumes many different
forms. Sometimes it originates under isolated conditions, and is autogenetic,
resulting then from various intrinsic causes, such as decomposition of blood
clots, or of retained membranes, etc. In others it has a zymotic origin from
various extrinsic causes, which prove at times morbific, owing to the pecular
state of the patient. Frequently cases of puerperal fever result from over-
crowding in hospitals; at least they are always more prevalent in close build-
ings where there is no good ventilation. The disease ought not to be called
epidemic ; it is rather endemic. But there is another class of cases which
differs from these, especially in miasmatic sections. Some years since I wit-
nessed an epidemic of “black tongue” which occurred in Indiana. During
the height of the disease, which lasted two months, every case perished and
every lying-in woman in that neighborhood died of puerperal fever ; but as the
epidemic subsided, the virulence of the fever grew less, and some cases began
to recover. When, finally, the “black tongue” disappeared, puerperal fever
vanished with it, and the younger doctors then thought that they had dis-
covered the cause of the latter disease. I believe puerperal fever to be conta-
gious under certain circumstances, but think that it cannot be carried by the
physician after he has washed himself with carbolic acid.
Dr. JOHN L. ATLEE, of Lancaster, said:—I had attended a thousand cases
|P U E R P E R A L FE V F. R. , 857
of labor without seeing puerperal fever, and from this good luck had argued
that there was no necessity for more than ordinary cleanliness on the part of
the physician. But once I had a case of phlegmonous erysipelas, which I
dressed, and then, during the succeeding afternoon and night, attended three
cases of easy delivery. The next morning I left them in charge of a friend,
and went to Baltimore as a delegate to the American Medical Association. On
my return I found my friend waiting for me at the station, to take me to see
these women, all of whom had puerperal fever. I found one already dead, and
the other two hopelessly ill. Under the teachings of Hodge and Meigs, it
would then have been considered heresy to say that puerperal fever was com-
municable, and yet I carried the disease, having used no special disinfectant,
and I believe that I was the innocent cause of the death of those three ladies.
I therefore urge that the profession should use extraordinary measures against
personal infection and the carrying of this disease. -
Dr. J. P. WHITE, of Buffalo, said :—Puerperal fever was said years ago not
to be communicable, but most of us have changed our minds upon this point.
We may call it infectious or contagious as we will, but it has spread about
neighborhoods. I know of cases in which it has been carried, and I know that
it is communicable. The opposing opinions of Dr. Hodge, Dr. Meigs, and
others, have been overturned, and there is now no doubt that puerperal fever
is eminently contagious. No man has a right to go directly from a case of
puerperal fever, and attend another patient in labor. I know of no disin-
fectant that will make it safe to attend a case of labor after one of puerperal
fever. In the treatment of this disease, I place much reliance upon opium, for
which there is great tolerance in puerperal fever. I have given as much as one
grain of morphia every hour for forty-eight consecutive hours, and have been
rewarded for my boldness by the recovery of my patient.
I) r. E. H. TRENHOLME, of Montreal, said:—I have given from a grain to a
grain and a third of morphia, every hour, with positive benefit ; and I have
never lost a patient from puerperal fever, although I have met with five cases.
Dr. J. C. HUBBARD, of Ashtabula, Ohio, said :—I should like to test the
sense of the Section as to whether, in cases of puerperal fever, the child should
be allowed to remain in bed with the mother or not. Most physicians allow
the child to remain as long as it can get a drop of milk.
Dr. GEORGE W. MEARs, of Indianapolis, said:—I consider puerperal fever
more infectious than contagious, in the strict sense of those terms. I knew a
physician once to lose seven cases of labor from this cause within two weeks
(every case of the kind which he attended), notwithstanding that he had used
all necessary precautions, such as the free application of disinfectants, change
of clothes, etc. They were obviously all instances of personal transmission,
no other physician in the city having had a case of the kind to treat. A few
weeks’ absence from home served to free him from the infecting influence, no
other instance of the disease having subsequently occurred in his practice. I
believe it also possible that the fever arising from other causes than that of
erysipelas may be conveyed, but not as readily, by the attendant on labor.
According to my observation, when the infection arises from erysipelas the
child develops erysipelas and the mother peritonitis.
Dr. ALEXANDER R. SIMPsox, of Edinburgh, said:—The chapters in our
text-books, instead of being headed “Puerperal Fever,” as they are, should be
entitled, “On the Fevers of the Puerperal State,” not specially referring to
puerperal fever as an entity. The puerperal woman is liable to ordinary dis-
eases, but in her they assume peculiar features, and are so marked as to give
rise to the idea of a special disease, called puerperal fever. I believe that
often these fevers are merely typhoid fevers in the puerperal woman. In
some cases the development is due to the poison of scarlatina; but both ty-
phoid and scarlet fever are diseases which are as natural to the puerperal
woman as to the non-puerperal. I do not know whether such tables have
been drawn up, but I should like to see statistics of the results of wounds re-
858 LUSK, PUER PER AL FE VER.
ceived in battle, as to the difference in the ratio of recovery of those wounded
early in the day, when they are fresh, and those wounded later. Such data
would apply to cases of puerperal women ; whether the women are fresh from
a short labor, or exhausted by a long and tedious one. With our present
knowledge of the subject, it matters little, as far as treatment is concerned,
whether the poison be chemical or animal. To meet the difficulty of personal
infection, we should be careful not to carry the poison about in our daily
rounds. Most of the germ destroyers are acids, as carbolic, sulphurous, and
salicylic acids, but, as a disinfectant, I would call attention to one which can
be found in every household, and that is common vinegar; I have, on many
occasions, found it extremely efficacious. After extraordinary exposure, the
clothing should be fumigated with sulphurous acid. ..'
Dr. LUSK, in reply, said:—I beg to thank the Section for the attention
which has been given to my paper, and for the discussion which has followed.
In reply to Dr. Yeomans, I would say that it is true that the presence of
lactic acid in the blood causes endocarditis, but that I confined my remarks to
a single form of endocarditis, of which the great characteristic is the presence
of masses of bacteria upon the cardiac valves. But the great question is,
whether the poison can be destroyed after its inoculation has taken place. I
think that it can. I think that the mother ought to be separated, in these
cases, from the child, as it is better for both. I use Labarraque’s solution to
disinfect my hands, and have never carried the disease from hospital to pri-
Vate patients. • .
859
ON ELECTROLYSIS, WITH SPECIAL REFERENCE TO THE
TREATMENT OF OVARIAN CYSTS.
BY
FREDERICK SEMELEDER, M.D.,
OF VIENNA.
ELECTRICITY, the essential nature of which we are unable to explain,
reveals itself to us under all the different known forms of motion, both
as mechanical power and as molecular movement, whether as light, heat,
or chemical action. The phenomena of these are essentially identical ;
they are correlative, and are constantly being transformed one into
another. We can command, to a certain extent, by choosing among the
various sources of electricity, and by different arrangements of apparatus,
the particular manifestation which we wish to produce; but no form of
electricity can be generated which does not display, more or less, all its
various qualities. Especially is it impossible to conceive of any electric
current acting on a living body without causing chemical action, and
perhaps the only way in which electricity can act in the living tissues
is through its chemical effects.
Electrolysis is the name given to that application of electricity in which
chemical action is principally sought for, and, especially in medicine,
when, by the use of either the galvanic or the faradaic current, an
attempt is made to dissolve or destroy organic productions, infiltrations,
exudations, or distinct tumors. Electrolysis is extensively used for
industrial purposes (electrotyping, etectroplating, etc.), but its applica-
tions to medicine and surgery are as yet very limited ; this branch of
electro-therapeutics is still in its infancy, its philosophy is very imper-
fectly understood, the number of cases in which it has been employed is
small, and the data for judging of its value are widely scattered ; the time
for writing a treatise on medical electro-chemistry has not yet arrived.
The effects of electrical currents on simple, inorganic solutions are
easily understood ; but it is different when we have to deal with organic
and highly complex substances, such as are met with in the living body.
An electric current passing through common water decomposes it, setting
free oxygen at the positive and hydrogen at the negative pole; with a
solution of common salt a similar process goes on, the oxygen formed at
the positive pole acting on the salt and decomposing it. In the case of
liquids like those found in the living body, containing albumen and
azotic combinations, we know, as a general rule, that, at the positive
(oxygen) pole, albumen, fibrin, fat-acids, etc., are separated, while at the
negative (hydrogen) poie there appear the alkaline and earthy bases, iron,
and coloring matters.
If an electric current is passed through a watery solution of albumen,
in a short time (say five minutes) a clot will be found at each pole ; that
at the positive pole is the larger and denser, the wire (copper) becomes
green by oxidation, and the whole clot has a slight, greenish tinge; the
clot at the negative pole is more cloudy, soft, and diffuse, and of a gray-
ish tinge, while the wire becomes blackened from the development of
860 SE ME LED ER,
sulphuretted hydrogen. The same thing is observed (except that the
clots are smaller) when the wires are applied, after the shell is removed,
to the soft membrane which covers the white of an egg. The above
remarks apply to the constant, galvanic current ; although the faradaic
current also decomposes water and coagulated albumen, yet the electro-
lytic properties of any faradaic current, which a living subject can endure,
are so insignificant, that its value in this respect may be disregarded.
What has been described as taking place in an albuminous solution,
is precisely analogous to that which occurs in the living body, the effects
varying somewhat, however, according as both poles are introduced or
applied on the surface, or as one or the other is introduced while the
other is applied externally; and from a knowledge of these differences
may be derived varied indications for the therapeutic use of electricity.
With these introductory remarks, I beg to call the attention of the Sec-
tion to a new application of electricity in surgery; I mean the electrolytic
treatment of ovarian cysts. When, a year ago, I published my first
successful cases, a claim of priority was made by two gentlemen, one of
whom had indeed reported cures of ovarian cysts, by electricity, as long
ago as 1859. But these cases excited no attention at the time, and were
so entirely forgotten that in Prof. Schroeder's Essay on Gynaecology, in
Ziemssen’s Cyclopædia, no earlier cases were referred to than those of
Dr. Fieber, published in 1874. All that I claim is the credit of having
again brought the method before the profession, and I sincerely hope
that it will not require fifty years to elapse before the value of this mode
of treatment is acknowledged, as was the case with ovariotomy, the
great invention of Dr. McDowell, from whose deserved reputation I
would certainly be the last to detract.
But Science is constantly progressive, and what was yesterday con-
sidered a great triumph, may to-morrow be superseded, and just as
legitimately abandoned as it was praised the day before. Hence I do
not hesitate to repeat, before this assembly, my assertion, that I hope
within a short time to see ovariotomy abandoned, or at least restricted
to a very few exceptional cases. My grounds for entertaining this opinion
I have recently published at length, and shall not therefore repeat at
this time what I have already written; but I will merely say that six
cases of ovarian dropsy, which I have treated in this way, have been
completely cured in from four weeks’ to five months’ time, according to
the size of the tumor; and that in a case of fibro-cystoma of the womb,
under electrical treatment, the liquid contents of the cysts have been
absorbed, the fibrous, Solid masses remaining nearly unaltered. The
ovarian cases were not selected but were taken indiscriminately; the
cysts varied in size from that of a cocoanut to that of a pregnant uterus
at full term. In one case the tumor was undoubtedly monocystic, with
thickish contents; and in another polycystic ; in two cases the cyst con-
tents were quite thin ; while one was probably a case of dermoid cyst.
The ages of the patients varied from eighteen to forty-five years; one was
a virgin; one married, but sterile; and four had borne children.
The constant current was employed in all the cases; in one, no needles
were introduced, but both electrodes applied to the surface, and yet the
contents of the tumor were absorbed. The currents employed were mild
ones; no imflammation of importance occurred, and consequently no
adhesions were formed ; the pain was insignificant, anaesthetics never
having been required, and no patient having been confined to bed.
Thus far, no relapse has occurred. The method is equally applicable to
E L E C T R O L Y S IS FOR O W A RIA N C Y S T S. 861
single and to multiple cysts; to those with albuminous, with Saline, and
with fatty contents; to those with and those without adhesions; to
those which have and those which have not been previously tapped.
In one of my cases, after the liquid contents had been absorbed, hard,
cartilaginous bodies in the cyst remained, apparently unaltered; the
cyst walls, in all, underwent contraction, and a solid lump, of the size of
a small apple, remained when all the liquid had disappeared. One obvi-
ous advantage of this method of treatment over ovariotomy, is that it
does not deprive the patient of one of her most important organs. The
sittings, in my cases, usually lasted only a few minutes, and were repeated
daily—in one case, even during the menstrual period.
The modus operandi of this method of treatment is not thoroughly
understood. In addition to the decomposition and absorption of the
liquid, some change must take place even in those parts of the cyst walls
which do not come into direct contact with the electrodes, for the further
production of liquid is prevented. Dr. Althaus's theory as to the effect
of electricity on tumors containing saline liquids, is that, the salt being
decomposed, a caustic alkali is formed, and by setting up a mild inflam-
matory process increases the vitality of the tissues, and thus leads to the
absorption of the fluid.
Before resorting to ovariotomy in any case, the surgeon should at least
give electricity a trial; for, even if it fail, the patient will be in no worse
condition for the operation, while the risks of the latter more than
counter-balance the evil of a little delay.
PARACENTESIS, ASPIRATION, AND TRANSFUSION.
IBY
SIMON FITCHI, A.M., M.D. EDIN.,
OF ST JOHN, NEW BRUNSWICK, CANADA.
FIFTY years ago, paracentesis was seldom employed, except in cases of
fluid distension of the abdomen, bladder, or scrotum, after other means
of relief had failed, and then it was a clumsy and unvalued procedure.
The old trocar, having a triangular point and a big head, with a split
canula behind it, went in with a jerk, endangering intestine and testicle
in tapping for ascites and hydrocele; then the canula, pushed onwards
over the big head expanding the segments of its split end, would often
catch some bit of the three-cornered aperture, and fail to enter perfectly,
or in entering would tear or split up the edges of the aperture, and allow
the fluids to leak injuriously into or upon the neighboring tissues, as in
the operation for hydrocele, or in puncturing the bladder; and finally,
the instrument would leave a jagged, punctured wound, indisposed to
heal.
But at the present time paracentesis is called upon both to detect and
treat a marvellous variety of diseases, and some of them of great impor-
tance, such as hydrothorax, empyema, hydro-pericardium, ascites and
purulent deposits in the abdomen, cysts of the broad ligament and of the
Ovary, intra-pelvic and lumbar abscesses, retention of urine with im-
permeable urethra, distressing tympanitis, strangulated hernia, hydatids
and abscesses of the liver and kidneys, hurtful effusions within or about
the hips and other joints, hydrocephalus, and spina-bifida; and the pre-
sent duties of paracentesis are more critical, in consequence of the sensitive
and vital character of the textures and parts in and upon which many
of these diseases are situated, such as the lungs, the heart, the abdominal
viscera, the pelvic organs, the great joints, the spinal cord, and the brain.
In dealing with such diseases, in such parts, none of the trocars now
in use are equal to what is required of them, either for exploration or for
treatment.
Paracentesis now, with or without aspiration, with or without injection,
is commonly done either with a single tubular trocar having an un-
guarded point (which is most dangerous to the interior), or the guard is
an open canula, to be pushed over the point after it has entered, and of
itself only somewhat less dangerous if it gets in, while it is uncertain to
enter; and we will do wrong to employ these uncertain and dangerous
instruments if an efficient and safe instrument can be had.
The perfect trocar should be: (1) Easy of insertion, the puncturing
tube entering by a clean incision, and the protecting canula following
without the least stretching of the aperture, or possibility of failure; (2)
IIarmless when inserted, so that it shall not injure the interior of the
cavity, or adjacent parts; (3) Safe as a probe or sound, or artificial finger,
for internal exploration ; (4) Adapted to the aspirator and every form of
exhausting apparatus, both attachment and detachment being instanta-
neous; (5) Competent to give the freest eacit or entrance to fluids to be dis-
P A R A CENTESIS, As PIRATION, AND TRANSFUSION. 863
charged or injected ; and (6) Certain to leave an incised wound, ready to
heal. Let us now glance at the growth and present character of the
modern trocar, and try to ascertain what should be done towards per-
fecting it.
In 1850 the improvements seem to have commenced, when Sir James
Y. Simpson reduced the large head of the old trocar to the same size as
the shaft, so that it should stretch the orifice less, and, as the canula
could then be advanced without spreading, he omitted the split in the
end, and published his employment of a long and slender trocar of this
kind, with an exhausting syringe attached, as a means of diagnosis in
various internal enlargements, especially in pelvic tumors, and so initi-
ated the idea which Dieulafoy afterwards developed into his admirable
aspirator. The plan of having the canula itself pointed, so as to penetrate
independently of the stylet, was first conceived by Fergusson, of London,
who in 1853 devised a pen-like tubular needle, for injection of perchloride
of iron in the treatment of naevi and aneurisms. In 1858, Dr. Alexander
Wood, of Edinburgh, adapted this instrument to the subcutaneous in-
jection of morphia, and a modification of the same instrument is now in
universal use. Shortly afterwards, Mr. Spencer Wells enlarged this
little tubular trocar, for ovarian tapping, and had the edges of the
pointed end made sharp and cutting for one half the circumference of
the tube, whereby a semilunar incision is made ; and he added, or restored,
a shorter sliding canula on the outside, which, upon the puncture being
effected by the point of the inner tube, is pushed forward as a guard
against its further cutting action.
This instrument, superior in many respects to the old trocar and
canula, especially in that the wound made is incised, rather than punc-
tured, has still this grave fault of the old instrument, that the protecting
canula is on the outside. If the distal orifice of this outer canula be made
thin to pass with less resistance through the aperture made by the
pointed smaller tube, the open thin end will itself present a cutting edge
dangerous to the interior of the cavity and to the contained or adjacent
viscera. To lessen the difficulty of getting the outer canula through the
aperture, over the inner tube, the distal end is sometimes made obtusely
pointed, but this makes it only the more dangerous to the interior,
especially in the smaller or aspirator sizes of the instrument. If on the
other hand the terminal margin of the outer canula be blunted or made
thicker, it will present a ridge or shoulder outside of and behind the
entering point of the inner tube, liable to catch and carry before it the
sac, or the immediate investment of the cavity, and so fail to properly
enter.
Now, this accident may occasion considerable inconvenience, or even
be productive of great harm, in cases of simple tapping ; as for instance
in hydrocele and in retention of urine, where, if the tunica vaginalis
or bladder be not very tense, it is oftentimes difficult to get the outer
canula in without pushing so hard as to endanger its going in with a
jump, and hurting something, so tightly does the punctured membrane
cling to the inner tube in advance of the edge of the outer canula ; and
in empyema, with a thick and tough pleura, so much force is sometimes
required to urge the entrance of the outer canula, as to endanger a
separation of the pleura from the ribs. And in tapping for the tempo-
rary relief of ovarian dropsy, if the outer canula do not follow the trocar,
or inner tube, quite into the sac, or if in entering it catch and tear or
split up a fragile sac, more or less of the cystic fluid escapes into the
C) Zºe
A.
O O + FITC H.,
abdominal cavity, and forms one if not the chief cause of the fatality
which sometimes follows this simple operation.
I3ut should injection be attempted with an imperfect introduction of
the protecting tube, whether that tube be the canula of the old trocar,
or the outer tube of Mr. Wells's trocar, the result may be most disastrous.
I have seen intense peritonitis Occasioned by tincture of iodine thrown
upon the peritoneum in such an attempt to inject an Ovarian cyst, and
Syme, in his “Principles of Surgery,” noticing a like faulty injection for
cure of hydrocele, remarks: “If the liquid is allowed to remain in the
cellular substance, it gives rise to violent inflammation, and soon termi-
nates in sloughing of the scrotum.”
I have encountered on many occasions embarrassments similar to the
above, and in common with others had tried to obviate the uncertainty
of entrance of the outer canula, by cutting down to the bladder or tunica
vaginalis, or pleura, or peritoneum, or whatever might be the immediate
investment of the fluid to be evacuated; until it occurred to me to reverse
the relation of the tubes to each other, and have the protecting tube on
the inside. And while in Edinburgh, in 1871, I had a double, tubular
trocar made by Gardner upon the following plan : The outer tube,
smooth and of uniform size, has the distal end pointed and cutting like
a lancet, so that it penetrates easily, and to any depth, without any need
of previous incision of superimposed tissues; and the protecting tube,
being now inside, may be advanced into the interior of the cavity, with
absolute certainty of entrance, and without a possibility of even touch-
ing the margin of the aperture, or any of the tissues through which the
outer tube has passed. The cutting edges must rise from the point of
the trocar by a very acute angle, not more then 30° for the largest size
and only 15° for the aspirator sizes; and the cutting-edges must be very
thin and sharp, but of course sharp for only one-half the circumference of
the tube, the half next the point, as if sharp all around a circular piece
would be cut out, and a round hole left.
Instruments similar to the above were made under my direction by
Rrohne and Sesemann, in May of that same year, and were exhibited at
the next meeting of the British Medical Association, in London, August,
1873. The largest size is noticed in Spencer Wells's recent work on
“Diseases of the Ovaries,” p. 336. But the smaller sized instruments
seem to have been overlooked, for Mr. Alfred Goodrich, in a letter to the
British Medical Journal, August 8, 1874, says: “In emptying a cavity
with the aspirator the operator is often alarmed by finding the instrument
filled with blood, arising from the walls of the collapsing cavity being
forcibly sucked against the sharp point of the needle;” and he proposes,
as if it were his own idea, that the trocar consist of two tubes, the outer one
pointed, the immer one not so. But in the same journal for August 22,
Mr. George Brown, of the Northeastern Hospital for Children, referring
to Mr. Goodrich's suggestion of a trocar guarded by an inner tube,
remarks: “The idea is not original; we have had one in constant use
for more than twelve months, which was supplied by Messrs. Krohne
and Sesemann.” Now these excellent instrument-makers, in 1871, three
years before this correspondence, constructed my instrument, which, in
the catalogue of the museum at the forty-first annual meeting of the
British Medical Association, was designated “Wells's Trocar improved
by Fitch.”
This instrument is not perfect; for, although the entrance of the pro-
tecting tube is rendered free from the possibility of failure, yet the open
P A R A CENTESIS, ASPIRATION, AND TRANSFUSION. 865
end of this same tube is hazardous, especially in the aspirator-trocar,
where it must be thin and sharp, to avoid bulk; thus in tapping the
bladder, we dare not draw off the last of the urine, lest we injure the
lining of the contracting viscus, and this danger is pretty generally felt
by surgeons. In the August numbers of the journal just quoted, a corre-
spondence appeared in reference to a successful paracentesis for hydrops
pericardii, in which Mr. Singleton Smith, upon whose patient the operation
had been performed, admitted the risk which accrued, not only from the
unguarded point of the aspirator-trocar in the cavity of the pericardium,
as the fluid was drained off, but also from the sharp edge of a canula
rubbing against the pericardium, or coming into contact with the beat-
ing heart. About the same date, the Lancet, under the head of “Medical
Facts,” observed that in “tapping of the chest, when the fluid has been
evacuated by the exhausting apparatus, the lung in expanding may
strike against the sharp and hard canula. To prevent this, M. Béhier,
of Paris, uses a canula of soft metal to be introduced into the ordinary
tube, which, when the pleura is emptied, bends down against the parietes
of the chest, and the lung does not suffer.” Now a tube of soft metal
cannot be drawn very thin, and, were it made large enough for the bore
to be permeable to fluids, it would be too bulky to enter a small canula,
and then coughing or other movement of the patient would be liable to
throw the lung against the soft tube, and bending it down, stop the flow
prematurely. Perhaps enough has been said and quoted upon this point,
and upon the disadvantages of the open canula ; I think we all feel the
want of a safer trocar than any hitherto used.
I now announce a most important modification of the double tubular
trocar, which avoids the danger of the open canula, and by which the
instrument, while performing its highest achievements of discovery and
cure, may be used as a trustworthy exploring probe and sound ; and
which will, I believe, in time supersede every other form of the instru.
ment. Retaining my first improvement of making the outer canula the
puncturing, or rather the incising, trocar, I have had the distal orifice,
or open top, of the inner canula closed over by a rounded or dome-
shaped roof, so that, when it is projected beyond the cutting point of
the outer canula, the two tubes fit closely together, and the end of the
combined instrument feels perfectly smooth like the end of a rectal
sound, or catheter, or probe, and may be freely moved within the cavity
penetrated, whether this be an ovarian cyst, a uterine fibro-cyst, the
abdomen, the thorax, the bladder, a joint, or even the pericardium,
without danger of wounding any viscus or organ, puncturing any vessel,
or even Scratching or abrading the lining of the cavity, or of any parts
contained therein.
The base of this dome being of the same external circumference as the
inner tube, of which it is the continuation, and fitting the outer tube
accurately, there can be no escape of fluid till the dome is advanced or
pushed out so as to occlude and shut out the cutting point of the outer
tube ; then there is disclosed by this movement a fenestra, or oval
aperture on the under side of the inner tube, just below the roof, or dome,
cut out of the lower wall and one-third of each side-wall, of the full size
of the bore of the tube, and by which fluids may be freely evacuated or
injected ; the distal end of this segment is sloped off towards the dome,
so that no obstruction can lie there, while at the proximal boundary a
curved lip projects over one-third of the whole fenestra to prevent the
possibility of obstruction; and the fenestra thus guarded, and being,
55
866 FITCH,
moreover, on the under side, cannot be stopped by the wall of the
cavity coming into contact with it, nor by the falling upon it of any
natural textures, or layers of false membrane, or flakes of plasma, as
often happens with the open end of the old canula. If, while dis-
- d
---- ºl : Hºč
+---> = TE. E. E---------.
---
Fºy Z - &
Figures 1, 2, 3, represent the ovarian trocar; 4, 5, the aspirator trocars; the inter-
mediate sizes for paracentesis abdominis, paracentesis thoracis, etc., and the transfusion
trocar, are sufficiently represented by one or all of these figures. Fig. 1 shows the cutting
point (a b) of the outer canula advanced, ready for puncture, with the dome of the inner
canula retracted, shutting the instrument just behind the point (b) against ingress or egress
of fluid ; c is the thumb-rest for projection and retraction of the dome by the thumb of the
hand holding the instrument; d is a slot with a knob regulating and fixing the dome aud
point in any desired position; turning the knob one-half revolution into the proximal trans-
verse slot allows the tubes to be separated for cleansing and oiling; f is a continuation of
the inner canula, forming a tubular handle, which directs the current downwards—one end
of an India-rubber tube is drawn over the lower orifice of this handle ; k is a bit of glass-
tubing by which the character of the fluid may be observed, or its absence noticed; the
bulb is a simple expansion of the India-rubber tube (without valves or joints to interrupt
the easy flow of fluid or to whip the blood in transfusion). Fig. 2 has the thumb-rest
pushed forwards and turned into the distal branch slot, projecting the inner tube and dome
(m), sheathing the cutting edge and point (a b) of the outer canula, and disclosing the
fenestra (n) cut out of the under and side walls of the inner canula ; m, in Fig. 2, and o, in
Fig. 3, show the curved process of the lower wall of the inner canula, underlying the
proximal third of the fenestra, to prevent occlusion from contact of cyst-wall, or vein-wall,
or any floating substance. Fig. 4 is the aspirator trocar, with the dome retracted; Fig. 5
has the dome projected; e h is the nozzle; e the proximal end, over which the end of the
India-rubber bulbous tube or the tube of the aspirator may be drawn; f the conical distal
end to be inserted into (g) the funnel-shaped end of the inner canula, and fixed by a
turn of the hose-coupling nut (h). Fig. 6. The clamp forceps for holding the sac upon the
trocar during evacuation of the contents; also, for closing the orifice in the sac upon with-
drawal of the trocar, and preventing leakage of cystic fluid into the peritoneal cavity.
charging the fluid for which it was introduced, there be found an
aggregation of cysts, or a multilocular sac, this instrument may be used
as a long artificial finger to examine the interior of the original cavity,
and to feel for a proper place to enter, where it may be held till the
cutting point is advanced to make an aperture for its introduction.
Thus, in ovariotomy, it will be found extremely convenient, the left
hand supporting the tumor and the right holding the instrument,

PA R A CENTE's Is. As PIRATION, AND TRANSFUSION. 867
which can be instantly changed, by an easy movement of the same hand,
from a trocar to a sound, and vice versä, to define and puncture cyst after
cyst, until the bulk of the whole is sufficiently reduced to admit of with-
drawal through the abdominal incision, with only one aperture in the
cyst-wall first punctured, and this always occupied by the instrument
which thus prevents leakage; and the dome-trocar may here be used,
where the end of the open canula could not be with safety, to stir up
and liquefy the loculose contents, and to break down such obstructions to
the flow as imperfect septa and membranous intersections, while it still
plugs the original aperture, thus preventing escape of cystic fluid into
the cavity of the abdomen; and it oftentimes obviates the necessity of
enlarging the aperture in the cyst for the introduction of the hand,
which procedure should be avoided, as involving overflow of cyst-fluid
upon the peritoneum.
In operating for hydatids of the liver or kidney, the dome-trocar, of
aspirator size, may be used to loosen and dissever these little bodies
while the aspirator is extracting them through the same instrument.
And we may, with one of these smooth-ended instruments, of suitable
length, search for and drain off the last drops of urine, during aspirato-
puncture of the bladder, which we dare not do with the end of the open
canula, much less with the sharp point of the Ordinary single-tube aspi-
rator needle; or, while the dome instrument is within the bladder, we
may use it to explore the interior both before and after emptying it.
In cases of intractably enlarged prostate, I believe that we may properly
reach the bladder by perforating this gland with a dome-trocar having
a less curve than an ordinary sound, and thus not only relieve the bladder
at the time, but give permanent release from the oft-recurring retentions.
I have forced a common strong catheter through the prostate in such a
case; and the patient, who was previously nearly worn to death with
his disability, is now enjoying a new prostatic bit of urethra, and is inde-
pendent of instruments.
For explorations of bone, we may insert a probe-sized instrument, with
the point projecting, till we reach the proper depth ; then, advancing
the dome, we have a harmless probe with which to search for caries or
exfoliation, leaving only a capillary wound, without entrance of air or
exit of blood. The dome, in all the sizes, should be solid or accurately
floored over, to prevent lodgment of anything there which might im-
pede its easy withdrawal from the cavity.
The life-giving operation of transfusion may, I think, be quickly and
well done with this instrument. A short dome-trocar, of suitable size,
having been attached to each end of an India-rubber tube a foot long,
with the middle expanded into a bulb, one of the trocars is inserted into
the vein which is to furnish the blood, and, when the apparatus is filled,
the other trocar is introduced into the receiving vein, when the opera-
tion is completed. The tubes are closed and opened at their distal euds
by retraction and projection of their domes, which prevents the possible
admission of air; and no valve or stopcock is needed. The receiving
vein should be exposed by a short incision, but the supplying vein will
generally be sufficiently prominent to be entered without previous dis-
section. As soon as the lancet-end of the outer tube is inserted, the
dome is projected, and the tubes thus guarded may be safely pushed as
far as required, downward into the furnishing vein, and upward into the
receiving vein, and no ligature will be needed. Thus time, so valuable
868 FITCH,
in this operation, is saved, disturbance of the vein is avoided, and injury
to the interior of the vein need not be feared.
If the mediate method be preferred, a common glass, or hard India-
rubber, or metal, syringe, with the piston removed, and the nozzle in-
serted into a flexible tube, armed with one trocar, will be a suitable
reservoir into which the blood may be caught, as in ordinary venesection;
or the blood may be defibrinated by whipping, and strained into the
syringe ; the dome with the open fenestra is left projected till the trocar
fills, then it is retracted, closing the fenestra, and leaving the point of the
outer tube ready for puncture. Upon inserting the trocar, we need not
replace the piston, for sufficient and more steady propulsion may be ob-
tained by merely raising the syringe.
The hole in the side of the nozzle, used by Mr. Wagstaffe, is liable to
occlusion from the contiguous wall of the vein; in the dome-trocar this
is obviated by a curved projection of the tube-wall over the proximal end
of the fenestra, open at the sides, as previously described. In this opera-
tion it is very important that the dome be solid to prevent lodgment of
clot.
The aspirator attachment deserves attention, for it can be applied to any
syringe or exhausting apparatus; the adjustment is effected instantane-
ously and without moving either trocar or exhausting apparatus, or twist-
ing the flexible, connecting tube, by merely pushing the end of the aspi-
rator nozzle into the funnel-shaped end of the inner canula, and fixing
it by one turn of a loose ring-nut, like a hose-coupling. The India-rubber
tube connecting the nozzle with the aspirator has the usual bit of glass-
tubing, so that the current may be observed or its absence noticed.
Some peculiarities of the different sized instruments should be men-
tioned. The ovarian trocar has a thumb-nut (for which I have to thank
Dr. Thomas Keith), by which either the cutting point or the dome may
be advanced or retracted, and fixed in either position by the thumb of
the hand holding the instrument. The proximal end of the inner canula
is prolonged into a hollow, curved handle, very convenient to hold by,
while it also directs the current of the flowing liquid downwards; and
one end of an India-rubber tube, three feet long (with a bit of glass tub-
ing in it), may be drawn over the lower orifice of this hollow handle, to
conduct the fluid into a receiving vessel; the middle of this tube is ex-
panded into an elastic bulb, by which the flow through the tube may be
promoted until the siphon current is established ; and we may use it for
washing out or for injecting the cavity. Mr. Wells's grapples may be
slipped upon this trocar, or long, light clamp-forceps, with ring ends, may
be used to seize the sac, upon or even before puncturing, and, held in the
hand with the trocar, will accommodate themselves to the varying dis-
tances to which the trocar enters.
The trocar for paracentesis abdominis has a curved, hollow handle con-
tinuous with the inner tube like the ovarian trocar.
All the sizes below that for paracentesis abdominis, have their proximal
ends adapted to the aspirator nozzle, and therefore a separate, curved,
hollow handle is provided to fit all of them, and may be instantly fixed
to either by a ring-nut, similar to that of the aspirator nozzle; and with
this handle an India-rubber tube and bulb may be used, as with the
ovarian trocar, when we wish to simply empty a cavity without the
aspirator.
The instruments may be of any size. Of those which I have had
made, the ovarian trocar is ten inches long, including the handle which is
P A RACENTE SIs, ASPIRATION, AND TRANSFUSION. 869
four inches, with the internal diameter of the inner tube half an inch.
Dr. Washington L. Atlee tells me that he has used one of these in his
last forty-one ovariotomies, and expresses unqualified approval of it.
The abdominal trocar is six inches long, including two inches for the
handle, the calibre equalling that of a No. 11 catheter of the American
scale, 17 of the French. The smallest sizes correspond with Dieulafoy's
aspirator needles; of these, two are each seven inches long, and fine, for
the bladder and deep tapping; two are four inches each in length, and
stouter, for hydrothorax, transfusion, etc.; one is short and very fine, for
hydro-pericardium, spina bifida, etc.
UTERINE HEMORRHAGE DURING GESTATION.
BY
E. II. TRENHOLME, M.D., B.C.L.,
PROFESSOR OF MIDWIFERY AND DISEASES OF WOMEN AND CHILDREN IN BISIſ OP’s COLLEGE,
MONTREAL ; ATTENDING PHYSICIAN TO THE WOMAN’s HOSPITAL ; FELLOW of THE
OBSTETRICAL SOCIETY OF LONDON, ETC.
THE object of the present paper is simply and briefly to point out a
form of hemorrhage met with during pregnancy, heretofore unrecognized
by writers upon midwifery. It is foreign to my purpose to speak of the
subject in general, or even to recall to your minds some excellent papers
that have lately appeared from the pens of the well-known and honored
Dr. Fordyce Barker, and others.
I will first offer the history of the following case, as illustrating the
subject :—
Mrs. N., act. 39 years, and of English parentage, was a feeble, anaemic woman,
of dark complexion, spare in flesh, and of a lymphatic temperament. She had
been married some sixteen years, and was the mother of five children, the
ly 4- ºr o o vºc of a rvo She h a ri ko oo in deserted law, h or h in c.
M-3 A. WJ -i
ty
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*T*. c + * v. Li C& V-1 kJ v. V. 1 i \- # *- :-} vv 1 J.) 11 v i 11 vi S-
g
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y v i 1 i º v_y tº U v i t w 1-1. W. A l l i w w Cit. No {2} C H it, y \ , t U 1 J V-W 1. Cºu Jº Vy e
tº.
tº-
band after the birth of her last child, but he had returned to live with her
during November and part of December, 1874, after which time he had taken
his final departure for parts unknown. The menstrual flow had appeared as
usual in January, 1875, but for the first time had been rather profuse, and
had never entirely ceased ; although the hemorrhage had moderated between
ſº º & e
tº * t y * -.
the terms, it had been increasingly severe at each period up to the removal of
a dead foetus, of about the size of a third or fourth months’ child, on August
7, 1875. For some months the patient had had constant pains in the uterus, of a
sharp cutting character, and, as she remarked, “not at all like labor-pains.”
The condition of the patient, and the persistence of the pains, with the bleed-
ing, led me to suspect malignant disease of the Organ.
To make a diagnosis, the os was dilated sufficiently to allow the introduc-
tion of the index finger, when I felt a globular body, well up in the cavity of
the uterus, and barely accessible to the touch. Dilatation of the os was con-
tinued until the greater part of the hand could be introduced. From the out-
set there were no indications of the presence of the decidua ; the mucous mem-
brane around the lower segment of the uterus was smooth and glossy to the
touch ; the cavity of the womb was found to be occupied by a projecting body
somewhat like a large sessile tumor, with its base toward the right side, and
occupying about one-quarter of the superficial surface. This body was felt to
be a foetus in its amniotic and epichorial decidual envelopes ; the point of coa-
lescence between the epichorial and parietal deciduaº was easily recognized.
The condition of matters having been determined, the membranes were rup-
tured, and the foetus with its placenta removed. This, however, was not
effected without difficulty, as the epichorial membrane had to be forcibly sepa-
rated at the point of its uterine attachment ; the sensation felt in so doing was
very perceptible and characteristic. The parietal decidua was in no way inter-
fered with by the delivery thus accomplished. The uterus contracted well, and
the patient made a good recovery without any subsequent return of hemor-
rhage.
UTER IN E H E MOR R H A G E. 871
The uterine decidua has been the centre of attraction to many able
investigators during the past few years. Much has been done toward
elucidating its anatomy and physiological functions. The changes, truly
marvellous, that occur during ordinary menstruation are somewhat defi-
nitely known. From this basis, so well established, we may reasonably
hope for rapid advancement in the successful treatment of uterine dis-
ease, and from the same source we may expect to obtain hints for the
more correct appreciation of some of the pathological conditions met
with in pregnancy.
To understand the irregular development and behavior of the mucous
membrane, we must bear in mind its regular and normal course in gesta-
tion. This course may be briefly stated as follows: (1) Hypertrophy and
folding of the mucous membrane preparatory to the reception of the im-
pregnated ovum ; (2) The imbedding of the ovum in the decidua, and
the consequent dividing of that membrane into three, viz., the utero-epi-
chorial, the epichorial, and the parietal decidua ; (3) The subsequent
union of the epichorial and parietal decidua, forming one homogeneous
membrane. As soon as this is accomplished, the uterine cavity is per-
fectly occluded, and any discharge from the interior is impossible.
A normal conception and gestation must proceed in the above order ;
when any serious deviation occurs, difficulties must follow ; deficient
vital action, and excessive vital action, alike work mischief. In the lat-
ter case, a fold of the mucous membrane may protrude into the canal of
the cervix, or even pass outside the external os; a case of this nature
came under my notice a short time ago, in which the protruding mass
appeared to be a plug of tenacious mucus; and it was only when this
was forcibly removed that the nature of the case became known. I need
hardly say that abortion followed. On the other hand, deficient vital
action is followed by imperfect development of the membrane, and an
absence of that perfect union of the epichorial and parietal decidua, which
takes place in normal pregnancy. This form of abnormal development
is met with, as might be expected, in anaemic and exhausted women; it
also occurs in those of apparently good, general health, but whose vital
powers have been exhausted by too frequent and rapid gestations. Na-
ture tries to meet the requirements of the case, but her powers are too
feeble to do so efficiently.
The epichorial decidua, being deficient in vitality, fails to enlarge and
allow the embryo fair scope for development. The envelope acts as a
compressor, forcing the foetus toward the placental surface, and at the
same time interfering with its nutrient supply and growth. The ovum
and its envelopes, in fact, form a sort of sessile tumor, such as was
noticed in the case referred to.
The muscular structure of the uterus is apt to be excessive in growth,
and not deficient, as at first thought we might be inclined to suspect;
we know, however, that hyperplasia or subinvolution are not indications
of excessive vital activity, but rather the reverse; most probably it will
be found that subinvolution is markedly present. Clinical facts indicate
this view as probably correct. In the case mentioned, the uterus was
much larger than was necessary for the accommodation of the foetus.
There was no impediment to the escape of any fluid from the left Fallo-
pian tube to the vagina, a condition which would permit of free men-
struation if that function could really be performed during gestation,
which I very much doubt. That hemorrhage can really occur from the
cavity of the uterus, and that, too, from a decidua of pregnancy without
872 TRENHOLME, UTE RIN E H E MOR R H A GE.
causing abortion, is quite possible, and need not be doubted ; perhaps
we have in this condition the clue to the mystery of super-foetation.
The purport of these remarks is to explain the cause of the uterine
hemorrhage met with during gestation. The form of gestation and the
condition of the uterus itself give an easy solution to what has heretofore
been inexplicable; the exact point or points of hemorrhagic escape will
undoubtedly be ascertained hereafter. The condition of the enlarged
uterus, the character of the mucous membrane, and the unnatural and
irregular strain upon the organ, are sufficient factors to account for the
monthly and continuous flow of blood referred to. We know that ses-
sile and submucous tumors are frequent causes of uterine hemorrhage, and
as this form of pregnancy resembles these cases in their chief outlines, it
is naturally followed by similar results.
As to treatment, I have but little to say. When we meet with such
pregnancies, whether complicated with metrorrhagia or not, it seems to
me that the proper treatment is to induce abortion. Apart from the ex-
hausting hemorrhages, cases are met with in which the uterine distress
and constitutional disturbance are so great as to urgently demand our
interference; there is little ground for hesitancy in the matter, as we
cannot reasonably expect a normal termination to an abnormal ges-
tation. -
The following conclusions seem to be justified by what has gone
before:—
I. That an abnormal development of the uterine decidua is not apt to
OCC Ul I’.
II. That hemorrhages other than those of placenta praevia can take
place from the cavity of the gravid uterus, only in cases where there is
an abnormal condition of this membrane.
III. That menstrual hemorrhages can take place from the cavity of the
uterus without accompanying abortion.
IV. That this condition might permit of superfoetation.
V. That the treatment indicated in such cases of gestation, when the
uterine and general distress are great, is to remove the products of con-
ception, whether such distress is or is not accompanied by metrorrhagia.
873
OHRONIC INVERSION OF THE UTERUS.
BY
JAMES P. WHITE, M.D.,
PROFESSOR OF OBSTETRICS IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF BUFFALO.
IN introducing the subject of Chronic Inversion of the Uterus to the
Section on Obstetrics, I propose simply to bring prominently forward
facts and conclusions already in a great measure laid before the profession,
and to urge the claims of the operation described to the confidence of
this representative body.
Never having witnessed the occurrence of the accident in question, I
will not attempt to describe its causes or the manner of its occurrence,
but shall consider chiefly the question of treatment or restoration. The
gravity of the accident and the sad condition of its victims will be con-
ceded by all who have observed the miserable state of those suffering from
its effects. Without discussing the possibility of spontaneous reduction,
which has been asserted by one or two recent writers to sometimes take
place, it certainly does not occur with sufficient frequency to warrant
delay in our efforts for artificial reposition, in the expectation that a cure .
will be effected by the unaided efforts of nature.
Until quite recently, inversion of the uterus, unless restored within a
short time after its occurrence, was regarded by all writers as entirely
incurable, and the unfortunate female was left without hope of restora-
tion, to drag out a loathsome existence. So miserable has the sufferer
from this terrible accident been made by it, that relief by extirpation of
the organ, with all its attendant dangers, and consequent deformity if
succeeded by recovery, has been acceded to as preferable to living on in
this deplorable state. Meigs, I suspect, at the time he wrote gave very
briefly the sentiments of the profession in relation to the practicability
of restoration, in his “Letters to his Class,” on the diseases of females.
Speaking of a case of six months’ duration, after describing the feeble
and exsanguine condition of the woman, he says: “What are you to do
for the patient 7 Will you reposit or reinstate this womb : You can’t.
You might as well try to invert one of the non-gravid uteri on my
lecture-room table as to reposit this one. The time is gone by. You
have no art or skill, nor any power equal to the performance of such a
miracle of surgery as that.” All the authorities of the same date
regard the reposition of the uterus, after involution, as highly improbable,
and do not direct any efforts to be made for its restoration. Churchill,
Ramsbotham, Velpeau, and Bedford content themselves with directing
such measures as will contribute to the comfort of the woman, and with
suggesting that removal of the organ may, in extreme cases, be resorted
to. Notwithstanding the success which has attended the operation for
reduction of the inverted uterus during the last few years, especially in
America, the more recent writers still seem incredulous. They continue
to give the same directions for the alleviation and treatment of this con-
| Letters to his Class, by Charles D. Meigs, M.D., page 232.
874 J. P. WHITE,
dition that are to be found in the older authors. I have myself treated
by reduction, since March, 1856, twelve cases of uterine inversion, varying
in duration from immediately after the occurrence of the accident to no
less than twenty-two years. Reduction in all was effected at the first
effort, and, as far as could be ascertained, without laceration of tissue. By
similar measures other gynaecologists in this country and in Europe have
repeatedly succeeded in accomplishing reduction in cases of chronic in-
version, and yet the feasibility of the method is by no means uniformly
admitted by writers and practitioners at the present day.
Thus, Leishman, whose recent work on Midwifery is justly regarded
as high authority, at first hesitatingly admits that “elastic pressure
alone, or aided by incisions in the neck, will overcome every case of in-
version except when fixed by inflammatory adhesions,” but subsequently
goes on to describe the method of removing the uterus “when the doom
of the patient seems fixed;” and adds, under such circumstances, “we
can have no hesitation in resorting to a measure so extreme as the
removal of the organ.” Schroeder, a German authority whose work has
been translated and published in this country, dismisses the whole sub-
ject of chronic inversion by saying, “Reposition is easy as long as the
os is not yet firmly contracted; otherwise great difficulties may be met
with, and repeated trials under chloroform may become necessary.”
Meadows, in England, in his Manual of Midwifery, says: “When the case
has remained unrelieved for many weeks, though attempts should always
be made to secure reduction, etc., yet the chances are very greatly against
success.” Courty says that, if reduction be impossible, it will be necessary
to resort to palliative treatment or to extirpation of the uterus for its radi-
cal cure. Dillinger, in a work republished in London in 1871, says:
“Chronic inversion is held to require palliation ; if that is vain, removal
by ligature or excision.” Barnes, of London, thinks it necessary to
invent some new operative procedure, in Order to avoid “the various
methods of amputating the uterus, or of effecting forcible reduction, as
by Professor White's method,” etc., and accordingly recommends in-
cisions in the neck, and gives a plate of an elastic pessary, to aid in
effecting gradual pressure. He very justly admits the failure of elastic
bags in the vagina, as they, when distended, stretch the vagina exces-
sively, require a firm point d'appui in the perineum, which cannot always
be had, and also fail to exert pressure upon the fundus with sufficient
force and directness. He might also have added, in relation to the
elastic bags, that they produce painful pressure upon the rectum and
neck of the bladder, and cannot be borne by the patient for any conside-
rable time.
In the abstract of Society proceedings, given in the Obstetrical Journal
of Great Britain and Ireland, republished in Philadelphia, in the August
number, 1873, will be found a very full report of a discussion in the
Obstetrical Society of Dublin, on the subject of chronic inversion of the
uterus. Two cases, of six and seven months respectively, were reported
by Drs. Kidd and Johnston, giving rise to a debate on the subject in
which several members present participated. Dr. McClintock, in the
course of his remarks, said that he was satisfied that cases would arise
where all manipulations would entirely fail to replace the organ. The
President, Dr. Evory Kennedy, said that, in dealing with these cases of
| Leishman’s System of Midwifery, American edition, p. 417.
* Manual of Midwifery, American edition, page 315.
C H R ONIC IN W E R SION OF TH E U T E R U S. 875
inversion, they could not classify them merely as acute and chronic. He
thought there was an intermediate stage, in which it was just possible to
reduce by compression the uterus back into its place, but when that stage
was passed, the thing became impossible. He looked upon it that up to
four or five months after the accident the case was not a chronic one,
and that facilities still existed for reduction which did not exist at a
later period. Again, that he was not aware of reduction having been
effected after fifteen years. He thought that the condition of the tissue
would be so altered in the course of ten or fifteen years that it would
be totally impossible to effect reduction at the end of that time.
In the January number of the Obstetrical Journal, for 1876, a descrip-
tion of the amputation of an inverted uterus is published without one
word of editorial comment. It was of only three months’ standing, and
was excised with the écraseur by Professor Martini Barta, as the only
means of arresting the hemorrhage incident to this condition. During
the present year also, I find published, in the American Journal of
Obstetrics, an article “On Ablation of the Body of the Womb in irre-
ducible Uterine inversion, by External Hysterotomy,” by M. Donné, of
Paris. This paper, which was read before the French Academy of
Medicine, arrives at the conclusion that external hysterotomy is an
extreme surgical resource, but precious in cases of irreducible inversion."
But it is useless to multiply citations illustrative of the hesitation and
prejudice which still prevail on this subject, recommending, as several
authors do, for the relief of uterine inversion, an operation of much greater
danger to the patient than reduction, and one which leaves her, when
she escapes with her life, in a sadly mutilated condition.
Whence this almost universal want of confidence? The cases of reduc-
tion are now so numerous, and the operation, in my opinion, so demon-
strably practicable, as not to admit of doubt. I am utterly unable to
account for this unbelief, and feel, therefore, justified in detaining you
with a brief history of the steps by which I arrived at a different conclu-
sion. Some remarks upon the method of operating, and a reference to
three illustrative cases, will also be added.
There may be found in the Buffalo Medical Journal for March, 1856,
an account of a case of inversion of eight days’ standing which had been
reported, with a description of the successful operation for its reduction,
to the Buffalo Medical Society in the preceding February. I concluded
that article with the following remarks: “This case is regarded as inte-
resting in many respects. It will encouragé the growing belief among
accoucheurs that reduction may be undertaken with reasonable hope of
success, at a period much later than most writers have heretofore advised.”
In the same article, alluding to a case of fourteen days’ standing which
had fallen under my observation long before (in 1842), and in which, in
accordance with the teachings of that day, no attempt at restoration had
been made, I added: “With my present views upon this subject, I should
abandon such a case as hopeless only after a long effort at reposition.”
Fully convinced, from the result of the efforts made in this instance,
eight days after inversion, of the feasibility of restoring the uterus in
many cases heretofore considered irreducible, I did not meet with an
opportunity of putting my convictions to the test until March 12, 1858,
when I visited Mrs. M., near Hornellsville, N. Y., who had been confined
on the 22d of September previously, almost six months before, and, after
| American Journal of Obstetrics, June, 1876, page 348.
876 J. P. WHITE,
about one hour's continuous effort, succeeded in repositing the uterus,
which had been completely inverted. A full account of this case, with
illustrative plates and a description of the manner in which reduction
was accomplished, was published in the July number of the American
Journal of the Medical Sciences for 1858. Permit me to crave indulgence
for one word in relation to priority in this operation. Tyler Smith, in
London, on April 24, 1858, published in the London Medical Times and
Gazette an account of a successful operation for inversion. But I submit
that this was forty-two days after my operation in Hornellsville, and
more than two years after I had taken the initiative and had published
my views and “hopes,” in connection with the report of a case of eight
days’ duration. -
Upon this point, I trust that I shall be pardoned for gratefully quoting
the following passage from an able article on this subject by the late Dr.
Henry Miller, the impartial and distinguished Professor of Obstetrics in
the University of Louisville: “Before I proceed to do this [give an
account of the method of manipulation pursued by Dr. White], it is meet
that I should pay a tribute of honor to our countryman, Professor James
P. White, who has not received the credit he so well deserves for his
leadership in the revolution of gynaecological practice which he inaugu-
rated.” The writer then proceeds to a careful analysis of the facts which
led him to the above conclusion, which it is unnecessary here to detail.
On August 24, 1858, in the presence of Professors Austin Flint, Austin
Elint, Jr., Thos. F. Rochester, W. H. Mason, and others, I reduced an
inverted uterus of over fifteen years’ standing. A full account of this
case, as reported to the Buffalo Medical Association, with the remarks
of the above-named distinguished gentlemen, will be found in the Buffalo
Medical Journal for October, 1858. The difficulty encountered in the
operation bears no proportion to the duration of the inversion. I believe
it to be as difficult to restore the uterus immediately after complete invo-
lution has taken place, as at any subsequent period. In No. 9 of my
series, a case of only six months’ duration (at Port Dover, Canada, reported
to the Medical Society of the State of New York, and published in the
Transactions of that body for 1872), reduction was far more difficult than
in the case of fifteen or in that of twenty-two years. In the case of six
months, two protracted efforts, under chloroform, had been made before
I saw the patient; each attempt had been succeeded by some peritoneal
inflammation, and it was the opinion of all present at the final operation
that reduction was protracted in consequence of firm adhesions of the
uterus to the surrounding tissues. The same difficulty was encountered
in my tenth case, one of nearly seven years’ duration, in New Bedford,
Mass. At an early period in the history of this case, as will be seen by
the excellent report of Prof. Bixby, the écraseur had been applied, and
such pressure made as resulted in breaking the chain of the instrument,
the operation being succeeded by inflammation, which produced adhesions.
The remark of Evory Kennedy, that “the organ undergoes such change
in process of time as to render reposition impossible,” is not well founded.
The uterus becomes as small and inflexible immediately upon the conclu-
sion of involution, which, according to the best authorities, occurs within
twelve or at most sixteen weeks after delivery, as at any subsequent period
| Thoughts on Chronic Inversion of the Uterus, specially with reference to Gastrotomy
as a substitute for Amputation of the Uterus. By Henry Miller, M.D. Richmond and
Louisville Medical Journal, April, 1870, p. 14. -
C H P O N T C IN V E R S I O N OF T H E U T E R U. S. 877
before the menopause. Reduction, therefore, at the expiration of twenty
years, is not more difficult than after the same number of weeks, as far
as the manipulation of the organ itself is concerned.
There is, however, an intervening period between the commencement
and the conclusion of the process of involution, when the organ must,
in my opinion, be handled with more care. Whilst undergoing this
change, the uterus does not possess the firmness and elasticity of the
unimpregnated organ, nor the muscular flexibility and toughness of
that at full period of gestation. Whilst in this transition state, under-
going the process of fatty degeneration, it is, I apprehend, far more
brittle and liable to rupture than after this change is fully accomplished.
In the cases in which the operation was resorted to at eight days, at
three weeks, and even at five weeks after delivery, as in my eighth case,
the organ did not possess the firmness of normal uterine tissue in the
unimpregnated state. In the report of the last case (eighth) will be
found the following remarks: “Indeed, I am induced to suspect that at
this period after delivery the uterus cannot be subjected, without danger
of laceration, to manipulations which would be perfectly safe at a later
period after complete involution has taken place. The sensations occa-
sioned by pressure were such as to excite apprehensions lest the tissues
should yield under the fingers.” It may be added also that this was the
first case in which the repositor was used, and the safety of the structures
may be attributed, in part, to its aid during the operation.
It will probably be found safer, in view of this friable condition of the
tissues after the commencement of involution, to wait for the comple-
tion of this process, notwithstanding the increased difficulties of the
operation occasioned by such delay. Priestly, in his lectures on the
subject of the involution of the uterine parietes, assures us that “with
the advance of the fatty transformations, the uterus becomes in a corre-
sponding degree friable, and continues so until it has completely returned
to its normal condition,” and that “it is occasionally so soft and friable
whilst affected by this fatty degeneration, that a sound passed into the
uterine cavity might be readily pushed through the uterine walls.” The
impression given whilst manipulating the uterus in the course of involu-
tion confirms these remarks of Dr. Priestly, and leads me to suspect
increased danger in all operative procedures upon the organ during this
physiological process.
In relation to the modus operandi of the operation of reduction, there
is little to be added to the description given in 1858, of the manner in
which reposition is accomplished. There seems great and unnecessary
ambiguity and confusion on this subject. In all recent cases, the fundus
uteri can be pressed into the body and neck, or “dimpled,” as it is
termed, by pressure upon the most depending part. In this manner I
am certain that the two cases which were reduced immediately after
delivery, and to some extent that of eight days’ duration, were carried
up. In the case of Dr. Lockwood's patient, in 1861, the womb had been
inverted for about forty minutes when I arrived. Administering some
paregoric and brandy to relieve the patient’s semi-collapsed condition, I
seized the uterus, pulled, off the partly adherent placenta, and passed
my hand, with the fundis before it, up through the neck and into the
| Report of two cases of Chronic Inversion of the Uterus, with a description of the Uterine
Repositor. Hy James P. White, M.D., Transactions of the New York State Medical
Society for 1872, page 200.
878 J. P. W HITE,
cavity of the replaced womb, with scarcely more difficulty than would
be encountered in inverting a wet bladder. Retaining my hand there
for a short time, contraction soon came on under the influence of the
ergot and stimulants which had been freely given. The patient made a
good recovery, and has since borne children. So with the case of eight
days, it is stated in the report that, “having succeeded in “dimpling’ the
fundus, pressure was maintained with the thumb at that point until the
hand had become nearly powerless. To preserve this depression whilst
the muscles of the hand were permitted to rest, a rectal bougie about
twelve inches in length and one inch and a fourth in diameter, was carried
along in its place, fixed in the dimple, and pressure unintermittingly con-
tinued through it, by the left hand outside the vulva. Gradually, the
concavity of the fundus was found to be deeper, until it finally became
completely restored.”
This is doubtless the manner in which reduction takes place in all
recent cases, whilst the organ is large and the walls flexible, and I was
at first led into the error of supposing that this same method obtained
in all cases. This delusion was, however, completely dispelled by my
first case of chronic inversion, of six months’ standing, in the account of
which the following description of the method of reduction is given.
“There can be no doubt that the os first commenced to yield, and pressed
down upon the intra-vaginal hand, which, it will be recollected, inclosed the
entire body and fundus of the uterus, and the upper extremity of the bougie,
and kept them in contact. This part [the os] gradually dilated, and passed
down upon and over the neck, which in turn dilated and doubled down upon
itself. The fundus did not perceptibly dimple in its centre or at either Fallo-
pian orifice, and was not reflected upon itself during the operation. The
organ was too firm, and the cavity too small, for any depression to be made
upon the walls of the fundus. In recent cases, on the contrary, reduction may
doubtless be effected by doubling-in, or dimpling, the fundus, and using it as
a wedge to dilate the neck and os. That reduction takes place in all cases
after complete involution by thus dilating the os and reflecting it down over
the neck and body consecutively, has been several times verified by examina-
tions made by competent observers, as well as by myself, during the progress
of these operations. The uterus and vagina in complete inversions represent
a continuous bag or sac doubled or reflected upon itself, with the open ex-
tremity of the sac securely fixed. Pressure upon the closed end of the bag
(the fundus) will, it is plainly perceived, under such circumstances, result in
straightening the bag by completely turning it the other side out. So with
the parts concerned in inversion. Pressure upon the fundus, if gentle and
well directed, pulls open first the mouth of the womb, then its neck, and finally,
if persevered in, doubles the body upon itself also, and carries the fundus
through the os, and neck, and body, to its normal position.”
I have nothing to change in this description, given twenty years ago,
of the modus operandi of reposition in chronic inversion. In the cases of
fifteen years’ and of twenty-two years’ standing, the attention of the
distinguished gentlemen who were present was called to this fact (the
reflection of the OS upon the neck and body), and they were requested to
pass a finger up beside the hand of the operator and verify the observa-
tion. Similar careful examinations were made by those present at the
two most difficult of all my reductions, that at Port Dover, Canada, and
that at New Bedford, in both of which peritoneal inflammation had
been excited by previous surgical interference, resulting in adhesions,
and in both also the same relation of parts was ascertained to exist
during the progress of the operation. In my opinion it would be unwise
C H R O NIC IN V E R SION OF THE U TE R U S. 879
to double in the fundus upon the body, after complete involution, even
if it were practicable to do so. The size of the tumor to be carried up
through the cavity of the neck and os, would be increased by this intro-
flexion, and would, by just so much, augment the difficulty of reduction.
Any one who may make the effort to dimple the fundus of the unim-
pregnated uterus into the cavity, will perceive that it is impossible to
effect reduction or inversion in this manner even upon the dead subject.
By this explanation all the apparent discrepancies, as to the manner of
reduction, can be reconciled. One practitioner has operated on a recent
case, and restored the womb by dimpling in the fundus, whilst his no
less observing and truthful fellow has restored the involuted organ by
reflecting the os over the neck and body, without at all being able to
depress the fundus. -
It is incorrect for Dr. Barnes to call the procedure just described, “a
forcible reduction.” I submit that there is no conceivable method of
dilating the os and neck of the uterus less forcible than that of making
gentle, elastic pressure upon the fundus, producing thereby equable and
moderate traction by the vagina which is attached within the os in com-
plete inversion. The vagina pulls open the os with less liability to
laceration than the pressure of the tent, the India-rubber bag, or any
other mechanical means can do. Does any gynaecologist of the present
day hesitate to dilate this canal for the removal of intra-uterine growths?
T}oes any uterine pathologist believe that it would be impossible safely
to dilate the os and bring down the fundus of the uterus—completely
inverting the organ—if carefully and perseveringly undertaken If
these questions are affirmatively answered, why may we not pull open
the neck by means of the vagina in the same gentle manner as we could
press it open when in a normal position, and thus carry the fund us up
through it by means of pressure upon that part when it is in a down-
ward direction? Perhaps I may be too sanguine, but my present belief
is that well-directed pressure upon the fundus, if continued long enough,
will, in all cases, unless prevented by firm adhesions, result in restoration
or reposition, no matter how much time may have elapsed since inver-
sion has occurred. Observation and careful reflection based upon the
cases which have been committed to my charge, now numbering twelve
in all, and varying in duration, as already stated, through nearly a
quarter of a century, confirm me in the opinion first expressed in 1858.
Indeed my convictions are very decided, and I am incredulous as to
the necessity of ever resorting to amputation, or to the still more objec-
tionable operation of gastrotomy. True, the womb may not always be
reduced at a single sitting, as in all the cases which I have encountered ;
but, by means of the “repositor,” uniform and gentle pressure can be
maintained until the osis fully dilated and the fundus pushed up through
it. The insurmountable difficulty heretofore has been supposed to con-
sist in our inability to maintain uniform and persistent pressure for a
sufficient length of time. The hand would soon become fatigued, and
another hand, even of the same individual, could not be substituted with-
out losing a part of what had been gained. This loss is increased when
the hand of a fellow practitioner is introduced to continue the operation.
No doubt great physical endurance, being able to maintain one position
for a great length of time, has been an essential element of success. The
various substitutes which have heretofore been resorted to for continuing
pressure when the operator has become exhausted, have utterly failed.
The elastic bags, so often called in requisition, press more upon the viscera
880 J. P. WHITE,
resting upon the large surfaces anteriorly and posteriorly situated, than
upon the fundus, which has no firm Ossific base of support as have the
rectum and bladder. The uterus ascends very soon, owing to the yielding
nature of the vagina and perineum, and escapes from the reach of the dis-
tended vaginal bags. The repositor (which will soon be described), when
it is deemed better to proceed in a more gradual manner, or when it may
be found impossible to effect reduction by a single effort, can be received
with the uterus into a large cylindrical speculum, and, by means of a
“T” bandage, can be made to press directly upon the fundus until the os
is gradually dilated and all resistance overcome. By means of the large
spring at the Outer extremity, the amount of pressure can be graduated
to an ounce. The disk of this instrument will follow up the fundus,
without compressing painfully the urethra or rectum, by means of this
continuous elastic pressure in the upward direction, until the fundus
disappears in the os and neck. Any intelligent assistant can be trusted
to increase or diminish the pressure, during the absence of the operator,
as the exigencies of the case may demand.
The construction and action of the “uterine repositor” will be readily
understood by reference to the accompanying wood-cut, Figs. 1 and 2.
sš
FA / ), iſ/
Zºº º
dº º º &
*
غf.--~.
- \ 24% ſ
º
º \
-- º \
d ~. |
ſºlſº 2.
Fig. 1. a. Uterus in process of reduction. b. Anterior lip or wall of the uterus with
the fingers of the left hand pressing upon it and assisting in pulling open the uterine cavity.
c. Posterior uterine wall semi-reflected. d. Anterior vaginal wall. e. Wooden or hard
rubber stem of Repositor, its enlarged extremity held in contact with the fundus by the
intra-vaginal hand of the operator. f. Distal extremity of stem made into a screw, so as to
be fastened into g, a coil of No. 11 steel spring wire, requiring eight or ten pounds pressure
by the breast of the operator, against which it is placed, to bring it down.
Fig. 2. h. Uterine extremity of stem e, which is terminated with a soft India rubber disk
13 inch diameter, the concavity into which the fundus is received being about one-halfinch
deep, with its terminal margin thin and soft.
The instrument is composed of a stem of wood or hard rubber, curved
to conform to the vaginal curvature, with a coil of steel wire attached to
the outer extremity, whilst the other end is expanded and hollowed so
as to receive the fundus of the uterus in its concavity or disk. The edge
of this disk is tipped with soft rubber, being an inch and three-eighths
in diameter, and about half an inch deep. The concave extremity of




C H R O N IC IN W E R S I O N OF T H E U T E R U S. 881
this instrument is carried up into the vagina and placed in contact with
the fundus, and then firmly held by the hand in the vagina. The outer
end of the instrument, or coil of wire, is placed against the breast of the
operator on the same level with the uterus. By means of this large cir-
cular spring, the instrument readily keeps its place on the clothing of
the operator, and leaves the other hand free to be used above the pubes
to assist in fixing the uterus and assist also in forcing open the dilating
Os, which can ordinarily be plainly felt through the abdominal walls.
The spring at the outer end of the instrument enables the operator
without danger of lacerating the tissues to keep up a constant gentle
pressure upon the fund us, and by leaning forward to increase this pres-
sure intermittingly. The force thus exerted is applied more directly
upon the fundus by means of the repositor than would be possible if the
thumb and fingers were used, or the round end of the large bougie. I have
often been delighted, since I have used the repositor, to find that it gave
me a third hand which did not become fatigued, and which permitted me
to use the left hand in manipulating over the hypogastrium, while the
right easily held the instrument in contact with the fundus, and firmly
grasped that part of the uterus which was not yet reflected, and which
remained in the vagina. The disk, in which the fundus rests, is less
likely to bruise or lacerate the organ than any other mechanical appli-
ance. The intra-vaginal hand compresses the body and fundus, and
lessens its vascularity, whilst something is gained by intermitting the
pressure, also lessening by its use the exhaustion incident to unintermit-
ting muscular effort on the part of the operator. -
It may be well to state that the patient is always placed at the side
of the bed with the feet resting in the laps of intelligent assistants, each
of whom is also charged with the care of the knee and hand of that side.
The hips of the patient are brought quite to the edge of the bed, which
is raised so as to bring the parts on a level with the breast and arms of
the operator. He should occupy the space between the extremities of the
patient, resting upon his knees. This position gives him greater mobility
than the sitting posture, and is much less fatiguing than standing. It is
best to manipulate the uterus freely, thus rendering it more flexible and
lessening its vascular congestion, before commencing the effort of restora-
tion. The back of the hand should rest in the concavity of the Sacrum,
and should be completely introduced into the vagina, the body and fun-
dus of the uterus with the upper end of the repositor being firmly grasped
in the palm. The anaesthetic should be entrusted to a competent practi-
tioner, and should be carried not only to insensibility, but as far as it can
be without danger. It is unnecessary to add that the operation should
never be undertaken without having had the patient’s bowels com-
pletely evacuated a few hours previouſly. It is also unnecessary to say
that it should not be undertaken during the menstrual flow. Some-
times, however, the hemorrhage is so continuous that the menstrual epoch
is not well marked, when the operation may be proceeded with without
fear of dangerous hemorrhage. It is remarkable, in view of the slight
causes which usually give rise to hemorrhage in most cases of inversion,
how little blood is lost during the manipulations incident to restoration.
This is doubtless in a great measure due to the fact that the bleeding is
controlled by the compression exerted by the hand around the body and
fundus. Nor, if the manipulations are gently and carefully practised, is
the danger of metritis by any means as great as might be expected.
I shall now give the histories of three typical cases, one of six months’,
56
882 J. P. WHITE,
one of seven years’, and one of twenty-two years’ duration. In order
to secure confidence in the feasibility of the operation, and avoid the
bias which inevitably attaches to the observation of an enthusiast, I
have selected two which were kindly reported by distinguished gentle-
men who witnessed the operations. The first case is one of six months’
duration, and the first in which I effected reduction after complete in-
volution, although I had already successfully treated two cases of much
shorter duration. &
CASE I."—On the third of March, 1858, Dr. C. D. Robinson, of Hornellsville,
wrote to me that he “had been called in consultation with a neighboring phy-
sician, and found a patient with an inverted uterus of more than five months’
standing.” My opinion was desired as to “the possibility of returning the
inverted organ and the propriety of extirpation.” In my reply, the impro-
priety of removal, unless as a last resort, was insisted on, and the hope ex-
pressed that a prolonged and well-directed effort might succeed in reduction;
and it was said that, in my belief, it was due to the poor woman that the
attempt should be made before she was abandoned to the evils of chronic
inversion. A few days subsequent to this date, I was requested to visit her at
my earliest convenience. Engagements in the city prevented my complying
with this request until the twelfth of March. On accompanying Dr. Robinson
to the residence of the patient, Mrs. A. M., I found her extremely anaemic,
confined to her bed, and suffering greatly from the loss of blood.
The history of the case, as furnished by herself, her husband, and the medi-
cal gentlemen who had been in attendance, was as follows: At the age of 30
she was taken in labor at the maturity of her second pregnancy, on the 22d
day of September last, Dr. Batten in attendance. This labor was natural to
the conclusion of the second stage, when she gave birth to a large male child.
Placenta adherent, but removed at the expiration of about thirty minutes,
and its delivery followed by copious flowing, severe pain, and faintings. The
prostration was so great as to require the constant use of stimulants during
the succeeding forty-eight hours, and for three weeks she continued extremely
weak and faint. At about this time she took an aloetic cathartic, which occa-
sioned violent efforts at stool, accompanied by pains resembling those of
labour. Profuse hemorrhage followed these straining efforts, and a large
pear-shaped tumor made its appearance through the os externum. The neck
or smaller extremity of this body was at the vulva, and the larger extremity
down between her thighs. By the assistance of her husband, she was enabled
to return this tumor within the vulva, when a messenger was dispatched for
Dr. Batten. Dr. B., upon his arrival, introduced his hand into the vagina
and carried the uterus high up into the pelvis, and resorted to astringents
and cold for the purpose of arresting the flow of blood, which continued pro-
fuse and difficult to control. The prostration being at this time very great,
the horizontal posture was enjoined, stimulants and tonics were given, and the
bowels were moved by enemata.
During the succeeding three months she had occasional hemorrhages, which
were severe, with constant discharge of muco-sanguinolent matter. Two or
three times, during this period, she so far improved as to walk about her room
and partially supervise her domestic affairs, though looking very pale and
being very feeble. About the middle of January she had another severe
attack of hemorrhage, the tumor again presented itself externally, and was
again returned as before; that is, pushed back within the vulva. Dr. B. again
visited her, and prescribed such remedies as seemed necessary to control the
flowing. Since about the first of February she has been compelled, from the
debility consequent upon the exhausting, sanguinolent and leucorrhoeal dis-
charges, to preserve the recumbent posture. Lactation, doubtless, has added
| Wide Amer. Journ. of Med. Sciences, July, 1858.
C H R O N IC IN V E H S I O N OF T H E U T E R U S. 883
to the exhaustion, and being confined to her bed she has little appetite, the
stomach is irritable, and the bowels are costive. Ever since the patient took
the aloetic cathartic and the tumor made its first appearance between the
thighs, she has been aware of the existence of something unnatural in the
vagina. This body has occasionally made its appearance externally, requir-
ing the assistance of her husband to replace it, and she has had frequent
attacks of a “straining sensation” described as accompanying its first com-
plete descent. She has suffered greatly from all the symptoms arising from
exhaustion and from sympathy with the uterine irritation necessarily developed
by the malposition of the womb. The pulse now numbers 130; she is
blanched or wax-colored, and grows dizzy and faint when raised to the semi-
recumbent posture, and cannot be moved without experiencing a sense of pros-
tration. It should have been stated that, on February 25, Dr. Robinson, of
FIornellsville, and Dr. Reynale, of Dansville, visited the patient in consulta-
tion with Dr. Batten, when inversion of the uterus was diagnosed, and measures
calculated to ameliorate her condition were resorted to.
Upon making a careful examination (nearly twenty-five weeks having now
elapsed since confinement), the fundus of the uterus is found just within the
os externum, and about one inch and three-fourths in its transverse diameter,
and scarcely exceeding an inch in its antero-posterior diameter (Fig. 3). The
body and neck of the organ occupy the vagina, and the neck is not more than
one inch in diameter, and feels like the pedicle of a polypus. The inversion is
recognized as complete, and the organ is no larger than when in its natural
position six months after delivery. Introducing a large cylindrical speculum
into the vagina, the fundus of the uterus passes readily into its cavity, thus
demonstrating the complete involution of the uterus, and bringing distinctly
into view the rough mucous membrane of its now outer covering, which bleeds
upon the slightest touch with the finger or sound. It is seen to be covered
with muco-purulent matter also, and is not susceptible of indentation by
pressure with the point of the sound.
Fig. 3. Fig. 4.
Fig. 3.−Position of the uterus in chronic inversion. º
Fig. 4.—Vagina put upon the stretch by pressure upon the fundus.
The bowels having been freely moved by an enema, I proceeded to the ope-
ration of reduction in the presence of Drs. Robinson, Reynale, Batten, Dimick,
and Mr. J. W. Robinson, medical student. The patient was placed, for the
operation, upon an elevated, firm bed, with the hips brought quite to its edge,
the knees separated, the feet resting in the laps of Drs. Reynale and Robinson,
with directions to each to support a knee and hand of the patient, and prevent

884. J. P. W H ITE,
her from moving about. Dr. Batten brought the patient moderately under the
influence of chloroform, which was continued throughout the operation, whilst
I placed myself upon my knees, between the patient's legs, her pelvis being at
a convenient elevation for manipulation. I introduced my right hand com-
pletely into the vagina, and firmly grasped the entire body and neck of the
uterus. It may here be remarked that the parts were so firmly contracted as
to render the introduction of the hand difficult. At the same time that the
entire uterine tumor was grasped by the right hand, a large rectal bougie was
carried up, and also received into its palm and held firmly in contact with the
fundus of the uterus, the hand being sufficiently large to receive both, and
keep them in apposition. Continuous, gentle pressure was now made upon
the external extremity of the bougie with the left hand, whilst the right com-
pressed the uterine tumor, and kept the upper extremity of the instrument
directly upon the fundus, and, with the dorsum of the hand in the concavity of
the sacrum, directed the force in the axis of the pelvic cavity, putting the
vagina completely upon the stretch (Fig. 4). This pressure was exerted, and
this position unintermittingly maintained, although the force was not to such
a degree as to endanger laceration of the utero-vaginal connection, until my
strength was nearly exhausted from continuity of effort. At length, and when
about to relinquish the task, the uterine tumor began to shorten at its neck,
and the mouth of the organ to push upon the upper surface of the hand. No
depression or dimpling of the fundus was at any time perceptible. Ascending
more and more rapidly as the neck diminished in length (Fig. 5), the fundus
finally passed out of the hand, and was easily pushed by the bougie through
the mouth and neck of the organ up to its proper position (Fig. 6).
Fig. 5. Fig. 6.
~TT-_^
Fig. 5-Manner in which the os and neck double upon the body.
Fig. 6.-After complete restoration.
In order to verify the restoration, Simpson's sound was introduced alongside
of the bougie, and was found to enter a little more than two and one-half
inches above the os, which could now be distinctly felt. The large speculum,
already referred to, was now slipped up around the bougie, when the os was
brought distinctly into view, surrounding also the bougie. The sound was
again carried through the os to the fundus, through the speculum, and all the
medical gentlemen present saw that it passed easily beyond the mouth, to the
shoulder of the sound, and could not, without force, be carried further. Thus
was demonstrated not only the reduction of the uterus, but that the organ
was accurately measured, and found scarcely, if at all, enlarged. The specu-
lun) and sound were now withdrawn, the patient carefully removed to the bed,

C H R O N IC IN W E R SION OF T H E U T E R U S. 885
and the bougie retained in place by the hand, to prevent reinversion. Mean-
While, stimulants were given to sustain the patient, and ergot in such doses as
were deemed likely to excite the tonic contraction of the uterus. The patient
soon recovered from the effects of the chloroform, and expressed herself as
feeling quite as comfortable as before the operation from which she had suffered
but little. The discharge of blood was slight, and, when the effects of the
chloroform had passed off, and she had taken a little brandy and water, she
expressed herself as feeling comfortable. Pulse not sensibly changed in
quality, and numbering the same as before the operation.
Drs. Robinson and Batten remained with the patient during the succeeding
night, alternately maintaining the bougie in the uterus, supporting it gently,
and rendering such other attention as the patient required. Continuing the
pressure upon the fundus of the uterus was perhaps unnecessary, but it was
thought safe not to withdraw the bougie until the next day."
March 13, Dr. Robinson wrote: “The patient is quite comfortable; pulse
108. Free from pain. Withdrew the bougie this morning, and found the os
uteri embracing it pretty firmly.” Tonics with nutritious diet were continued,
and quietude in the horizontal position enjoined. On the 15th, he wrote:
“The patient is quite comfortable this morning. Made a digital examination,
and found the uterus perfectly in situ, and mouth well contracted. Has some
appetite. Pulse 100.” March 23, he again wrote: “She is improving; has
been much annoyed by neuralgia and sickness of stomach, but both are giving
way, as is the leucorrhoeal discharge. The treatment has been sustaining
(porter, wine, quinine, iron, etc.), with nutritious diet.” In conclusion, Dr. R.
adds: “She will get well, and I feel gratified in the success of the effort of
restoration, not only on account of the patient being relieved of a loathsome
malady, but also that I have been instrumental in contributing to the profes-
sional reputation of one for whom I feel a deep friendship, as your success in
this case will relieve obstetrical surgery from the opprobrium which has hith-
erto been attached to it in cases of chronic inversion of the uterus.” In reply
to a letter of inquiry from me, Dr. Robinson wrote, April 22: “I visited her
yesterday, and found her very cheerful and able to sit at the table and take
tea with us. Her final recovery is now beyond all doubt. In short, the ope-
ration has been as successful as its most sanguine friends could desire. Her
convalescence has been protracted ; slow, perhaps; but when we take into
account the great prostration from the long continuance of the malady, and
the exhausting hemorrhages and leucorrhoeal discharges to which she had been
subjected, the only wonder is that she has recovered at all.” This patient, I
am informed, nearly twenty years after reduction (September, 1876), is quite
well, and able to attend to her household duties.
CASE II.”—In July, 1872, Dr. George T. Hough, a very intelligent prac-
titioner in New Bedford, Mass., wrote me to know “if I could be induced to
come there and operate upon a case of chronic inversion of the uterus which
had lately come into his hands.” After long efforts to persuade the incredu-
lous sufferer and her friends of the feasibility of making an effort for her relief,
I was at length invited by him to visit her on the 15th of May, 1873. In
passing through Boston on my way to New Bedford, I called upon Dr. George
H. Bixby, the celebrated gynaecologist of that city, and invited him to accom-
pany me. Dr. Bixby was present at the operation, rendered valuable assist-
ance, and furnished the following report to the American Journal of Obstetrics,
which I take the liberty of transcribing with many thanks, not only for this
report of the case, but for his many courtesies.
Mrs. H., aged 35, native of New Bedford, first menstruated during her thir-
teenth year. She married at fourteen, and has given birth as follows: the
1 In all subsequent cases the bougie has been withdrawn immediately after restoration,
as there is little or no danger of spontaneous reinversion while the patient is kept quiet
and in the horizontal position.
2 Wide Transactions of the New York State Medical Society, 1874.
886 J. P. WHITE,
first, fourteen years after marriage; the second, eighteen months after the
first. She was attended in her last confinement, more than six years ago, by
an irregular practitioner. After the delivery of the child, the medical attend-
ant left the patient for two hours, and on his return proceeded to remove the
placenta in a very rough and hurried manner. For three weeks convalescence
proceeded as usual. She was then taken with profuse hemorrhage. The latter
continued in varying quantities and intervals for several weeks, when the
family physician was called. Upon examination, he diagnosticated uterine
polypus, and a surgeon was summoned to remove it. Accepting and confirm-
ing the opinion of the attending physician, the operation was immediately
undertaken. The wire of the écraseºur was with some difficulty applied about
the pedicle, but upon making traction it parted. Upon close inspection, after
the accident, it was ascertained that the case was one of uterine inversion,
originally partial, but rendered complete by the previous manipulation.
Nothing further was done at this time.
June, 1872, Dr. George T. Hough, of New Bedford, was called. He found
the patient confined to her sofa, where she had been almost continuously since
her last confinement. She was thin and chlorotic ; menstruation had been
regular as to time, but profuse. She suffered, in the intervals, from frequent
attacks of hemorrhage, which were provoked by exertions as slight as walking
across the room. Frequently slight hemorrhages through the entire interval
of menstruation ; at other times there was a complete absence of the same. A
vaginal examination revealed the following: External genitals normal; within
the vagina, a round, regular, comical body, more or less immovable, and con-
stricted at its superior extremity. Upon the application of the usual diag-
nostic signs, Dr. Hough pronounced the case one of chronic inversion of the
uterus. Not feeling quite sure of his diagnosis, Dr. Johnson, of New Bedford,
was called in consultation. Dr. Hough's opinion was confirmed by Dr. J. In
June, 1872, Dr. Hough consulted Prof. James P. White, of Buffalo, by letter,
and subsequently Dr. White was called to see the case.
On the sixteenth of May, 1873, an examination was undertaken by Dr.
White, in the presence and with the assistance of the following gentlemen :
Dr. Mason, of Norwich, Ct., Professor of Physiology in the Buffalo Medical
College, Drs. Hough, Johnson, Hooper, Vermeyne, and Hayes, of New Bedford,
and Dr. Bixby, of Boston. Artificial teeth removed and urine drawn; etheriza-
tion commenced by Prof. Mason. When completely anaesthetized, the patient
was placed upon her back across the bed with her pelvis near one side, in a
favorable position to allow the lower extremities to be flexed and rest in the
laps of two seated assistants. By palpation the uterine tumor in the Supra-
pubic region was found wanting. The excessive emaciation of the patient
rendered this point easily demonstrable. By the vagina, the finger came in
contact with a smooth, round, cone-shaped body, more or less movable, and
constricted at its upper extremity. By the sound, a complete cul-de-sac was
found encircling the entire constricted portion. By recto-vesical exploration,
no interposing tumor was found, and the finger in the rectum was separated
merely by the rectal and vesical walls from the sound in the bladder. The
case having been clearly recognized as one of chronie inversion of the uterus,
the operation of reduction was undertaken as follows: Prof. White as-
sumed the kneeling posture before the patient, and between the two seated
assistants. The left hand, well-lubricated, was carefully introduced into the
vagina, and the fingers slowly insinuated under and about the mass. While
the latter was sustained by the palm of the hand, the constricted portion
was embraced by the thumb and finger from opposing sides. With the
right hand, Dr. White's “ egg-beater, uterine repositor,” was introduced
into the vagina, its concave extremity placed against the fundus or cone
of the tumor, and its spring-end against the chest of the operator. This
done, the right hand. now free, was employed for making counter-pressure
above the pubes, or for any other desired purpose. Gentle but unyielding
C H R O N IC IN W E R SION OF T H E U T E R U S. 887
pressure, rendered equable and manageable by the action of the Spring, was
continued without any variation for thirty minutes, little more force being
exerted than that required to compress the spring. Thirty minutes after
the commencement of the operation, patient in good condition ; hemorrhage
insignificant; tumor in vagina still firm; constriction unyielding. One hour
from commencement of the operation, hemorrhage insignificant ; tumor more
soft ; a tendency to collapse, manifested by retarded respiration and pulse,
was combated by the injection of an ounce of clear brandy into the rectum,
to which the heart’s action promptly responded. The use of the “egg-beater
repositor” was now continued, its action varied by a slow to-and-fro motion
of the body upon the spring. At one and a half hours, the patient continued
to bear the operation well; hemorrhage insignificant ; pulse somewhat accele-
rated ; tumor more soft and compressible ; a large-sized, gum-elastic, rectal
bougie was substituted for the “egg-beater.” At two hours and ten minutes,
under the pressure of the bougie and manipulation with the fingers, the con-
striction suddenly relaxed, and the organ assumed its normal position. The
patient rallied from the anaesthesia in less than a quarter of an hour. Re-
action took place slowly. Notwithstanding this prolonged manipulation,
neither the vagina nor the perineum was in any way injured.
Dr. Hough thus writes in regard to the subsequent condition of the patient :
The day after the operation there were symptoms of metritis, which rapidly
disappeared under appropriate treatment. There were no bad symptoms fol-
lowing the operation, but two weeks after she suffered from a slight attack of
pneumonia from exposure to a draſt of cold air at night. One month after the
operation : She has sat up, has a good appetite, sleeps well, and gains strength
daily; vaginal examination reveals the uterus in a normal position. Some
months afterwards, desiring to know the condition of the patient, I addressed
a note of inquiry to Dr. Hough, to which the following reply was received :-
NEw BEDFord, Jan. 16, 1874.
My DEAR DR. WHITE:- At your request I visited Mrs. H. yesterday. She says, “Tell
the Doctor that I am perfectly well in every respect,” and she seems so. Upon inquiry, I
find all the functions normal; menstruation perfectly regular, lasting two days; scanty, if
anything. She has lost her chloro-anaemic look, and has a good color. Fats and sleeps
well, and in fact is well. Very respectfully yours. GEO. T. Hough.
CASE III. In the winter of 1871–2, I received a letter from Dr. O. C. Strong,
of Colden, informing me that there was in his neighborhood a case of inversion
of more than twenty years’ duration. The Doctor had been called in to pre-
scribe for the patient during one of the attacks of flowing from which she had
suffered ever since the birth of her child, now twenty years old. Not content
with the assertion that she was “bleeding to death,” and seeing her exsanguine
and feeble condition, the Doctor resolved, if possible, to ascertain the cause of
the hemorrhage, before undertaking to prescribe a remedy. Upon instituting
a careful digital examination, he recognized what no one who had preceded
him in the treatment had ever suspected—complete inversion of the uterus.
He soon after wrote me on the subject, asking whether I would be willing to
undertake its reduction, etc. Considerable time elapsed before the patient
could be made to believe that there was any hope of her relief from a malady
which had prostrated her for more than twenty years. At length, through the
persuasion of her physician, Dr. Strong, she was induced to invite me to under-
take its reduction. The case was reported by A. T. Livingston, M.D., assistant
physician in the New York State Lunatic Asylum, in Utica, and from his notes
I make the following extracts:—'
The history of the patient, prior to the time of the operation, has been
obtained principally from a thesis presented to the faculty of the Buffalo
Medical College, in February, 1871, by Dr. O. C. Strong, of Colden, N. Y. Mrs.
&
| Buffalo Medical Journal, August, 1872.
888 J. P. W HITE,
A. D., then aged twenty-four, and residing in Buffalo, gave birth to a female
child, July 15, 1850. The midwife who attended her in her confinement, experi-
enced some difficulty in the removal of the placenta, but finally succeeded in
pulling it away. This act was followed by so much hemorrhage as nearly to
destroy the woman’s life. From this time until the day of the operation she
suffered a continual loss of blood, which twice a month amounted to flooding.
She consulted various physicians in relation to her condition, but received
no benefit from any of them. This is not surprising when we are told that,
until Dr Strong was called to see her in 1870, no physician had ever proposed
to make an examination per vaginam with the view of determining the cause
of the hemorrhage. -
March 2, 1870, Dr. Strong was called to attend Mrs. D. He found her
lying upon a bed, about which were evidences in abundance of the terrible
flooding which had just occurred. Upon making a digital examination, he
discovered a tumor about the size and shape of a small pear, occupying the
vagina, which, after a careful specular examination, he diagnosed as an inverted
uterus. Dr. S. informed his patient that he considered that her condition
permitted the use only of palliative measures, and advised the use of tonics
and local astringents. Afterwards, learning of Dr. White's previous, successful
operations for chronic inversion of the uterus, a correspondence arose between
that gentleman and himself, with reference to the case of Mrs. D., which re-
sulted in an invitation to Dr. White to visit the patient, and, if upon exami-
nation he should think it advisable, to attempt the reduction of her uterus.
June 23, 1872, Prof. White, with Profs. Julius F. Miner and M. G. Potter,
Drs. Geo. N. Burwell, W. C. Phelps, and the writer, whom he kindly invited
to accompany him, proceeded to the residence of the patient in the town of
Colden, N. Y. She was found to be feeble and very anaemic, and slight hemor-
rhage from the tumor was then occurring. Prof. Potter, who was requested
to take charge of the anaesthetic, administered some chloroform to the patient,
and the tumor was then examined by several of the gentlemen present. It
resembled in size and shape an ordinary hen's egg, and was suspended in the
vagina by a long, narrow pedicle continuous with its upper and smaller ex-
tremity. This appearance, particularly the small and elongated cervix, led
some who examined it to doubt its being a uterus at all, and to consider it
rather a polypoid growth. But a probe could not be passed along the pedicle
into the os, as might have been done had the tumor been a polypus, nor could
the uterus be detected by palpation over the abdomen. A uterine sound passed
into the bladder could be felt by the finger in the rectum above the tumor, and
by the hand placed over the hypogastrium ; also the finger, passed up the rectum,
came in contact with the anterior abdominal wall as felt by the other hand.
All these diagnostic means proved the absence of the uterus from the situation
which it ordinarily occupies. By these negative proofs, Dr. White was entirely
convinced that the tumor was the inverted uterus, and he therefore proceeded
to attempt the reposition of the same in the presence of the above-named
gentlemen, and of Drs. Strong, of Colden, G. H. Lapham, of Aurora, and Davis,
of Boston. Dr. Potter had produced anaesthesia by chloroform, which he now
exchanged for ether, with which he kept the patient anaesthetized during the
operation. Dr. White assumed a kneeling posture in front and between the
legs of the patient, who had been placed upon the side of the bed with her hips
projecting a little beyond its edge, and her feet resting in the laps of Drs. Miner
and Phelps, who sat on either side of Dr. White, each supporting a knee and
holding a hand of the patient. Dr. White then introduced his right hand into
the vagina, and began manipulating the tumor. This manipulation consisted in
compressing the uterus, which relieved its congestion and rendered it more
pliable, and in making gentle pressure in the line of the axis of the pelvis by
the use of the uterine repositor. After continuing this a short time the doctor
brought the tumor down to view, when a glance sufficed to assure the doubting
of its true nature. By the pressure which had been exerted the neck had been
C H R O NIC IN V E R S I O N OF T H E U T E R U S. 889
shortened and dilated, the body and fundus reduced in size, the superior angles
(now inferior) were distinctly seen, and altogether the tumor then presented
the normal outline of a uterus of small size. The repositor was again intro-
duced, and a pressure of eight or ten pounds exerted by it, and, at the same
time, compression was made by the hand within the vagina upon the portion
of the uterus protruding beyond the os, the same hand also retaining the fundus,
uteri and the repositor in coaptation, whilst the left hand was employed in
pressing above the pubes or through the rectum. When, in this manner, the
cervix had been made to embrace the fundus, the uterine repositor was substi-
tuted by a large rectal bougie, with which pressure was continued until the
close of the operation.
At the end of an hour and fourteen minutes, Dr. White was obliged to dis-
continue his efforts on account of the benumbed condition of his intra-vaginal
hand, caused by the pressure upon it of the narrow and unyielding vagina.
The fundus was at this time within the cervix and above the os, and the doc-
tor considered the reduction substantially accomplished. He requested Dr.
Miner to continue the manipulation, which he did, and in sixteen minutes, or
just one hour and a half from the beginning of the operation, Dr. Miner en-
joyed the satisfaction of announcing that the uterus, which for twenty-two
years had been completely inverted, was now as completely reposited. Two
hours after the operation, when we left her, the patient was quite as comfort-
able as could have been anticipated. An opiate was administered, and direc-
tions were given the attendants to keep her perfectly quiet for at least a
fortnight. By letter dated June 27, Dr. Strong reports: “Mrs. D. doing
better than we had dared to expect.” July 2, Dr. Strong writes: “Our patient
is doing well, and nothing has yet interfered with her progress toward re-
covery.” July 19. “Since the operation upon Mrs. D., nothing has trans-
pired to mar the beauty of the result. The pulse has at no time exceeded
ninety per minute.” At this time a careful examination “shows the uterus
occupying its normal position, the intra-vaginal portion of the neck presenting
the ordinary appearances of mild cervicitis. The patient is now about upon her
feet some portion of her time, and everything points to a rapid, and I think,
perfect cure. She has had no sanguineous discharge since the operation.”
On the 23d of August, two months after the operation, the following letter
was received :- -
MY DEAR Doctor :—Allow me to congratulate you on the perfect success of your opera-
tion upon Mrs. D. I have delayed writing thus long that I might not be required to retract
any statements made in regard to the success of the operation. The most sanguine could
not have expected so good a result. She now does her own work, goes on foot to the
neighbors', rides ten miles and returns over the hills, and in fine now seems competent to
perform her part in life. At the expiration of four weeks from the operation, she had a
regular menstrual discharge, which seemed perfectly normal both in regard to amount and
character. Your obedient servant, O. C. STRONG.
In order to ascertain her subsequent condition, I addressed a note of inquiry
to the doctor, and received the following reply:—
º CoLDEN, Jan. 20, 1874.
My DEAR Doctor :—Your note of inquiry is received. In reply permit me to say that
Mrs. D. is in the enjoyment of good health ; that her menses are regular; that in her
present appearance one can see nothing to tell the tale of those twenty-two long years
of suffering; nothing that speaks of terrible floodings; and, in fine, nothing to show that
& )
she ever possessed an inverted uterus. Very truly yours, O. C. STRONG.
It would seem an unnecessary expenditure of the time of this learned
body to detail the remaining nine cases. Those related fairly illustrate
the state of the organ at the different periods of the accident, and the
mode of operating for its restoration. The result has been, in all the
cases encountered, restoration by manipulation on the first trial, and as
is believed without serious injury to the tissues, thus confirming the
conviction that all cases are curable, irrespective of their duration.
890
CASE OF RETROVERSION OF THE GRAVID UTERUS;
TREATMENT BY PUNCTURE; RECOVERY.
BY
THOMAS F. ROCHESTER, M.D.,
PROFESSOR OF PRINCIPLES AND PRACTICE OF MEDICINE IN THE MEDICAL DEPARTMENT OF THE
UNIVERSITY OF BUFFALO.
ON December 17, 1874, three children, the eldest ten years of age,
were attacked with a severe form of scarlet fever. Their mother, with
characteristic maternal devotion, was almost their only nurse, although
at the time of their seizure she had commenced the second month of her
fifth pregnancy. She was on her feet a great deal, and very frequently
lifted and bathed the children, although herself of slight and delicate
frame. To this she ascribed the unusual pressure and bearing down ex-
perienced in the recto-vaginal region, such as she had never felt in her
previous pregnancies.
A little after midnight on March 17, 1875, her husband informed me
that his wife feared a miscarriage, as she was in great pain, and flowing
profusely. Visiting her immediately, and making a digital examination,
I found the vagina filled with an elastic, globular mass, as large as the
foetal head at full term. Nothing like an os uteri could be found. The
sub-pubic space was tightly filled, as was also the perimeal; it was im-
possible, by rectal exploration, to pass the finger above the lower segment
of the tumor. The hemorrhage was free, and was found to emanate
entirely from the urethra. A catheter was introduced with considerable
difficulty, the instrument taking a backward and downward direction,
and serving for the evacuation of about six ounces of very bloody urine.
So impacted was the vagina, and so strong was the pressure upon the
rectum, that it was impossible to make the vesico-rectal exploration by
the catheter and finger.
The case was presumptively one of retroversion, or rather of complete
eversion of the pregnant uterus, at or exceeding four months. The con-
dition was so grave that the attendance of my colleague, Prof. James P.
White, was obtained in consultation as soon as possible. He made a
most critical examination, and was, like myself, unable to find the os
uteri. We concurred in the opinion that it was either complete eversion
or an immense haematocele, and that, in the former event, any attempt
at restoration was out of the question on account of the strong pressure
and great size of the tumor, and that the attempt would probably be
followed by metritis or rupture, or both. * , , it
It was resolved to puncture the mass with a small exploring trocar,
and the tumor was accordingly pierced at its most depending portion,
when about four ounces of clear, straw-colored fluid passed through the
canula. There was no blood, the fluid being evidently liquor amnii.
Half a grain of morphia was administered, and the patient was left to
obtain a few hours of much needed rest. At 5 P.M. the patient was
very comfortable. She was now placed in the knee-face position, and an
endeavor was made to lift the fundus; but this could not be done. The
T. ET R O V E R S T ON OF THE G R A V IID UTE R U S - 891.
bloody urine was still passed, but not as frequently or as painfully as
before. The morphia was repeated. º
On the morning of the 19th, slight labor-pains set in, and increased in
force and frequency very gradually. With each pain the mass sensibly
contracted, and the everted fundus was lifted a little toward the rectum.
Shortly after midnight, on the 19th, the pains became forcing, and, at 3
A. M., a flattened sphere, the foetal head, emerged under the pubic arch.
At 4 A. M. a male foetus, nine inches long, was expelled, and very soon
after was followed by the placenta and membranes. The intra-vaginal
tumor was now diminished about one-half in size, but still retained its
completely capsized position, and it was still impossible to feel the os
uteri. It was not thought proper to make any immediate effort towards
restoration. At 5 P. M. eight ounces of urine, slightly tinged with
blood, were removed by the catheter, and during the two following days
the urine was drawn, morning and evening, constantly improving in ap-
pearance. -
On the 22d, copious alvine evacuations followed a soap-suds enema, and
on the evening of the same day the OS uteri was distinctly felt under the
pubic arch, and the fundus had receded to the sacral hollow. From this
time forward the catheter was not used. On the 22d, there was an
abundant lacteal secretion, which disappeared spontaneously in about
ten days. The patient was instructed to lie upon her face and sides, and
to avoid straining at stool. By April 5, she was apparently perfectly well,
the lochia had ceased, and there was no vesical or rectal irritation. The
uterus became gradually reduced in size, but still retained its retroverted
position, and it was still thought safest to defer attempts to replace it.
The patient was in fact too well to be disturbed, and had manifested no
serious symptoms, except local ones, during the severe ordeal through
which she had passed. She was always bright and hopeful, suffered little
pain, and had at no time any febrile movement; her pulse was only ac-
celerated to 100 for the two days preceding the expulsion of the foetus.
She was instructed to use warm vaginal and rectal enemata daily, to
maintain the recumbent or semi-recumbent position, and to await the
proper time for interference, which she very patiently did.
On May 1, her menstrual period came on, and lasted five days. On
May 13, Simpson's sound was passed in, to the depth of three inches, and
the uterus was by its aid placed in the proper position, from which, how-
ever, it fell back within a day or two. This operation was repeated, once
a week, until the second period returned, which was on May 31. On June
10, the uterus was placed in position ; on the 19th, it had receded again,
was restored with the sound, and was now retained in position with a
cradle-shaped, hard-rubber pessary. This was worn with entire comfort
for six months, and was then removed. The uterus has since retained
its proper position. The patient is apparently perfectly well, but has not
been again pregnant."
Remarks.-This case has been presented, certainly not for its novelty,
but to illustrate the successful result of a method of treatment. When
1 June 11, 1877. The patient is again three months advanced in pregnancy. She con-
sulted me at the end of the second month, when the uterus was again found retroverted. It
was replaced by the repositor, but it was found necessary to retain it in situ by a pessary,
and the three-winged instrument of Thomas was employed successfully, after failure with
the cradle-shaped one previously worn. At the present date, gestation is progressing
favorably.
892 R O CHESTER, RETRO v ERSION OF THE GRAVID UTER Us.
we consider the number of fatal cases on record, and when we further
consider the serious injury that has frequently resulted to both bladder
and womb, either from entire neglect or from repeated and protracted
attempts at restoration, and when we remember that in the greater pro-
portion of cases of retroversion of the gravid uterus, even if the organ
is replaced by posture and manipulation, the operation is almost always
followed by abortion and metritis, may not the procedure which has been
described be more safe than the treatment usually adopted : I do not
wish to be understood as advocating puncture or tapping of the womb,
through its walls, in preference to separation or rupture of the mem-
branes through the OS uteri, when this is accessible; but only when, as
in the case reported, the os cannot be reached.
8
9
3
SECTION ON OPHTHALMOLOGY.
P. R. E S I D E N T OF T H E S E G T I O N .
R. BRUDEN ELL CARTER, F.R.C.S.,
OF LON DO N.
W I C E - P R E S I D E N T S .
WILLIAM THOMSON, M.D., HENRY W. WILLIAMS, M.D.,
OF PHILAD ELPH I A. O F BOST ON.
S F. C. R. E. T. A. R. Y.
JOIIN GREEN, M.D.,
. OF ST. LOUIS.
0N THE COMPARATIVE WALUE OF CAUSTICS AND ASTRIN-
GENTS IN THE TREATMENT OF DISEASES OF THE
CONJUNOTIWA, AND ON THE BEST MODE OF
APPLYING THESE REMEDIES.
BY
HENRY W. WILLIAMS, A.M., M.D.,
PROFESSOR OF OPHTHAI,MOLOGY IN HARVARD UNIYERSITY.
THE conjunctiva, one of the least in extent, but one of the most im-
portant, of the mucous membranes, is the seat of affections singularly
various in form and degree—from the simplest transient congestion to
the most violent inflammatory processes and most persistent structural
alterations. On the treatment of these depends, often, the preservation
or the loss of the most important of our special senses, and the fairest
prospects in life may be blighted by either mismanagement or neglect.
In preparing the paper which I now offer to the Section on Ophthal-
mology, I have avoided a recapitulation of every theory as to pathology
and treatment, and offer simply a few practical suggestions, with no wish
to unduly depreciate the value of other means and methods than those
for which I express a preference. Skilful men will know how to use
various instrumentalities to attain good results. Nevertheless, it is desi-
rable, and important, to discriminate among the agencies at our com-
mand, and to select such as practically prove best adapted to the cure,
tuto, cito, et jucunde, of the diseases which we are considering.
A considerable number of conjunctival affections require little or no
treatment, and are injured rather than benefited by the use of other
than the mildest remedies. The hyperaemia caused by the presence of a
foreign body subsides upon its removal; the injection depending on
astigmatism, or other defects of refraction, disappears after the selection
of suitable eye-glasses; the sub-conjunctival ecchymosis following a blow,
or the rupture of a small blood vessel, is re-absorbed, perhaps quite as
rapidly, without our interference. If, in these cases, we prescribe a lotion
894 H. W. WILLIAMS,
or a collyrium, it should be quite unirritating. So also in traumatic
injuries of a simple character, and after operations for strabismus or
pterygium, the healing processes go on without assistance from applied
remedies. Chemical injuries, because of their graver nature and the
degree in which the cornea may be involved, oftener require our aid; but
even here, emollients and sedatives rather than active stimulants are
most useful.
With the above-named exceptions, and apart from certain complica-
tions hereafter to be considered, diseases of the conjunctiva may be
divided into two classes requiring essentially different management. The
first includes a comparatively simple, limited, and benign, though some-
times chronic, affection; the second embraces several conditions of gene-
ral and often severe conjunctival inflammation. The prominent feature
of the first class is the development of small elevations or papulae, one or
several in number, usually situated at or near the border of the cornea,
though they may form elsewhere on the ocular conjunctiva. The sum-
mits of these may be whitish, as if containing a minute quantity of pus;
more frequently they are red; and they may vary in-size, but are commonly
about that of a hemp-seed. Usually a fasciculus of vessels runs to each of
these papulae; but there is no general injection of the conjunctiva, except
as far as may be the result of friction of the papulae against the inner sur-
face of the lid. Children are the most frequent subjects of this disease.
The tendency of this affection is towards a disappearance of the symp-
toms at the end of a few days, even when no treatment is employed.
Therefore, no active remedies of caustic or astringent nature are needed,
and they tend to delay rather than hasten the recovery. Calomel or other
insufflations are similarly useless. All annoying remedies are moreover
objectionable on account of the age of the majority of the patients. Simple
lotions, cold or tepid, with water, or milk and water, may be used. Two
or three times a day, a few drops of a solution of ten grains of borax in
an ounce of water, or of camphor water, may be dropped into the eye
from a teaspoon or a drop-tube. This usually proves a soothing and
refreshing collyrium, grateful rather than painful to the patient, and
appears to have a sufficiently astringent and stimulating effect to pro-
mote absorption of the papula. Although the ordinary duration of these
small pimples rarely exceeds ten days, it is not uncommon, whatever
treatment has been employed, to find successive crops of them, at inter-
vals of a week or two. This disposition seems to be best obviated by
continuing the use of the borax collyrium, once or twice a day, for some
time after recovery, so as to modify the condition of the conjunctiva.
Where the papulac are slow in disappearing, the application of a crayon
of alum, once in a day or two, to the inner surface of the lower lid, is
often useful and is nearly painless. The astringent reaches the affected
spot as the lid returns to its place, and seems sometimes to excite a more
rapid resolution. The papulae themselves should never be directly touched
with caustic or astringent crayons or solutions.
Very rarely, the disease takes a more chronic form, the papulae being
as large or larger than a split pea, and sometimes umbilicated at the
centre. Though persisting longer, and for a time intractable to treatment,
the prognosis is always favorable. Tonic general remedies, and some-
times change of air, are useful adjuvants to the mild local applications.
Solutions of atropia have of late been too much in vogue in the treatment
of this form of disease. Though far less dangerous than the strong caus-
tic remedies which were formerly indiscriminately employed, yet an
I) IS E A SES OF CO N J U N C T IV A. 895
unnecessary resort to them has grave disadvantages. In cases of corneal
ulceration they may be of much service, in lessening the irritability and
photophobia; whilst in these less serious conjunctival affections their
action upon the pupil does but increase the intolerance of light, and,
by exciting strong contractions of the lids, creates a disposition to cor-
neal ulceration as an effect of friction.
The second class of conjunctival affections comprises catarrhal con-
junctivitis in its acute and chronic forms, trachoma, purulent and
gonorrhoeal conjunctivitis, ophthalmia of new-born children, and diph-
theritic conjunctivitis; each of which conditions has an importance
claiming distinct consideration.
When the conjunctiva becomes affected from exposure to cold, dust,
or other simple causes of irritation, the first symptom is injection with
an increased flow of tears—soon followed by a velvety thickening of the
palpebral conjunctiva and a slight mucous secretion. These phenomena
may occur so suddenly that the patient feels sure that something has
been blown into his eye; but the scarlet, velvety appearance of the lining
of the lids, as distinguished from the mere vascular hyperaemia excited
by the presence of a foreign body, renders the differential diagnosis suffi-
ciently easy. At this stage, caustics and strong astringents are alike to
be avoided, or used with great reserve. Frequent bathing with cold or
tepid water according to the sensations of the patient, with applications,
four or five times a day, of a few drops of a solution of ten grains of
borax in an ource of camphor-water, or of five grains of alum or one grain
of sulphate of zinc in an ounce of water or rose-water, will generally cut
short even a sharp attack and remove the symptoms within three or four
days. Occasionally this form of conjunctivitis is epidemic, large numbers
of persons being attacked within a short time. Similar, with perhaps
somewhat more active, means, are here called for ; one or two touches
inside the upper lid with a crayon of alum, or, very rarely, a single light
touch with a crayon of sulphate of Copper, acting as useful auxiliaries in
arresting the symptoms in an early stage. If neglected or if too actively
treated, the thickened conjunctiva assumes a more or less granulated
aspect, and a chronic phase of disease is established which requires more
active measures. The lining of the lids, especially the upper, from
hypertrophy of the conjunctival follicles, now resembles in appearance
the surface of a raspberry, and the sub-conjunctival tissues become so
infiltrated that the lid-movements are difficult. The secretions are
greatly augmented, causing abundant flow in the daytime, and aggluti-
nation of the lids at night. Iſere, as in another affection next to be
described, the mild remedies, sufficient for the lesser degrees of inflamma-
tion, are of little avail. Caustics or astringents, of considerable potency,
seem to be our only resource.
Trachoma differs widely, pathologically, from catarrhal conjunctivitis,
though often coexistent with and complicating it. It consists essen-
tially in a neo-plastic formation ; at first in small, oval-shaped, semi-trans-
parent masses, resembling grains of tapioca ; and sometimes increasing
until the conjunctiva, with its subjacent textures, is largely transformed
into a dense, nearly structureless mass, which, as recovery takes place,
is not replaced by normal tissue, but is followed by contraction of the
conjunctiva and incurvation of the tarsal cartilage. Here, the prognosis
is less favorable, the recovery slower, and the danger of secondary lesions
of the cornea much greater than in the catarrhal form of conjunctivitis,
896 - H. W. WILLIAMS,
But the local treatment of the two affections has much similarity, and
may be either caustic or astringent, or both.
Nitrate of silver is the caustic most relied on in the treatment of con-
junctival affections, though other means have from time to time been
tested and enjoyed ephemeral reputation. The methods of using it, and
the means employed to limit its effects, vary with different ophthalmolo-
gists. The crayon of pure nitrate and the nearly saturated solution,
formerly much used, are now rarely employed, but have given place to
the lapis mitigatus, as it is termed, in which one part of nitrate of silver
and two parts of nitrate of potassium—or two parts of silver and one of
potassium—are fused together; or to solutions of nitrate of silver of
from ten to forty or more grains to an ounce of water. The caustic is
applied, in most cases, to the surface of the everted, upper lid, more or less
lightly or extensively, the stick of lapis mitigatus being preferred by
some, the solution of nitrate of silver by other authorities. When
thought advisable, the action of these substances is limited by the imme-
diate application of a neutralizing solution of salt and water, or pure
water, or both of these, to the cauterized surface. The frequency of the
repetition also varies greatly, in the practice of different individuals:
once, twice, or thrice a week, daily, or oftener, according to the intensity
of the symptoms or the preferences of the practitioner. Moreover, some
rely wholly on this means; others employ auxiliary treatment. Theories
as to therapeutic effect also vary with different observers, some seeking
to destroy the apices of the granulations, while others, deprecating such
an effect, use the caustic with more reserve, and, virtually, as a strong
stimulant only. - -
In the class of astringents employed as topical applications by the
physician himself, may be named, crayons of sulphate of copper ; the lapis
divinus, composed of equal parts of sulphate of copper, alum, and nitrate
of potassium moulded into sticks; crayons of alum ; and strong solutions
of tannin in glycerine. Of these, the crayon of sulphate of copper forms
the best type; as combining the several qualities of convenience, effi-
ciency, and safety. The alum crayon has an excellent effect in mild
forms of conjunctivitis, but is inefficient in the severer and chronic affec-
tions. The lapis divinus seems less reliable than the crayon of pure
sulphate of copper. Tannin and other vegetable astringents, from which
theoretically we should expect so much, have always proved, in my
hands, in whatever proportion or combination, inferior to the mineral
astringents; whether as a means of energetic action upon the conjunc-
tiva, or as used in collyria to produce milder continuous effects.
The sulphate of copper cannot be fused in moulds, like nitrate of silver
and lapis divinus, but the crayons have to be shaped from crystals of
the substance. Unfortunately, these are generally much broken at the
laboratories in packing for the market, but if good crystals can be found
it is easy to cut from them crayons of convenient size. The harder parts
of the crystal, free from pores or water of crystallization, are to be chosen.
Nothing would be needed to obtain ample supplies of the crystals, or of
crayons already shaped from them, but the knowledge that there was a
demand for them, as they are easily made from crystals obtainable at the
laboratories, and they require no care in keeping, being little changed
by exposure to air or light. A single crayon lasts a long time, and may
be used, like a silver probe or a bistoury, for successive cases, care being
of course taken to wipe the crayon after every application. The crayon
of sulphate of copper should be applied, as a rule, rather lightly to the
º
T) T S E A S E S () F C O N J U N C T I V A. . 897
conjunctiva of the everted upper lid ; this lid, in which the circulation
is more readily congested, being usually more diseased than the lower
lid. It is rarely necessary to touch both lids, as a portion of the remedy,
dissolved by the moist surface over which it is passed, is carried by the
movements of the lids to every part of the conjunctiva. In sluggish
cases the crayon may be applied more heavily, or may be more frequently
repeated. *
Used as above described, the crayon of sulphate of copper does not act
on the conjunctiva as a caustic, but only as an energetic astringent and
stimulant. In the more acute cases, the pain, after the first or even after
several applications, may continue for some time; though it is much less
severe and enduring than when caustic has been used. Bathing the eye
with water shortens and mitigates the smarting. While the pain is
much prolonged, the crayon should be used lightly and perhaps less
frequently than after the eye has become more tolerant of the remedy.
The touch may then be harder, and may be repeated daily or less often,
according to the judgment of the physician. When the crayon is well
borne, cases often improve the more rapidly according to the greater
frequency of its application ; this being especially observed in many
chronic cases, trachomatous, and other.
That many cases of muco-purulent or trachomatous forms of conjunc-
tivitis may be successfully treated with nitrate of silver, pure or combined,
does not admit of a doubt. Its action requires to be carefully watched,
and good judgment must be exercised in determining the frequency and
severity of its application, and in neutralizing at once any excess of the
caustic. More benefit is obtained from its moderate than from its too
free use. Care must also be taken not to continue it too long, as not
infrequent instances have occurred in which the conjunctiva has acquired
an indelible, olive stain, or even become quite black, from the prolonged
instillation of a moderately strong solution. If employed, caustics should
not be solely relied on, but should be supplemented by other milder
remedies of stimulating or astringent nature, which may be more or less
frequently applied by the patient or his friends.
The use of caustic as an application to the eye is not without its
dangers. Its active properties render it a destructive agent in unskilful
hands; and it sometimes disappoints even the most experienced Oculist.
The application of the crayon of sulphate of copper involves no such
consequences as are inseparable from the use of nitrate of silver. If it
happens to be injudiciously employed, no special harm is done and no
immediately destructive effects ensue from its use. It is, therefore, a far
safer agent in inexperienced hands.
It remains to consider whether the general results of treatment will
be more successful under the one or the other plan.
My own experience, which has included careful personal observation of
the practice of nearly every European oculist who has had celebrity
within the last thirty years, has satisfied me that better and quicker
results, with far less danger and suffering, are obtainable from the use
of astringents than from the use of caustics. Many years since, I made
comparative tests of the value of these two classes of remedies in severe and
chronic forms of conjunctivitis, on a large number of patients. Selecting
cases where both eyes were equally diseased, I treated all the right eyes
with nitrate of silver, and all the left eyes with sulphate of copper. Of
course, no differences of constitution could influence the effect produced, as
might, perhaps, have been alleged had merely a certain number of patients
9 |
898 H. W. W. II, LIAMS,
been chosen for each mode of treatment and the same remedy used in
both their eyes. The uniform result was a more rapid gain in the eyes
treated with the crayon of sulphate of copper. Some of the eyes treated
with nitrate of silver went on tolerably well, though slowly ; but others
did so badly that, after vain attempts to succeed by varying the strength
of the caustic applications, I was at last compelled, in order to avert
threatened loss of the eyes, to substitute the use of the sulphate of
copper, under which they recovered. In no instance was it necessary to
abandon the sulphate of copper and resort to another remedy.
A very important adjuvant to treatment, either by caustics or astrin-
gents, as applied by the physician himself, consists in combining with
these the more or less frequent use, at home, of a milder astringent or
stimulating collyrium. Of these, the mineral seem to be superior to the
vegetable astringents, as also to the purely stimulating class of collyria,
such, for instance, as those containing wine of opium or corrosive subli-
mate. Many substances have been employed with more or less advan-
tage. Among those most in use may be mentioned solutions of nitrate
of silver, sulphate of zinc, acetate of zinc, sulphate of copper, sulphate of
cadmium, alum, and borax. Of these, the sulphate of zinc seems by far
the best for the forms of conjunctivitis which we are considering, as it
appears to have a more astringent with less irritant action than either
of the other remedies. The silver, copper, and cadmium solutions, are too
actively stimulating, with less of astringent effect; the alum and borax
are too mild. The sulphate of zinc solutions may vary from half a grain
to four grains to the ounce of water or rose-water ; and a few drops may
be poured into the eye from a teaspoon, a drop tube, or otherwise, two,
three, or four times a day. In cold weather the spoon may first be
dipped into hot water for a moment, so as to warm the collyrium, if the
eye is sensitive as to the temperature of the drops. I have found the
sensations of the patient a useful guide in determining the strength of
collyrium likely to be of most benefit to him. If a solution of a given
strength, say of two or of three grains to the ounce, causes smarting for
more than five minutes, it should be diluted one-half, or until it no
longer gives more than a few minutes’ pain. Thus graduated, the colly-
rium should be used often enough to keep up a moderate remedial influ-
el) (‘e.
Acetate of lead, in substance or solution, formerly much in favor even
with the profession, and still in common popular use, should never be
put into the eye. It has no special remedial value to warrant its em-
ployment; and whenever the conjunctivitis is, or becomes, complicated
with corneal ulceration, great harm is done; the acetate being decom-
posed, and an indelible deposit formed on the ulcerated surface, causing
permanent opacity of the cornea. It is therefore better to erase it from
the list of ophthalmic remedies.
More actively virulent forms of conjunctivitis are found under the
designations of purulent conjunctivitis, gonorrhoeal conjunctivitis, and
the conjunctivitis of new-born children. Purulent conjunctivitis, some-
times termed Egyptian Ophthalmia or Ophthalmia of Armies, is marked
by far more rapid sequence and violence of symptoms than the catarrhal
or trachomatous affections. In pauper asylums, schools, and barracks,
it may speedily extend to a large number of persons by direct infection
of healthy eyes with the purulent discharge from those which are dis-
eased. This is largely conveyed through the promiscuous use, in such
institutions, of articles of toilet, wash-basins, towels, etc.; and is some-
D IS E A S E S OF CO N J U N C T IV A. 899
times purposely introduced ; the fearful risk of blindness being incurred
for the sake of avoiding military or other duty, or of obtaining some
hospital privilege. Enormous tumefaction of the conjunctiva and of the
entire lid, and copious muco-purulent discharge, characterize this dis-
ease. Serous or even phlegmonous chemosis of the subconjunctival
cellular tissue often forms a dangerous complication, interfering with
the proper nutrition of the cornea ; and ulceration of that structure may
result from the direct pressure of the swollen lid, or from the continued
maceration in the copious purulent secretion.
Gomorrhoeal conjunctivitis is even more intense in its symptoms and
rapid in its course. Caused by infection with gonorrhoeal matter or with
the discharge from an already diseased eye, it is more common in men
than in females, the fingers being often the medium for conveying the
urethral discharge to the eye. One eye only is usually affected at the
outset. The frequency of phlegmonous chemosis, and consequent danger
to the cornea, is greater than in the simple purulent affection. So rapid
is the course of the disease, that an eye may be lost by sloughing of the
cornea within twenty-four hours from the moment of infection.
Active cauterization of these forms of conjunctivitis, especially the
gonorrhoeal, was formerly practised as an abortive treatment, in the hope
of substituting a less dangerous traumatic inflammation for the specific
infection. This idea has been generally abandoned, and the modern
treatment is in all respects milder. As general means, tonics, instead of
copious depletion, are in favor; and, as regards local treatment, great im-
portance is to be attached to the frequent use of mild detergents, injected
beneath the swollen lids, to remove the abundant purulent secretion. If
caustics are used, the applications should be neither too strong nor too
frequent, and should be at once neutralized—as otherwise they tend to
increase the phlegmonous chemosis and perhaps destroy the cornea. They
should not be continued if corneal ulceration has begun. If the crayon of
sulphate of copper is applied at all during the active stages of the disease,
it should be lightly used ; but it is most serviceable in removing the
granulations which remain after the active symptoms are abated. The
application of cold compresses, constantly renewed, to the lids; frequent
removal of the fast accumulating secretions; and the keeping up an influ-
ence on the diseased conjunctiva by means of mild astringent collyria,
appear to form the most reliable treatment. Solutions of five grains of
alum or ten grains of borax to an ounce of water may be injected several
times a day, and a solution of half a grain to two grains of sulphate of
zinc may be used three or four times in twenty-four hours. The appli-
cation of a crayon of alum to the inside of the lid, once or twice a day,
is sometimes of great apparent benefit, and is safely and easily applied
as an auxiliary to the astringent solutions. It is nearly painless, and
has little stimulating action as compared with its astringent qualities.
It should be used by introducing it beneath the lid without everting it.
If the case is seen early, these means are generally effectual; but unfor-
tunately the vitality of the cornea is in many instances already destroyed
when the patient first applies for advice, and the prognosis is then un-
favorable. .
No disease of the eye imposes greater responsibilities upon the general
practitioner than ophthalmia neonatorum, the conjunctivitis of new-born
children. Occurring within a few days after birth, under circumstances
which, in a large proportion of cases, preclude a consultation with any
practitioner of special experience, the preservation or loss of sight must
900 H. W. WILLIAMS,
depend on the skill of the family physician. A slight conjunctival injec-
tion and tunnefaction, with some mucous discharge, is not uncommon in
infants, and yields to simple means of cleanliness. TSut true ophthalmia
neonatorum, preceded perhaps only by a slight reddish hue along the
skin of the upper lid, becomes within a few hours an intense inflammation.
The lids are tumefied, livid, sometimes projecting much beyond the
supra-orbital ridge, or even completely everted from the enormous swell-
ing of the conjunctiva. The chemotic infiltration of the cellular tissue
beneath the ocular conjunctiva often causes this to overlap the cornea or
even to hide it. The secretion is exceedingly abundant. This disease is
one of the most destructive, but happily also one of the most manageable,
of the affections of the eye. If neglected, or if treated with inert domestic
remedies such as injection of breast milk, or with more harmful means
such as the application of poultices, the result is too frequently the loss
of one or both eyes. Equally baneful consequences follow the use of
harsh measures. The great danger attending the use of caustics, in any
form, or of very strong astringents, and the needlessness of resorting to them,
cannot be too strongly insisted on. The symptoms invariably yield to a
mild treatment, if reasonably begun and faithfully carried out. If, as is
sometimes the case, the cornea has already become more or less cloudy
before the attention of the physician is called to the eyes, this furnishes
an additional reason for refraining from strong caustic or astringent
remedies, which are never well borne when the cornea has become in-
volved.
The first indication is to insure the utmost attention to cleanliness.
The copious, muco-purulent secretion should be washed from the eyes
every two hours, every hour, or even every half hour if necessary.
Should the great tumefaction of the lids prevent their being readily
opened so as to permit free discharge of the pus, the nozzle of a small
syringe should be passed beneath the swollen upper lid, and an injection
thrown in to completely wash out the conjunctival cavity. For this
purpose tepid water may be used in the milder cases; in those of more
severity a solution of alum, five grains to the ounce, may be alternated
with the injections of water. These injections should be repeated hourly
or oftener, according to the severity of the case, during the day, and two
or three times during the night. They are nearly painless, and the
nurse or mother should be taught how to make them. In a few days
the discharge lessens and the swelling of the lids diminishes; but the
treatment must be kept up, though with less frequency. The physician
should not fail to assure himself, by daily inspection, as to whether the
cornea retains its normal appearances ; and where the swollen condition
of the lid prevents a view of the cornea, an elevator should be carefully
used to draw up the lid. If the cornea is seen to be even slightly cloudy
at its centre, a drop of a solution of sulphate of atropia, two grains to an
ounce of water, should be put into the eye twice daily, to lessen the
danger of hernia of the iris in case corneal ulceration and perforation
should occur. This haziness and ulceration may come on very early in
the disease, as a result of the continuous pressure of the lid upon the
cornea, or as the effect.of its constant immersion in the purulent secre-
tion ; but this threatening condition may also supervene at a later stage,
and after marked amelioration of the active symptoms; so that the phy-
sician, unless Ön his guard, may lose the battle in the moment of ap-
parent victory.
The use of the nitrate of silver or of lapis mitigatus, is still recom-
D IS E A SES OF C O N J U N C TIW A. 901
mended by some of the continental European oculists; but the milder
plan above described has been, for many years, almost exclusively in use
at the ophthalmic hospitals of London, and especially at the Moorfields
Royal London Ophthalmic Hospital, probably the largest institution
in the world for the treatment of eye-diseases, and certainly the most
distinguished for the celebrity of its medical staff. In my own experi-
ence, success has always attended the mild plan of treatment; and I
have seen so many examples of the destructive consequences of harsher
methods, that I cannot regard them otherwise than as unnecessary and
injudicious.
Two classes of complications of conjunctivitis are worthy of our atten-
tion, in their relations to the questions of remedial action which we are
considering. In one of these classes the conjunctivitis results from other
morbid processes; in the other class the morbid conditions are the con-
sequence of pre-existing conjunctivitis. In the first class, including
cases where conjunctivitis appears as a symptom in keratitis, iritis, or in
other inflammations of the interior structures of the eye, the conjunctival
injection is not to be regarded as a disease, and its treatment, if any,
must be subordinate to or modified by that of its primary exciting cause,
the removal of which often suffices for the cure of the secondary con-
junctival symptoms. In most of these conditions the use of caustics and
astringents is contra-indicated. Instead of relieving, they excite yet
further congestion of the external membrane, and increase rather than
lessen the deeper seated inflammation. Tepid, unirritating lotions, and
collyria containing a few grains of borax, may be used as sedatives, if
the patient finds them agreeable. Active use of either caustics or astrin-
gents is also to be avoided in conjunctivitis accompanying corneal
ulceration, or the presence of papules on the epithelial layer of the cornea,
in children; as also, especially, in ulcerations of the cornea in adults,
Occasioned by debility, in old age, or as a sequela of Smallpox or other
depressing disease.
The second class of complications embraces those conditions resulting
from conjunctivitis, usually from its chronic duration, as seen for instance
in pannus and secondary keratitis. Here, the attention must primarily
be directed to the removal of the original disease, by such remedies as
have been already indicated ; but we must be careful to make such modi-
fications of treatment as may be required by the Secondary symptoms or
structural changes, while we avoid the error of regarding these as the
essential morbid conditions and directing our treatment solely to them.
Eor example, in the affection styled pannus, where the epithelial layer of
the cornea has become so thickened and vascular as to resemble a piece
of red flannel, it is useless to attempt to remove this vascularity by divi-
sion or scarification of the vessels. The abnormal condition of the exter-
nal layer of the cornea is the result of constant frietion by trachomatous
or other granulation of the lids, and is to be cured through the removal
of these by the patient use of astringents. After the friction has ceased
to irritate the corneal surface, the injection and cloudiness gradually fade
away. If ulcerative or exudative processes have begun in the cornea
itself, caustics are not admissible, but the use of atropia should be com-
bined with the astringent remedies, the continuance of which in modera-
tion is necessary for the removal of the granulations. A certain degree
of vascularity is essential to the absorption of the cloudy transformations,
and disappears as these fade away.
Some other more exceptional complications should be briefly referred
902 H. W. WILLIAMs,
to. When chronic conjunctivitis accompanies obstruction of the lachry-
mal passages, mild astringent collyria may be combined with the appro-
priate means for the removal of this obstruction. When it is coincident
with disease of the Meibomian glands or ciliary bulbs, these collyria may
be used in connection with diluted citrine ointment, or other suitable,
topical applications, along the edges of the lids. When it appears during
an attack of herpes zoster ophthalmicus, or ensues after paralysis of the
orbicularis, caustics are scrupulously to be avoided as being likely to pro-
mote ulceration of the cornea, to which, in these circumstances, there is
always a predisposition; only the mildest astringents should be used.
In chronic thickening of the conjunctiva and eversion of the lids in old
people, commonly called “blear eyes,” attention should be given to the
lachrymal passages, and the everted lid should be brought to its place by
a frequent but mild use of astringents, patiently followed up. These
should not be applied, nor should caustics be used, upon the everted and
dry portion of the conjunctiva, as they only serve to harden, and, as it
were, tan the surface; but the crayon of sulphate of copper or of alum
should be applied, very lightly, to the non-everted portion of the con-
junctiva. As this part becomes more healthy, the everted lid is drawn
more and more to its proper place, the remedy can be applied more
largely, and the improvement finally extends to the whole of the affected
tissue.
The conclusions which seem to be warranted by the facts presented in
the foregoing paper, may be summed up as follows:—
I. In a considerable number of essentially transient affections of the
conjunctiva, and in pterygium or other growths, no active treatment by
caustics or astringents is required.
II. When disease affects only a limited portion of the conjunctiva, as
in phlyctenular inflammation, the mildest stimulating or astringent
remedies are usually suffiéient.
III. In the acute and chronic forms of general conjunctivitis, astrin-
gents are, as a rule, Safer as well as more efficacious than caustics, and are,
therefore, better adapted to the requirements of the general practitioner.
T)ISCUSSION ON DR. H. W. WILLIAMs's PAPER.
After the reading of the preceding paper, Dr. C. R. AGNEW, of New York,
said:—I would like Professor Williams to say with more minuteness what he
would do in a case of ophthalmia neonatorum in which the swelling was so
great as to produce complete eversion. Suppose he were called to see a child
ten days old, in whom the inflammation was such as to have caused complete
eversion of both eyelids; let him tell us what applications he would use, and
how, and how frequently, he would use them. I agree mostly with Prof. Wil-
liams's views; I recognize the force of his arguments in favor of mild treat-
ment, and the propriety of his protest against the too heroic measures often
employed ; but I want him to go further and tell us what he would do in such
a case as I have described.
Dr. H. W. WILLIAMS said:—I can hardly imagine a case more unpleasant
to meet with than such an one as that supposed by Dr. Agnew ; nevertheless,
those cases in which the excessively swollen, upper lid covers the lower, and
confines the discharge, are even more dangerous. I would, however, prescribe
treatment similar to that which I have advised in Iny paper, but should give
very close personal attention to the case. I have never known the most critical
stage in such cases to last longer than forty-eight hours, and I would make three
or four visits every day, and be sure at each visit that the lids if everted were
D IS E A SES OF CO N J U N C T IV A. . 903
placed in position, and the child not excited by the use of painful caustic appli-
cations. There is no difficulty in replacing the lid, but each time the child
cries the lid becomes again displaced. The case should be faithfully followed
up with mild local treatment. I would use the alum crayon, three or four
times a day, as it causes little or no pain and does not distress the child, as
would any strong or caustic solution. &
Dr. E. WILLIAMs, of Cincinnati, said:—While I agree with the doctrines
of the paper just read in many particulars, I disagree with them in regard to
Some essential points of treatment. It has been my custom to treat these
cases much more emergetically than is advocated in the paper, and I have never
had a single case of ulceration occur during treatment in an inſant. I evert
the lids, thoroughly cleanse them, and brush them with a solution of nitrate of
silver of the strength of from five to ten grains to the ounce, washing it off with
salt water. Scarcely without exception the patient returns the next morning
with eyes greatly improved. I continue this for three or four days, once a day,
and when I have the disease under control continue the treatment by the use
of astringents. I believe that in some cases the sulphate of atropia is very use-
ful, but in inſants half a grain to the ounce is as strong a solution as it is
prudent to use. -
I) r. H. W. WILLIAMS said :—I agree that in some cases it is well to use the
stronger astringents, and perhaps an application or two of sulphate of copper.
Sometimes I find it necessary to use active astringents, but even then, when
danger is past, I return to the milder applications. I have known cases in which,
lunar caustic having been used by the family physician, the eyes have been
spoiled.
I) r. C. R. AGNEW said : — I would ask Prof. Williams how he would treat the
worst typical case of gonorrhoeal conjunctivitis, if called in within twenty-four
hours, there being as yet no corneal lesion ?
I) r. H. W. WILLIAMs said:—I have seen cases of that kind, with serous blood-
stained discharges, in which I have thought it well to apply a strong astrin-
gent. I would say that I do not mean to limit myself or any other gentleman
too strictly to the rules laid down. Every case must be treated by itself; but
I have aimed to lay down a rule which is generally applicable.
Dr. JoHN GREEN, of St. Louis, said :-Prof. Williams’s paper conveys the
impression that in the purulent ophthalmia of new-born children success is
uniformly to be expected if the case is treated early enough ; nevertheless cases
sometimes occur which do not turn out so well. I have seen two such cases
in which the cornea was lost although carefully treated from the beginning of
the attack.
Dr. GEORGE STRA weſt IDGE, of Philadelphia, said :—The modes of treatment
which have been advocated are totally different, and yet have both been pur-
sued by gentlemen of large experience. I have faithfully tried both methods.
That which Prof. Williams, of Boston, proposes, is a good method when it can
be carried out, but it is impossible to do that except in a hospital, or in a rich
family, whereas these cases mostly occur among the poorer classes. My
experience has been that after the acute stages have passed by, much benefit
may be obtained from the use of the mitigated nitrate of silver.
Dr. S. D. RISLEY. of Philadelphia, said:—I have been struck with the extreme
mildness of the treatment recommended by Prof. Williams. In the Ophthal-
mia of new-born children, it has been my custom to use the mitigated stick,
neutralizing any excess, as I can thus confine its action to the conjunctiva and
spare the cornea. One other application which I have used with equally satis-
factory results, is a twenty per cent, solution of carbolic acid in glycerine. It
has the advantage of causing less pain than the nitrate of silver. Although
painful at first, the pain subsides in a moment, and the child is subsequently
more comfortable than after the use of the nitrate.
Dr. GEORGE C. HARLAN, of Philadelphia, said:—I see many of these cases
at the Children's Hospital. Until four years ago, I never used nitrate of siiver
º
904 H. W. WILLIAMs, DISE ASES OF CONJ UNCTIVA.
of a strength greater than four grains to the fluidounce, but since then I have
used as strong a solution as ten grains to the fluidounce, and so far from giv-
ing excessive pain it seems to give relief, and the children are more at ease
after the immediate effects have passed off. In addition, I give directions for
the use of an alum solution of the strength of five grains to the fluidounce as
often as may be necessary to prevent the accumulation of pus.
Dr. J. H. Pool.E.Y., of Columbus, Ohio, said:—I employ the sulphate of
copper, and it seems to me the better remedy for chronic conjunctivitis. I am
not in the habit of using as strong solutions of nitrate of silver as Dr. Wil-
liams, of Cincinnati; using but five grains to the ounce. Stronger solutions I
think very objectionable, and the mitigated stick cannot always be used with-
out leaving a scar on the conjunctiva. I prefer to cleanse the eyes with a
sponge rather than with a syringe, and I order the use of cold water.
Dr. E. WILLIAMs said:—I wish to say by way of explanation that, when I
spoke of treating all infants uniformly, I did not mean to imply that I always
employed solutions of the same strength. I have never seen more than two
cases of diphtheritic conjunctivitis, and they were in children, not infants; each
lost One eye. When we invert the lids, we see on the surface a somewhat
grayish and consistent film, but this is easily removed and is not at all connected
with diphtheria. I make it a point always to get this off. In speaking of my
success I do not mean to disparage that of any one else, but I have found my
plan of treatment successful, short, and certain.
Dr. WILLIAM THOMson; of Philadelphia, said:—It seems to me that there
is no difference of opinion with regard to the successful use of nitrate of silver,
but only as to the mode of its application and the strength of the solutions to
be employed. Applications made to the whole conjunctival sac, and so coming
in contact also with the cornea, should not be stronger than two grains to the
fluidounce; and I believe that it is generally better thus to bring the solution
in contact with the whole conjunctival surface, than to make stronger applica-
tions to a part only of the diseased membrane.
Dr. C. R. AGNEW said:—I feel somewhat embarrassed in telling what my
views are, because I find that when we come to the subject of the report, we
find cases behind the paper in which mild applications are confessedly not
sufficient. We should stand ready to treat particular cases according to
particular phases. If I find the eyelids sticky, and without much purulent
discharge, my common direction is to bathe with a solution of common salt.
If I find inflammation increased, and the discharge more watery, and wine-
colored, I take the head of the child between my knees, bathe the eyes with
water applied by a sponge, apply a solution of nitrate of silver, and then give
some simple ointment to prevent the adhesion of the eyelids and the collec-
tion of pus. If the case goes on to a still worse condition, and it is evident
that the cornea is to give way, I anticipate the evacuation of the aqueous
humor by paracentesis. With regard to gonorrhoeal ophthalmia, it is oftenest
the case that it destroys the cornea within thirty-six hours, and that when
it is not destroyed in this time, the case gets well. What we need to know is
what to do when the lids begin to stiffen, and the fluid turns reddish or wine-
colored. In a case of that kind I would give an injection of morphia in the
corresponding temple, and run a pair of scissors into the external canthus,
and cut down to the Orbit, hoping to get a good spouting of blood. I would
then pour water on the corresponding side of the head to encourage the
bleeding, and finally repeat the application of morphia to produce sleep. Un-
less there is a decided improvement, I evert the eyelids and make an applica-
tion of nitrate of silver, and afterwards apply iced cloths, which should be damp
and cold, but not wet.
The President, Mr. R. BRUDENELL CARTER, of London, said:—The differences
in the treatment recommended are far more apparent than real, and would melt
away in the presence of individual cases. Prof. Williams without doubt
desires to show the danger of very strong astringents and caustics, and I believe
that the Section will generally agree in his conclusions.
9
()
5
ON TUM()RS OF THE OPTIC NERVE.
BY
H. KNAPP, M.D.,
OF NEW YORK.
A VLRY limited number of tumors of the optic nerve has hitherto been
recorded. W. Goldzieher, in a very valuable paper on the subject,
published in Graefe’s Archiv für Ophthalmologie, 1873, states that in
modern medical literature he has found only six cases of the kind, to
which he himself adds three others. I have found records of a few addi-
tional cases, and have seen three myself, two having been under my own
care and one under that of Dr. E. Gruening at the New York Ophthal-
mic and Aural Institute. I shall give a brief sketch of some of these
cases, in order to obtain the data necessary for a general description of
the affection.
CASE I.—(Described by A. von Graefe, in his Archives, vol. x. part 1, p. 193
etc., 1864.) A farmer, aet. 23, had first noticed, two years previously, diplopia.
and protrusion of his right eye. The exophthalmos increased steadily, but the
diplopia subsequently disappeared from the sight of that eye becoming iost.
No pain was felt until a few weeks before the patient was first seen, when
secondary infiltration of the cornea set in. On examination, there was found
exophthalmos of 9’’’, in the direction of the orbital axis; the lids could not be
closed ; the mobility of the globe was restricted in ward, but in other directions
was free; the centre of motion coincided with that of the globe. Behind the
globe, a soft, elastic tumor was felt; S. = 0. The retinal veins were tortuous
and dilated, the arteries attenuated. The inner half of the optic disk was
swollen, with abrupt, slightly overlapping borders, reddish, and concealing the
blood vessels; the outer half was level.
Graefe diagnosticated a relatively benign, orbital tumor, probably of a ſibro-
sarcomatous nature. From the fact that the centre of rotation corresponded
with the centre of the globe, he concluded that a stratum of loose connective
tissue separated the tumor from the globe. The freedom of the outer half of
the optic disk led him to the supposition that the blindness was not caused by
compression, but by the immediate transition of the tumor to the nerve, or
possibly by its origin in the nerve itself. The tumor being situated within the
muscular funnel, and surrounding the optic nerve, its extirpation with preserva-
tion of the eyeball, he said, could not be thought of. He enucleated the eyeball,
slit the stratum of connective tissue in front of the morbid growth, laid the
bluish-red looking tumor bare, and removed it without difficulty. The opera-
tion was followed by alarming cerebral symptoms, intense headache and
nausea; the pulse fell from 80 to 52 beats, and the temperature rose to 40° C.
(104° F.). These symptoms subsided upon the appearance of an extensive
suppuration in the wound. The patient recovered.
The tumor, examined by Recklinghausen, was pear-shaped, a 4, 2
than a pigeon's egg, partially soft and gelatinous, and partially fibrous. The
bulk of the optic nerve lay as a compact cord on one side of the tumor, and
was covered, together with the whole tumor, by a tough, fibrous capsule. The
limit of the nerve which looked toward the tumor, was ill-defined. The fibres
of the cord-like portion of the optic nerve were preserved in their whole course,
the others entered the tumor and were lost in it. This condition was found
ped, a little larger
$ tº *-
906 - KN APP,
in both the cut ends of the nerve, that is at its entrance into and its emergence
from the tumor. The growth therefore was a myroma of the optic nerve,
originating in the inner sheath and perineurium internum. The swelling of the
inner half of the intra-ocular end of the optic nerve was caused (according to
the examination of Schweigger) “by a proliferation of indifferent (lymphoid)
cells, as might be expected in so young a formation.”
CASE II. —(Described by A. Rothmund, Zehender's Klin. Mon., 1863, S.
261.) The patient was a healthy looking girl of fifteen years. At the begin-
ning of her second year, her left eye began to be pushed forward and down-
ward, and was excessively painful. She could see with that eye. In the
course of four or five months the eye became blind, but kept free from pain ;
yet the lids were swollen every now and then. From that time to her six-
teenth year, she felt no annoyance from the eye, though it slowly but constantly
grew larger. When seen by Dr. R., the orbit was occupied by a roundish,
faintly fluctuating tumor, the size of a large hen's egg. The tumor was
totally covered by congested conjunctiva, but incompletely by the lids, and
moved harmoniously with the healthy eye in every direction. Remnants of
the cornea were recognizable at its apex, which was very tender to the touch.
The palpebral fissure was two and a half inches in length, and the orbit was
greatly distended.
Dr. Rothmund removed the tumor in the manner of an ordinary enucleation.
Its pedicle was severed near the optic foramen. In some weeks the orbital
wound was closed by granulations. The patient recovered.
At the posterior end of the tumor a piece of the optic nerve, 3” in length,
was preserved. The growth was a total degeneration of the optic nerve, con-
sisting of fibrous tissue which inclosed smaller and larger cysts, the cavities
of which were pervaded by a network of white, delicate fibres containing a
vascular, gelatinous substance. The microscopic examination, made by Prof.
Buhl, showed the characteristics of a mya:Oma, which is frequently met with
in other nerves. The eyeball had been flattened by the tumor in such a way
that the optic disk touched the cornea.
CASE III. — (A. von Graefe, Arch. f. Ophth., x. 1, S. 201, 1864.) The
patient was a young lady, aet. 24, who for two years had noticed a slight ex-
ophthalmos with amblyopia and contraction of the visual field of her left eye.
With the ophthalmoscope Graefe discovered choked disk and spontaneous
arterial pulsation. During the next five years the exophthalmos slowly in-
creased, while sight was reduced to quantitative perception of light. The ex-
ophthalmos measured 8", and showed a marked deviation outward. Mobility
preserved, but reduced in every direction. The centre of rotation corre-
sponded approximately to the centre of the globe. A soft tumor was located
immediately behind the eye, more on the nasal than on the temporal side.
Between the upper and inner recti muscles it could be seen through the con-
junctiva as a smooth, reddish-yellow intumescence. In the outer part of the
field of vision, there was no perception of light. The optic disk was atrophic.
The patient was operated on by Langenbeck, who first enucleated the eye-
ball, and then the tumor, which did not extend to the apex of the orbit. It
was as large as a pigeon's egg. The optic nerve passed as a flattened cord
along its nasal side, but a considerable part of it entered the tumor and was
lost in it. The posterior part of the eyeball was flattened by the pressure
from the tumor.
The tumor, examined by Recklinghausen, was found to be a myazo-sarcoma
of the optic nerve. Its anterior part contained a cyst, around and behind
which there was a soft, partly gelatinous substance, consisting of very delicate,
interlacing fibres which inclosed round and oval cells. The gelatinous liquid
which could be pressed out of the tumor grew very opaque on addition of
acetic acid. Larger portions of the tumor showed a substance almost entirely
composed of cells, between which some larger blood vessels ramified.
CASE IV.-(Described by E. Neumann, in Archiv für Heilkunde, xiii. S.
TU M O RS OF THE O PTI C N E R V E . 907
310.) The patient, aet. 20, had suffered from headache for six years, and had
noticed a protrusion of her eye for three years. The mobility of the eye was
preserved, and was only a little restricted in an upward direction. The vision
was almost normal. On palpation a hard immovable tumor was felt sur-
rounding the posterior part of the globe on all sides. Dr. Jacobson, of Königs-
berg, removed the eye together with the tumor.
The tumor was three-quarters of an inch in length, the size of a walnut, and
immediately behind the eye surrounded the optic nerve, which passed quite
loosely across it. The neoplasm was connected with the outer sheath, which
on section showed itself as a distinct, white border-line. The inner sheath was
Smooth and shining. Between the two sheaths, delicate cords were stretched
When the nerve was drawn away from the tumor. The microscopic examina-
tion discovered that the structure of the tumor was partly compact, partly
alveolar. The alveolar part had a stroma which resembled that of a cancer,
inclosing accumulations of fusiform cells in concentric layers. The centres of
many cells were incrusted. Teased preparations showed that these fusiform
elements were flat endothelioid cells. The compact part of the tumor consisted
of coarse fibrils, here and there inclosing numerous accumulations of sarcoma-
tous cells. The periphery of the tumor consisted of adipose tissue. The tumor
is styled by Neumann apsammoma, on account of the prevalence of the incrusted,
arenoid bodies in the alveolar part of the tumor.
CASE W.—(Described by H. Knapp, in Archives of Ophthalmology and Oto-
logy, vol. iv. pp. 323–354, 1875, with four plates.) Mrs. J. K., aet. 40, was first
examined in August, 1871. Her left eye was normal in function and struc-
ture; the right protruded about 5” in a forward and slightly downward direc-
tion. The protrusion had begun six months previously, and the sight of that
eye had gradually become impaired. She suffered from occasional headaches,
which always increased the protrusion of the eye. The movements of the globe
were somewhat restricted, chiefly in an upward direction. There was no pul-
sation, nor bruit. S. with + 10 Sn. #; F. complete. The optic disk showed
a steep elevation, arteries small, veins dilated and tortuous. The ophthalmo-
scopic condition did not materially change for three years. In June, 1874, a
hardish tumor was felt, on palpation, on the inner and upper side of the poste-
rior part of the globe. It moved with the eye. A free space was felt between
the tumor and the orbital wall. The globe was dislocated slightly outward,
and considerably downward (4///–5’’’), but mostly forward (6'''). Inversion
was perfect, whereas the strongest eversion brought the corneal margin no
Inearer than 2''' from the outer commissure; downward rotation was free, but
upward rotation moved the eye no higher than the horizontal median plane; S.
gº. F. complete. Media clear, pupil responsive. Papilla raised, with abrupt
borders, like a “jockey-cap.” Wenous hyperaemia marked, General health
good. For the last years, great pain in eye and head. The diagnosis of orbital
tumor could now be more specifically revised into that of a tumor of the optic
nerve, and acting upon this supposition I attempted, on June 10, 1874, to enu-
cleate the tumor while preserving the eyeball. I succeeded in the following
IIla, Ill) e1, ...—
I opened the conjunctiva by a circular section between the inner and Supe-
rior recti muscles, and laid the anterior portion of the tumor bare. Then I
introduced my left forefinger into the wound, and under its guidance freed the
hardish tumor from the soft, surrounding orbital tissue. After that, I dis-
sected the mass from the posterior part of the globe, with which it was con-
nected by a thin layer of connective tissue. Further, I severed the optic nerve,
and then introduced my finger as deeply into the orbit as possible. Not being
able to reach the apex of the tumor, which was close to the optic foramen, I
cut the tumor across as near the summit of the orbit as I could reach. Now
I rotated the growth on its antero-posterior axis, and severed such connections
with its surroundings as had before escaped. All this was done with a pair of
strabismus scissors. Then I introduced the closed blades of a stronger pair of
908 - KN APP,
Scissors, curved on the flat, behind the tumor, and lifted it out of the wound. This
produced sufficient free space in the orbit to enable me to remove the little part
of the tumor which had been left. I seized it with a pair of strong scissors, had
it drawn forward by an assistant, and excised it, always using my left forefinger
as a guide. The eyeball, which had been turned aside, was replaced, and the
conjunctival wound closed by sutures. Though the tumor was located within
the recti muscles, none of them had been cut. The tension of the globe was
not changed. The inner half of the eye was anaesthetic, the outer half sensi-
tive, though a little dull. The fundus gave a reddish reflex, but its details
could not be seen on account of irregular detachment of the epithelium from
the cornea, giving the latter the appearance of frosted glass.
The reaction from the operation was very moderate. The patient now
totally lost her headache. On the third day the fundus oculi was visible, and
appeared uniformly milky-white. A small whitish-gray infiltration was noticed
on the lower part of the cornea. On the fourth day this infiltration had in-
creased, but the fundus could be seen through the clear part of the cornea
above it. In the milky surface two dark-red streaks were visible, which had
increased the next day, and proved to be the main branches of the retinal
veins. Every day new retinal vessels were filled with blood, and in some
weeks there was a picture of very marked retinal congestion. (See Fig. 2,
Tab. IX., Arch. Ophth. and Otol., 1875.) The fundus had so far cleared up
that only the region around the papilla and yellow spot appeared milky, the
remainder having its natural color. Gradually this milky appearance disap-
peared, and then extensive retinal hemorrhage took place, which disappeared
slowly, and left the retina and inner part of the choroid atrophic and degene-
rated. (See Plate X., loc. cit.) The infiltration on the lower part of the
cornea, which I have mentioned above, disappeared after the eye had been
protected by carefully closing the palpebral fissure. The cornea has never
since lost its lustre, and but little change took place in the interior of the eye
for two years. Lately, some membranous opacities in the vitreous have ap-
peared. The eye has its natural size, is a little more deeply set in the orbit
than its fellow, squints somewhat inward and downward, but has not been the
cause of any annoyance. The cornea is bright throughout, though its inner
half is still as anaesthetic as immediately after the operation. At this time,
two years and three months after the operation, the tension of the eye is di-
minished, and there is some blood in the vitreous. The patient looks healthy,
and there are no symptoms of a relapse.
The tumor was a little above the size of a walnut (30 by 27 mm.), and uni-
formly hardish. Its base was slightly concave, covered with a thin layer of
connective tissue which had united it to the sclerotic. The optic nerve passed
through it. The outer sheath of the nerve was well recognizable, though its
fibres were more or less separated by the elements of the pseudoplasm. The
intervaginal space was a little enlarged, and filled with the tissue of the growth.
This, when well hardened in Müller's fluid, was uniformly finely granular. It
had no capsule proper, but was loosely covered with the adipose tissue of the
orbit. Under the microscope, the growth showed a typical specimen of scir-
Thous cancer. A stroma of fasciculated connective tissue inclosed alveoli
filled with epithelial cells, which had no more intercellular substance between
them than was necessary to cement them. In the neighborhood of the nerve,
a limited number of arenoid bodies (sand-globules) were seen embedded in
connective tissue, yet not numerous enough to give even a part of the tumor
the character of a psammoma. The whole growth was very vascular, and a
good part of its stroma had undergone colloid degeneration. The inner sheath
was thickened, and infiltrated with colloid and lymphoid bodies, nowhere with
cells of an epithelial character. The interfascicular tissue of the nerve was
somewhat thickened. In it, and between the nerve fibrils, there were very
numerous lymphoid cells, either single or arranged in rows and clusters;
7m flammation of the nerve. The same change was seen in the intra-ocular end
TU M O RS OF THE O PTI C N E R W E. 909
of the optic nerve—a well characterized specimen of neuritis optica descendens.
For a detailed description of the specimen, and remarks on many interesting
points connected with this case, see Arch. of Ophth. and Otol., vol. iv., 1875,
pp. 323 et seq., and Plates IX.-XII.
CASE WI.—(Described by L. Krohn in Zeh. Klin. Mon., 1872, S. 103–108.)
A married woman, thirty years of age, had a tumor the size of a fist in the
right side of her abdomen. It had begun six months previously with local
pain, which was followed by general debility, emaciation, headache, vomiting,
and gradual loss of sight in both eyes. A tumor was also developed in the
left side of the abdomen. The eyes, when examined six months after the
beginning of the disease, were totally blind, and, ophthalmoscopically, exhi-
bited marked pictures of choked disk, with some retinal hemorrhages. The
patient died eight months after the beginning of the disease.
The autopsy showed carcinomatous tumors of both ovaries; all the other
organs were normal; the cranial cavity in particular contained no morbid
formation. There was a small intumescence in each optic nerve near the scle-
rotic. The intumescence was caused by a new formation in the intervaginal
space, consisting of a tissue which was rich in large round and polygonal cells,
and had the arrangement of a cancer. The same kind of cells pervaded the
inner sheath and the interfascicular connective tissue, and were very numerous
around the central blood vessels. They extended in the nerve and inter-
vaginal space as far as the lamina cribrosa, but did not enter the eye. On the
other end, they could be followed a little beyond the optic foramen. . The
intra-ocular end of the optic nerve was infiltrated with lymphoid bodies.
CASE WII.—(Described by W. Szokalski, in . Annales d’Oculistique, t. xlv. p.
43, 1861.) A boy of four years, healthy and well nourished, had a considerable
forward protrusion of his left eye, which was perfectly movable. His parents
attributed this condition to a severe contusion of the temple, received four or
five months previously. The sight was good; by ophthalmoscopic examination,
the retinal veins were found enlarged. The exophthalmos increased, the eye
became very painful and sensitive to light, the lids could not be closed, the
cornea grew opaque, the eye blind, and the other eye became the seat of sym-
pathetic irritation. There was no tumor felt between the globe and the orbital
walls; but the orbital tissues were a little more prominent and elastic than
usual. None of the symptoms of a vascular tumor were present. Szokalski
made the diagnosis of cystic tumor directly behind the eye, near the optic nerve,
within the recti muscles. He extirpated the contents of the orbit. After having
enlarged the palpebral fissure and made a circular incision around the globe,
close to the orbital wall, he felt with the finger a hard, nodular, and movable
tumor behind the globe, which he isolated from its surroundings by incisions
along the orbital walls (rasant les parois de l'orbite); then he drew it forward
with a strong hook, and, with Scissors, severed it near the summit of the orbit.
A profuse hemorrhage was arrested by placing a piece of ice in the orbit for
two minutes.
The eyeball proved to be quite healthy. A centimetre behind the globe, the
optic nerve entered into a nodular, transversely oblong tumor, the size of a
filbert, through which the nerve passed in the direction of its smaller diameter,
like a string through a bead. Its outer sheath passed directly over the tumor,
where it became thicker and more adherent. The substance of the tumor was
hard, grayish, fibrous, grating under the knife; it presented under the micro-
scope, reticular areolae, in the midst of which, caudate, uni-nucleated or multi-
nucleated cells were accumulated. The nervous fascicles, after their entrance
into the tumor, spread like a fan and were imperceptibly lost in its centre; on
its other side they reappeared, and entered convergingly into the other end of
the nerve. The growth “undoubtedly took its origin in the neurilemmatic
partition-walls of the optic nerve, and unquestionably was of the nature of a
scirrhous cancer.” Though the nerve was divided as near the optic foramen
910 KNAPP,
as possible, its transverse, cut surface showed, by its gray color, that the
pseudoplasm had already penetrated into the cranial end of the nerve.
The wound healed so rapidly that the patient was able to leave the hospital
at the expiration of three weeks. For almost five years the boy was in good
health, but then a local relapse took place. When he presented himself again,
the orbit was filled with a hard, somewhat elastic tumor, which projected in
the shape of a small apple beyond the distended eyelids. The child was pale,
but otherwise healthy, and complained of some lancinating, periorbital pain.
The tumor was nowhere adherent to the orbital wall, and, therefore, easily
removed. The patient did well enough during the next two days, but, on the
third, convulsions and vomiting set in, and he died of meningitis on the sixth
day after the operation.
An autopsy revealed congestion of the pia mater at the base of the anterior
lobes, and a greenish, sero-purulent exudation at the anterior part of the base
of the skull cavity. Under the left anterior lobe, in front of the Sylvian fossa,
was a tumor, as large as a nut, growing from the degenerated optic nerve
without implicating the chiasm. The adjacent brain substance was softened.
The tumor was dense and consisted of a scirrhous substance.
The optic foramen was dilated and filled with a granulated, reddish sub-
stance, which connected the cranial with the orbital tumor. The orbit was
enlarged to about twice its natural size, mainly at the expense of the ethmoid
and maxillary sinuses. The tumor removed from the orbit contained on its
posterior side a large cyst, which had been opened during the operation and
had yielded about two ounces of a yellow serum. Sections in different direc-
tions through the tumor displayed a scirrho-cancerous, lardaceous substance,
grating under the scalpel. Some softened portions of it contained a brain-like
substance.
I have made a detailed extract of this case on account of its singular
clinical and pathological interest. The original and secondary tumors
are pronounced scirrhous cancer by the author, yet his description .does
not fully convince me. The original tumor may have been a fibroma,
and the relapsing tumor a myxo-fibroma. According to the author, both
tumors were Scirrhous cancers, the secondary one having undergone par-
tial softening in its interior. -
These seven cases, together with eight others, form the material from
which I shall endeavor to frame a general description of the affection
under consideration.
Pathologically, the following species of tumor have been observed :—
(1) Myacoma, in five cases. -
(2) Fibroma myaromatodes, in two cases.
(3) Sarcoma myaromatodes, in two cases.
(4) Glioma myaromatodes, in one case.
(5) Fibro-Sarcoma, in one case.
(6) Psammoma (perhaps alveolar sarcoma or carcinoma), in one case
(E. Neumann).
(7) Scirrhous cancer, in two cases,
(8) Secondary cancer, from primary cancer of ovaries, in one case.
The majority of these tumors consisted either of pure mucoid tissue
(five cases, 33 per cent.), or contained a considerable proportion of mucoid
substance in addition to their prevalent tissue. In most of these cases
the pseudoplasm originated in the inner sheath and the interfascicular
connective tissue of the nerve. To these should probably be added the
case of scirrhous cancer of Szokalski, the recurrent tumor in which case
contained also a large cyst. In three cases (glioma myxomatodes, fibro-
TU M O RS OF T H E O PTI C N E R V E . 911
sarcoma, and secondary cancer) the tumors may have sprung from the
tissue of the subvaginal space and the inner sheath. Two tumors of a
carcinomatous structure (Neumann and Knapp) originated in the Outer
sheath.
Symptomatology.—The age of the patients varied from one and a quarter
to forty years. There is no decided preference for either eye.” The
prevalent symptom is exophthalmos, either directly forward, in the
direction of the orbital axis, or showing besides a secondary deviation
in accordance with a greater development of the tumor on one side.
The motions of the globe are preserved, but more or less restricted. On
palpation, directly behind the globe a softish tumor is felt, the move-
ments of which correspond more or less to those of the eyeball. A free
space can be recognized between the tumor and the orbital wall. Neu-
ritis descendens is a constant symptom in the early stages, and atrophy
of the nerve in the later stages of the affection. The sight is more or
less impaired, the field of vision being restricted when the pseudoplasm
originates in the inner sheath and perineurium internum. Sight is less
impaired, and the visual field remains complete, when the tumor springs
from the outer sheath. Intense and persistent pain has been noticed in
the cases of cancer (Neumann, Knapp, Krohn); in the other cases there
was pain only when the eyeball was inflamed, with the exception of one
case of myxoma (Gruening) in which intense pain was felt after the pro-
trusion of the eye had existed for four years without pain.
The course of the disease shows in all cases a slow but steady increase
of the tumor. The longest duration observed was fifteen years (IIey-
mann and Rothmund). First, the posterior part of the eyeball is flat-
tened, and the eye becomes hyperopic; then the eye protrudes, and
neuro-retinitis sets in ; then opacity, ulceration, and perforation of the
cornea occur; after which the coats of the eye are so much pressed
together that the optic disk touches the cornea. The ultimate, sponta-
neous issue cannot be known from the published cases, since the tumor
in all was extirpated, and recovery took place, except in one case in
which a relapse implicating the brain occurred, and in which the patient
died from meningitis in consequence of a second operation.
The observations on record are not sufficient to enable us to form a
reliable prognosis as to the natural course of tumors of the optic nerve.
All the cases in which the tumor was removed ended in recovery, which,
with the One exception of a fatal recurrence, seems to have been perma-
ment. Sight is, of course, destroyed in all cases.
The treatment, until lately, consisted in the removal of the tumor,
together with the eyeball, which operation offers no difficulty. Two
years ago, I succeeded in removing such a tumor, and preserved the eye.
About one year since, Dr. E. Gruening did the same in another case.
Both of these cases have continued to do well. In one case (Graefe), the
operation was followed by suppurative inflammation in the wound ; in
another (Szokalski), the operation caused death by meningitis. In none
of the other cases was the operation followed by any unpleasant symp-
tom.
In conclusion, I may say that tumors of the optic nerve form, at pre-
sent, a sufficiently understood chapter of surgery, and that their differen-
tial diagnosis is quite possible. Extirpation relieves the patient from
disfigurement and pain, and prolongs life. By improved modes of
operative procedure, the tumor may be removed while the eye, which,
though blind, is better than a glass eye, is preserved.
ORBITAL ANEURISMAL DISEASE AND PULSATING EXOPH-
THALMIA: TIIEIR DIAGNOSIS AND TREATMENT.
BY
E. WILLIAMS, M.D.,
PROFESSOR OF OPIITIIALMOLOGY IN MIAMI MEDICAL COLLEGE, CINCINNATI.
THE differential diagnosis between genuine intra-orbital aneurism and
pulsating exophthalmia from other causes, is by no means easy. Till
recently, all cases of protrusion of the eyeball, with pulsation, were set
down as orbital aneurisms as soon as encephaloid, meningocele, and one
or two other rare affections, had been excluded. A careful study of the
literature of the subject, in the light of pathological anatomy, has un-
settled this long established opinion. The case of so-called aneurism by
anastomosis, in the orbit, published by Travers in 1808, presented symp-
toms, in common with many that have since been published, that are now
known to be frequently present in affections of the vascular system en-
tirely outside of the orbit. A warm difference of opinion prevailed as
to whether these were cases of aneurism, by anastomosis, or of circum-
scribed or diffused aneurism of the ophthalmie artery. But all located
their starting point in the orbit.
Such were the views generally entertained till the publication of Nóla-
ton’s celebrated ease in 1856. True, Baron, in 1835, had presented to the
Paris Anatomical Society a specimen of aneurism of the carotid in the
cavernous sinus, in which the symptoms, during life, had been pulsating
exophthalmos and intense murmur heard by the ear over the protruded
eye. These were the typical, symptoms that passed current for orbital
aneurism, both before and after that time. The strong significance of
this observation was not then noticed. In 1853, Aubry had the good
fortune to secure an autopsy in a patient in whose case all the symptoms
of orbital aneurism had been present, and that diagnosis had been made.
No arterial lesion whatever was discovered. The ophthalmic vein was
greatly dilated and its branches enlarged, forming the “bossy, vascular,
pulsating tumors observed during life.” The vein was as large as the
little finger, and its coats very thin, and it freely communicated with
the greatly dilated cavernous sinus. The sinus terminated behind in a
cul-de-sac, the communication with the inferior petrosal sinus being cut
off. Though observed in 1853, this case does not seem to have been pub-
lished till 1864. In 1841, M. Gendrin made public a case with symp-
toms of orbital aneurism, in which a post-mortem examination showed
this interpretation to have been incorrect. “The ophthalmic vein was
varicose and distended with coagulated blood. The internal carotid and
origin of the ophthalmic arteries were surrounded by an adherent clot,
continuous with a clot infiltrated into the arterial tunics.” Mr. Walter
Rivington very plausibly explains this condition as indicating an aneu-
rism of the internal carotid in the cavernous sinus, which had ruptured.
Nélaton's first case is so important in the pathological history of this
disease, that I will transcribe it entire from Mr. Rivington's resumé of
O R B I.T A. L A N E U R IS M A. L DIS E A S E . 913
cases in connection with his excellent paper on Pulsating Tumors of the
Orbit, in the Medico-Chirurgical Transactions for 1875. In that paper
he gives the most complete collection of cases, and the most systematic
and thorough criticism of them, that I have met with. The case of
Nélaton is as follows:—
“Male, 21. Right eye. Thrust with the ferule of an umbrella in the left
lower eyelid. Symptoms and Progress.--Abundant bleeding from the nose,
and ptosis of the right upper eyelid. Wound of the left eyelid healed rapidly,
but at the end of some days the right eye became more prominent, with diplo-
pia and mydriasis. Two months later, left eye was healthy; right eye promi-
nent ; ptosis; dilated veins on the surface of the upper lid; pupil largely
dilated ; external strabismus; absence of movements of the eyeball ; diplopia.
. . . . Patient blew blood habitually from the right nostril; paralysis
of the right third pair; pulsation of the eyeball; bruit de Souffle continuous, with
re-enforcements during arterial pulse ; absence of thrill. A little later, bruit
de miaulement, audible also to the patient. He continued to blow blood from
the right nostril, and at times had epistaxis.” Nélaton diagnosed wound of
the right carotid in the cavernous sinus. The patient died not long after from
bleeding at the nose, and the autopsy fully confirmed the diagnosis. “The
body of the sphenoid bone was fractured, and the right internal carotid was
found torn across in the cavernous sinus. The sphenoidal sinus communicated
with the cavernous sinus on the one hand, and with the nasal fossae on the
other, and through this communication the hemorrhage had taken place.”
Hirschfeld, in 1858, had a case presenting similar symptoms, as the result
of injury, in which the diagnosis of effusion of blood compressing the
motor nerves before their entry into the orbit was made. T)eath occurred,
and a blood clot was found in the cavernous sinus, enveloping the third
and compressing the ophthalmic nerve. The clot covered a small circu-
lar hole in the carotid, which looked as if it had been punched out, and
which was occupied by a string of decolorized clot about two inches
long, and passing into the mass of coagulum. The bones were sound.
This case is of great value, as it proves that the usually accepted symp-
toms of intº aneurism may be produced by a lesion of the carotid
artery ; and also that a sharp blow on the face or head, without fracture
of the base of the skull, may cause a rupture of the internal carotid.
Nunneley had occasion to make a post-mortem examination of a patient
whose carotid he had ligated five years before for orbital aneurism. He
found a circumscribed aneurism of the ophthalmic artery at its origin
«n the cranium. In another similar case the post-mortem appearances
seemed to indicate the existence of an aneurism of the internal carotid,
which had ruptured into the cavernous sinus. These cases and others
induced Nunneley to look for the seat of so-called orbital aneurism rather
in the cranium than in the orbit. In a paper, in 1864, he says: “In the
great majority of such cases of protrusion of the eyeball, there is no
disease whatever in the orbit. The seat of it is most commonly intra-
cranial. The protrusion of the eyeball is passive, and the other distress-
ing symptoms are secondary, depending upon obstruction to the return
of blood through the ophthalmic vein. That this pressure in the great
majority of acute, spontaneous cases is caused by an aneurism of the
carotid as it emerges into the cranium, or of the ophthalmic artery in
its intra-cranial portion, near its origin, is I think now certainly proved.”
The cases of traumatic origin he explains in a different way, but by inju-
ries and changes in the cavity of the cranium and not in the Orbit.
In Bowman’s case, in which “all the capital signs of orbital aneurism
58
914 E. WILLIAMS,
were present in a high degree,” there was no aneurism found after death.
The cavernous simus, and the circular, transverse, and petrosal sinuses,
were filled with clot softening in the centre, and the enlarged ophthalmic
vein was plugged at its opening into the cavernous sinus. The great
Nélaton had a second case, with the current orbital-aneurismal symptoms,
following a fall from a carriage, where death occurred after ligation. Iſe
had diagnosed an arterio-venous communication in the cavernous sinus.
A fracture through the body of the sphenoid bone and pars petrosa of the
temporal, was found on both sides. On the left side a sharp point of the
temporal bone was detached, and had probably penetrated the carotid
and the wall of the sinus. At all events there was found a small hole in
the carotid, below and externally, connecting it with the sinus, which
was dilated ; and the ophthalmic vein was dilated and tortuous. In a
case of Dr. Oettingen, the symptoms were much the same, excepting that
the veins of the eyelids were not particularly affected, and that the bruit
was audible only over the eye; the patient died two years afterwards. No
arterial lesions were found, but there was partial obliteration of the orbi-
tal veins. Dr. Oettingen attributed the symptoms during life to throm-
bosis of the orbital veins, and alleges the case as proof that blocking of
the orbital veins alone, with no trouble behind, may produce pulsating
exophthalmos and bruit. In 1868, Wecker lost a patient fifty-two days
after ligating the carotid. The symptoms were as usual. The post-mor-
tem examination showed great dilatation of the ophthalmic vein, and
extensive atheromatous degeneration of the inner coat of the carotid. As
no description is given of the state of the cavernous and other sinuses,
Rivington thinks it not improbable that the extreme dilatation of the
ophthalmie vein and its frontal branches, forming “the pulsatile thrill-
ing” tumors observed during life, may have resulted from the existence
of a fissure in the internal carotid, in the cavernous sinus, which was
overlooked at the post-mortem examination.
To aid in the differential diagnosis between orbital aneurism and other
lesions which produce many of the same phenomena, I will give the par-
ticulars of three cases, in two of which I think that this rare affection
really existed.
Case of Spontaneous Cure of Orbital Aneurism by Rupture.—Mrs. K., act.
55, in good health, of medium size, rather spare in form, dark hair and eyes,
sallow complexion. In June, 1875, her friends noticed an unusual redness of
the right eye. She had had no injury, pain, sudden noise, or anything what-
ever to attract her attention to the eye, but remembers feeling some transient,
neuralgic pains in the temple of that side. The injection of the eye increased
slowly till September, when undue prominence was noticed. The congestion
of the eye was increased by hard work, but was not influenced by straining or
stooping. The exoplithalmos had probably existed and increased for some
time before it was observed.
The patient consulted me first in September. There was then a striking
exophthalmos of perhaps a fourth of an inch, the ball presenting directly for-
wards and the movements being perfect, except for a slight limitation in all
directions. No ptosis, no sluggishness of pupil, no diplopia, and W. = 1. By
the most careful examination with the finger pressed between the globe and the
orbital margin, no pulsating tumor was felt. But to the touch and to the eye
there was a marked pulsation of the globe and the surrounding tissues. The
subconjunctival veins were enormously injected and tortuous, forming a wreath
around the cornea by their large and numerous inosculations. The ophthal-
moscope showed the veins of the retina equally dilated and tortuous, with the
usual appearances of choked disk, but I could see no pulsations. The arteries
O R. BIT A. L. A N E U R IS M A. L DIS E A S E . 915
were not as straight as usual, but otherwise not altered. For want of time to
examine the case further, the patient was told to abstain from all hard work,
stooping, or straining, and to return for further examination in a few days.
When she returned I found her condition essentially the same. For want of
time, I again deferred further examination till another day, which was fixed
upon. I explained to her the serious nature of the disease, and what might
eventually become necessary. To my great regret, I saw her no more for five
months, so that I did not have a chance to watch the progress of the case.
On the 12th of February the patient returned with the following history. Up
to three weeks before, her condition had continued the same as when I last saw
her. There had been no increased pulsation ; no enlargement of the vessels of
the forehead or pulsating prominences around the eye ; she had never heard
any bruit with the pulsations, and was not conscious of the latter except as she
felt the eye with the finger. She stated also that on January 20 the eye had
become somewhat painful and more prominent, had throbbed more strongly,
and by the next day had become extremely painful. Then the globe was sud-
denly pushed almost out of her head with excruciating pain and great redness.
In her own language she thought that the eye would “burst out of" her head.
She applied to her family physician, Dr. Fishburn, who reported to me in
writing as follows:—
Mrs. K. first called my attention to her eye, in the evening of January 20, 1876. I
made a hasty examination at the moment, regarded it as a mild case of conjunctivitis, and
requested her to call next day. On the 21st I was summoned to see her at her home. I
found her face so much disfigured by a swelling over the right eye, that I hardly recog-
nized her as the patient I had seen the day previous. The eye had the appearance of
having received a terrible contusion from direct violence. The swollen and discolored lids
were so firmly closed that it was impossible to separate them, and the effort caused exqui-
site pain. I directed the constant use of cold water and acetate of lead dressings, and a
saline purgative, to be followed by quarter of a grain doses of morphia every three hours
till the pain should be relieved.
22d. Patient worse; could not bear the cold water dressings; removed them and applied
dry heat, which gave some relief. I ordered four leeches, to be followed by formentations
of poppy capsules.
23d. Found her very much improved; pain had moderated and swelling subsided con-
siderably. I was now able to separate the lids; found the conjunctiva in a highly inflamed
condition, and the tumefaction so great as to cause the ocular and palpebral portion to
protrude between the lids, while a chemotic swelling surrounded the cornea. There was
also great protrusion of the eyeball. Ordered a three-grain solution of atropia to be ap-
plied every three hours, and continued the anodyne fomentations, covering them with
oiled silk.
24th. Patient improving; treatment continued.
25th. Improvement, and same treatment. In addition, I applied to the conjunctiva,
with a brush, a few drops of a solution of nitrate of silver, gr. v.j-f3.j.
26th. Swelling of the lids, and vascular congestion subsiding. The same treatment was
continued till Feb. 12, when the patient was again referred to Dr. Williams.
At this time the exophthalmos was much greater than when I had seen the
patient in September. The cornea stood half an inch in advance of its natu-
ral position, and was hazy, with extensive abrasion of the epithelium, and an
intense zone of circumcorneal redness. I attributed the keratitis to the great
prominence and exposure of the cornea. The patient said that her eye was
much less prominent now than three weeks before, after the severe attack of pain
and protrusion. Vision was very imperfect, explained in part at least by the
state of the cornea. Movements of the eye much limited, but equally so in
all directions, and no diplopia; pupil dilated by a tropia, which had been con-
stantly used. There was now absolutely no pulsation felt anywhere over the
globe, or between it and the orbit. The eye could be pressed into the socket
a line or more, but did not pulsate in the least, neither was any bruit to be
heard on auscultation. Fundus of the eye dimly seen by the ophthalmoscope,
and great swelling of the disk recognized. Ordered free use of atropia, and
eye to be kept closed by wet bandage and compress.
916 E. WILLIAMS,
Feb. 14. Improving rapidly; exophthalmos much less ; cornea clearing ;
W. = }}, with + S. 40. Choked disk, and remarkable enlargement and ser-
pentine appearance of the veins, extending to the extreme periphery of the
retina, with isolated points of ecchymosis. The arteries are small, partially
obscured, especially on the papilla, but pulsate distinctly when pressure is
made on the globe.
Feb. 21. Ball receded decidedly; cornea clear ; W. = }#, and patient reads
No. 8 at 8" with –– 7% ; field of vision perfect; external vessels smaller, and
eye less red ; movements perfect.
Feb. 26. Eye receding ; sclerotic less vascular, and showing white; W. = }};
spots of effused blood still seen, especially at the sudden flexures of the retinal
veins; outlines of the disk not yet sharp. Through March all the symptoms
continued to improve.
April 8. The external vessels have disappeared above and below; the scle-
rotic looks more natural, and the exophthalmos is reduced to barely one-sixth
of an inch ; vessels of retina much smaller and straighter, and the hemorrhages
becoming absorbed. Patient feels no inconvenience from the eye, and is gain-
ing sight with the general improvement. On the 10th of June the patient is
still better. Only two vessels forming a loop near the outer margin of the cornea
attract attention. With this exception the eye appears as well as the other.
There is a very slight degree of exophthalmos, not noticeable to the patient or
to her friends; movements perfect, and pupil of medium size, but sluggish
like the other; W. = 3; with + 36. Fundus greatly improved ; no traces of
blood ; disk nearly natural ; and veins reduced in size and but little winding.
On September 29, the patient called, at my request, for examination. The eye
was perhaps one-twelfth of an inch more prominent than the other, but this
could not be noticed without a critical examination. No trace of the external,
enlarged vessels was seen except two small ones with a slight loop on the outer
side of the cornea. W. = }} with + 42, almost equal to the other eye. On
ophthalmoscopic examination, with dilated pupils, I could detect no material
difference in the fundus of the two eyes, both appearing normal, and the arte-
ries pulsating under same external pressure. By pressing the eye backwards
with the finger, it seemed to be checked by a firm substance at the apex of the
orbit, which did not exist on the other side. The patient was perfectly well.
I wish now to consider the question of diagnosis. Am I justified, in
the present state of our knowledge on this subject, in calling this a case
of intra-orbital aneurism : The symptoms of aneurism were, it seems to
me, unmistakable. The pulsations of the protruded ball were synchro-
nous with the systole of the heart, partly controlled by pressing the
globe backwards against a yielding, elastic resistance, and completely
stopped by pressure on the common carotid. I unfortunately lost the
opportunity to investigate the bruit de souffle with the aid of the stethe-
scope, but there is every reason to believe that it was there, and that it
could have been heard. An important point in favor of the theory of
orbital aneurism is that the patient herself never heard any bruit. In
the great majority of intra-cranial aneurisms, the sound to the patient is
audible, and often very distressing. In orbital aneurism, further away
from the auditory nerve and labyrinth, with little or no direct bony con-
duction, I apprehend that the pulsations are not heard by the patient
himself. There was no paralysis of any of the nerve trunks which pass
near the cavernous sinus, and which are so often affected by direct pres-
sure in cases of arterio-venous aneurism of the internal carotid. In short,
all the symptoms were limited to the orbit, and all of an aneurismal
character. The aneurismal sac was not very large, else it would have
been felt by deep pressure of the finger; and it was not sufficiently firm
to produce paralysis of the muscles and optic nerve by direct compression.
ORBIT A L AN E U RIS MAL DISE ASE. 917
There was no dilatation of the branches of the ophthalmic vein, forming
pulsating tumors, as in arterio-venous aneurism in the cavernous sinus.
The only serious obstruction to the return of the venous blood from
the orbit, was confined to the veins of the eyeball, external and internal.
The trunk of the ophthalmic vein could not have been seriously com-
pressed without manifestations in its frontal and other branches. The
symptoms were therefore all arterial in their origin, and confined to the
orbit and globe of the eye. No well-authenticated case of arterio-venous
aneurism in the orbit has ever been demonstrated by post-mortem exam-
imation. Besides, the symptoms were not of a character to make that
supposition possible, much less probable. Of course encephaloid, menin-
gocele, and venous tumors are excluded. It was not an erectile tumor,
nor an aneurism by anastomosis in its restricted sense. The history, symp-
toms, and termination, all point to a circumscribed a neurism of the oph-
thalmic artery, in the orbit, which eventually ruptured, became diffuse,
and was cured. I do not think that anything but an arterial hemorrhage
could have pressed the globe so far forward and produced such extreme
tension. That the aneurism must have been sacculated, with thin elastic
walls and a small communication with the ophthalmic artery, is rendered
probable by the occurrence of rupture and recovery without obliteration
of the artery. That the artery is not obliterated, is sustained by the
fact that arterial pulsations are observed in the optic papilla when ex-
ternal pressure is made on the ball. It could only be such a cause that
would ſail to produce more serious pressure on the ophthalmic vein, the
rotatory muscles, and the optic nerve. That circumscribed aneurism of
the ophthalmic artery does occur, though perhaps very rarely, is proved
by the post-mortem examination in Guthrie's case, in 1825, where an
aneurismal pouch was found on the artery in each orbit.
Some years ago also I treated a case in which I feel conſident that there was
an intra-orbital aneurism. The case was that of a young man who was shot
in the eye by a small pistol. The ball passed through the globe and lodged
deep in the socket, causing the eye to collapse and atrophy. The patient was
treated by the late Dr. Blackman, and some months afterwards came to have
an artificial eye inserted. On examination I found a round, pulsating, elastic,
compressible tumor in the back and inner part of the orbit, about the size of
a pigeon's egg. The man was not aware that anything was the matter till I
called his attention to it. There was an aneurismal bruit heard with the
stethoscope placed over the tumor, but not heard over the head or by the
patient. It was exactly synchronous with the action of the heart and was
completely stopped by pressure on the carotid. There were no venous enlarge-
ments in the socket or on the forehead. The globe was reduced to the size of
the end of my little finger, so that the tumor could readily be seen and fully
examined by palpation. I put the patient in the recumbent position, with the
head raised; gave careful doses of digitalis, and had digital compression of
the carotid tried for two days. It became irksome and painful to the patient,
and my assistants gave out. So I called in Dr. Blackman, and we agreed to
try instrumental compression of the carotid, which succeeded in completely
curing the disease; and I afterwards fitted the patient with an artificial eye.
He lived till recently, and died of phthisis.
These two cases are, I think, shown with reasonable certainty, by the
symptoms and result of treatment, to have been genuine examples of
orbital aneurism. In my case, published in the Medical Record, 1868,
diagnosed as orbital aneurisin and cured by ligation of both carotids,
thirty days apart, I am now satisfied that there was an arterio-venous
aneurism of the carotid in the cavernous sinus. I have since seen a case
918 E. WILLIAMS,
with essentially the same symptoms produced by the passage of a cart
wheel over the man’s head. I never saw the man but once, and know
not what became of him.
Case of Suspected Orbital Aneurism.—T. W., aet. 24, of stout figure, robust
health, and sanguine temperament, was injured by the horn of a calf on Janu-
ary 18, 1876. The point of the horn struck the lower lid, glancing inwards
and backwards and entering the orbit just above the tendo-oculi, causing an
ugly contused wound and a severe concussion. The wound bled profusely,
but healed in the course of a week, without surgical treatment. There was
no bleeding from the nose, nor ocular hemorrhage, nor was the patient rendered
unconscious by the shock. Sight was not affected, and there was no diplopia,
headache, giddiness, nor other symptom of injury of the brain. There was
no protrusion noticed. About five weeks after the accident, while stooping
and driving a cross-cut saw, a sharp pain was felt above the right eye, running
back over the ear to the temple. This sharp, peculiar pain came on at intervals,
several times during the day, but was always provoked by stooping and strain-
ing, and soon passed off when the patient straightened himself up, and rested
from sawing.
There was no giddiness, throbbing, or bruit. Late in April it was first
noticed that the sight of the eye was misty at times, but without pain or other
symptom of trouble. For this failure in sight a physician was consulted, who
first detected an undue prominence of the eye. From that period, about May
1, till within the past four weeks, the exophthalmos increased slowly, but
varied very perceptibly between morning and evening, being always greater
in #!, 6 m or thin or S$ in or, Flo own i + k, a c. -o no ni no ſl + of ion ºn 1 v., When I first, Saw
Al 11 U i i V, 1.1 v 1 1, 1 was - M-91 il V- \ly U 1.4 V, 1.1 A U. Ill Clu kJ l’e H, fl. 13) e (; SU 35, O}} {\ } } • w y }}{2}} -i. A H S tº *J -ºu w
-
this patient, three weeks ago, there was a striking exophthalmos of over one-
fourth of an inch, with slight injection ºf the sclerotic conjunctiva, and some
serous, chemotic Swelling within the external commissure. Corresponding to
this were seen some large, deep-seated, in osculating vessels on the sclerotic.
The pupil was larger than the other, and somewhat sluggish. The movements
of the globe were limited by the prominence and the stretching of the muscles,
but there was no paralysis. There was a divergence of 1%" when fixing with
the other eye, and the motion upwards and inwards was less excursive, but
there was no diplopia, which I explained by the imperfect sight. Strongly
marked features of swollen disk, and some heuritis; boundaries of disk obscured,
and veins very large and tortuous to their extreme branches; slight alteration
of macula lutea, blurring its distinctive features. Vision very defective in
consequence of a large central Scotoma, which patient expresses as well defined
but not complete.
Tension of the globe natural. No pulsation whatever of the globe nor bruit
on auscultation. When the eyeball is pressed directly backwards, it is arrested
by a solid resistance. Diagnosis: Tumor of some kind at apex of orbit, pro-
bably of an aneurismal nature. In the complete absence of the three most
characteristic symptoms of aneurism, pulsation, bruit, and some degree of
elasticity on pressure, I rely upon the evident traumatic origin of the difficulty ;
its peculiar history; the absence of inflammatory symptoms, and the exclusion
of the symptoms Of either benignant or malignant tumor at the apex of the
orbit. The symptoms followed so soon after the injury, and in the beginning
were so characteristic, as to make this opinion more probable than any other.
The sudden, sharp, severe pain running backwards over the temple, and caused
by stooping and straining, coming on about four weeks after the blow, might
be explained by the sudden rupture of the ophthalmic artery, directly as it
enters the orbit through the Optic foramen. Its coats may have been weakened
by the original concussion, or the very slight rupture occurring there might
have been plugged by the formation of a coagulum. The history of several
published cases of supposed orbital aneurism, makes this latter supposition at
least tenable. If the vessel then split or the plug was then suddenly dislodged
O R B I.T A. T., A N E U R IS M A. L. D. IS E A S E . 919
by the increased congestion from stooping and straining, why did not imme-
diate protrusion of the eye, pulsation, bruit, etc., occur 7. It may be that the
opening was very small, and close in the narrow apex where rapid expansion
and consequent protrusion were prevented. It will be remembered that not
till this occurrence was the vision impaired ; and that, the troubled sight took
the patient to a physician who first detected the exophthalmos. The imme-
diate effect of a slow oozing of blood from a small arterial rent in the supposed
situation, would, of itself, be pressure upon the optic nerve and very slow
protrusion of the ball without pulsation. As the sac, fed by so small a source,
enlarging almost imperceptibly, may be filled as it forms with coagulated
blood, and make a solid mass without pulsation either from its own expansion
or from impulse conveyed to it by the throbbing, small artery, the complete
absence, as yet, of pulsation and bruit may be accounted for. The same ex-
planation would account for the absence of any serious symptoms of pressure
on the ophthalmic vein or other structures. Of course this theory of the case
must as yet be considered as Open to question. The characteristic symptoms
may yet be developed and make the case clear. My Opinion, however, is so
strongly in favor of an arterial lesion, that I believe that the symptoms can be
relieved by systematic pressure on the carotid. As the patient is present, it
gives me great pleasure to submit him to the Section for examination. I
can only say that with one exception the symptoms are to-day what they were
three weeks ago. The tension of the globe is now minus. It was not so then."
[The patient was then presented.]
In conclusion, I will sum up the symptoms which seem to justify the
diagnosis of true intra-orbital aneurism, as follows:—(1) If traumatic in
origin, the nature of the injury. If it is by direct penetration of the
orbit by a long, slender body, or a small shot or similar foreign sub-
stance, the ophthalmic artery may have been wounded, as was probable
in one of my cases. (2) If the injury to the head or face, though severe,
is not attended by symptoms of fracture of the base of the skull, or, in
the absence of the positive symptoms of fracture, if the severity and
character of the trauma are not such as to make such a lesion probable.
(3) The strictly rhythmical character of the pulsations, if such exist.
(4) The limitation of the region over which the bruit is heard, to the
eye and orbit. (5) The strictly intermittent character of such bruit.
(6) The fact that the patient himself does not hear the souffle, or, if so, very
slightly. (7) The less frequent occurrence of paralysis of motion or sen-
sation, or of any symptoms indicating a disturbing cause in the cavity of
the cranium. (8) The less frequent and less serious impairment of vision.
(9) The absence, except at an advanced period, and even then the less in-
tensity, of the symptoms of obstruction in the ophthalmic vein, such as
the existence of soft, thrilling, pulsating tumors around the eye, and of
enlarged and pulsating frontal veins. (10) The complete curability of the
disease by direct compression through the eye; or by compression of the
common carotid ; or by ligature of one (the corresponding) carotid.
The symptoms, till recently, accepted as characteristic of intra-Orbi-
tal aneurism, are much graver and more extensive in their distribu-
tion. When we submit them to the test of pathological anatomy, as far
as such cases have been examined, it is seen that they depend on lesions
This patient was seen again on April 15, 1877, when there was great protrusion of the
eyeball with aggravation of all the other symptoms; a tumor could now be felt behind the
globe. Enucleation of the eyeball was resorted to, when the tumor, which was firm and
fibrous in character and the size of a small pullet's egg, was readily removed. It was
situated between the optic nerve and the inner wall of the orbit, but was not firmly con-
nected with either. (July 5, 1877.)
920 E. WILLIAMS, ORBITAL AN E U R IS M A L DISE AS E.
beyond the orbit. Of the 73 cases reported in Mr. Rivington's paper, in
12 only were autopsies made. Some of Mr. R.'s conclusions I will quote:
“In no single instance has aneurism by anastomosis, or cirsoid aneurism
within the orbit, been verified by post-mortem discovery.” “In no sin-
gle instance has an arterio-venous aneurism been found within the orbit
at a post-mortem examination.” “In no case have the symptoms of
intra-orbital aneurism been proved to be due to a tearing across of the
ophthalmic artery at or near the optic foramen.” In the case of Guthrie,
an aneurism was actually found in each orbit. In one case, no arterial
lesion was found, but partial obliteration of the orbital veins, with evi-
dences of previous inflammation in the orbital tissues. In the other ten,
in which autopsies were made, the symptoms were caused by disease of
the vessels just back of the orbit, in the cavity of the cranium. Of these,
some were dependent upon obstruction to the return of the venous blood
from the orbit to the brain. In one a small aneurism existed on the oph-
thalmic artery at its origin from the internal carotid. In three there
was rupture of an aneurism of the internal carotid, within the cavernous
sinus. In One, “simple dilatation and atheromatous degeneration of the
internal carotid artery in the cavernous sinus.” “In three, traumatic
cases, a direct communication between the carotid artery and the cavern-
ous sinus was found.”
Finally, a word as to treatment. Compression, either direct, or of the
common carotid, or both, is advisable in all cases, and succeeds in some.
Coagulating injections may sometimes be successfully practised, but
require great caution. And finally, ligation of one or both carotids will
be nearly always necessary for the extra-orbital cases
v
-a, -a y *** *- necessary -*. *-* .4.- *, *, *-* tº k-ºw *-, *-ſ º
*A
921
SPONTANEOUS CURE OF CONGENITAL PULSATING
EXOPHTHALMOS.
IBY
GEORGE C. HARLAN, M.D.,
SURGEON TO WILLS HOSPITAL, OPIIT HALMIG AND AU RAI, SURGEON TO THE CHILDREN's HOS PITAL,
PHILADELPHIA.
TIIIs case was reported at the last meeting of the American Ophthal-
mological Society, but since then the aneurismal tumor has sponta-
neously undergone complete consolidation. The following abstract of
the history, to date of last report, is taken from the transactions of the
society referred to :—
L. L., aet. 25. General health good. Left eye always prominent, and left
side of head larger than right. IIas always had a “ rushing sound in his head
and eye.” Left eye enormously protruded, forced downwards and outwards,
and immovable. No useful vision. Whole left side of face hypertrophied.
Mucous membrane of left side of mouth thickened, and left side of tongue
twice as large as right. A localized tumor, probably a distended vein, above
and to inner side of ball, and a doughy swelling of the soft parts extending
about an inch above the orbit. There was strong pulsation, and an aneurismal
bruit could be heard several feet from the patient’s head. Five years after the
first examination, the protrusion had slightly increased, but the bruit had de-
cidedly diminished. The supra-orbital and frontal vessels were much distended,
and pulsated strongly, and this a neurismal condition extended down the angu-
lar branch of the facial, on the right side.
On December 27, 1875, the patient came to me, complaining of pain
in the eye, and over the bridge of the nose, and along the course of the
angular artery on the right side. There was slight erysipelatous inflam-
mation at the seat of pain, but not much change in the appearance of
the parts. The bruit had entirely disappeared, and there was no thrill
in any of the vessels, and no pulsation anywhere except in the localized
tumor above the ball. The supra-orbital vessels were scarcely percepti-
ble. IIe had not been under any treatment, as he was not able to keep
up even occasional, intermittent compression of the carotid, on account
of the giddiness and faintness which it produced. The continuous appli-
cation of iced water was directed.
December 31. There was violent pain in the tumor and head. The
tumor was increased to at least twice its former size. Pulsation was
just perceptible. The exophthalmos was enormous, and the eye could
no longer be covered by the distended lids. The patient was admitted
to Wills IIospital, and anodynes were given in large doses, and dry cold
substituted for the iced-water applications.
January 2, 1876. The pain was somewhat relieved, and all trace of
pulsation in any part of the tumor had disappeared. The cornea was
completely anaesthetic, and was beginning to slough. The pulse was
feeble, and the pulsation of the left carotid was weaker than that of the
right. From this time the pain and swelling gradually subsided, and
922 HARLAN, PULSATING EXO PHTH ALM OS.
when the patient left the hospital, on February 2, the tumor was com-
pletely consolidated, and had considerably diminished in size.
No satisfactory way of accounting for this sudden and unlooked-for
termination of the disease suggests itself to my mind. It is interesting
as illustrating the possibility of spontaneous cure under circumstances
that would seem to be about as discouraging as possible, and suggests
the inquiry, what percentage of cases, if let alone, might end in the same
way 7. This question cannot be answered, as nearly all reported cases
have been subjected to some kind of surgical treatment.
I find records of five other cases of spontaneous cure, all but one hav-
ing been of traumatic origin.
CASE I. Collard ; quoted by Erichsen (Science and Art of Surgery, Ameri-
can Edition, 1869, p. 643). A man, 41 years of age. Injured by fall on back
of head. Bruit, pulsation, exophthalmos. Symptoms entirely disappeared in
three years and a half. -
CASE II. Erichsen (Ibid.). Man, 44 years of age. Fall on head. Attacked
by symptoms of aneurism of left orbit in most marked manner. Bruit, pulsa-
tion, exophthalmos. Ligature of carotid urged by Mr. Erichsen but declined
by patient. At the end of fourteen months the symptoms had, to a very great
extent, disappeared. -
CASE III. Holmes (American Journal of the Medical Sciences, July, 1864).
Man, 23 years of age. Gunshot injury. Exophthalmos, chemosis conjunctivae,
bruit, pulsation. In about three months all the symptoms had entirely disap-
peared, except slight congestion of the conjunctiva.
CASE IV. France (Guy's Hospital Reports, 1853). Woman, 38 years of
age. Point of umbrella thrust into orbit. Exophthalmos, pulsation of eye-
ball, and defined, pulsating tumor above and to inner side of globe; complete
blindness. All the symptoms but blindness disappeared in eight months.
CASE W. Julliard, of Geneva (“Note sur un Anévrisme Intra-orbitaire,
etc.,” quoted by Rivington, Medico-Chirurgical Transactions, London, vol. lviii.
p. 272). Woman, 69 years of age. Spontaneous. Enormous exophthalmos,
pulsation, bruit, chemosed conjunctiva. In two months all the symptoms but
exophthalmos and blindness had disappeared. A few months later, the exoph-
thalmos was also gone.
In none of these cases was any local treatment resorted to, except that
in two or three instances gold applications were employed in the early
stages. In connection with the case reported to the Section by Dr. Wil-
liams, and that now submitted, they make a total of seven instances of
spontaneous cure of this affection.
Though statistics prove beyond doubt that ligation of the carotid
affords the largest percentage of cures, it is well, before deciding upon its
performance, to remember not only the possibility of cure by milder
means, or even without resort to any surgical procedure at all, but to
bear in mind also that, though one of the most brilliant operations in
surgery, it is not without its chances of failure and its dangers of a fatal
result. All the operations that I have been able to collect, including
two of Dr. T. G. Morton's, not yet reported, furnish sixteen per cent. of
deaths and about the same proportion of failures, leaving only sixty-eight
per cent. of cures and partial cures.
923
ARE PROGRESSIVE MYOPIA AND CONUS (POSTERIOR STA-
l’IIYLOMA) DUE TO IIEREDITARY PREDISPOSITION, OR
CAN THEY BE INDUCED BY JOEFECT ()F REFRAC-
TION ACTING THROUGH THE INFLUENCE
OF THE CILLARY MUSCLE 2
BY
EDWARD G. LORING, J.R., M.D.,
OF NEW YORK.
AFTER a careful consideration of the above question, I have come to
the conclusion: (1) That hereditary predisposition, though undoubtedly
a potent cause, is not only not the sole cause, but not even the predomi-
nating cause, of progressive myopia; and (2) That the action of the ciliary
muscle, taken by itself, exerts but little influence on the production of
myopia, and still less on the formation of the cone.
The arguments on which these conclusions are based will be found in
the following remarks:—
The belief that “like begets like” has been formulated in the speech
and crystallized in the proverbs of every people since the world began,
and although this uniformity of opinion exists as to hereditary predis-
position, and its influence on the organism in general, a great deal of
doubt has been expressed as to the degree of effect which it produces on
particular and individual organs, and especially on those which fulfil
the functions of special sense. Nor can it be doubted that grave objec-
tions have from time to time been raised, and many weighty arguments
advanced, which would go to show that the effect of direct transmission
could not be so readily detected, nor so clearly demonstrated, in regard
to the special senses as to the organism as a whole. Still, in later years,
as proofs have gradually multiplied and apparent discrepancies have
been reconciled, the opinion has gradually become more general that,
beneath a mass of apparent contradictions and almost endless ex-
ceptions, there lies a general tendency of inheritance which authorizes
us in assuming that even with our special faculties there is a uniform,
though perhaps, from want of knowledge, a rather flexible, law, which
controls, to a degree at least, their form and character.
In none of these is it claimed that this law of transmission is made
more manifest than in sight, the noblest and most intellectual of all our
faculties. Thus it has been assumed by the preponderance of authorities,
that the specific type of the organ of vision has its varieties of form and
perception, every one of which may owe its origin to the force of he-
redity. Thus it is held that color blindness, strabismus, hypermetropia,
and myopia, are transmissible by generation, so that according to
Lucas (1) there are families among which many of their members owe
1 The numbers attached to the names of the authors refer to the bibliography at the end
of the paper.
924 LO RING,
to hereditary influences alone the conformation of their optical appa-
ratus, and the fact of their range of vision being short or long. It is
further claimed that the statistical results of Funari(2), supported by the
statements of Piorry (3) and Portal(4), have shown that most myopes are
the sons or grandsons of myopes. It is certainly not necessary for me to
remind the members of this Section that views, similar to, if not iden-
tical with, those just quoted, as to the hereditary tendency of myopia,
have held sway successively in England, France, Germany, and in this
country, and indeed in every country. Nor would the time allotted to
this paper allow me, even if your patience would, to cite the long list of
distinguished names through whose authority this wide-spread opinion
has had and still has its existence; still, for the sake of the arguments
which are to follow, I should like to be allowed to refresh your minds in
regard to the opinions of a very few of those who in our own time have
done so much towards moulding the prevailing opinion as to the heredi-
tary nature of myopia.
Thus Stellwag von Carion(5), in discussing the causes of myopia and
the elongation of the eyeball, says “the predisposition to this is of course
congenital, and is, as a rule, hereditary,” and adds, in speaking of the
staphyloma and its relation to the scleral protuberance, that the “exqui-
sitely hereditary character of the affection can also be brought forward
as a proof of this.” Jaeger(6), while emphasizing the fact that myopia
is not the “prerogative of industry,” declares that “posterior staphyloma
is hereditary to a predominating degree.” And Donders(7), in speaking
of the causes of myopia, affirms that “the predisposition is almost always
congenital, and in that case it is, moreover, nearly always hereditary.
Beer, Jüngken, Bohn, Von Hasner, and many others, have referred to
its hereditary nature, and I believe even that from time immemorial
the conviction thereof has been general among the people.” Many more
examples quite as explicit as these might be cited here, were it necessary,
since, as you are well aware, every standard work on ophthalmology is
replete with them.
It would be supposed, from the force of the expressions and the weight
of authority from which they come, that these opinions in regard to the
predominating influence of heredity in myopia would be based on exact
and extensive statistical information which would embrace, certainly, as
wide a scope as from grandfather to father and from father to son. Yet,
as far as I am aware, no such statistics exist, at least of such a nature as
to satisfy the exacting demands of modern science. It is very true that
both Donders and Jaeger have—as indeed we all have—been struck with
the frequency with which myopic parents bring to us their myopic
children; but, as you are well aware, the mind, in these matters, is more
prone to be struck with resemblance than with dissimilarity, and no
account is taken or recorded any where, as far as I know, of how often
the reverse holds good, that is, how often children with myopia are
brought by parents who, on actual examination, are shown to have normal
eyes, and whose ancestors on both sides, as far as known, were never
near-sighted. Moreover, I found that among 715 well-educated and intel-
ligent persons, whom I examined for this special purpose, the percentage
of those who had normal eyes themselves, but whose parents were myo-
pic, was nearly identical with the percentage of those who were not only
myopic themselves, but who had myopic parents. That is to say, that
the percentage of emmetropic children from myopic parents was as high
as that of myopic children from myopic parents. No one more fully
P R O G. R. E S S I W E M Y O PIA A N D C O N U. S. 925
recognizes or more freely admits than I the liability to error in statistics
gathered thus as it were at second-hand. Nothing but the tabulated
observations of three generations at least can be of much value as regards
heredity, but as such do not exist, I offer the above for what they may
be worth.
These observations would, however, seem to be in accordance with
those of others. Thus Cohn(8), in his investigations as to the refraction
of the eyes of school children, found that out of all the myopes there
were only 2.7 per cent. whose father or mother were myopic. I found
that only 6.11 per cent. had either father or mother near-sighted. With
both parents myopic, the percentage falls with Cohn(9) to 1.04 per cent. and
with me to 1.11 per cent. Erismann(10) found, however, from his statis-
ties that 30.6 per cent. of the myopes had one or both parents myopic.
Taking, then, Erismann's percentage, which is an enormous increase over
Cohn's and mine, as a basis, we find, even then, that two-thirds, or
seventy per cent., of the myopic children had parents who were not myo-
pic. This certainly does not show, as far as statistics are concerned, a
marked hereditary tendency, or warrant, it would appear, the expression
of so decided an opinion as that which we have quoted from the leading
authorities.
There are, however, in the absence of exact statistical knowledge, seve-
ral factors of less importance, it is true, but still of sufficient force to aid
us materially in the solution of the problem, and amongst these the most
important are necessarily those of an anatomical nature. For if in any
case of disease it can be shown that an anatomical formation is pecu-
liar to a certain disease, the presumption is that it is congenital as a rule;
and the earlier it shows itself the more likely is it to be hereditary. That
both of these conditions have been fulfilled in regard to myopia by the
change known as posterior staphyloma, is almost universally admitted.
Thus Stellwag(11) declares that posterior staphyloma is due to congenital
malformation, while Jaeger(12) says that “the increase in the axis is usu-
ally accompanied with a cone which is mostly congenital, and frequently
hereditary,” and adds that he has seen “typical cases of it in the eyes of
new-born children both in life and after death;”(13) and Donders(14) only
strengthens the almost universal opinion when he declares that from the
frequency with which changes in the bottom of the eye have been observed
with the ophthalmoscope, myopia and staphyloma have become nearly
synonymous terms. This statement he supports by a reference to
Graefe(15), who had previously declared that, in myopia of , to #,
ninety per cent. showed that peculiar change in the fundus, and adds that
he himself(16) believes the proportion is much nearer one hundred per
cent. Still there can be but little doubt that the general and rather
sweeping assertion that posterior staphyloma is synonymous with myopia,
is somewhat exaggerated. For out of 500 myopic eyes I found only 20.5
per cent. affected with the crescent. Cohn(17) in 1004 cases of myopia,
between the same ages, that is, from 6 to 21 years, found the cone present
in only 20 per cent. ; while Max. Conrad's(18) examinations in 1001
myopes showed 28.1 per cent. The average of these results would then
show that only 22.3 per cent. of myopic eyes have the cone. Of my own
cases there were only one-fourth which showed any change whatever,
while there were three-fourths of the eyes which showed no deviation
from the normal standard. This is certainly at variance with the
accepted views, though it is corroborated as seen above by the extensive
statistics of Cohn and Conrad, the unanimity between the results being
926 LO RING,
very remarkable. When, however, we come to the proportionate fre-
quency of the cone in regard to the three classes of refraction, we find
that it predominates to a marked degree in myopia. Thus I found of
2265 eyes examined, that of the emmetropic eyes 3.33 per cent. had cones
more or less developed ; of the hypermetropic 3.49 per cent. ; while in the
myopic the percentage rose to 20.56 per cent., or six times as much as
in either of the other classes. We are forced to conclude, therefore, that
there is an anatomical variation predominating in myopic over other eyes,
although the frequency with which it occurs has been, it would appear,
much overrated—certainly for this country. Still, too much weight
should not be put upon this fact as an argument as to the congenital
and hereditary character of the cone, since, in the first place, an anomaly
which makes its appearance in only about one-fourth of the cases, and
under the most favorable auspices for its development, that is, in school
children between the ages of six and twenty-one years, cannot be said to
be strongly congenital.
Moreover, it is a fact that, although, as stated by Jaeger(19) and Von
Hasner, well-marked cones are found in new-born children, they are,
as known to all, and admitted by them, comparatively rare; while they
increase in frequency in after life, and with close application ; and often-
times in eyes which have been shown by repeated ophthalmoscopic ex-
aminations to have been previously free from the slightest trace. From
these facts, and from the fact that myopia consists as a rule simply of an
elongation of the globe, which would, from purely mechanical reasons,
produce a crescent, a doubt has arisen, in my own mind at least, whether
after all the cone was an expression of congenital malformation of the
scleral protuberance, or indeed of any part of the scleral split.
For, if it had any connection with the split, we should suppose it would
be in reality what both its name and alleged anatomical origin imply,
that is, an actual protrusion of the sclera, or at least an excavation or
limited thinning of this membrane, as is invariably the case with a true
coloboma, as demonstrated as well by the ophthalmoscope as by dissec-
tions. Dut I hardly need remind those of you who use the upright
image that there is almost never the slightest difference in level between
that part of the sclera which represents the come and the adjoining
portions, and this, too, no matter how large the crescent is. The cone is,
in fact, not a true staphyloma; and it is only when applied to the entire
posterior portion of the eye that the name is at all applicable, and we
should be forced to assume that the whole posterior part of the eye was
congenitally defective, or at least that parts were so which were widely
separated from the scleral protuberance. -
The second anatomical variation which is supposed to be characteristic
of the myopic eye, and One which has had great importance attached to
it, is the peculiar conformation of the ciliary muscle, which is supposed
to be congenital. From the labors of Iwanofi (20) it was shown that the
ciliary muscle in highly myopic eyes varied from that in other eyes, not
only in general outline, but also in its composite structure. In the
drawing (Fig. 1), which is taken from Iwanoff, the shape and outline of
the muscle in the three classes of refraction are contrasted with each
other. The solid line represents the muscle of an emmetropic, the dotted
that of a myopic, and the broken line that of a hypermetropic, eye. It
will be seen that the muscle in the myopic eye extends further back
along the sclera than in the normal eye, and is, moreover, broader. It will
be observed also that the short side, or leg, of the triangle, which repre-
P R O G R E S S I V E M Y O PIA A N D C O N U. S. 927
sents the muscle as a whole, forms in the normal eye nearly a right angle
with the Sclera, while that in the myopic eye forms an acute angle, with
the apex towards the inner portion of the eye. As to its component
parts, it was shown that the circular fibres found in the normal eye were
Tio.T. N
O *s
either very much reduced or entirely wanting in the myopic eye, while
they were increased in the hypermetropic eye. It was, therefore, assumed
that, inasmuch as the myopic eye from its structure had no demands for
active accommodative efforts, the reason why the circular fibres were not
present was because they had become atrophied from disuse, so that the
entire triangle marked A had disappeared. While, on the other hand,
the circular fibres had been so increased by active accommodative demands
in the hypermetropic eye as to occupy the superadded triangle B. It was
further shown by Iwanoff that not only had the circular fibres become
atrophic, but that the longitudinal had become hypertrophied. From
this it was assumed that the action of the muscle had been changed, and
that, instead of being compound, the circular fibres drawing toward the
axis of the eye while the longitudinal drew directly forward, the action
had become solely the latter, so that the muscle had become what the
author calls a pure “tensor choroideae.” If we should accept this theory,
we would have the apparent reductio ad absurdum, as the author himself
says, in the development of a force which he supposes to produce active
accommodation, in an eye which does not require or use it; for traction
on the choroid and consequent relaxation of the zonula is supposed by
Helmholtz and other physiologists to be the important element in the
production of accommodation.
It would certainly lead me too far to enter in a discussion of this
subject, but it seems as if a very important factor, and one which night
produce a marked effect on the form and shape of the muscle in the
myopic eye, had been neglected in the consideration of this question. This
is the effect of distension of the investing membranes of the eye, which
in some cases is enormous, as, for example, where progressive myopia is
developed very rapidly and to a very high degree. It would, therefore,
certainly seem more natural to attribute the change in form and structure
to this than to any difference in function of its component parts. Thus if
the posterior pole of the eye should yield, the insertion of the muscle at its
choroidal end would be drawn back as seen in the drawing, and the angle

928 LORING,
which, as we have seen, was a right angle in the normal eye would then
become acute, since the insertion around the canal of Schlemm and adja-
cent parts would remain stationary. The few so-called circular fibres
which form an amastomosing network, whose meshes run more or less
perpendicular to the direction of the longitudinal fibres, would on being
stretched assume precisely the opposite direction, and would then have on
section the same general direction as the longitudinal, as would of course
also the so-called radiating, fibres. Moreover, as the horizontal and
vertical diameters also increase somewhat in these highly myopic eyes,
the zonula would be stretched, and would then draw with a gentle but
sustained traction on the muscle, the general direction being perpendicular
to the axis of the eye. Thus the fibres of the muscle would have a
tendency to draw apart, and the muscle to increase in bulk. This tension
On the Zonula would also account for the fact that the lens is flatter in
high degrees of myopia than in the normal eye. Thus appearances
hitherto supposed to be congenital might occur from a simple mechanical
cause, acting during life in an eye which was not congenitally myopic,
and with no hereditary tendency.
Thus while not denying the hereditary tendency towards a too yield-
ing sclera, I have become more and more convinced that there are many
cases in which the cone is simply the expression of a purely mechanical
effect, distension, from which all the peculiar appearances of the crescent
might result without there being the slightest connection between the
cone and any congenital or hereditary tendency whatever. Does the
inguinal ring never give way, or the fibres of the bladder become re-
laxed, or the pleura distended, or ascites occur, or even the bony cavity
of the head enlarge, except through hereditary tendency? and if these
can owe their origin, as they often do, to exciting causes which are
purely spontaneous and fortuitous, why may not that distension of the
Sclera, which is myopia, take place, especially when the growing and
elastic membrane is subjected to over-use, without our being compelled
to attribute it “almost invariably to congenital and hereditary influ-
ences?” Clinical experience would point to such a conclusion, for it is a
fact that cases occur where myopia with all its characteristic signs is
produced in eyes which were previously normal; that is, in the eyes of
adults, who have passed therefore the period of development, and whose
family history shows no hereditary tendency. This, too, notwithstand-
ing Donders's(21) assertion that he has never seen “myopia arise after
the twentieth year in eyes which were previously normal.” I have seen
several such cases, and I doubt not that most practising ophthalmolo.
gists have had the same experience. -
If this distension of the sclera did take place, there would be, neces-
sarily, a change in the refraction of the eye, and this would have a de-
cided weight in determining the question of hereditary influence. For
if it could be shown that normal eyes which, according to the theory of
heredity, would presuppose normal, i. e., emmetropic, ancestry, or better
still if it could be shown that hypermetropia, the direct opposite of
myopia, with the opposite hereditary tendency, could and did frequently
pass into myopia, then it would be an almost convincing proof that
myopia could be and often was produced in spite of hereditary influence
against it. -
That an emmetropic eye can and does pass into a myopic eye, and that
it has been proved to do so by direct observation, I think will be ad-
mitted by the great majority of observers. But that a hypermetropic
P R O G. R. E S SIV E M Y O PIA A N D C O N U. S. 929
eye can pass into an emmetropic or normal eye, and thence into a myopic
eye, is still a matter of great doubt in the minds of some of the best
authorities. Thus Donders(22) says: “I have never seen a hyperme-
tropically constructed eye become near-sighted.” An opinion which he
corroborates and strengthens in many other passages in his world-re-
nowned book. Jaeger(23), however, makes a diametrically opposite
statement, and declares that an interchange of refraction does take place,
and that “thus an hypermetropic as well as a normally-constructed eye be-
comes a myopic eye through posterior staphyloma at the posterior pole
of the eye.” Stellwag(24) proclaims the same thing in very nearly iden-
tical terms. Various authorities too numerous to mention have ranged
themselves on one side or the other of these Opposite opinions, though I
think that the majority of the more modern observers are tending
towards the view expressed by Jaeger, that an interchange of refraction
from a hypermetropic to a myopic eye can and does take place. Still it
must be admitted, when it comes to actual demonstration, that the few
cases which have thus far been cited are not sufficient in number or accu-
racy of detail to be of the slightest weight. One would certainly sup-
pose, d priori, that such cases would have been observed in great num-
bers, and the fact that they have not, in the past decade when refraction
has been so minutely studied, would seem to point very strongly to the
fact that they did not exist.
In the dearth, therefore, of sufficient direct proof by observation of
the passage in the same person of emmetropia into myopia, and the
almost total want of such evidence of change in hypermetropia, we are
forced to the consideration of collateral evidence which, it appears to
me, if correctly taken and properly appreciated, is nearly as convincing
as that of actual observation. I allude to the proof furnished by statis-
tics taken from large masses of individuals, which show the propor-
tionate rate in which the different classes of refraction occur at different
times of life, and with different degrees and kind of application of the
eyes. From the statistics of Ware(25), in 1813, and in later years from
those of Szokalski(26), Schürmayer(27), Jaeger(28), Ruete(29), and others,
very important facts were obtained. Thus it was shown by Ware that
myopia was more common in cities than in the country, and that it in-
creased in frequency and in degree with the age and amount of close
application, while Ruete also called attention to the deleterious effect of
insufficient and faulty illumination. These facts were afterwards cor-
roborated by Cohn, but unfortunately Cohn's statistics, extensive as they
are, are not suitable for our purpose, since, from the manner in which
they were compiled, no correct idea can be obtained from them as to the
frequency with which, in comparison to each other, the three different
classes of refraction occur.
The statistics to which I shall call your attention are those made by
Erismann(30) in Russia, Max Conrad(31) in Germany, and those by Dr.
R. II. Derby and myself in this country. I choose these as examples since
they are the only ones which I know of where sufficient numbers were
used, and where, at the same time, the conditions of investigation were
the same, or nearly the same, in each. Thus they were all upon the eyes
of school children between the ages of six and twenty-one years, and the
trial by glasses and Snellen's type at twenty feet were the basis of the
examination; while all the more commonly occurring degrees of refrac-
tion from the lower (gº) to the highest grades were included. Every eye
was examined by the Ophthalmoscope in the cases reported by Dr. Derby
j9
930 LO RING,
and myself. Erismann's statistics were made in St. Petersburg on the
eyes of 4358 scholars; Conrad's at Königsberg on 3036 eyes, and Dr.
T)erby’s and mine on 2265 eyes in New York. The results of these sta-
tistics are arranged in a tabular form in the diagrams marked respectivly
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A H iſ ZV V VIT VI. VIII I II III IV V VI Vit VIIſ
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P R O G. RESS IV E M Y O PIA A N D C O N US . 931
from the youngest to the oldest, as in the American diagram. This last
is made necessary from the fact that the arrangement of the classes dif-
fers in this country from that in the foreign schools. Since, however, the
successive classes correspond almost exactly to the successive ages, this can
make no practical difference, especially as both the Russian and German
statistics were calculated in both ways, and no material variation found
between the results of the two methods. As it is the result of the entire
school term, that is from six to twenty-one years, which now interests
us, and which is the same in all countries, the comparison between the
different nations is a just and fair One.
The numbers running longitudinally on the diagrams show the in-
crease and decrease in percentage, each of the larger spaces representing
tem, and each of the subdivisions five per cent. The line marked E
represents the curve which emmetropia takes in the different years, M.
the myopic and II the hypermetropic curve. It will be seen on inspec-
tion, that, however much these curves differ in degree in the different
diagrams, and amongst themselves, they all show that the refractive
power increases with the advance in life.
Thus in the Russian diagram the frequency in which II occurs dimin-
ishes from 67.8 per cent. in the lowest class to 36.2 per cent. in the
highest, while M increases from 13.6 per cent. to 42.8 per cent. Emme-
tropia increases a little, from 18.6 per cent. to 21 per cent. In the Ger-
man diagram, H descends from 16.2 per cent. to 6.70 per cent. : M rises
from 11.1 per cent. to 62.1 per cent. ; while E decreases from 72 per
cent. to 30.40 per cent. In the American diagram, II rises from 9.47
per cent. to 12.24 per cent. ; M rises from 3.55 per cent, to 26.79 per
cent. ; E sinks from 86.98 per cent. to 60.97 per cent. It will be seen
from the Russian diagram that the emmetropia remains about the
same through the entire series of classes, while the myopia steadily
increases. If we assume that this increase, which is equal to 29.2 per
cent., is due to emmetropia passing to myopia, we are forced to assume
that the balance is maintained by hypermetropia passing to emmetropia
to supply the deficiency. According to this diagram a part of the
hypermetropia must become emmetropia, and if a hypermetropic eye
can become emmetropic by increasing its refraction, it would be absurd
to deny that it could not, by a little further increase, become myopic.
So too in the German diagram it is seen that the increase in myopia,
which equals 51 per cent., is greater than the decrease of emmetropia,
which is 41.60 per cent., that is, is greater by 10 per cent. It must conse-
quently have taken this increase from the hypermetropia, which is indeed
seen to have decreased 10 per cent. From the American diagram it will
be seen that the emmetropia decreases 26 per cent., while the myopia in-
creases only 23 per cent., so that in this case the myopia may have been
derived from the emmetropia alone. The slight increase in the hyper-
metropia may be explained by a small amount of latent H becoming
manifest as the age advanced. The increase in refraction, however,
though not so great as in the other two diagrams, is nevertheless very
marked. It will, moreover, be seen in both the Russian and German
diagrams that, while the lower grades of refraction E and II predominate
Conrad also gives a separate curve, as determined with the ophthalmoscope. For the
sake of simplicity and uniformity in the diagrams I have omitted this curve. and taken only
those which were determined with glasses. The increase in refractive power is, however,
more marked with the Ophthalmoscope than with glasses. Still I cannot persuade myself
that it is, on the whole, as accurate With the instrument as with test types,
932 LO RING,
in the lower classes, a complete change occurs, and, M becomes the pre-
dominating refraction, and that this change takes place at a compara-
tively early age. Thus in the Russian diagram the line M crosses the
line E at the fourth class, or what would correspond on the American
diagram to the years 12–13. It crosses H at 14–15, when myopia becomes
the predominating refraction, being in the highest class twice as frequent
as the normal eye. Precisely the same thing occurs in the German dia-
gram, where \ſ, rapidly rising, crosses both H and E, being in the highest
classes twice as common as the normal eye. In the American diagram,
however, E remains all through by far the predominating refraction, the
line E not only never crossing those of II or M, but remaining at a dis-
tance amounting at its lowest point in respect to M at its highest, to 34
per cent., and in respect to H at its highest, to 43 per cent.
This would show, if the numbers were great enough to prove it, and
I think they are, that not only is there less myopia in this country in
school children than in either Russia or Germany, but that emmetropia
is the normal eye in all classes, which agrees with what Donders(32)
found among the Dutch. For it may be assumed that after the age of
twenty-one the refraction as a grand whole changes but very little, and
that any slight change towards myopia in early adult life is more than
counterbalanced by acquired hypermetropia in later life. Moreover, as
we have taken as a standard the very class where myopia would be most
frequent, that is in over-worked school children, it is fair to assume that
the proportion of myopia would be less and not greater in other classes,
especially in the lower and middle ranks of life. In order to make a
better comparison between the three nations, as far as the myopia is con-
cerned, the myopic curve of the three preceding tables has been trans-
ferred to a separate diagram, Table IV.
As an additional means of estimating the effect which the hereditary
influence has on myopia, a comparison was made as to the frequency in
which myopia occurred in the three principal nationalities of which our
public schools are composed, that is, among the pupils of German, Ame-
rican, and Irish parentage. It was found that of all the German scholars
24 per cent. were myopic, of the Americans 20 per cent., and of the Irish
15 per cent. ; so that even in this country, and under the same school
influences, myopia occurs more frequently among the descendants of
Germans than among either the Americans or Irish. The compara-
tively low percentage of myopia among the Irish is certainly remark-
able. It is, however, in accordance with the assertions of various
authors as to the immunity from myopia among the inhabitants of Great
Britain. There can be no doubt that as a nation the Germans show a
strong tendency towards myopia. Whatever may be the cause of the
trouble, it is certainly a fact that the statistics of myopia taken in
German schools show a decided increase over those taken in this country,
which can be seen by comparing the statistics taken by Dr. Cheatham (33)
in New York, by Dr. D. B. Williams(34) in Cincinnati, and Drs. Prout
and Mathewson(35) in Brooklyn, with those taken in Germany. In
comparing these statistics the different basis on which they are compiled
should be taken into consideration, especially with those of Cohn, as he
did not include myopia less than als, while in those cited above and made
in this country go was included.
From the evidence furnished by such statistics made in different
countries and by different observers, I do not, while admitting the heredi-
tary tendency, see how we can exclude the fact that there are many eyes
P R O G R E S S I W E M Y O PIA. A N D C O N U. S. 933
which, under prolonged tension of the accommodation, pass from hyper-
metropia to emmetropia, and thence to myopia with all its attending
signs and symptoms, and this too in spite of hereditary influence to the
contrary.
This factor of prolonged tension of the accommodation brings us at
once to a consideration of the second proposition of our subject, which
is whether posterior staphyloma and progressive myopia can be produced
through the influence of the ciliary muscle. Before proceeding to discuss
this, I would call your attention to the fact that the question does not
refer to the entire act of accommodation, which implies the action of the
recti muscles as well as that of the ciliary muscle, but is limited to the
latter alone, and consequently I am desirous that it should be kept in
mind that my remarks are confined to the share which the ciliary muscle
alone takes as an agent in the production of myopia and the cone. There
are two ways by which the ciliary muscle could render an eye previously
not near-sighted, myopic. The first would be by increasing the curvature
of the lens by active, that is, positive, contraction; and the second, by pro-
ducing an elongation of the antero-posterior axis. That such an increase
in curvature of the lens does, by contraction of the muscle, take place,
with the effect of temporarily increasing the refraction of the eye, is now
universally admitted. The only question which interests us here is
whether the increased curvature of the lens through the agency of the
ciliary muscle ever becomes permanent, and thus transforms an eye from
an emmetropic or hypermetropic to a myopic eye. That such was the
opinion of the earlier oculists I need not remind you, down even to the
time when Cramer declared that there were myopic eyes in which the
curvature of the lens corresponded to that in the normal eye when
adjusted for near objects. Nor need I dwell on the revulsion of feeling
which followed when it was learned from the labors of Helmholtz, Knapp,
and Donders, that this last fact was not correct, and that the curvature
of the lens in myopic eyes was shown to be if anything less than in the
normal eye. A revulsion of opinion which culminated in Donders's(36)
declaring, though formerly a firm believer in its occurrence, that he had
never, since the true nature of refraction had been understood, been com-
pelled to resort to an increased curvature of the lens as an explanation of
myopia, while Giraud Teulon declares that there never has been a single
well-authenticated case put on record.
The opinion that myopia is never due to increased curvature of the lens,
has, however, been combated from the first by a few of the very best authori-
ties, especially by Jaeger(37), who declares that “frequently the sole cause
of myopia is the increased curvature of the lens,” and by Stellwag(38), who
in his last edition affirms that “increase in convexity of the lens is indis-
putably an important pathogenetic cause of short-sightedness;” and it can-
not be doubted that this opinion, certainly as regards the initial cause of
myopia, is gaining ground among the younger school. Still, notwithstand-
ing the plausibility of the theory that increased curvature of the lens causes
myopia, there is, it must be confessed, but little actual proof of its existence
from such a cause. Indeed it must, I think, be admitted that the proof
both experimentally and clinically points just the other way. Thus
experimentation shows that by actual measurement the curvature of the
lens is less if anything in a myopic than in a normal eye. Then comes
the great clinical fact that in those cases of hyperimetropia of a high
degree, proved to exist in young children who are watched from year to
year, the amount of the total hypermetropia does not decrease under
934 LORING,
accommodative efforts, while the manifest does increase year by year in
spite of such efforts. Thus the patient is compelled to go, not from
stronger to weaker glasses, but from stronger to stronger, in spite of
every effort to maintain the former amount of curvature of the lens. The
very frequent occurrence, too, of adults with very high degrees of hyper-
metropia, who have been straining their ciliary muscle to the utmost for
years to overcome their optical defect, is decidedly against the view that
the curvature of the lens becomes permanently increased by over-tension;
as is also the fact that in high degrees of hypermetropia where there is
little or no manifest, the total is revealed by the ophthalmoscope, and
then coincides with an amazing exactness with that produced by the full
effect of atropine. Such facts as these, and many others might be quoted
to sustain them, warrant us in the belief, until more convincing proof to
the contrary is offered, that as a rule the action of the ciliary muscle has
no effect in producing a permanent increase of curvature of the lens, and
thus becoming a cause of myopia—no matter what the original condition
of refraction. In regard to the second point in our investigation, that
is, whether the ciliary muscle is capable of producing an elongation of
the axis, thus causing myopia, it will be sufficient to call to mind that
Young's(39) and IIelmholtz's(40) investigations prove the impossibility of
such a result.
But it may be urged—as, indeed, it has been frequently, especially
since Dobrowolsky’s(41) investigations—that, even if the natural, or
what may be called the tonic, contractions of the muscle, do not pro-
duce myopia by directly increasing the curvature of the lens, spasmodic
or clonic contractions do; and that the myopia first produced by in-
creased curvature of the lens is followed by irritation of, and traction
on, the deeper-seated membranes, which lead to true myopia—that is, to
an elongation of the axis. If this were so, we should expect to find the
signs of irritation more frequent where the strain of the ciliary muscle
was the greatest—that is, in hypermetropic eyes. But it is an undenia-
ble fact, as pointed out by Donders, and confirmed by every observer
with the ophthalmoscope, that the injection of the nerve and the signs
of irritation are not any greater than in the normal eye. Moreover, we
should find, if simple traction on the choroid could produce the cone.
that these would be most frequent where the traction of the muscle was
the greatest; and this, too, independently of any increase of the length of
the axis—that is to say, in hypermetropic eyes. For, if simple traction
on the choroid could produce the cone, it would make no difference how
short the axis was ; all that would be necessary would be an increased
action of the muscle, and this we get in hypermetropia. Now, not only
clinical experience, but actual statistics, show, as has already been
pointed out, that the crescent is found less frequently in hypermetropic
eyes than any other. Moreover, if traction on the choroid could and did
produce the cone, we should expect to find it in all eyes, no matter what
their refraction, at the inside of the nerve, since this would be the place
of all others in the circumference of the nerve where the traction would
be soonest and most powerfully felt, for the simple reason that it is the
shortest line between the two points of attachment. Moreover, the
crescent would have a rapid tendency to become circular. 13ut ninety-
nine times out of a hundred the cone is at the outside of the nerve, and
there remains.
But not only do we have positive proof in hypermetropic eyes that
increased action of the ciliary muscle, per se, does not produce the cone,
P R O G R E S S I W E M Y O PIA A N D C O N U. S. 935
but we have equally strong negative proof, in myopic eyes; for the greater
the myopia, the less the positive contraction of the ciliary muscle.
And many cases occur of the development of the cone towards adult life
in eyes which were not at the time of development of the crescent using,
nor had ever used, any active accommodation at all; that is, in eyes whose
far point had always been from twelve to eight inches. Of all eyes
these are the most prone, on over-use, to progressive myopia and the
formation of the cone, while it is a clinical fact that, in many of these
cases of rapidly increasing myopia, the myopia is at once checked by
carrying out the far point by glasses which decrease the amount of con-
vergence, but which increase sometimes to a great degree the demands on
the muscle, especially where, as in young people, we completely neu-
tralize the error in refraction. I do not mean to say that the cone is not
due to irritation and traction, for I am firmly convinced that traction on
the choroid in the plane of its extent, and pressure on its surface, are the
principal if not the only causes of the cone. But what I do mean is
that this traction takes place from extension at the posterior pole of the
eye, not by the contraction of the ciliary muscle at the anterior parts.
It has never been demonstrated in the slightest degree that the ciliary
muscle exerts the least traction on the posterior parts of the choroid.
Indeed, the little experimental evidence which we have is directly
opposed to such a supposition, as is indeed all the clinical evidence.
There is, moreover, to say the least, a strong doubt whether the muscle
exerts any traction even on the anterior portions of the choroid, and some
of those who have been hitherto the most enthusiastic supporters of the
theory of the meridional portion of the muscle being a direct “tensor cho-
roideae,” seem to have modified, if not completely changed, their views.
Thus Iwanoff (42) latterly, after describing the anatomy of the meridional
portion, and its mode of insertion into the J. suprachoroidea, says:
“Now, with such a disposition of the meridional portion of the muscle
with the L. Suprachoroidea, and with such a structure of this latter, it is
self-evident that the deep layers of the choroid (choriocapillaris and mid-
dle choroid) cannot be essentially stretched. Consequently, the entire
effect of the contraction of the ciliary muscle will limit itself to an
extension of the ciliary body, which, as is known, is in the closest con-
nection with the zonula of Zinn, while in the choroid itself, at the most,
there will be only an extension of the L. suprachoroidea. This is per-
fectly evident when we bear in mind that that part of the choroid which
is situated behind the ora Serrafa has no direct connection whatever with
the Zonula.” Nevertheless, that enforced and maintained contraction
of the ciliary muscle should produce that nervous exhaustion and irrita-
tion, with altered nutrition, which always occurs in the case of an over-
tasked muscle, is most natural. That this irritation should extend to
the surrounding parts, causing increased vascularity, and, what is more,
increased secretion, by which the intraocular pressure is augmented,
might, I think, occur to some degree, in spite, too, of the assertion of
Leber that the vascular supply to the ciliary muscle is so arranged that
the circulation is not impeded by its confraction. Still, from what has
already been stated, I am inclined to believe that this increased intra-
Ocular pressure, which is so potent a factor in the production of myopia,
occurs much more frequently from other causes, especially from faulty
convergence, than from the simple action of the ciliary muscle. This
leads lue to believe, although I appreciate most highly the labors of
936 LO RIN G,
Dobrowolsky,' that spasm of the ciliary muscle, so well recognized and
described by the elder writers, has been somewhat exaggerated by the
younger school both as to its frequency and the amount of influence it
exerts in the production of myopia.
I have not the time to go into an extended discussion of this question,
which it surely deserves, and must therefore content myself by pointing
out the fact that it would appear that two important conditions have
been ignored in the works of Dobrowolsky and his followers, Schiess-Ge-
museus (43) and Dr. Derby (44) of Boston. The first is the physiological
effect of atropine, which is to reduce the refraction to an amount which,
according to Donders (45), would be expressed by + ºn, or even + "g. The
ordinary emmetropic eye then under atropine would be a hyperimetropic
eye of go. Are we to assume, then, as Dobrowolsky does, that a de-
crease of refraction which amounts to only a # 6, , , o, Tºg, or even 5's, is
the result of spasm, and not the action of the drug, when the physiologi-
cal action is often equal to six times the amount; and especially are we
to assume this when solid atropine has been used three or four times a
day for three or four weeks, or even months?
Dobrowolsky(46) gives a table of 105 cases of myopia. In 69 of these
there was a decrease after the use of atropine—that is, in seventy per cent.
IBut of these cases, when we make an allowance for the physiological
effect, only thirty remain. Of these thirty, after this allowance, six
show a decrease of g; n or less, twelve of + p or less, seven of go, three
of 4%, and two of T's or less. So that there are only five cases in the
entire number which show a moderate degree of spasm, and only two of
these a high degree; and in all these five cases the myopia is of an exces-
sive grade, varying between as and "g. Now, these high degrees of
myopia are just the conditions in which we always expect, whether there
be any insufficiency or not, an apparent increase in the refraction, caused
by an excessive muscular strain at convergence. This is invariably ac-
companied with a displacement of the relative accommodation inward,
and the slight temporary decrease in the refraction caused by the use of
strong atropine invariably returns as soon as the atropine is left off,
unless the strain on the convergence is relieved by suitable means. Ex-
ceedingly interesting in this connection are some of the results published
by the earlier writers—Bonnet, Cuvier, Philips, and Jules Guérin—but
particularly the case related by Giraud Teulon (47), of extreme myopia,
in which tenotomy of the external rectus suddenly diminished the
myopia by T's, or from to g. IIad this amount of decrease in refraction
been brought to light by the use of atropine, it would certainly have
been put down by these observers as due to spasm; and it just as cer-
tainly would have returned the moment the atropine had been discon-
tinued, unless the strain on the interni had been removed. The analogue
of this, the sudden development of manifest II, which had been pre-
viously latent, after tenotomy, is too common an occurrence to need any
comment whatever. It strikes me, therefore, that want of attention to
these two points, namely, the physiological action of atropine and the
associated action of the recti interni on the accommodation, has led these
observers into a false estimate of the frequency of spasm, and its pre-
dominating influence in the production of myopia. Certainly my own
! I cannot agree with a recent writer, who says: “To Professor Schiess belongs the
credit of utilizing the researches of I)obrowolsky for ophthalmic practice.” Whatever
there is of merit in this matter belongs, both theoretically and practically, entirely to
Dobrowolsky.
P R O G. R. E S S I V E M Y O PIA. A. N. D. C. O N U. S. 937
experience does not coincide with that of these observers, and I fail to
find a frequent or great diminution, even in myopic eyes of young
children, after the use of atropine. This I was glad to see had been the
experience of Donders(48), as expressed by him at the last International
Congress.
Up to this point we have been occupied with a consideration of the
action of the ciliary muscle as a whole, but a theory has been started
that contraction of the muscle can take place in the direction of one
meridian alone, or in different meridians in different degrees at the same
time. Thus, according to Dobrowolsky(49), a complete interchange of
kind and degree of astigmatism, as well as change of direction in the
axis, may result from these meridional contractions, so that an eye which
was originally hypermetropic in one meridian may by a counterbalancing
contraction of the muscle become an emmetropic eye, or an emmetropic
eye an astigmatic eye, with M in one meridian alone, or M in all me-
ridians, and more pronounced in one than the rest ; and so on with a
change in all the varieties of astigmatism which could be produced
through positive accommodation. It is claimed that this is a fertile
Source of myopia.
That a slight change in a meridian, whether of refraction or direction,
should take place, would not appear strange; for there is nothing abso-
lutely stable in the human body. This would, moreover, be in accord-
ance with what has been supposed possible by many and corroborated in
some degree by certain investigations made by Woinow.(50). But any
such remarkable changes as are pointed out by Dobrowolsky, either in
kind or degree, I have never met with myself, nor do I know of any
sufficient corroboration of them by others. For this reason I do not
feel warranted in expressing an opinion in regard to them ; certainly
not one which would imply a belief as to their active agency in produc-
1ng myOp1a.
These views of Dobrowolsky were followed by those of Dr. Thom-
son(51), of Philadelphia, based on the old theory of the antagonistic
action of the two portions of the ciliary muscle. According to these
views, not positive accommodation alone, as with Dobrowolsky, but
even negative accommodation took an active part, through the contrac-
tion of the radial fibres of the ciliary muscle as opposed to the circular
fibres. Thus a defined traction in a meridional direction was brought
to bear on the choroid, which would naturally exert its influence at a
corresponding point at its attachment at the circumference of the disk.
This would produce the cone, which would then lie in the plane and
direction of this traction.
I can only say in regard to this that our present knowledge of the
action of the ciliary muscle does not support this conclusion. For not-
withstanding the many attempts to prove the fact of negative accommo-
dation, ever since the discovery of the ciliary muscle, not the slightest
trace of its existence has ever been demonstrated ; while on the other
hand the fact of its non-existence has been, it would seem to me, incon-
testably shown. Until, then, the existence of negative accommodation
has been proved, it would be a waste of time to speculate on what would
be its effect on myopia, or rather what its effect is. We have no right
to assume both the cause and effect too. But admitting the existence of
negative accommodation to the fullest degree, even to the extent that it
surpasses the positive, many facts would have to be explained before its
effect on the cone could be admitted. First, why is it that we see the
938 LO RIN G,
highest degrees of myopia with immense cones, and either not a trace of
astigmatism, or, if present, of such a very low degree as to preclude the
idea that the cone is the result of the astigmatism : Secondly, why is it
that we see such very high degrees of simple myopic astigmatism without
a vestige of a come? Thus in the past few months I have seen the follow-
ing cases where there was no trace of a crescent: one case of ; c., two of
# c., one of ; c., two of . C., one of H'ſ e., three of TT C., and four of ', c.;
all simple, myopic astigmatism. Thomson(52) himself has reported some
eases of excessive asymmetry of the cornea, in which, to use his own
words, “it is worthy of remark that in this last case, with such high
degree of myopia and the use for years of glasses so unsuited, there was
not the slightest appearance of the crescent at the optic disk.” Again,
it would have to be shown why it is that the cone sometimes runs in
the same direction as the meridian of greatest curvature, and sometimes
in that of the least, or again in neither. Then, too, if traction in one me-
ridian had anything to do with the direction of the cone, why is it that
it is limited so often to the outside of the nerve, and does not extend
equally in the same direction on the opposite side : since it can hardly
be assumed that these meridional contractions take place only in one-half
of the ciliary muscle, and this, in the vast majority of the cases, the
outer half.
We should have also to explain why it is that in sections of myopic
eyes we find the choroidal pigment layer drawn away from the outer
edge of the nerve and over the inner edge. In regard to the appearances
of traction upon the vessels, and other details of the fundus as seen with
the ophthalmoscope in astigmatism, I would say that this, as far as my
experience goes, corresponds to the distortion produced by the optical
defect of the refracting media, which causes the line of traction to appear
to be always in the meridian of greatest curvature.
This brings me to the close of my remarks, from which I would in
keeping with the condensed character of my paper make the following
brief conclusions:–
I. From the fact that there is so large a percentage of children who are
myopic, but whose parents are not near-sighted, while the myopia in-
creases directly with the amount of increased tension of the eyes, and
from the fact that an interchange of refraction may occur, whereby an eye
which is not congenitally myopic may become so in spite of hereditary
tendency, it would seem to follow that hereditary predisposition, though
undoubtedly a potent cause, is not only not the sole cause, but is not
even the predominating cause of myopia. -
II. In regard to the second question, as to whether the ciliary muscle
acting through faulty refraction can produce myopia and the cone, I
conclude that the action of the ciliary muscle, taken by itself, exerts
but little influence on the production of myopia, and still less on the
formation of the cone.
I cannot refrain before closing from asking you once more to bear in
mind that the questions submitted were not as to what the causes of
myopia were, but simply the influence of two fixed and defined factors
in its production. The briefest consideration of these two subjects which
I could possibly make, has already led me beyond the limits of the time
allowed, and I fear also of your patience. I have for these reasons been
compelled to forego saying much which I am conscious that a just con-
sideration of the subject would demand, and to discard much that I had
already written.
P R O G R E S S I W E M Y O PIA AN ID CON U. S., Q39
J3IBLIOGRAPHY.
(1) Lucas, P. Traité philosophique et physiologique. Tome i. p. 391, 1847.
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Funari. Annales d'Oculistique. Tome x. p. 145.
Piorry. Heredité dans les Maladies. p. 120.
Portal. Considération sur les Maladies de Famille.
Stellwag von Carion. On the Eye. American Transl., 1873, p. 354, p. 703.
Jaeger. Einstellungen des diopt. Apparates, u. S. w., 1861. S. 7
Donders. Accommodation and Refraction of the Eye, 1864, p. 350.
Cohn, H. Untersuchungen der Augen von 10,060 Schulkindern, u. s. w.,
1.
Leipzig, 1867. S. 53.
(9) Ibid., p. 129.
(10)
(11)
(12)
(13)
(14)
(15)
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(17)
(18)
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(29)
Erismann, F. Ein Beitrag zur Entwickelungs-Geschichte der Myopie.
Graefe’s Archiv, Band xvii. Ab. 1. S. I.
Stellwag. Die Accommodationsfehler des Auges, 1855. Wien Sitzung-
be richte der mathem-naturw. Classe der kais. Akademie der Wissen-
schaften, Bd. xvi. S. 225.
Jaeger. Einstellungen. S. 27.
Ibid., 37.
Donders. Accommodation and Refraction, p. 354.
Graefe. Archiv für Ophth., 1854, 13. 1. S. 394.
Donders. Accommodation and Tefraction, p. 443.
Cohn, H. Untersuchungen. S. 61.
Conrad, Max. Die Refraction von 3036 Augen von Schulkindern mit
{{icksicht auf den Uebergang der Hypermetropie in Myopie. Inaugural-
Dissertation. S. 38.
Jaeger. Einstellungen. S. 37.
Iwanoff. Graefe's Archiv, B. xv. A. b. 3. S. 284.
J)onders. Accommodation and Refraction, p. 384.
Ibid., p. 349.
Jaeger. Einstellungen. S. 104.
Stellwag. On the Eye. American Transl., 4th Edition, p. 723.
Ware, J. C., F.R.S. Observations Relative to the Near and Distant
Sight of different Persons. Phil. Trans. Royal Soc., 1813.
Szokalski. Prager Wierteljahrschrift für pract. Heilkunde, 1848.
Schürmayer, J. H. Handbuch der Medicin Policei. S. 61, 1856.
Jaeger. Einstellungen. S. 20.
Ruete. Untersuchungen über die Augenkrankheiten bei Schulkindern,
Zeitschrift für Medicin, Chirurgie, u. s, w. Neue Folge B. v. Heft
4. Leipzig, 1866.
Erismann. Graefe’s Archiv, Band xvii. A b. 1. S. 13.
Conrad, Max. Inaugural-Dissertation, Könisberg. S. 16.
Donders. Accommodation and Itefraction, p. 341.
Cheatham. Boston Medical and Surgical Journal, May 27, 1875, p. 633.
Williams, D. B., Ibid.
Prout and Mathewson, Ibid.
Donders. Accommodation and Refraction, p. 394.
Jaeger. Einstellungen. S. 26.
Stellwag. On the Eye, 4th Edition, American Transl., p. 704,
Young, Thos. Mechanism of the Eye. Phil. Trans., 1801.
940 LO RING,
(40) Helmholtz. Karsten's Encyclopædia der Physik, 1856.
(41) Dobrowolsky. Beiträge zur Lehre von den Anomalien der Refraction,
u. S. W. Zehender klin. Monatsblätter. Ausserordentliches Beilage-
heft, 1868.
(42) Iwanoff, Graefe, und Sämisch. Handbuch der Augenheilkunde, Band i.
- Theil. 1. S. 27 7.
(43) Schiess-Gemuseus. Beiträge zur Therapie der Myopie, Basel, 1872.
(44) Derby, H. Trans. American Ophth. Soc., 1874, p. 138.
(45) Donders. Accommodation and Refraction, pp. 174, 600.
(46) Dobrowolsky. Zehender ausserordentliches Beilageheft, 1868. S. 37.
(47) Teulon, Giraud. Ophth. Hosp. Reports, vol. v. p. 381.
(48) Donders. Report of fourth International Congress, London, 1872, p. 69.
(49) Dobrowolsky. Graefe’s Archiv, xiv. Ab. 3. S. 50.
(50) Woinow. Graefe’s Archiv, xv. Ab. 2. S. 167.
(51) Thomson, Wm. Trans. American Ophth. Soc., 1874, p. 132.
(52) Thomson, Wm. Trans. American Ophth. Soc., 1875, p. 310.
T)ISCUSSION ON DR. To RING's PAPER.
After the reading of the preceding paper, Dr. J. GREEN, of St. Louis, said:—
As bearing on the question of the influence of hereditary transmission, we must
remember that we scarcely ever see myopic children whose parents and grand-
parents have been equally subjected to the general exciting causes of myopia.
Taking, therefore, into account this absence of exciting causes in the ease of the
ancestors, it will not do to assume the absence of hereditary predisposition to
myopia even where there has been no declared myopia in parents and grand-
parents. Again, in all our published statistics there is great imperfection as
regards the recognition of astigmatism, and yet among the causes which pro-
duce indistinctness of vision, and thus favor the development of myopia, astig-
matism certainly holds an important place. The statistics are thus of less
value than many suppose, in clearing up this part of the subject. It is a very
significant fact that in such cases of myopia as give the patient trouble enough
to lead him to consult an oculist, we find astigmatism oftener present thali
absent ; hence, in investigating the causes of myopia, we must make more
careful studies of the refraction, not merely with reference to myopia and
hypermetropia, but also with reference to astigmatism.
i) T. W. THOMSON, of Philadelphia, said:—I think that Dr. Green has called
attention to an important fact in alluding to the large number of cases of astig-
matism which complicate myopia. That myopia is very often progressive, we
know, but I think from observation that cases of myopia, pure and simple,
are hard to find. High grades of myopia are, as a rule, characterized by
astigmatism, and therefore we ought to consider whether most cases of pro-
pressive myopia have not commenced as slight cases of astigmatism. If we
accept the conclusions of the paper, the question of progressive myopia would
be hopeless, and we would have nothing to do but to look on and see people
growing worse day by day. If it is conceded that astigmatism is often an
efficient cause of myopia, We have then a remedy in cylindrical glasses. I
think that astigmatism is one of the active causes of progressive myopia.
Dr. LoRING said:—I would call attention to the fact that astigmatism was
not mentioned in the question for discussion, but I admit that it has something
to do with myopia. Dr. Thomson takes a gloomy view of the subject. I
believe that, if we go on as in Germany, the time will come when myopic re-
fraction will predominate. In keeping children in school twelve hours a day,
poring over books, a great hygienic principle is overlooked, and, as long as
P R O G. RESS IV E M Y O PIA. A. N. D. C. O N U. S. 941
this is done, so long will there be myopia. I cannot agree that the time will
ever come when myopia will be prevented by the use of cylindrical glasses.
Dr. H. W. WILLIAMs, of Boston, said:—Dr. Loring says justly that myopic
astigmatism is a form of myopia. I think it is conceded that hypermetropia
and astigmatism are hereditary. I know several instances in which persons
are myopic in one eye, and emmetropic or hypermetropic in the other, and I
would ask if there is a hereditary predisposition to myopia in one eye, and not
in the other ? And I have seen such cases, in which at a later period the
myopia has increased, and in which the hypermetropic or emmetropic eye has
become myopic. I am satisfied that myopia is largely due to artificial causes.
The President, Mr. R. BRUDENELL CARTER, of London, said:—I remember
the case of a young lady who was brought to me with a low degree of hyper-
metropia in one eye, and a high degree in the other. In the case of her father
and mother both eyes were hypermetropic. I do not believe that statistics will
enable us to arrive with certainty at any conclusion upon this subject. In look-
ing back I can recall a few cases of myopia which were the result of accident.
I remember at least one case in which this condition was produced by a blow.
Dr. THOMSON said:—With regard to Dr. Loring's second conclusion, I think
that the whole question resolves itself into whether or not the ciliary muscle is
a single or a double muscle, and that unless new light is thrown on the subject
by an appeal to clinical observation, there is nothing to do but to accept this
conclusion. I am convinced that the changes in the back part of the eye in
myopia have something to do with the existence of astigmatism, and that the
appearances which they assume are largely dependent upon the direction of
the principal meridians of the astigmatic eye. If a conus is found in any part,
there will be found to be a relation between the direction of the conus and that
of the cylindrical glass which gives the highest vision. I believe that I have
established the fact that in many cases of myopia of high grade, say one-fifth,
one-sixth, or one-seventh, in which neutralizing spherical glasses have been
habitually worn, the optic nerve is free from distortion, and has no displace-
ment, but that when astigmatism, even of low grade, is found conjoined with a
high degree of myopia, a conspicuous conus will be found.
Dr. E. WILLIAMs, of Cincinnati, said:—I have seen several cases which I
may cite in confirmation of Dr. Thomson's remarks. I remember the cases of a
distinguished lawyer and of a merchant, both over fifty years of age, who had
worn glasses since they had left school, and in neither of them was conus found.
When we find a patient wearing the proper glasses, and seeing perfectly with
them, we rarely find a conus, but when vision, even with the glasses, is more or
less indistinct, we may expect to find the conus.
Dr. S. D. RIs LEY, of Philadelphia, said:—I think that we rarely see progres-
sive myopia with conus without astigmatism, and, on the other hand, that
conus is not confined to myopic eyes, but is a very frequent occurrence in
hypermetropic eyes with astigmatism. I recall two cases in which conus and
myopia had appeared while under observation, and were attended by marked
asthenopia which was relieved, and further choroidal change arrested, by the
rest afforded the ciliary muscle by a carefully adjusted, correcting glass. I
am convinced, from clinical experience, that the ciliary muscle has much to do
with progressive myopia and the formation of the conus.
Dr. THOMSON said:—I know of a number of cases of asthenopia from insuf-
ficiency of the internal recti, which bear upon this question. In one case, in
which the asthenopia had existed over a period of thirty years, and had caused
much distress, and in which the asthenopia was perfectly relieved by the use of
proper prismatic glasses, there was absolutely no trace of conus in either eye.
Dr. LORING said:—The use of concave glasses often stops the development
of the conus and the myopia, and, nevertheless, the use of the glasses forces
the accommodation more than when they are not employed. All admit that
concave glasses are useful in myopia, yet concave glasses act directly upon the
ciliary muscle. That the ciliary muscle has two antagonistic functions is, to
say the least, extremely improbable.
942
ON THE RELATIONS BETWEEN OORNEAL DISEASES AND
REFRACTIVE LESIONS OF THE EYE.
BY
GEORGE T. STEVENS, M.D.,
OF ALBANY, N. Y.
OF the various structures of the human body, few have been subjected
to such thorough, critical, and we may add profitable, examinations in
respect to the histology and pathology of their tissues, as has the cornea.
The names of many of the most learned and illustrious investigators are
inseparably connected with this small structure, and the extent and value
of their researches indicate its importance. Yet it must be conceded
that of the advantages derived from the histological and pathological
studies of this part, comparatively few have reverted to the structure
itself, and candid observers must agree that in the etiology of corneal
diseases the advance has not been in proportion to the added knowledge
of its structure and pathology.
A review of the history of the etiology of corneal diseases would show
that, since writers of half a century ago, after allowing for the agency of
mechanical and chemical injuries and the pressure incident to certain
forms of conjunctival disease, united in ascribing the cause of corneitis
to scrofula and arthritis, few important advances have been made in
determining the causation of these diseases. To the genius of Mr. Hutch-
inson we owe the discovery that in a clearly defined class of cases of cor-
neal disease, the cause may be found in the diathesis peculiar to inherited
syphilis, and that if we would best meet the indications for treatment in
these cases we must directly attack the inherited taint. But the propor-
tion of such cases is not large, and there remain after excluding those
which arise from mechanical pressure, injuries, chemical irritations, and
a few other exceptional causes, the very large residuum of cases which
by nearly all authors are regarded as manifestations of struma.
Of phlyctenulae of the cornea, the form of corneal disease which the
surgeon most frequently encounters, a learned |French writer of recent
times' says that the pustules are the first and the most frequent manifesta-
tion of scrofula; they are, he says, benign scrofulous exudations. Although
this view is not fully accepted by some modern writers, it meets with but
the mildest opposition, and the doctrine that the prevailing cause of
corneal diseases and especially of phlyctenulae is struma, is, I believe, the
one generally accepted. . The truth is that the condition called struma is
far more frequently developed by corneal diseases than are corneal troubles
developed by struma. One of the most positive evidences of the exist-
ence of struma, is supposed to be found in the presence of enlarged cer-
vical glands, but the enlargement of these glands does not usually precede
the corneal disease, but is its result.
The fact, well known to ophthalmic surgeons, that patients who have
been cured of corneal diseases are quite liable to return after a few months,
1 Bazin, Leçons sur la Scrofule.
C O R N E A L DIS E A S E S A. N. D. R. E. F. R A CT IV E L E S I O N S. . 943
or even weeks, with renewed attacks of the disease, showing conclu-
sively an inherent tendency to such troubles, led me a year ago to seek
for the cause of the tendency. The excessive nervous irritability, photo-
phobia, and muscular spasm, and the general failure of nutrition in these
cases, induced me to regard corneal diseases, especially of the phyctenular
form, as a manifestation of functional nervous derangement. The fact
of the easy cure and the frequent recurrence of the diseases strengthened
this opinion, and as I had at that time been led to the belief that many
functional nervous diseases owed their origin to anomalous refraction of
the eyes, I turned to the eyes themselves to seek for the cause of irrita-
tion. A few careful examinations Satisfied me that a more extended
search should be made in this direction, but the difficulties encountered
in ascertaining the refractive condition of the eyes of patients suffering
from corneitis, especially from phlyctenular corneitis, are great; the in-
tolerance of light, the youth of the patients (for phlyctenular corneal
troubles are most frequently found in children from two to eight years of
age), and their general irritability, all contribute to render such examina-
tions tedious to both patient and surgeon. To these difficulties I attribute
the fact that the well-known maxim among ophthalmic surgeons, to test
the refraction of all diseased eyes, has been so far disregarded ; for the
practitioner whose time is fully occupied by the usual duties of his pro-
fession, will find the attempt to examine a large number of these patients
in this respect a severe tax upon his time and strength.
I cannot better illustrate the result of my search in this direction
than by relating the history of the following case. The first part of the
history well illustrates the oft-repeated experience of every ophthalmic
surgeon, while the second part will illustrate my own experience in
Several cases since my attention has been specially directed to this subject.
L. R., a bright boy seven years of age, was, about two years ago, brought to
me, suffering from phlyctenular ulcers of both eyes. He had, previous to the
eye trouble, enjoyed excellent health, had passed through the usual experience
of childhood in respect to infantile diseases with safety and ease, and was
regarded as a perfectly healthy and robust child. There was no history of
syphilis or of scrofula in the family of either father or mother, both of whom
were perfectly healthy people. Treatment for a few days by means of atropine
and stimulants applied to the mucous surface of the eyelids, sufficed to effect
a speedy cure of the ulcers, and the boy remained well for about three months,
when he passed through a similar experience which was repeated a third and
a fourth time within a little more than a year. At the close of the second
attack, I observed that the cervical glands were swollen as they had not been
previously, and with each attack there was more general irritability and more
evidence of defective nutrition. During an attack about a year since, his
mother called my attention to a defect in her own eyes, which, on examination,
I found to consist in hypermetropic astigmatism of ºr, and which induced
me to test the refraction of the bºy’s eyes. I found hypermetropia s”, with-
out astigmatism, and advised that he be required to wear + 42 glasses when
engaged in studies or in playing with toys. My advice was accepted, and the
boy's eyes have since remained well, and with the correction of the refractive
evil the so-called strumous symptoms disappeared.
The following case, which has been reported in another connection, will
illustrate the relations existing between this and another form of Inani-
festation of nervous trouble.
Mr. F. A. R., of Minnesota, consulted me in September last in regard to his
little daughter's eyes. She was a lyright girl of ten years, with a defect in her
944 STEVEN's,
speech, and was evidently suffering from chorea. On account of her nervous
condition she had been kept out of school for more than a year. The trouble
for which I was consulted was the presence of a number of small ulcers at the
border of the cornea. On testing the refraction, I found astigmatism requir-
ing for its correction a + 36 cylinder. Glasses were procured, and after brief
treatment for the ulcers, resulting in their cure, the father returned with his
child to his western home. In the latter part of March, of this year, he again
presented the child for treatment, she being again subject to corneal ulcers.
I learned that from the time of leaving Albany the child's health had greatly
improved, and her nervous symptoms had disappeared. A month Or two pre-
vious to the last visit, however, her glasses were broken, and she was without
them for some time. The nervous symptoms began to return, and the corneae
were again affected with ulcers.
In looking over the records of one hundred and fifty cases of corneal
disease in which the refraction has been examined with as much accu-
racy as the difficulties necessarily encountered would permit, I find that
in 80 per cent. there have been serious refractive lesions. Even in two
cases which were typical of the physical conformation so clearly de-
scribed by Mr. Hutchinson as characterizing the offspring of syphilitic
parents, a high degree of hypermetropia was found after the infiltrated
corneae had become sufficiently transparent to allow of a determination
of the refractive condition, and it is interesting to remember that the
flattened facial features described by Mr. Hutchinson are those recognized
by ophthalmologists, and so well described by I’rof. Donders, as indica-
tive of hypermetropia. In these cases, as in all others in which the re-
fraction has been determined, after the cornea has been affected, allow-
ance must of course be made for changes in the form of the cornea which
may have resulted from disease, but as in each of the cases alluded to a
high degree of hypermetropia was found (T's and +1) the defect could
hardly be ascribed to this cause.
In my efforts to determine the refraction in these cases, I have often
been obliged to be satisfied with an examination of the unaffected eye
by means of test letters, or by the ophthalmoscope alone. In several
instances the examinations have been made after recovery from the
disease. Among the refractive errors, hypermetropia seems to rank
first as a cause of corneal affections; second, astigmatism ; and third,
unequal degrees of myopia. A larger number of cases than I have ex-
amined would be necessary to determine the relative frequency of these
conditions. Simple myopia of equal degrees in the two eyes, I have
not found except in young children in whose cases the refraction has
been determined by the ophthalmoscope. In these cases, I suspect an
astigmatism not recognized by this means of examination.
It is important to notice two conditions which are often associated
with corneal diseases: First, the herpetic eruption which is so common
in phlyctenular corneitis; and second, an inflamed condition of the
free border of the eyelid. The herpetic eruption which appears about
the lips, checks, and nose, in cases of phlyctenular corneal troubles, is
conceded to be the result of irritation of branches of the fifth nerve.
That it is due to the reflex irritation from the ciliary nerves, I think it
reasonable to suppose, for I have often seen these herpetic eruptions
about the cheeks, nose, and lips, disappear quickly after correcting the
refraction of the eye, and with no further treatment. The blepharitis
would also in most instances seem to be one of the manifestations of
reflex irritation from the same cause, as I have long observed ; and the
CO R N E A L DIS E A S E S A N D R E F R A CT IV E L E S I O N S. 945
swelling of the lids, which is of itself sometimes the immediate cause of
corneal lesions, is, I believe, one of the various results of the peripheric
irritation beginning in the ciliary body.
That a reflex nervous irritation, like that arising from the strain upon
the ciliary muscle in erroneous refraction, can interfere in the nutrition of
the cornea, there can be no doubt ; and, if we watch the course of a cor-
neal phlyctenula, we shall see that nutrition is disturbed first by irrita-
tion of the vaso-motor nerves of the conjunctiva; for here we observe,
before the appearance of any efflorescence of the cornea can be discovered,
the fasciculus of red vessels, and indeed, if promptly met by appropriate
treatment, this can usually be made to disappear before the herpetic pus-
tule is developed at all.
May it not be a mistake to regard the herpetic pustule as the centre
of irritation around which the vascular injection of the conjunctiva
forms an objective expression ? Were this the case, would not the pus-
tule appear first, whereas, frequently, it is entirely aborted Ž Is it not
more probable that the condition of the vessels in this congested fasci-
culus, is such as to clog the passages through which nutritive material
should pass to supply certain portions of the cornea, and that the por-
tion in which nutrition is most defective, suffers first from this inter-
ference 2
60
SECTION ON OTOLOGY.
P R E S I D E N T O F T H E S E (; T I O N .
CLARENCE J. BLAKE, M.D.,
OF BOST ON .
W I C E - P R E S I D E N T .
ALBERT H. BUCK, M.D.,
O F NEW YOR. K.
S E C R E T A R Y.
H. N. SPENCER, M.D.,
OF ST. LOUIS.
THE IMPORTANCE OF TREATMENT OF AURAL DISEASES IN
THEIR EARLY STAGES, ESPECIALLY WHEN ARISING
3. FROM THE EXANTHEMATA.
BY
ALBERT H. BUCK, M.D.,
OF NEW YORK.
TIE object of selecting the subject of this paper for discussion by a
body of men interested in otology, must be, not to draw out the different
opinions of otologists on the subject (for there can certainly be but one
opinion), but to have the attention of the profession at large directed to
the importance of early treatment in aural diseases. The pleading of a
single individual would perhaps fail to carry conviction to the minds of
many members of the profession, while the same statements, made by
the same individual acting as the mouth-piece of such a body of skilled
men as is here gathered together, may be likely to receive the thought-
ful consideration which the subject demands.
In discussing this subject, I shall take into consideration chiefly the
acute, purulent affections of the middle ear, as it is in these that judicious
treatment proves so beneficial, and the want of it at times so disastrous.
In catarrhal affections it might also be shown that treatment in the
early stages of the trouble was in general productive of very satisfactory
and marked results, while in the later stages it rarely proved of any
benefit whatever. It will be sufficient, however, for my present pur-
pose, to make use only of those acute affections of the middle ear which
naturally end in the formation of pus, and which very often become
chronic.
The question of the frequency of chronic otorrhoea, is a difficult one to
determine with any degree of accuracy. Owing in part to the prevailing
popular belief that it is dangerous to arrest a discharge from the ear, and
in part to the answer which very many physicians give to the parents of
948 BU C K,
such patients—“ your child will outgrow it”—hundreds upon hundreds
of individuals never present themselves for treatment either in private
(aural) practice or in the clinics of our public institutions. Hence we
have no means of finding out accurately how large a percentage of the
population of any given community is afflicted with this morbid condition.
We know, however, that these cases constitute from twenty to thirty
per cent. Of all cases of ear disease that come under the aurist’s care, either
in hospital or in private practice. We also know that among our ac-
quaintances a certain number are troubled, and have been perhaps for
years, with a discharge from one or both ears. Again, if we inquire how
the disease originated, we find that, in a large proportion of the cases, it
is referred back to an attack of scarlet fever, or measles, or nasal catarrh.
In this way we get hold of two important facts: first, that chronic dis-
charge from the ear is a common disease ; and, second, that taking cold,
and the exanthematous diseases, are the chief sources from which it
originates. Two questions here present themselves: (1) Is a chronic dis-
charge from the ear a sufficiently serious affection for either the physi-
cian or the patient to give much thought to it? and (2), admitting the
serious nature of the disease, can anything be done to diminish the pre-
valence of such chronic otorrhoeas
Satisfactory answers to these two questions will furnish the best eluci-
dation of the title which stands at the head of this paper.
I. Is Chronic Discharge from the Ear a serious Affection 2–I answer
unhesitatingly, yes. In the first place, it is annoying to the patient and
disgusting to those who associate with him. In the next place, it is an
indication of the existence of a process which may at any time seriously
threaten the patient’s life. Here, again, statistical proof of the correct-
ness of my statement is not easy to furnish. Medical literature contains
numerous accounts of cases of chronic Otorrhoea that have terminated
fatally. Almost every practitioner, too, has met with one or even
several such cases in the course of his practice. Many also have seen
such cases terminate fatally under the form of meningitis, and have never
once thought of the part played in the disease by the chronic otorrhoea.
These are well-known facts, and admitted, I think, by all. But how
does an inflammation of the ear pass into the condition of a chronic
otorrhoea, and how may the latter cause the death of the patient 7 To
render this clear, let me narrate to you the probable history of such a
C&ASé2.
A strong, healthy boy, ten years old, is taken ill with scarlet fever.
The disease runs a moderately severe course, and bids fair to subside
without any serious after-effects. The tonsils are red and swollen, and
the entire naso-pharyngeal region is evidently in a markedly inflamed
condition. While in this state—say in the second or third week of the dis-
ease—the boy begins to complain of an earache. The first night, warmth
is applied to the ear, and in this way the boy gets some temporary relief.
The next day, however, the pain continues, and the family physician,
who perhaps by this time has discontinued his daily visits, is consulted
as to what shall be done to relieve the boy of his earache. Laudanum is
prescribed ; a drop or two of it to be instilled into the ear, and a piece
of cotton-wool saturated with the remedy to be inserted into the outer
canal. This too, perhaps deadens the pain a little, but still the boy
passes a second night in suffering, and the third day finds him steadily
growing worse. By this time the earache proper has become merged in
a painful and throbbing sensation, involving not only the ear itself, but
E A R I, Y T R E A T M E N T OF A U R A L I) IS E A S E S. 949
also the entire side of the head, and especially the mastoid and Occipital
regions. The instillation of laudanum is repeated, and perhaps sweet oil
is added. The third night is passed in miserable suffering, the boy
obtaining a few snatches of sleep by the aid of opium administered in-
ternally. On the fourth day—a large blister in the mean time having
been applied behind the ear, only to add to the boy’s discomfort—a slight
discharge makes its appearance at the outer orifice. As this discharge
becomes more copious, the pain subsides, and in the course of a few days
the patient finds himself able again to eat, sleep, and move about as when
he was well. For a year or more afterwards he remains free from serious
pain in the ear ; the discharge, however, persists, and at times there is a
sense of discomfort in the ear, perhaps not amounting to actual pain, Wut
still sufficient to indicate the existence of a tolerably active inflamma-
tory process. Finally, the patient some day contracts a bad “cold;” the
otorrhoea ceases, the pain in the ear and corresponding side of the head
becomes intense, the parts behind the ear become very painful and
tender, there is fever—in a word, the inflammation of the tympanum has
spread to the adjacent bony structures and to the meninges of the brain,
and death soon follows. Death may also follow in other ways, but for
our present purpose it is not necessary to describe other modes of fatal
termination.
Now, to appreciate clearly how dangerous a disease an inflammation
of the middle ear may become, and to understand fully the rationale of
a successful treatment, it is necessary that one should possess a tolerably
clear idea of the anatomical relations of the middle ear. These are, in
brief, the following:—
The middle ear (or tympanum) is a small cavity about five-eighths of
an inch in length, half an inch in height, and from an eighth to a quarter
of an inch in breadth. The drum-head, or membrana tympani, consti-
tutes the greater part of one of the sides of this cavity—the Outer one—
but at all other points (with some unimportant exceptions) its walls are
of bone, covered by an exceedingly thin, vascular mucous membrane. In
health, this cavity possesses an outlet (the Eustachian tube), but when
its lining mucous membrane becomes inflamed, this outlet undoubtedly
closes, and we then have to deal with an inflammation occurring in a
closed cavity, the walls of which are everywhere of bone, except at one
spot, and here the resistance of a strong fibrous membrane must first be
overcome before the fluid can escape, and before the conditions of a closed
cavity can be done away with.
Now let us suppose that inflammation has attacked this cavity. What
takes place : The vessels of the mucous membrane become gorged with
blood, the mucous membrane itself becomes swollen and Oedematous, and
the valve-like tympanic orifice of the Eustachian tube becomes closed to
all secretions that might otherwise find an escape through this channel.
This is the first stage of the trouble, and it may last only a few hours, or
it may be prolonged for even three or four days. This is the stage in
which the application of a few leeches in the neighborhood of the ear
may suffice to check the entire trouble. But, if the inflammation con-
tinue, stasis will occur in the capillaries and veins, and serum will be
forced by arterial (cardiac) pressure through the walls of the blood vessels,
through the surrounding tissues, and finally into the cavity of the tym-
panum. After the cavity has become filled with the exudation, each suc-
ceeding portion of fluid exuded must find room for itself by forcing the
membrana tympani outwards. The disease has now reached its second
950 BUCK,
stage. The tympanum is filled with serum, in which pus corpuscles are
rapidly increasing in number, the membrana, tympani is bulged out-
wards and pulsates, capillary and venous stasis is general, and great pres-
sure is being exerted upon all the soft parts contained not only within
the tympanum proper, but also within the communicating system of
bony cavities, the antrum and mastoid cells. If now the membrana
tympani be not abnormally resistant, the pressure will soon cause a
thinning, and eventually a rupture, of the membrane at some particular
spot. The pressure, which is the chief source of the pain, then ceases,
the exuded fluid becomes more decidedly purulent in character, and
escapes through the perforation, and the parts in due time return to a
mayural condition. In a large minority of cases, however, the termina-
tion is not so favorable. Owing probably to the great resisting power
of the membrana tympani, the intra-tympanic pressure continues for a
much longer period—perhaps even for several days—before a perforation
is finally established. In these cases, it must be remembered that the
tympanic mucous membrane is also functionally a periosteum. Iſence
the continued pressure is apt to result in superficial death of the under-
lying bone in one or more places. But there are also other points that
should be remembered: the blood vessels of the tympanic mucous mem-
brane communicate freely with those of the adjacent dura mater, which
is separated from the mucous membrane by only a thin septum of bone,
and the mastoid veins empty directly into the lateral sinus.
lf all these points be borne in mind—the anatomical and pathological
conditions, and the impotent or even harmful treatment pursued—should
any one be surprised at the terrible results that often follow inflamma-
tion of the ear, or wonder any longer at the large percentage of indi-
viduals in every community who go through life with an offensive dis-
charge from this organ 7
II. This brings us to our second question: Can anything be done to
diminish the prevalence of such Chronic Otorrhoeas 2–In answering this
question we shall confine ourselves, in accordance with the spirit of our
subject, to the consideration of those measures which tend to prevent
the inflammation from reaching what might be termed a third stage,
one that is characterized by inflammation of neighboring organs, by pro-
liferation of the soft tissues, and by carious processes in the subjacent
bone. In a few cases, in the early part of the attack, warm applications
and leeches are sufficient to prevent the inflammation from reaching the
higher, second stage. In the majority of cases, however, we are unable
to prevent this increase, and are consequently brought face to face with
a middle ear in the condition of inflammation to which I have given the
name of second stage. This is the time when paracentesis of the mem-
brana tympani produces such beneficial effects, and the earlier it is per-
formed, in this stage, the greater its efficacy. In this one slight opera-
tion, which in itself is neither dangerous nor very painful, lies the power
to prevent the whole train of disagreeable and dangerous symptoms to
which I have alluded so fully above. It is not far from the truth to say
that every fatal case of purulent inflammation of the middle ear must, at
some time in its course, have passed through a stage in which, by a
resort to this operation, the progress of the disease might have been
arrested, and the tendency of its course changed from an unfavorable
to a favorable One.
In illustration of the speedy relief from pain which often follows the
!,
E A R L Y TRE ATM E N T OF A U R A L DIS E A S E S. 951
operation, especially in children, let me narrate briefly the following
Cà S62 : —
A child, three years old, had been complaining of earache in the right ear
during the greater part of the day. (For several days previous to this, she
had been suffering from a marked nasal catarrh.) The pain in the ear was
paroxysmal in character, and the child evidently had a high fever, though no
measurement of the temperature was made with the thermometer. As night
came on, the pain became more severe, and the intervals between the paroxysms
shorter. Toward morning I was sent for, as the pain had become constant,
and the child was in great suffering. An examination with the speculum and
reflected light showed an Oedematous and bulging membrana tympani (posterior
half), the neighboring parts being very red, though as yet but little swollen.
In the most prominent portion of the membrane I made an incision scarcely
three millimetres in length, and involving simply the different layers of the
membrana tympani. This was almost immediately followed by a watery dis-
charge (without the aid of inflation), which ran down over the child’s cheek.
At the end of three or four minutes the child had ceased crying, and in less
than a quarter of an hour she was fast asleep. At first the discharge was very
abundant, and mainly watery in character, but it steadily diminished in quan-
tity and became thicker, until finally on the fourth day it ceased altogether.
On the tenth day the most careful examination of the ear could not detect any
trace of either the inflammation or the artificial opening.
It would have served my purpose better, had I been able to offer in
illustration a parallel case of acute, purulent inflammation following
scarlet fever or measles; but unfortunately I cannot find in my records
a single such case which came under observation as early as the second
or third day after aural symptoms had manifested themselves. The
morbid process, however, is practically the same in both cases, and the
benefit to be obtained by early surgical interference cannot be materially
less in cases following scarlet fever than in those following an acute nasal
catarrh. The tendency to desquamation, and the enfeebled state of health
following a moderately severe attack of scarlet fever, may, it is true,
prolong the subsequent subacute stage of the aural inflammation for a
few weeks, but the prospect of ultimate complete restitutio ad integrum is
almost as certainly secured by timely interference in the one case as it is
in the other. No harm can come from perforating the membrane too
early, but months or even years of annoyance and suffering may be
entailed upon the patient by resorting to the incision after the mischief
has already been done. It then often fails to relieve even the pain.
In calling special attention to this operation, I do not wish to be
understood as advocating it as the only means of treatment in such cases;
I simply choose it because it is the most important one, and because its
wonderful efficacy is susceptible of proof.
This is perhaps the best place to comment upon the view held by the
late Mr. James Hinton, of London, respecting the efficacy of paracentesis
of the membrana tympani in acute affections of the middle ear. In his
work on “The Questions of Aural Surgery” (pp. 130 and 131), I find
the following: “Since the real relief of the symptoms depends upon the
escape of the matter through the membrane, it would seem an obvious
inference that the membrane should be, at the earliest possible period,
incised. And this is recommended by almost every writer; but expe-
rience of this method has left a doubt upon my mind. In the few cases
in which I have had recourse to it during the acute stage of an inflam-
mation, I have not found the results very satisfactory, and in two in-
952 BU C K ,
stances in which the inflammation existed on both sides, and I incised
one membrane only, the progress of recovery seemed retarded rather than
expedited ; I must, therefore, hold an undetermined position on this
question.” Such an opinion, coming from one whose authority in oto-
logical matters is so weighty, is calculated to prevent many from resorting
to the operation, and that, too, notwithstanding the fact that in another
part of the same work (p. 133) he says: “But whatever may be the best
method of treatment in simple, acute catarrh" of the tympanum, there
seems to be no doubt that immense evil might be prevented by free
incisions of the membrane in very many of the cases in which it becomes
inflamed during the course of the exanthemata.” The example which
Mr. Hinton cites, in evidence of the doubtful efficacy of paracentesis,
furnishes at the same time a satisfactory explanation of the reasons why
the incision failed to afford relief. In the first place, the incision consisted
of a mere “prick with a cataract knife,” and, in the second place, it was
not made until the eighth day of the attack, or, in other words, late
in what I have described as the second stage. Under such circumstances
it is certainly not to be wondered at that the paracentesis failed to afford
the desired relief.
My own experience leads me to recommend the operation unhesi-
tatingly ; in fact, without it, I believe the physician will be able to do
comparatively little toward preventing those disastrous results to the
hearing, to the general health, and even to life, of which I have already
spoken more than once in this paper.
On looking over my records of cases (in hospital and private practice),
I find that I have had occasion to perform this operation seventy-six
times, on fifty-eight persons, for the relief of pain. In each of these
cases the membrana tympani was either “red and swollen,” or “bulged
outwards,” from the pressure of the fluid in the middle ear. In seven
cases the paracentesis was performed on the 2d day of the disease, in
four on the 3d day, in seven on the 4th day, in five on the 5th day, in
four on the 6th day, in two on the 7th day, in ten on the 8th day, in two
on the 10th day, in six between the 11th and 15th days, in one on the
20th day, in two between the 21st and 25th days, in one on the 30th day,
in three between the 31st and 55th days, and in four at unknown periods.
In twenty-nine cases, permanent relief from the pain was afforded within
a few minutes or hours; in six other cases immediate relief was afforded,
but the pain returned, either the next day or on some subsequent day;
in eight others, the pain did not subside until the 2d, 3d, or 4th day after
the incision ; in four others, the Operation afforded no appreciable relief;
and finally, in eleven instances, the patients did not return to report the
result of the operation.” Of the twenty-nine cases in which the opera-
tion proved quickly successful in relieving the pain, six had reached the
2d day of the disease, three the 3d, four the 4th, four the 5th, two the
6th, two the 7th, four the 8th, one each the 12th, 14th, and 15th days,
and one an unknown stage of the disease. In other words, the operation
1 Mr. Hinton's “simple, acute catarrh” is nothing more nor less than an acute inflamma-
tion of the middle car, going on to the formation of pus, and to the exertion of a pressure
equally great with that which takes place in the acute inflammation following the exanthe-
mata. While, perhaps, the ultimate results are not quite as disastrous in the cases which
develop in the course of a simple nasal catarrh as in those which accompany the exanthe-
matous diseases, there is not a sufficient difference to justify any material difference in the
course of treatment that should be pursued in the two classes of cases.
* These eleven cases all occurred in hospital practice.
E A R I, Y T R E A T M E N T OF A U R A L DIS E A S E S. 95.3
may be said to have been quickly successful in cases chiefly of recent
date. On the other hand, of the eighteen cases in which the pain re-
turned, or in which there was little or no relief from the incision, five
were subsequently relieved by incision of the mastoid integuments, eight
by subsequent incision (or incisions) of the drum-head, and two by
leeches. In twenty-five out of the fifty-eight cases, the day (of the dis-
ease) on which the discharge ceased was noted ; in the remaining cases,
either no note was made regarding this point, or the patients did not
return to report their condition. In regard to the twenty-five, the facts
are as follows: in six cases the discharge ceased on or before the 8th day
of the disease, in seven between the 9th and 15th days, in two between
the 16th and 22d days, in five between the 23d and 40th days, and in
five between the 41st and 65th days. As far as the incomplete records
go, therefore, in not a single case did there remain a permanent chronic
Otorrhoea with perforated membrana tympani.
Surely this record justifies me in recommending unhesitatingly the
Operation of paracentesis of the tympanic membrane. I am sorry to
say that I have never had the opportunity of testing the value of this
operation in those very cases in which we have every reason for believing
that it would prove of the greatest value, namely, in those which occur
in the course of the exanthematous diseases. II inton, however, as we
have seen, speaks in strong terms in its favor under these circumstances,
and I believe that all or nearly all the authorities hold the same opinion.
IIaving shown how serious are the results which often follow an
unchecked, or improperly treated, acute inflammation of the middle ear,
and having also shown, as far as it is possible to demonstrate such a fact,
that we are in possession of at least one means of preventing (in the
great majority of cases, if not in all) these disastrous results, what more
can I say to impress upon the profession “the importance of treatment
of aural diseases in their early stages, especially when arising from the
exanthemata ?” The opinion expressed by Prof. Edward Clarke,' of
Boston, in 1858, and reiterated by Von Tröltsch and Hinton—that a
physician who treated a case of exanthematous fever without inquiring
into the condition of the ear, was guilty of great neglect (or words to
that effect)—might be uttered with as much appropriateness to-day. I
would go still further, and say that a general practitioner who is unable
to obtain a view of the external auditory canal and membrana tympani
by means of the speculum and reflected light, is not properly fitted to
practise medicine. While it may not be necessary for him to study
otology, or to become skilled in aural manipulations, it is very necessary,
if he wish to fulfil his duty toward his patient, that he should be able
to determine by actual examination, whether or not the membrana
tympani is being pushed forcibly outwards by the products of inflam-
mation within the tympanum. If he be able to determine this point,
and an hour's schooling will put him in possession of the necessary
technical knowledge, I am sure that, where it is indicated, he will not
be slow in taking successfully the second step, namely, the incision of
the membrana tympani.
Medical students are taught very thoroughly how to amputate a leg,
and their knowledge of the relations, distribution, etc., of arteries and
nerves, will be found, at their examination for the degree of Doctor of
Medicine, to be quite perfect; but has the new graduate the slightest
| American Journal of the Medical Sciences, 1s53.
954 BUCK,
practical knowledge of how he should deal with an acute inflammation
of the ear . Upon the medical schools, then, rests the chief responsi-
bility for the prevailing indifference and ignorance among practitioners
regarding these matters, and to the schools, therefore, the profession
must look for assistance in bringing about a reform.
In conclusion, let me recapitulate briefly the main points which a con-
sideration of the subject suggests:—
I. Chronic otorrhoea is at the present time a very common disease, due,
in most cases, to the want of proper treatment during the acute stage of
the affection.
II. It is by no means a harmless affection.
III. It may be fairly classed as a preventable disease, at least among
those who possess a healthy constitution.
IV. I’aracentesis of the membrana tympani, if resorted to during the
first few days of the acute attack, and if not carried out too timidly, i. e.,
if a free incision be made and not a mere prick, is almost a sure pre-
ventive of the subsequent, chronic disease.
V. The Profession at large, and especially the medical schools, should
give this subject more earnest thought than they have in the past.
As some may be interested to ascertain further details regarding the
cases referred to above, I append in a tabulated form the main points of
interest in each of the fifty-eight cases, as far at least as my imperfect
records furnish this information. And here I may say that it is not
unfair to assume that the great majority of the patients in whom the
result of the incision was not ascertained, failed to report their condition
simply because they had been relieved of their sufferings, and did not
feel the necessity of visiting the hospital again.
E A R L Y TRE AT M E N T OF A U R A L DIS E A S E S.
955
Tabular View of Fifty-eight Cases of Paracentesis of the Membrana Tympani.
10
ll
12
13
14
15
16
17
18
i
9
40
40
23
24
33
30
49
3
48
2
S
.d
º
2's rº
##. gº 5 #| -
###3 #3: š
.2 - T 3 ..? Tº cº
Condition of Condi- ſº S.2 = * 3: 8
Cause. membrana | tion of sº, 33 | Relief from's #. = Remarks.
tympani. |mastoid , P: E º pain. P, 2.É s
region.s 5 § 3. # = #3
Expo- Fed and Tender | 7th Speedy. 28th.
Sll I'ê bulging.
Not | Bulging, but | Normal. 2d Immediate.] Not
stated. not very red. stated
“Cold | CEdematous Tender 6th. Entirely 10th Paracentesis repeated twice (with
in the and bulging ; free from or 11th equal benefit) in same ear during
head.” neighboring pain at end following two years.
parts red. of 6 hours.
Not Posterior half) Not 2d Speedy. Not
stated. bulging, red. stated. state d.
Sitting |Post. half red, Tender | 14th |Relieved in Not Three leeches also applied at same
in a and bulging ; 12 hours. | Stated. | time.
drau’t small perf.
of air. in the ant.
inf. Quadrant. -
Not Membrane Not 8th Immediate. Not Subsequent fresh attack. Incision re-
stated. bulging both stated. Stated. peated. Result not stated.
anteriorly
and
posteriorly.
Not |Red, bulging, Tender 12th |Relieved in Not
stated. and a few hours. | Stated.
pulsating.
Not Red and Not 11th | No marked | 26th
stated. swollen. stated. relief till 4
days later.
Caught | Post. half Not 8th Pain Not
cold. I swollen and stated. gradually stated.
red ; small subsided.
perf. anteri-
Orly.
Not Red and Not 6th Not known. | Not Patient did not return to the In-
stated swollen. stated. known. | firmary.
Caught Red and Not | About | Not known. | Not Patient did not return to the In-
cold. swollen. stated. | 21st known. | firmary. -
Not Red and Not 3d Pain 14th Leeches also applied at the same time.
stated. bulging. stated. gradually
subsided ;
slight recur-
F6]] Cè.
“Run “ Much in- Not 8th Pain Not,
over by flamed.” stated. gradually stated.
a wa- subsided;
gon.” no return.
River Post. half red| Not 4th |Only tempo-| Not On the seventh day, two incisions in
bathing and bulging. stated. rary relief. stated. the membrana tympani, one ante-
riorly, one posteriorly; also leeches.
On the thirty-seventh day opened a
s - large abscess behind the ear.
River Post. half red] Not 5th Pain soon Not
bathing and bulging. stated. Subsided stated.
entirely.
Not Red and | Tender | 8th Almost Not
stated. bulging. immediate stated.
relief.
“Severe Bulging. Slight- End of Within two. In the Leeches also applied at the same time.
cold y 1st hours. COU TS6 Two days later the other ear became
III the, tender. of a few similarly inflamed, and at end of first
head. days. day I in cised membrana tympani in
two places, affording escape, as in
the case of the first ear, to bloody
serum. Leeches also applied. Im-
mediate relief followed.
Not Bulging. Not 2d At the end 7th On the fourth day the other ear became
.Stated. stated. of a few painful. The following day incised
Iminutes. the membrane and afforded immediate
relief from pain, as in the case of
the first ear.
Not Diffusely red Very 3d or Very slight Not Relief obtained only by an incision of
stated. background ; tender. 4th of if any stated. the mastoid integuments.
landmarks decided relief.
Il () [. pain ;
recognizable. 21st of
disease.
Not Membrane | Tender | Not |Not known. | Not Patient did not retnrn to the Infirm-
stated. bulging. stated. known alry.
Not Bulging and | Not Not Not known. | Not Patient did not return to the Infirm-
stated. red. stated. stated. known alry.
** Took CE dematous, Not Not Almost Not
cold.” and bulging stated. stated. immediate stated
| posteriorly. relief.
956 B U C K ,
# .
t E = 3
op § o P- - ?
3 : 3 3 = E &
35 P. S. . . § 2 & 5
º .2, a ;: 3. ..? ~'cs &
Condition of Condi- ºc.º.º. 3 * 3 & 8
No. Age Cause. membrana | tion of ‘sº #3 | Relief from's F.C. : Remarks.
tympani. |mastoid .*:: pain. > = 33
region. ; 5 § 3. à e 3.3
23 7 River Red and Not 3d Believed 18th Two days later (fifth day) membrane
bathing bulging. state d. SOOIl. again bulging and parts painful.
Incision repeated. No return of pain
afterward.
24 || 70 | Not | Posteriorly | Not About | Pain miti- || About | Permanent relief not obtained until
stated. and superi- 1 stated. 42d gated, but | 60th after incision of mastoid integuments
orly, red and not entirely on about the fifty-second day.
bulging. relieved.
25 || 3 | Not |Post. half red| Not 7th Relieved | About
Stated. and bulging. stated. SOO fl. 28th
26 || 25 | Syphi- |Membrane red|Tender | About |No material About | Relief obtained permanently only by
litic and swollen ; 8th relief. 20th an incision of the mastoid integu-
Il 3,80- small perf. ments on about the fifteenth day.
pharyn- anteriorly.
gitis. -
27 | 29 | Not |Membrane red|Tender | 2d Gradual | About
Stated. and swollen. of acute | Subsidence, 65th
exacer- with no
bation return.
(about
53d
since
first
attack).
28 19 Not Membrane red| Not 4th Gradual 39th
stated. and Swollen. stated. subsidence
With no
- return.
29 || 57 Not Red and Not 10th | Immediate Not
stated. bulging. stated. relief, but stated.
pain return-
ed later,
though not
so violently
30 22 River : Posterior Not 5th | Soon after- | 12th
bathing half bulging stated. wards.
and red.
31 || 49 | Not Post. half Not | ºth or |But little if | Not | Poor health (syphilitic). Acute exa-
- stated. bulging and stated. | 6th of any relief. stated. cerbation of an otitis med, pur. of
red ; small actual two months’ standing. Four days.
perf. anteri- Palil. after first incision, which in the
orly. mean time had healed, pain again be-
came severe. Made a second and
very free incision through posterior
half of membrane. During following
ten days, three more incisions, each
one affording only temporary relief.
Permanent relief was finally obtain-
ed after an incision had been made
through the mastoid integuments,
and, still later, one through the skin
lining the external auditory canal.
32 5 Not Red and Not 14th ||Not known. Not | Patient did not return.
Stated. swollen. Stated. stated.
33 40 | Not |Red, parched, Tender 3d Immediate. 36th Two days later pain returned, though
stated. and slightly with less severity than before.
bulging. seventh day of attack made a second
incision. Relief from pain lasted
twelve days, when, the perforation
having nearly healed, the pain re-
turned. It was not severe, however,
and may have been due to a furuncle
... in the meatus. After this, rapid and
complete recovery.
34 || 7 || “. COld Bulging Not 2d Speedy. Not
in the posteriorly. stated. Stated.
head.”
35 || 30 Not Red and NO 4th | Relief in 1 5th
clear. swollen. tender- or 2 hours.
IlêSS.
36 4# | From Red and NO 3d Only slight | Not On fourth day, I made a free incision
use of bulging. tender-|(a mere relief. Stated. through the posterior half of mem-
post. ness. prick). brana tympani. Entire relief in a
nasal few hours.
syringe -
and salt
Water.
37 || 11 Not Red and No 20th Very little | Not
clear. Swollen. tender- until after | stated.
Ilê SS 48 hours.
OWel'
mastoid
but
SOIIlê
OWer
occiput.
On
E A R L Y
957
TREAT MENT OF A U R A L DIS E A SES.
No.
38
39
40
4]
42
43
45
46
47
48
49
51
57
58
Age
24
5
16
22
38
2
2
.c.
* . .
- E =
• * e = # 3.
; : 3 # 5 g :
gº º ºr re; 35 - Sº so
a d 35 ..? Tº sº gº
Condition of Condi- |3.3.2 : is 33 8
Cause. membrana | tion of 5 33.3 | Relief from s : L = Remarks.
tympani. mastoid ...’ H = pain. > 3; 3
region. < 3 & #. > 3 #3
p- H-4
Not Red and No 3d or | Not ascer- Not Patient did not return to the Infirm-
known. | Swollen. tender- || 4th tained. 2,S CéI'- ary.
Il G. S.S. tained.
Not Red and NO 14th | Not ascer- Not Patient did not return to the Infirm-
known. | 8 Wollen. tender- tained. 8,S Cel’- alry.
Il G. S.S. tained.
Not Post. half No 15th. Speedy Not
known. bulging ; tender- relief. Stated.
small perf. Ilê SS.
in ant. half.
Not | Inflamed and | Not Not | Not ascer- Not | Patient did not return to the Infirm-
known. swollen. Stated. ascer- tained. 3,SC&I'- ary.
tailled tained.
Blow |Post. half red Tender | About | Not ascer- Not | Patient did not return to the Infirm-
on the and bulging. on pres- 30th tained. 3,S Cel"- ary.
€ 3,1". SUI l'é. tained.
River Much Not 5th | Not ascer- Not Patient did not return to the Infirm-
bathing| inflamed. stated. tained. 3, S CéI'- ary.
tained.
River Congested Not About | Very little About | Second incision on fortieth day, the
bathing and uneven. state d. 25th relief until 48th pain having returned.
2 days later.
* : A Red and Tender | 8th Almost Not | Pain returned next day, and on the
cold.” bulging; on pres- immediate ascer- eleventh day, the membrana tympani
small perf. Sll I'G. 1:elief. tained. being again in a bulging condition,
anteriorly. I made a second and free incision.
Leeches applied at same time to mas-
toid region. Patient did not return to
the Infirmary.
Not Red and Not Sth | Pain soon | 14th Pain returned on the eleventh day,
stated. SWOllen. stated. subsided. and was relieved by leeches. It re-
turned again on the thirteenth day,
and was again relieved by leeches.
Rapid recovery afterwards.
Not Red and Not 5th | Relief in a In the
stated. swollen. stated. few hours. | course
of a few
days.
Caught Red and Yot 5th | Relief in a | 13th
cold. bulging, es- stated. few hours.
pecially
posteriorly.
Acute Red and No 2d Relief in a 4th A year later the incision was repeated
nasal bulging. tender- few minutes in the same ear, under the same cir-
catarrh Il e SS. cumstances, and with equally bene-
ficial and speedy results.
Not, Red and No 8th No relief Not High fever, apparently total deafness,
stated. bulging. tender- until 24 stated. and symptoms of general Ineningitis
Ilſe SS. hours later, at time of making the incision. The
When a dis- other ear also involved.
charge
appeared.
Not |Red, diffusely No 8th |Entire relief. 14th
stated. swollen, and tender- (leech’s in a few
Oedematous. | ness. having hours.
failed
to give
relief)
From GEdematous No 2d Relief in a 3d
use of and slightly | tender- few hours.
nasal bulging. Il G SS.
douche.
Not Red and NO 3d. Relief in 15th Leeches failed to give relief on second
stated. bulging. ten der- less than an day.
Ilê SS. hour.
Not Red and Tender 4th Marked re- About
stated. bulging on pres- lief in a few 65th
posteriorly. sure. minutes.
Un- Red and Not 10th Not ascer- Not Leeches also applied. Patient did not
known. bulging ; stated. tained. 3.S Cºr- return to the Infirmary.
perforation tained. -
anteriorly.
River Diffusely Not | About | No decided About | Abscess formed behind the ear and was
bathing swollen. stated. 50th relief until | 64th opened by an in cision. By the sixty-
48 hours eighth day, the abscess had also
later. healed.
Not Not stated. Not 8th But little Not Second incision on the eleventh day.
stated. stated. relief. 2.S Cer. Patient did not return afterwards to
| tained. the Infirmary.
Not Not stated. Not 6th Marked re- Not Second incision on the ninth day, the
stated. stated. lief in a ascer- pain having returned, and the dis-
short time. tained. charge having ceased. Patient did
not return afterwards to the Infirm-
ary.
958
ON THE BEST MEANS OF TESTING THE HEARING.
BY
CHARLES H. BURNETT, M.D.,
AURAL SURGEON TO THE PRESBYTERIAN HOSPITAL, PHILADELPHIA.
IN the following paper I shall endeavor to give a sketch of the known
relation of hearing to the watch, the tuning-fork, and speech, the gene-
rally accepted tests. After a consideration of normal hearing, it shall
be my aim to show how the diseased ear is affected by these tests, and
wherein they give information as to its state, and wherein they fail to
do so. Afterwards, a conclusion may be better arrived at as to the best
form of test or tests for the hearing. It will be necessary to review the
writings, discoveries, and opinions of leading physiologists and aurists
of the last two or three decades, and by this means the ground of the
best labors will be fully gone over. Nothing is promised as original on
my part ; rather shall it be my aim to bring together, at such a time as
this, the doings of others, as impartially and completely as lies in my
power.
No precise standard of normal hearing has been defined. The normal
ear hears all sounds which fall upon it; but it cannot be said, d priori,
where good hearing ceases and defective hearing begins, for, in many
senses, hearing is a relative term. Just as there is an average standard
for the amount of food, excretion, etc., there might be an average
standard for hearing. The sense of hearing must be regarded as com-
posite, consisting as it does of the ability to perceive not only a great
variety of sounds, musical or periodic, but also those which are irregular
or noisy. All such sounds can be heard singly or together. Hence, the
sense of hearing may be said to lie in a collection of elements, largely
nervous, which can be aroused singly or together. The mere fact that
more than one sound can be heard at the same time, shows that the organ
of hearing is composed of a number of structures arranged so that each
can receive its definite impression.
THE WATCH.
Some form of watch-work, or ticking apparatus, has been used a long
time as a ready means of testing the hearing. In this way the pocket-
watch, mantel-clock, metronome, or an especially contrived, ticking
machine, has been called into requisition. Such a test has usually been
all that has been deemed necessary, and in many cases has seemed to
satisfy both patient and physician as to the amount or state of hearing.
Gradually, as the anatomy and physiology of the internal ear became
better known, the idea arose of assigning to the cochlea the hearing of
music or musical notes, and to the rest of the labyrinth, more especially
to those parts in the vestibule, the perception of noises or irregular
vibrations. When this theory obtained currency, the watch was classed
B E S T M E A N S OF TEST IN G T H E H E A R IN G. 959
among noises and not musical sounds, though its beats were regular in
their occurrence.
Be this theory of the physiology of the two parts of the internal ear
false or true (it is not my province nor intention to review or criticize it
here), Oscar Wolf has shown that the tick of a watch is a low form, if
I may use the term, of musical note, with a not easily determinable
pitch. Its impulse, therefore, cannot produce irregular waves of sound.
All watches, metronomes, and the like, must therefore be classed under
the head of instruments producing musical tones, and of course each
watch, ticking apparatus, etc., has its own peculiar pitch. But at best
these instruments give out but two notes, of short duration, and decidedly
poor in harmonics.
This accounts for the inferiority of the watch, etc., as a test for hearing,
and also explains why some affected ears appear to hear the watch better
than others, and also why it is that there is so much difference in the
relative manner of hearing the voice and watch, on the part of those hard
of hearing.
According to Wolf, the tick of a watch should not be classed under
noises, for it is really a musical sound with very high overtones, the short
duration and intensity of which fall in a few seconds from their maximum
to nothing. “With the ticking of a watch, we test the patient with but
two tones out of the whole scale, and those neither very pure nor precise.
The hammer or anchor strikes upon the cog-wheel, and by its impact calls
forth two weak tones, which are somewhat intensified by the resonance
of the watch-case. The pitch of these notes is not easily determinable;
the intensity is measured by the observer according to the average dis-
tance at which persons of normal hearing are able to perceive the tick.”
This has proven very unsatisfactory as a test, because it is often found
that a watch is heard relatively better or worse than the voice, etc. This
is very easily explained when we reflect that with the watch we have
only tested the power of the ear to hear two relatively weak and impure
tones. Wolf therefore says: “Should it happen that the patient has a
disturbance of the nerve-fibres corresponding to these two tones, it is
conceivable that, while absolutely deaf to the ticking of the watch, he
may hear other far weaker tones which hold a different position in the
scale, and, on the other hand, that the patient may hear the ticking of
the watch at a relatively greater distance, and at the same time misun-
derstand certain spoken words, and even loudly spoken tones.”
Such a disturbance of fibres in the nervous apparatus of the ear most
likely happens even with the diseases of the middle ear, for Politzer” has
shown that the tympanic vessels are connected most closely with the
vessels of the cochlea ; hence, tympanic disease is more than likely to
bring about labyrinthine disease. Therefore, the above test is just as
applicable in diseases of the tympanum as when the disease is primary
in the labyrinth.
The Tick of the Watch or Clock.-Even a child will tell us, “The clock
says tick, tock;” to its ears, therefore, there are in the sound made by the
watch, vowel sounds of “i’’ and “o,” and consonant sounds of “t” and
“ck.” Now, vowels and consonants are musical notes of certain, definite
pitch, and therefore it may be said that even in this simple way a watch-
tick is musical. This view of the watch-tick, viz., that it is an alternation
! Archives of Ophthalmology and Otology, vol. iv. p. 69.
* Correspondence with the writer, 1876.
960 BURNETT,
of two notes simply, would explain in a measure why one clock is heard
better than another by an affected ear. For, even when the intensity is
the same, one watch is apparently heard better than another. This is
due to the fact that the pitch of one appeals more strongly than that of
another, to the ear which is being tested.
The Stop-watch.-Of all forms of ticking apparatus, the stop-watch is the
most useful. Besides its power as a test, we also possess in it a means
of finding out whether the patient really hears the sounds of the watch,
or whether he thinks he does because he knows a watch is being held
near his ear. This means has often been the first to declare that the
patient’s statements respecting his subjective state are not entirely reli-
able. Such occurrences, while testing with the watch, serve to show
how unreliable this apparatus is, as must be all tests in the use of which
the surgeon must accept the patient’s statement alone, as to how much is
perceived. Not only are adults of the greatest intelligence and fairness
of intention sometimes utterly self-deceived by the watch-tests, but chil-
dren as a rule give entirely unreliable statements respecting their ability
to hear a watch. This, of course, is perfectly well known to all aurists,
and I am sure that they have long ago concluded that accuracy in the
use of any form of ticking apparatus can only be obtained by the em-
ployment of some form of stop-watch, since by this means they can find
out whether a patient really is aware of the going or the stopping of the
ticking.
Some observers have gained a similar end by alternately holding and
removing a diaphragm of paper between the ear and the watch. In
Some instances, even while the ticking continues, the patient who has
been hearing it will state that he now no longer hears it. This may be
a perfectly true statement, and is explained by the fatigue of the ear.
Every one must have noticed that in some forms of chronic aural catarrh
the ear seems to lose its power of accommodation, or, as one may say, the
power of continued listening. This has been specially noted by some
writers (Weber-Liel and others), and is explained as being due to a fail-
ure in the muscular functions of the middle ear. It appears not only
when testing with a watch, but also with speech. It is more likely to
Occur with a watch, however, because of the sameness of the test note,
and the consequent continued use of the same parts of the hearing appa-
ratus. Hence the watch may be a better test for this condition of the
ear than the more variable vocal sounds, since the latter, playing up and
down a series of notes, allow momentary rest of some parts of the ear,
while others are being called into action.
Not only can the smallest amount of hearing be detected by means of
a loudly ticking watch, but the same means may aid in prognosis in
chronic diseases. The watch which I have found preferable, can be
heard from 50 to 60 feet. If this watch is heard by a patient only a few
inches, I feel obliged to give an unfavorable, or at best a guarded, prog-
nosis as to the recovery of hearing. In such a case of excessive impair-
ment of hearing, the loudness of the watch rather than the pitch of its
note is to be considered, for if the ear cannot hear such intense ticking
as that alluded to above, it certainly cannot retain much of its function.
In such cases, a small pocket-watch would be useless, for not only can it
not be heard by a very defective ear, but even an ear far from being very
deaf cannot hear the faint sounds of a watch. Hence the intensity of
the sounds of a ticking apparatus is of more importance than the pitch
of its poor musical tone. -
B E S T M E A N S OF TEST IN G T H E H E A R IN G . 961
The Use of the Watch in Bone Conduction.—The watch is heard, per ossa,
poorly by most persons over fifty years of age. Hence, it must be ex-
pected that the young will hear the watch much better by bone conduc-
tion than the old. Bearing this in mind, the ticking apparatus, of what-
ever form it may be, will generally give some clue to the state of bone
conduction in our patients. But the usual weakness of its vibrations
will interfere with its value as a test in this respect. The tuning-fork,
however, is able to communicate its powerful vibrations through the
bones of the head to the auditory nerve.
Conclusions respecting the Watch.--It may, therefore, be said that the
watch, being a low form of musical apparatus, giving out one or at best
two notes, poor in harmonics and lying near each other in the scale, is
a test of only limited value. It may, however, be of great use, if its
intensity is increased, in judging of the quantitative hearing in a given
case. In very defective hearing, it is to the small amount of hearing still
remaining what a lens is to a small object, for it enables the surgeon to
find out if any hearing be present, and about how much. As a test for
bone conduction its value is limited, both by the age of the patient and
by the weakness of the notes. Although of some value in this respect,
it falls far below the tuning-fork as a test for the sound-conducting power
Of the bones of the head.
THE TUNING-Fork.
Tittle, if anything, has been added to our knowledge of the use of the
tuning-fork in aural diseases since Politzer wrote his papers on this sub-
ject in 1868.' Dr. Urbantschitsch, of Vienna, has pointed out what he
calls the deaf points (tauben Punkte) of the normal ear. These “deaf
points” he discovered while experimenting with the small tuning-fork,
passing the latter to and fro past the ear. Any one can satisfy himself
on this matter by simply passing a small tuning-fork, with the line of
the vibrating times at right angles to the side of the head, backwards.
and forwards in the plane of the auditory canal. A point will be reached
where suddenly the sound fades or disappears, to be heard again when
the fork is moved either way from this point. This is purely physio-
logical, and should be borne in mind in testing.
The tuning-fork, like the watch, may be used in two ways as a test:
(1) By the air, aerial conduction: this is a test applied to the sound-
conducting apparatus and secondarily to the nerve ; (2) By the bones of
the head, bone conduction : a test applied primarily to the auditory
nerve, and secondarily to the sound-conducting apparatus. For the fork
thus used shows whether sound can be conducted away from the ear in
a given case, or whether, being impeded in their escape from the sound-
conducting parts, the sound-waves are thrown back on the perceptive
part of the organ. -
If the note of the fork be not very loud, and if the times of the instru-
ment be properly clamped, the sound will not be heard further than a
ew inches from the ear. Thus one ear can be tested through the air,
without risk of participation in the test on the part of the opposite organ.
n addition to this advantage, a tuning-fork of low note and with well
lamped times, when used alongside the ear, cannot be heard through the
* Wiener med. Wochenschrift.


























61
962 BURNETT,
bones of the head. For these reasons a tuning-fork is of value as an
aerial test. But, while highly musical, it has the great disadvantage,
like the watch, of giving out only one note at a time, which may or may
not be heard relatively better than another note by the affected ear, and
therefore, like the watch, the tuning-fork is of limited usefulness as a
teSt.
In order, therefore, to derive a wide advantage from the tuning-fork,
one must either be at the inconvenience of shifting the clamps on a sin-
gle fork, or else possess a large number, permanently graded in their
pitch. Such a set of forks, to be of real value, must be most carefully
graduated in order to correspond with the power of the ear to perceive
the intervals between musical notes, otherwise certain fibres of the organ
of hearing will be left out in testing. Such a set of tuning-forks for
testing is not only difficult to obtain, but extremely costly. The tuning-
fork, therefore, though possessing many excellent qualities as a musical
test, through the air, is limited in its practical application.
It may be stated, as an axiom, that the normal ear hears the tuning-
fork better through the air than through the bones of the head; but
chiefly in the latter way has it been used as a test.
According to Politzer, E. H. Weber first settled the point that a
vibrating tuning-fork, in contact with the bones of the head, was better
heard in that ear the external auditory canal of which was stopped by
the finger. This phenomenon was long unexplained, until Mach, on
purely theoretical grounds, advanced the view that the reason of this lay
in the hindrance offered by the finger in the auditory canal, to the
escape of the sound-waves from the ear. Politzer, having in mind this
phenomenon, thereupon made a series of experiments upon the human
ear, and came to the conclusion that the above-named, augmented per-
ception of sound, upon closing the external auditory canal, was due to
(a) the reflection of sound-waves from the bones of the head through the
air of the external auditory canal to the membrana tympani and audi-
tory ossicles; and (b) to the hindrance which the sound-waves, passing
from the bones of the head to the labyrinth and tympanic cavity, met
in escaping from the ear. In the latter conclusion he was in entire agree-
ment with Mach.
If hearing a tuning-fork better on the deafer side is due to hindrance
of the escape of sound-waves, even while the external auditory canal is
open, stopping up the latter with the finger should increase the sound
of the tuning-fork. Dr. Roosa' is of the opinion that if closing the audi-
tory canal by the finger does not increase the hearing of the deaf side,
it is a sign that the nerve is affected. The late Mr. Hinton,” of London,
was inclined very strongly to the view that, when for other reasons he
could diagnose a nerve-affection on the deaf side, an increase of hearing
for the tuning-fork by stopping the deaf ear, was confirmatory of the
presence of disease of the auditory nerve. Politzer has shown (loc. cit.
that a nerve-affection may exist on the deaf side to such a degree tha
the delicate noise of a ticking watch is not heard better on the deaf sid
by bone conduction as long as the auditory canal is left open, but tha
by increasing the quantity of sound made to impinge on the nerv
through the bones of the head, either by stopping up the auditory can
and forcing more sound from a given source, as when using a watch,
by increasing the original amount of sound employed in the test,
1 Treatise on the Diseases of the Ear. * Questions of Aural Surgery.




























B E S T M E A N S OF TESTING THE EI E A R IN G. 963
when a large tuning-fork is used, then the diseased nerve, which is too
weak to reply to a small amount of sound, is stimulated into action by
the greater amount of sound-waves thrown on it. By remembering this
latter fact, the views of Roosa and Hinton are made to appear less at
variance than they seem at first sight, for the correctness of the theory
of each of these distinguished observers is dependent upon the amount
of nerve-disease, since it will be found that Dr. Roosa is correct if the
nerve is paralyzed, and that Mr. Hinton's theory is right if the nerve
still retains some of its power.
In alluding to sound-conduction through the bones of the head, Moos
says: “We have in it one of the most important means of making a diag-
nosis of disease of the internal ear.” He recalls the fact, already pointed
out by Johannes Müller, that, in cases of bone conduction, conveyance of
sound through the auditory Ossicles and through the air must not be
lost sight of “Since in every case of bone conduction, i. e., in cases where
the vibrating tuning-fork is placed on the vertex, or brought in contact
with the bones of the head, sound-waves pass into the ear in these two
directions, the tuning-fork cannot be used in this way as an infallible
means of making a differential diagnosis between diseases of the laby-
rinth and diseases of the middle ear; for it is well known by experience
that the tuning-fork fails to aid in cases of well-known disease of the
labyrinth, as well as in those of disease of the middle ear.”
Three-limbed Auscultation-Tube.—To confirm or correct the patient’s
statements, there has been advised the use of a three-limbed auscultation-
tube,” two arms of which are to be placed in the auditory canals of the
patient, and the third in the ear of the observer. If now a vibrating
tuning-fork be placed on the vertex of the patient, the auscultator can
perceive the sound of the fork, streaming from the ears of the patient.
By alternately pressing the two arms of the apparatus connected with
the patient’s ears, the auscultator can learn from which ear the greater
amount of Sound comes. It seems but natural to suppose that more
sound-waves must come from the less obstructed ear. The latter will,
as a rule, be the better hearing ear, unless its fellow be deaf, not from
obstruction in the sound-conducting parts, but from paralysis of the
auditory nerve.
The Interference-Otoscope.—A similar instrument, though one used in a
different way from that just mentioned, has been devised by Prof. Lucae,”
of Berlin, and is named by him the interference-otoscope. This instru-
ment consists of a double stethoscope of Scott Allison, the limbs of
which, intended to fit snugly into the auditory canals of the patient,
are eleven Paris inches long. At the junction of these symmetrical
arms is placed a T-shaped, glass tube, from the portion of which repre-
senting the standard of the letter, passes a rubber tube to a collector of
sound, half paraboloid in shape. Here the vibrating tuning-fork is placed.
To the other end of the cross piece of glass tube is fixed the rubber tube,
two feet long, for the auscultator. Lucae's experiments in this direction
were based on the fact that sound-waves, falling on a stretched mem-
brane, are only partly taken up and transmitted by it. The supposition
then naturally follows that sound-waves entering the external auditory
canal are only partly transformed into the peculiar, pendulum-like,
to-and-fro movements of the sound-conducting membrana tympani and
! Klinik d. Ohrenheilk., S. 41. * Moos, op. cit., p. 42.
* Archiv für Ohrenheilk., Bd. iii. 1867.
964 . BURNETT, t
the Ossicles. According to the greater or less extent to which the mem-
brana tympani takes up the sound-waves falling on it, this so-called
reflection of the waves of sound will vary in amount. The investiga-
tions made tend to elucidate experimentally this reflection, and the
probable influence on it of the changes of tension in the sound-conduct-
ing apparatus; also, from a study of these phenomena of reflected sound-
waves, the endeavor is made to obtain an objective expression of the
sound-waves taken up by the ear.
Physical Experiments.-Physical experiments show that (1) A stretched
and inclined membrane of India-rubber, placed in an artificial ear
made to represent as closely as possible the natural organ, will reflect
a certain quantity of the sound-waves entering the external auditory
canal; (2) Closure of the Eustachian tube increases slightly this reflec-
tion ; (3) Increased tension of the membrane shows that the reflection is
directly proportional to the tension; (4) This outward reflection of
sound-waves is greatest whenever the tension occurs simultaneously with
considerable changes in the density of the air contained in the tympanic
cavity.
In order to make practical application of these laws, Dr. Lucae devised
his interference-otoscope, by which the relative amounts of reflection from
both ears, it is claimed, can be determined. The results obtained in the
normal ear, by the use of this instrument, are thus given : (1) The normal
organ of hearing reflects a certain amount of the sound-waves entering
the external auditory canal; (2) The reflection increases in all changes
in the sound-conducting apparatus, especially those in the middle ear,
which lead directly or indirectly to an increased tension of the membrana
tympani; (3) The examination of persons with normal hearing, by means
of the interference-otoscope, shows that the different sensibility of both
ears, for the same tone, is caused by the different amounts of reflection
brought about by different tensions in the two sound-conducting appara-
tuses. Respecting the diseased ear, the conclusions are: (1) The interfe-
rence-otoscope shows in the majority of cases of disease, in analogy with
the observations made on those with normal hearing, a greater reflection
from the diseased ear; (2) This is found in a number of cases in which
the ear-mirror and the catheter reveal a disease in the external or middle
ear; (3) In the numerous cases of annbilateral chronic catarrh of the
middle ear, without perforation of the membrana tympani, the examina-
tion usually reveals a greater, though often a less, reflection from the
worse ear; in the latter instance a simultaneous disease of the labyrinth
may be supposed, and the prognosis becomes by far less favorable;
(4) The greatest worth of the method lies in the not uncommon cases in
which all other diagnostic means fail to show morbid changes in the
external and middle ear; here too, as a rule, a stronger reflection is
observed on the worse side, which points to a deep-seated disease of the
sound-conducting apparatus. Only in some few cases does the examina-
tion reveal a less reflection from the worse ear, in which cases a primary
disease in the labyrinth may be assumed with great certainty.
Tuning-Fork Vibrating on the Parietal Protuberance in a Normal Case.—
If a vibrating tuning-fork be placed on either parietal protuberance of
person with normal ears, it will usually be heard in the opposite ear
This is most easily perceived when a large fork of deep and heavy not
is used. This phenomenon, if it may be so termed, will often lead t
confusion in diagnosis, inasmuch as the examiner would at first expec
the fork to be heard best in the ear nearest to which the fork is placed































B E S T M.E. A. NS OF TEST IN G T H E H E A R IN G . 965
As it is heard best in the more distant organ, a conclusion might be made
that the latter ear was diseased in its conducting parts. Care must, there-
fore, be taken to have the vibrating instrument in the central line of the
head, either on the vertex or glabella, or held between or on the teeth.
An explanation of the above is perhaps most satisfactorily sought for in
Dr. Lucae's demonstration that vibrations which fall perpendicularly on
the membrana tympani produce much the strongest vibrations, and that
hence a tuning-fork placed on the parietal prominence, or the side of the
head, will be chiefly heard in the opposite ear. According to Dr. Lucae,
this is best perceived when the meatuses are stopped. But it can also
be perceived, as any one can find out, with perfectly open meatuses.
Conclusions respecting the Tuning-Fork as a means of Testing and Diag-
nosis in Diseases of the Ear.—It has been shown that the tuning-fork
has a twofold use: (a) as a test through the air, and (b) as a test through
the bones of the head; i. e., it is a test of the sound-conducting power
of the ear, and also of bone conduction of sound to the auditory nerve,
and of the perceptive power of the latter. In the first instance, its
advantages are that one ear may be tested without communicating the
sounds of the fork to the other ear, since a properly clamped fork cannot
be heard far enough when held before one ear to be perceived by the
other. The disadvantage in the tuning-fork is that it gives only one
note at a time, and, therefore, testing with that gives no information
respecting the ability of the ear to hear other notes. Its applicability,
therefore, is limited. Various notes may be produced by the same fork
by clamping the times at different points. But this necessitates some
delay.
The tuning-fork finds its greatest usefulness in testing bone conduction.
While it has never fully realized in this way all that was hoped for it,
as an aid in diagnosis, it is still the best means, and a very good one too,
of determining how much sound is conveyed to the auditory nerve
through the head-bones. Its musical nature, as well as its powerful
vibrations, render it far superior to the watch as a test for the conducting
power of the head-bones, unless the ticking of the watch is made to occur
with great force. Dut should the ticking of the watch equal in intensity
the vibrations of the fork, the former could never approach the latter in
musicalness. The tuning-fork is a means of comparison between the bone
conduction and aerial conduction of sound in the same person; for if the
vibrating tuning-fork be held on the vertex until its note is no longer
perceived by the person examined, and then held before his ear, if he now
perceive that the fork is still vibrating, it is fair to conclude that the
Sound-conducting apparatus is normal ; but if the fork, when no longer
heard through the air before the ear, be heard as soon as it touches the
vertex, the conclusion is inevitable that there is some impediment in the
sound-conducting part of the ear. This is all the more convincing if it
be borne in mind that there is being used the same note, and one, too,
growing a little weaker all the time, because, if vibrations of a tuning-
fork cease to be heard in front of an ear by aerial conduction, but are
able to communicate themselves while growing constantly weaker, through
the bones of the head, the inference of great derangement in the middle
or external ear (aerial sound-conducting parts) cannot be avoided.
Bone conduction, however, is of little importance to the patient, and
of great uncertainty as a guide to the aurist, because he is forced to rely
| Berlin klin. Wochenschr., No. 10, 1871.
966 BURNETT,
almost entirely on the patient’s statements as to what is perceived by
the latter when the test is applied. Therefore, the tuning-fork as a
means of testing bone conduction can never become of pre-eminent value.
At best, it must be used in conjunction with other tests, and its results
carefully weighed. Then, too, the musical education of the patient
most probably influences his answers respecting the sensations produced
by the tuning-fork vibrating on the vertex.
SPEECH.
By hearing speech, the intellectual development of the human being
is accomplished. There is no sound so familiar, nor so fondly longed for
at times, as the sound of the mother-tongue. A person with good hear-
ing can never realize the feelings of a deaf person so vividly as when
travelling in a strange land, surrounded by those speaking with each
other happily, gayly, and with varying expressions, but in a language
unknown to the lonely traveller. One falls into the position of an in-
valid, is treated with a kind of pity, and, alas, finds himself growing a
little suspicious and morose. -
The deaf person feels the loss of hearing the voice of others more than
the loss of the power to hear anything else. To recover the ability to
hear the familiar tones of the voices of his friends, he would gladly give
up all other hearing. So great is this struggle to hear what others say,
that the deaf gradually learn to understand the thoughts and words of
others by watching the lips of the speakers. The power to hear other
sounds well, may begin to fail without the knowledge of the patient, but
all his endeavors are concentrated, almost unconsciously, to catch the
varying sounds of speech. I have known young physicians to be almost
deaf to the ticking of a watch without knowing their loss until it was
accidentally discovered, for their ability to hear speech was retained.
All aurists are aware that patients are constantly surprised to learn how
deaf they are, as soon as their faces are averted from the speaker. Thus
the failure of hearing, in this respect, is detected very often, for the first
time, in the summer, when all are used to sitting either on the porch or
in the parlor, in the twilight and dark. As the light fades, and the faces
of those around are no longer plainly visible, the hitherto apparently
hearing person becomes aware that he is deaf. This is often assigned to
the night air, but, in reality, it is due to the loss of vision in the approach-
ing darkness. The surgeon will often gain great aid by a knowledge of
these facts, and also by observing the manner in which a partially deaf
person will look at the one he is addressing, and from whom he expects
a reply. Those of delicate sensibility soonest become aware of their
inability to hear the voice, for speech is not only a delicate sound, but is
highly valued by the cultivated. Those of less sensibility are not aware
of their loss of hearing speech, for they still hear loud sounds and even
music, as the latter is more powerful than the notes of speech. Hence,
it is surprising to find how large an amount of unconscious deafness exists
in the uneducated; they do not feel their loss as the cultivated do.
Very often the deaf are, in a measure, unaware of their aural condi-
tion, because they feel, instead of hear, so many sounds. Roosa has
found that the deaf and dumb may hear, i. e., feel, at the diaphragm, a
tuning-fork vibrating on the vertex. A man who had been struck on
the head, and in consequence had become totally deaf, informed me that
B E S T M E A N S OF TESTING T H E H E A R IN G. . 967
}
}
he could hear a tuning-fork vibrating on his vertex. This I doubted:
I believe that he merely felt the vibrations. Whether he heard them or
not, he could not hear the loudest shout into his external ear. The loss
of hearing speech was his great misfortune; this he desired to recover;
and in his case speech became the great test. The tuning-fork was value-
less because unreliable. g
The human voice was considered an admirable quantitative test, long
before the researches of Donders, Helmholtz," and Wolf, showed it to be
equally valuable as a qualitative test. Why it was that a patient could
hear some words much better than others, though spoken at the same
distance, was not explained and applied until O. Wolf published his
investigations into the acoustic characters of the various elements of
speech.
The human ear perceives as musical sounds, tones varying from 16
vibrations to 20,000 vibrations in a second. Preyer (Jena, 1876) has
lately placed these limits from 15 vibrations to 40,960 in a second.
Speech embraces only eight octaves, according to Wolf, viz., “R” with 16
vibrations, and “S” with 4324 vibrations in a second. In music, the most
agreeable notes, with the most distinct pitch, lie between 40 and 4000
vibrations per second, i. e., within the limits of seven octaves; those
which are admissible in the widest sense as musical, lie between 20 vibra-
tions and 38,000 vibrations per second, i.e., within eleven octaves.” In
this respect the ear far outstrips the eye, for the limit of the perceptive
power of the eye for vibrations of light rarely exceeds one octave.
Blake's experiments” with König’s rods, have shown that the human
ear, in some instances, hears distinctly, as musical, 35,000 vibrations in a
second. The ability to hear these very high notes is greater in youth (12
years) than in older persons. The former may distinctly hear a note of
40,960 vibrations per second, at a distance of 34 feet; from 18 to 20 years
of age, this note is heard only at 13–16 feet; and at the extreme limit
of 34 feet, only the tone of 36,864 vibrations per second is heard. This
ability to hear high notes greatly diminishes as age advances. Dr.
IBlake says: “In the majority of the cases of persons over fifty years of
age, and possessing apparently normal hearing, who were subjected to
these tests, an examination of the membrana tympani showed a varying
degree of opacity of the membrane, corresponding to a thickening of the
mucous coat.” All such sounds were heard much better when the mem-
brana tympani was perforated, especially near the posterior superior
periphery. In one case, where a small band of cicatricial tissue extended
from the posterior border of the perforation to the long process of the
incus, a tone of 65,536 vibrations per second was distinctly heard.
Wolf's Determinations respecting Hearing, Voice, Vowels, Consonants, etc.
—According to Wolf," it is impossible to establish the distance at which
the separate vowels can be heard, because the sound-sources from the
speaker and the hearing of the listener vary in different individuals, and
also because the sound-waves are so dependent upon the condition of the
atmosphere in which we are placed. At night we hear much further
than by day, because the ear is less distracted by a multitude of Sounds,
and because there is a much less number of sound-waves crossing each
other than in daytime. (1) Vowels are endowed with the greatest
strength of tone, i.e., they are heard and understood at a distance at
1 Sprache und Ohr, 1871. * Helmholtz, Tonempfindungen, S. 31.
3 Trans. Amer. Otolog. Society, 1872–1873. * Op. cit., p. 58.
968 BURNETT,
which all the consonants are inaudible; and (2) The consonants differ
very greatly in the strength of tone.
(1) Vowels.-Vowel-sounds are composed of a number of beautifully
harmonic Overtones, which accompany the fundamental note, and
strengthen the fundamental tone of the mouth. A good musician can
hear a perfect accord when a vowel-sound, especially “A,” is uttered with
clearness, which is said (Wolf and Appunn) to be specially observable
when the sound is made in the open air, where the sound-waves can
escape with greater precision than in a room. “A” (German, broad) has
the most overtones, five, and is heard the furthest, i.e., at 360 paces
(Wolf). The vowel “U” (“Oo,” English) has the fewest overtones, three,
and is heard with most difficulty of all vowels. It can be distinctly
heard only at 280 paces. The vowel “O,” containing many beautiful
harmonic overtones, is heard nearly as far as “A,” broad. German “E”
(English “A”) is heard at 330 paces; German “I” (English “E”) is heard
at 300 paces; English “I” is somewhat more powerful than English “A,”
and weaker than broad “A” or “O”; “Oi’’ comes close behind “E”; the
weakest of all diphthongs is “Ou,” as in out; it is a little stronger
than “OO.”
(2) Consonants.-The investigations of Wolf have led him to classify
consonants according to their acoustic and physiological laws, under two
heads, viz., those which are self.sounding (Selbstiónende), and those which
are sound-borrowing (tomborgende). The former class embraces those
sounds which are formed by the apparatus of the oral cavity, with a
sound which is independently audible, and which can be defined in its
pitch, intensity, and timbre. The second class comprises those consonant
sounds which attach themselves to a vowel-sound, and are obliged to
borrow from it in order to be distinguished by the ear; musically they
are to be termed the appogiatura, and note of complement to a vowel
sound ; such consonants are II, L, M, N, W.'
“II” is the weakest of all consonants when pronounced without a
vowel. It is lost at the distance of a few paces. Next in strength stands
“B”; “Ba” is heard further than “Ha.” “B” alone is heard at a distance
of 18 paces. The deeper a note is, the less effect it has upon the ear. “R,”
with only 16 vibrations in a second, is not distinguishable further off than
41 paces. “R” and “T” stand next; they are both heard about equally
well at 63 paces. “T” resembles pretty closely a simple note, but it has
a pitch which appeals more readily to the ear, and is therefore much bet-
ter heard than “B,” which otherwise is very similar to it. “K” is formed
with relatively favorable circumstances—that is, by means of a powerful
movement of the root of the tongue. The soft “F” is heard somewhat
further than the foregoing letters, i. e., at 67 paces. “S” is perceived at
a relatively greater distance than the foregoing on account of the pitch
of its fundamental note, which appeals to the ear by its sharp character,
especially when sharply pronounced ; and finally on account of its prop-
erties as a sibilant consonant. “To this latter property it owes its ability
to express disapprobation in public assemblies, to cry down opposing sen-
timents, and to enforce silence. Both its moral use and physical character
are inharmonic.” “S” can be heard very distinctly at 170 paces. “Sch”
is heard furthest of all consonants, because it possesses a full and rich
clang-tint, and is composed of three harmonic notes, which predominate,
while the inharmonic overtones or noises recede. The composite conso-
| See Wolf, Archives of Ophthalmology and Otology, vol. iv. p. 78.
B E S T M E A N S OF TEST IN G T H E H E A R IN G . 969
nant “Sch” (nearly – “sh”) can be heard at 200 paces. “M” and
“N,” unaccompanied by vowels, are only meaningless blowing of air
through the nostrils. “Mama” and “Nana” are understood at 180
paces, but at greater distances the sounds of “M” and “Nº” are lost,
while the vowel “A” is still heard." In calm weather it is extremely
interesting to ascend a high hill and listen to the voices of men below in
the valley or town. Words are no longer distinguishable, or, at best,
only those which are composed of “M” and “N” and vowels, as “Mama,”
“Nein,” etc. Vowels in all the other words are distinctly heard, follow-
ing each other in a curious interchange and with remarkable cadences,
because we are no longer able to join them together into words and sen-
tences.”
It is thus shown that in the component sounds of ordinary speech, a
wide range of tests, with different intensities of sound, is offered to the
aurist. Such a numerous set of sounds is needed in order to discover
which are heard best by an affected ear. One sound is not sufficient,
because an ear may be unable to hear some sounds while it hears others
comparatively well. Hence if only one or two sounds should be em-
ployed, as in the watch, just those notes, it might be, the ear could not
hear as well as others. Therefore, speech becomes most valuable, because
it is very varied in sound-nature, and also because it is ever at the com-
mand of the aurist, and the use of it is fully comprehended by the
patient. If one sound would do as a test, a sound-unit could be estab-
lished ; but it is seen upon short experience that a solitary and fixed
sound is not heard in the same way by all similarly affected ears, and
that, therefore, one sound cannot be assumed as a fair test. This throws
the surgeon back on speech, as containing a variety of sounds, by means
of which an average condition of the ear can be ascertained.
Very often whispers and words spoken in low tones are heard much
better than loudly spoken words, by an affected ear. This is due to the
damping of the vowels, whereby the consonants, which are less sonorous,
have a chance to be heard. And thus it is that a person hard of hear-
ing often asks not to be addressed loudly. Words may be heard, even
when the letters composing them, spoken separately, are not heard.
This is especially so for the letters B, P, T, K, and R (Wolf). The
reason of this is very apparent, for when letters are pronounced alone,
they are words. Thus “B” is composed of sounds of “b’’ and “e,” “P”
of pea, or p ee, “R” of k a y, while “R” is equivalent to sounds of
a re. In the latter instance, “R,” when pronounced, is altogether of a
different phonetic value from that which it has when standing at the
beginning of a word, as in “rat,” or at the end of a word, as in “tar.”
Whispering has an advantage over loud words in testing, since the for-
mer cannot be as easily conveyed as the latter through the bones of the
head, to the auditory nerve.
However, it must be borne in mind, that in Dr. Dennert’s observations”
made in a case in which the cochlea had been lost by necrosis, the normal
ear, though artificially stopped up as thoroughly as possible, could yet
hear whispers at a distance of six feet. Patients often state that they
hear music either of a piano or of an orchestra, but that they cannot hear
speech. This is due to the delicacy of the sounds of the human voice in
speech. The most delicate sounds of a violin are far more powerful than
| Wolf, loc. cit., p. 63. * Helmholtz, Tonempf., S. 118.
* Archiv f. Ohrenheilkunde, Bd. x.
970 BURNETT,
speech, and hence the ability of those hard of hearing to perceive instru-
mental music much better than the component sounds of speech, as has
been shown by Wolf.
Variable Hearing.—In some cases of chronic aural catarrh, the state-
ment that the hearing varies with the weather, health, etc., is made by
the patient. This is not always demonstrable, nor, if so, are the variations
in hearing very striking. But in some other forms of aural disease, va-
riable hearing occurs in a marked degree, and may lead to a knowledge
of the nature of the disease. There are not many cases of the kind I
allude to, recorded in aural literature. I have observed two cases; one in
which the hearing varied greatly with the position of the patient, being
least when he was in the upright position, and greatest when he lay
down. This variability was due to movements of fluid in the tympa-
num." The other instance of variable hearing occurred in a well-marked
case of acute aural vertigo, presenting features which, like those in a case
related by Hinton,” naturally led to the conclusion that the disease as well
as the variable hearing was due to derangement in the muscles of the
tympanum; for the attacks of vertigo were ushered in by the onset of tin-
nitus and hardness of hearing, which gradually increased in severity, cul-
minating in half an hour in nausea and vomiting, which were gradually
followed by relief of all the symptoms. During these attacks of buzzing
in the ear, the hearing was diminished, as could be shown by the watch
and voice. But as the function was restored as the attack passed off,
the idea naturally arises that the symptoms might have been due to
spasm in muscular structures in the middle ear. It also leads to the
conclusion that the term Ménière's disease, by which such attacks have
generally been called heretofore, has been applied too widely, if by it
disease only of the labyrinth or parts of it, has been meant. Aural
vertigo should be the general term ; Ménière's disease may be limited
to the labyrinth. It is highly probable that hearing, varying quickly
within short periods of time, could in no case be referred to alterations
in the labyrinth, for the latter, as far as they have been demonstrated to
exist, have been permanent changes, and not recurrent. Recurrence,
however, is a well-known feature in muscular spasms.
Hearing Lower Tomes better than Higher Ones.—In many instances
which have come under my notice, I have been informed by the patients
that they could hear some kinds of sounds very much better than others.
Thus, in two cases the patients voluntarily said that they heard thunder
(bass note) better than the chirping of crickets, or high tones on the
piano. And, on being tested with watches, one patient said that he
heard that watch better which gave the tick of a deeper note. Experi-
mentally, I have shown” that a deep note has the advantage over the
high ones in cases of increased labyrinthine pressure. In an increase of
the pressure within the labyrinth, the stapes becomes more fixed, and it
is at this point that the vibrations begin to grow less marked as the pres-
sure in the labyrinth increases. In such a case it is manifest that if
vibrations from without be normally conveyed to the stapes, they must
there meet with hindrance as they endeavor to reach the labyrinth.
Only the most powerful waves are able to overcome this obstacle, and to
force the stapes to undergo a to-and-fro movement with the rest of the
* See Philadelphia Medical Times, Oct. 17, 1874.
* Questions of Aural Surgery, pp. 262-263.
* Archives of Ophthalmology and Otology, vol. ii.
BEST ME ANS OF TESTING T H E H E A R IN G. 971
chain of ossicles. I have, therefore, thought that it might be asked:
Could not the inability to hear high notes, while low ones are heard
almost normally, be construed into a sign that the stapes is impeded,
either by undue pressure in the labyrinth, or by catarrhal fixation in the
oval window? That the cause of such a peculiar alteration in hearing
probably does not lie in an undue tension of the membrana tympani,
appears from the well-known physical fact that the tense membrane is
more sensitive or susceptible to vibrations of high notes than to those of
low ones.
Do the position and extent of perforations in the membrana tympani
cause variations in hearing-power for certain sounds 2 This question may
be answered in the affirmative, according to the experiments of Wolf.
He divides defects of the membrana tympani into five groups, viz., (1)
small defects in the lower segment of the membrana tympani; (2) defects
as large as a quadrant in the lower part of the membrana tympani; (3)
defects as large as a quadrant or a quadrant and a half; (4) defects as
large as three-quarters of the membrana tympani; and (5) complete defect
of the membrana tympani and loss of the malleus and incus. Vowels are
heard invariably better than consonants in all of these cases. I have
observed that defects of the membrana flaccida are always attended with
great hardness of hearing. This is probably due to an implication of the
joints of the ossicles.
In testing hearing, we must consider the way in which the sound is
conveyed to the ear, whether through the apparatus of the middle ear,
or by the bones of the head. The latter, without doubt, has more influ-
ence than has generally been supposed." It is really astonishing to dis-
cover the amount that one may hear with a normal ear stopped up. This
shows how much sound may be conveyed to the auditory nerve through
Osseous tissue. A want of proper appreciation of this fact has led to
great errors in testing hearing, in cases of one-sided deafness. Merely
closing the good ear, and leaving the poorer one open, is not sufficient.
The hearing must be tested, first, in the better ear when stopped up and
turned towards the examiner, the worse ear being open. When the
amount of hearing in the better one, made artificially deaf for sounds
through the air, has been determined, then we may see what effect
opening and closing the deafer ear has on the hearing of the stopped-up,
better one. The result will be the amount of hearing for the worse ear.
A plan similar to the foregoing, and one which I have used for a long
time, in cases of one-sided deafness, is the following: Place the patient
so that the affected ear is towards the surgeon. Then stop, with the
finger, the better ear, the ear not to be tested. This may be done by
the patient or by an assistant; preferably by the latter where great
certainty is desired. Then, with the affected ear open and turned to-
wards the surgeon, let tests of its hearing-power be made. When the
limit of hearing on that side is obtained, let the ear be closed as the
other is, and then, with the ear still turned towards the examiner, let
tests be made again. If the closure of the deaf ear, the one turned
towards the surgeon, cause no difference in the hearing-distance already
obtained, it is fair to conclude that whatever amount of hearing exists is
not due to a passage of sound through the external auditory canal of the
ear turned towards the surgeon. In such a case the conclusion must be
that either sound goes more easily through the bones of the head on the
! See important papers by Dennert and Lucas, Archiv f. Ohrenheilk., Bd. x.
972 BURNETT,
affected side than through the meatus to the auditory nerve, which
would be absurd, or that sound has reached the brain by the other ear,
and that the affected ear is totally deaf. If, however, stopping the
ear turned towards the examiner—the ear supposed to be the deafer—
make that ear still deafer, let the examiner approach the patient and
repeat the tests till they are heard once more. The second hearing of
them is evidently due to conduction of sound through all obstacles repre-
sented by cranial bones and the finger in the meatus, and must not be
regarded as aerial conduction. The extent of the power of the ear to
hear by aerial conduction will be expressed in the difference between the
limit of the first test and the limit of the second. Thus a patient may
hear speech as far off as eight feet, with the good ear stopped and turned
away, and the affected ear open. When the latter is stopped, speech is
no longer heard at eight feet, but it may be perceived by the patient at
a distance of three feet, both ears still being kept firmly stopped. In
such a case, not the former distance, but the difference between it and
the latter distance, viz., five feet, must be considered the amount of aerial
conduction by the external auditory canal, for that represents the amount
of loss of hearing caused by stopping the meatus.
Wolf's Word-Tests.-In testing the power of an ear to hear the human
voice, it seems to me that we gain some very practical hints from Wolf’s
system of word-tests. Wolf, in his very valuable work, has divided
defective drum-heads into five groups (vide supra, p. 971), and in each
of these he has applied a certain list of chosen words as tests. At the end
of his observation of the hearing in each group, he has struck an average
of the words heard, and has thus, as it seems to me, made a practical
suggestion. Printed slips with words containing the different vowels
and consonants at the beginning, middle, and end, might easily be arranged
in all languages, and the aurist provided with thern could always dis-
cover the ability of his patient to hear given vocal sounds. The average
of the patient’s misses and successes would give his hearing power.
A Conventional Sound-Umit.—A conventional sound-unit might be con-
structed so as to be of uniform and invariable intensity, but “intensity
of sound-sensation and intensity of sound-producing vibration are two
entirely different things. The first is a physiological phenomenon, and
varies with individuals like all such phenomena, and the second is a
dynamical phenomenon. To assert that the first is proportional to the
second, as all authors do, is to use à priori physics in which I have no
faith.” Hence if such a sound-unit were made, it would possess only a
limited value. It would also be open to the same objections as the
watch, or the solitary note of any other test. One sound can no more
become the test of hearing than one object can be the test of vision.
Even speech itself, which affords the most convenient as well as the most
ample test, will not fulfill all its capabilities unless it be studiously varied
so as to bring into play all its elements, with their varied phonetic cha-
racters and intensities.
ICessel has laid down four conditions which any form of acoumeter
should fulfill in order to Satisfy the wants of the aurist of the present
day: (1) The acoumeter must embrace a large range of tones in the most
carefully graduated series; (2) The strength of the tones must be always
the same; (3) The acoumeter must be able to test the hearing in one ear
at a time, both respecting air and bone conduction ; (4) The intensity of
! Prof. A. M. Mayer; Correspondence with the writer.
B E ST ME A. NS OF TESTING T H E H E A R IN G. . 973
the notes must correspond as nearly as possible with that of the voice.
Kessel has had an apparatus made which corresponds in the main with
the above conditions. The tones are produced by means of metal teeth,
which are set in vibration by keys placed in a brass cylinder, like those
of an ordinary music-box. The teeth give the notes of the scale of “C
major,” throughout seven octaves, and, if desired, can produce even eight
octaves. Discordant sounds may be produced by striking the notes of
several octaves at the same time. The cylinder is turned by a handle, to
which is fastened a pointer which indicates on a dial the pitch of the note
given out. The air conduction is effected by means of a rubber tube, con-
nected with the cavity of the apparatus. The latter is covered with poor
conductors of sounds, and packed in a case, so that the sounds produced
in the apparatus are inaudible even at a short distance from it, except
through the gum tube. Bone conduction is effected by bringing the
mastoid process into connection with a metal prong or bar, passing from
the back of the comb-like piece containing the teeth heretofore alluded to.
Since by this means the air in the external auditory canal is alternately
rarefied and condensed, and thereby the tension of the membrana tympani
and the pressure in the labyrinth altered, we have a means of finding
out under which of these conditions the hearing is best. The apparatus
also shows that when both ears are unequally excited by the same sound,
the latter is referred to the more stimulated ear, independently of direc-
tion. Thus if the right ear be brought near enough to the case to hear
the sounds through the packing, and if then the rubber tube be brought
around to the left ear, the observer will think the sound comes only from
the left.
I have never had any experience with the apparatus devised by Dr.
Ressel, but it seems fair to assume, from what is known of the character
of the voice in speaking as a test, that the instrument alluded to provides
the aurist with no better means of testing than he always possesses in
the use of speech.
There are needed, in any form of test, comprehensibleness, scope, deli-
cacy, gradations without great intervals, convenience of application,
inexpensiveness, and invariability. The watch and tuning-fork have
been described, and conclusions drawn respecting them. The further
the investigations have been carried, the more conclusive have appeared
the reasons for assuming that the voice will render most aid in determi-
ning the state of the hearing. Nothing is more convincing of this than
the fact that all artificial means, yet proposed, have been modelled more
or less after the voice, or some of the component sounds of speech.
Invariability would always be an argument in favor of any form of
test, and it has been urged in behalf of the watch, the tuning-fork, and
other forms of artificial test-means. This certainly is desirable for com-
parisons during treatment, no matter what form of test be used. But
every aurist can learn to modulate his voice so as to be able to command
always the same degree of loudness or lowness in making tests with it.
Even if artificial means were as superior to the voice in invariability as
some have thought, the far greater range of the latter as a musical appa-
ratus especially adapted to the ear, would place it far ahead in the list
of tests for hearing.
974.
THE FUNCTION AND UTILITY OF THE ARTIFICIAL
DRUM-MEMBERANE.
BY
H. N. SPENCER, M.D.,
OF ST. LOUIS.
I SHALL present a resumé of this subject, as far as it has been possible,
in a limited time and with the literature at my command, to obtain it,
and in addition I am happy in being able to submit so much of the pre-
sent status of the subject among aurists at home and abroad, as will be
my privilege.
With the desire to present something practical on a subject of such
practical importance as this, and which would carry authority with it, I
early addressed letters to as many of those who are engaged in this spe-
cial field as my time allowed, submitting questions which appeared to
me to cover every point, so that if possible I might be able from these
advanced sources to obtain the material which would admit of a crystal-
lization into truth.
It would be desirable to know accurately the condition of the ear
which indicates the employment of an artificial drum-membrane, the
contra-indications, and the best form of membrane under varying cir-
cumstances. It should not be a matter of taste, like the preference of one
prospect or one piece of music to another. As scientists, we should, as
far as possible, have fixed laws to govern us; yet, dealing with forces
which themselves vary, we recognize that this exactness is not always
to be attained.
It appears that Marcus Banzer, in 1640, first suggested the use of the
artificial membrane, not with the view of improving the hearing, but as
a protection to the cavity of the tympanum in cases where it was ex-
posed from loss of the normal membrane by ulceration. The construc-
tion of his apparatus was exceedingly rude, consisting of a tube cut out
of the hoof of the elk, with a bit of pig's bladder to represent the mem-
brane covering its proximal or inserted end. This was to be introduced
to half the depth of the meatus. There are allusions to this apparatus,
or to similar contrivances for the same purpose, in the writings of Le-
schevin, 1763, Autenreith, 1815, and Lineke, 1840. The appliance of
Autenreith, a description of which he published in the Tübinger Blät-
term für Naturwissenschaft und Arzneikunde, consisted of a short tube
of lead, very thin and elliptical-shaped, the inner end of which was
covered by a membrane made of the air-bladder of a fish, which was put
on wet and varnished after it became dry. Tincke describes his apparatus
in his treatise on diseases of the ear; it is substantially the same as that
of Autenreith. In 1842, Yearsley accidentally discovered an altogether
new use of the artificial drum-membrane, viz., as a means of improving
the hearing. I quote from a paper published in the “The Lancet” (July,
1848), entitled “On Deafness.”
1 B. i. H. 2, S. 129. * Handbuch der Ohrenheilkunde, 1845, B. ii. S. 446.
* Wide Allen, “On Aural Catarrh and Curable Deafness,” 2d edition, 1874, p. 366.
FUNCTION AND UTILITY OF ARTIFICIAL D RUM-MEMB RAN E. 975
Up to the present time, no successful mode of treating perforations of the
membrane of the drum, or the relief of the accompanying deafness, has been
discovered by the profession at large. The only means resorted to has been
the removal of pus or mucus from the tympanal cavity by syringing, or ren-
dering it free by passing air through the perforation, by way of the Eustachian
tube. Either of these proceedings will produce a temporary improvement of
the hearing in cases where the tympanum suffers from obstruction, but in many
others, when such a state does not obtain, they are of little if of any service.
I have, however, the extreme gratification of promulgating a mode of relief
for deafness attended by loss of the membrana tympani, which will cause great
surprise among the readers of The Lancet, not less from its extreme simplicity
than from the extraordinary success which generally attends its employment.
In 1841, a gentleman came from New York to consult me under the following
circumstances: He had been deaf from an early age, and, on examination, I
found great disorganization of the drum of each ear. On my remarking this
to him, he replied, “How is it, then, that by the most simple means I can pro-
duce in the left ear a degree of hearing quite sufficient for all ordinary pur-
poses 7 in fact, so satisfied am I with the improved hearing which I can Emyself
produce, that I only desire your assistance on behalf of the other ear.” Struck
by this remark, I again made a careful examination of each ear, and, observing
their respective conditions, I begged him to show me what he did to that ear
which I should have unhesitatingly pronounced beyond the reach of remedial
art. I was at once initiated into the mystery, which consisted in the insertion
of a spill of paper, previously moistened at its extremity with saliva, which
he introduced to the bottom of the passage; the effect of which, he said, was
“to open the ear to a great increase of hearing.” This improvement would
sometimes continue an hour, a day, or even a week, without requiring a repe-
tition of the manipulation.
Dr. Yearsley seized upon the idea which this case presented, and gave
to the profession an artificial drum-membrane which is known as “Years-
ley’s cotton-wool,” consisting of a small pellet of moistened cotton-wool
which is inserted to the bottom of the external auditory canal. Without
detracting from the rude attempts which had preceded this, and without
claiming for Yearsley that he had made a discovery, strictly so called, of
anything previously altogether unknown, yet it is due to him and to
ourselves, since discovery is a relative word, to credit him with being
practically a discoverer, for bringing to our knowledge and for giving
to the world this new use of a contrivance of which we otherwise
might have remained in ignorance until now. In 1853, eleven years
later, Toynbee gave to the profession another form of artificial mem-
brane, which he described in his “Treatise on Diseases of the Ear,” and
which was composed of a vulcanized India-rubber disk (the thinnest
layer of it that was procurable), through which was passed a silver wire,
fastened in the centre by means of two very fine plates of silver, having
a diameter of about three-quarters of a line. “The silver wire is of
sufficient length to admit of the membrane being introduced or with-
drawn by the patient, but is not perceivable externally except by special
observation.” I shall have to notice hereafter other forms of artificial
drum-membrane, which, while deserving a special mention, are not
properly referred to in this connection. -
It will be interesting now to consider the conditions of the ear which
admit of the use of the artificial membrane, and this will be profitably
studied by passing in review the theories and practical thoughts, on this
subject, of explorers in otology, from the period of Yearsley down to the
present time, augmented by views which are entertained by men of to-
976 SPEN C E R ,
day. To preface this step: It is not deemed necessary to refer to the
function of hearing, further than to state in general terms that the con-
ducting media involved are the membrana tympani, the machinery of
the cavity, and the membranes of the oval and round windows of the
inner wall of the tympanum. Like the media through which vision is
effected, there is so nice an adjustment of these forces that to have one
affected injuriously, influences the efficiency of each of the others, and of
the whole machinery. This need not to be demonstrated. It will be
understood, then, that, in considering what are the conditions of the ear
admitting of the use of the artificial membrane, we have not only to take
into consideration the membrana tympani and its functions, but what
are the functions of the tympanic cavity, etc., which are influenced by
every deviation from the normal condition of the membrane, and vice
versä. The artificial membrane is designed to supply some force that is
wanting, or that operates inefficiently, and this inoperative condition of
the conducting apparatus which can be thus measurably remedied, may
be due to a variety of causes, such as solutions of continuity of the
membrana tympani; changes in the lining membrane of the tympanum,
associated with perforation of the membrane ; loss of power in the ten-
sion-muscles of the cavity, with partial or entire destruction of the mem-
brane; loss of two of the Ossicles, the membrana tympani being gone,
the stapes in situ ; flaccidity of the membrane ; solution of continuity in
the articulation of the Ossicles. It may be considered, then, that it is
the design to show in what follows the rationale of the functional gain
by the artificial membrana tympani in these conditions, which I have
enumerated in the order of their frequency of occurrence.
Toynbee reasoned that the artificial membrane “confined the vibra-
tions to the tympanic cavity, and concentrated them upon the labyrinth.”
This conclusion he founded upon experiments which proved to him that
the guttural orifice of the Eustachian tube was closed “except during the
momentary action of certain muscles,” which made the tympanum a
shut cavity for all purposes relating to the passage of Sonorous undula-
tions, and next upon the experiment with the tuning-fork, which showed
that the sonorous vibrations communicated to the bones of the head
appeared much louder when the meatus externus was closed than when the
orifice was open. This led to the conclusion that the Sonorous vibrations
imparted to the cavity of the tympanum, could only make their due im-
pression on the membranes of the labyrinth when strictly confined to
the tympanic cavity, and Toynbee's artificial membrane was designed to
supply this, which he considered was the office of the normal membrane.
And in directing its application, he says: “As will be imagined, great
care must be taken to cut the membrane so that it shall fit the inner
extremity of the meatus with exactness; since if too large it would cause
discomfort, and if too small it would not fulfil its purpose of rendering
the tympanum an air tight cavity. It is not easy, in all cases, to fit the
artificial membrane so as not to allow of any communication between
the air in the tympanum and that in the external meatus; this however
is the object which should always be aimed it.” This view of Toynbee's
did not obtain for any length of time, as practical experience with the
use of the artificial membrane soon showed that, to effect the improve-
ment in the hearing, it did not require that the perforation should be
closed ; and this should have been apparent earlier when we consider that
Yearsley’s artificial membrane of cotton-wool preceded Toynbee's rubber
disk, and the increase of hearing effected by it could not be accounted
FUNCTION AND UTILITY OF A RTIFICIAL D R U M - ME M B R AN E. 977
for by Toynbee's mode of reasoning. As far as I know, Erhard and Von
Tröltsch were the first who suggested that the effect of this mechanical
aid to hearing did not depend upon its rendering the tympanum a closed
cavity, nor upon its affording a surface for the reception of sound, nor
upon its furnishing a conducting medium, but that it acted by virtue of
its pressure upon the stapes. This was first concluded when it was dis-
covered that in this position the greatest amount of improvement was
effected, and no philosophical explanation was essayed. It is but doing
Toynbee justice to add that his views subsequently underwent consider-
able modification, as will appear from a statement of the conditions of
the ear in which the artificial membrane will be found most efficient,
given in the supplement to the edition of his work, edited by Mr.
James Hinton, and which he was partly led to adopt, it is stated, by
intercourse with Dr. Julius Erhard, “who, without any perforation,
found his hearing much improved by the use of cotton-wool, and pub-
lished his experience in a paper entitled ‘Deafness Curable by Pressure.’”
These conditions are as follows:—
(1) Disconnection of the incus and stapes, the membrana tympani being
entire, but the tensor tympani ligament, or the mucous membrane of the tym-
panum, being relaxed. (2) Partial or complete absence of the long process of
the incus, the membrana tympani being entire. (3) Disconnection of the stapes
and incus, the membrana tympani being perforated, and the tensor ligament
or the mucous membrane of the tympanum being relaxed. (4) Partial or com-
plete loss of the long process of the incus, the membrana tympani being per-
forated, and the ligaments of the stapes being relaxed.
Erhard” says:—The improvement in the hearing is appreciated at the
moment that the surface of the artificial membrane which is being introduced
comes in contact with the surface of that which was formerly the conducting
apparatus, restoring the continuity which has been destroyed.
Von Tröltsch” says:—It is not yet determined definitely in which way the
artificial membrane produces its often astonishing effect. Various explanations
of its mode of operation are in favor. According to Lucae, it is the increased
pressure which is exercised upon the labyrinth-fluid, which is of outweighing
importance to everything else. Politzer refers the improvement in the hearing
to the removal of the irregular nodes (Schwingwngsknoten) which are produced
in every perforated membrane—and also to the rubber disk acting like the
true vibratory membrane, and serving to convey a considerable number of
vibrations to the ossicula. In the least number of cases is the increased hear-
ing to be referred to the closure of the cavity, which was Toynbee's theory.
In many instances we observe marked improvement where the rubber disk
does not effect closure of the opening in the membrana tympani. . . . . That
the closure of the opening is not essential, and not the true explanation in
solution of this enigmatical question, I was able to see in a case that presented
itself to me where I could close a very small opening in the membrane with
collodion, or a thick solution of gum, without producing the least effect upon
the hearing; whereas a very marked and immediate improvement resulted
from the introduction of the rubber disk, or of any other foreign body, so that
it would press upon the membrane. This pressure upon the membrane, or
upon the manubrium mallei, seems in most cases to be essential to effect the
desired result.
Politzer, in a very interesting brochure, entitled “Ueber das kiinstliche
Trommelfell und seine neueren Modifikationen,” which first appeared as an
1 1868, p. 452. * Krankheiten des Ohres, 1875, S. 230.
* Lehrbuch der Ohrenheilkunde. Fünfte Auflage, 1873, S. 400.
62
978 - SPEN CER,
article in the Wiener Medizimal-Halle, 1864, after a statement of the views
of Toynbee, says:—Although the phenomena upon which he founds his expla-
nation present themselves to every practical physician as correct observa-
tions, on the other hand, it must be allowed that they cannot altogether clear
up the question of mode of action of the artificial membrane. Opposing views
to those of Toynbee have been urged by other authors (V. Tröltsch, Erhard),
and are in more general favor at the present time. It may be stated posi-
tively that the view entertained by the latter author, i. e., that the artificial
membrane operates principally through pressure upon the remnant of the
membrane and the chain of bones, is the true explanation in the majority of
cases; this is more evident when we regard the pathological changes which
occur in the tympanum as a result of the catarrhal process, and which have
been more fully appreciated since Toynbee made his observations upon this
subject. If a post-mortem examination be made of a person who has suffered
from a suppurative, middle-ear catarrh, with perforation of the membrane,
there will be found in many cases that the ossicles are fixed through adhe-
sions, or are enveloped in adventitious tissue-formation. In other cases the
ossicles have become so loosened in their articulations from the inflammatory
process, that the slightest touch with an instrument causes them to fall apart.
It is evident that in such a looseness of the articulations of the chain of bones,
the sound-conduction would be interfered with in greater or less degree; espe-
cially would this be the case if there were complete separation, for instance,
in the incudo-stapedial articulation. In a case of this kind, now, the artificial
membrane would operate to improve the hearing through pressure, by restor-
ing continuity in the chain of bones and aiding sound-conduction.
The above-cited observations of Toynbee, upon which he rests his theory of
the mode of action of the artificial membrane, permit of another solution to
this question. If the membrana tympani is perforated, the deafness which
follows depends, first, upon the hole in the membrane by which the surface
for the reception of sound-waves is diminished, and consequently a less num-
ber of sound-waves are conveyed to the chain of bones: particularly is this
the case if the destruction of the membrane is in the neighborhood of the
manubrium mallei; second, upon change in the conditions surrounding the
ossicles, as by accumulation of secretion, or by loosening or fixation of their
articulations. Upon the latter changes depends the degree of deafness, as
experience proves that in large perforations, where no considerable change has
occurred in the condition of the chain of bones, there is, of course, a diminu-
tion in the hearing, but yet the hearing will still often be sufficient for ordinary
purposes, and the deafness never is in degree proportional to the extent of the
defect in the membrane. This phenomenon, which is so striking, has its ex-
planation in this, that in the large perforation, the sound-waves, without
being received and conducted by the remnant of membrane, and malleus and
incus, fall direct and full upon the foot-plate of the stapes and the membrane
of the round window, and so reach the labyrinth in considerable numbers.
The improvement in the hearing, in cases where the perforation is not exten-
sive, which is effected through the closure of the opening by means of a drop
of fluid, has its explanation in this fact, that, the continuity in the membrane
being restored, the irregular nodes are removed which exist in every case
where there is an Opening existing in the membrane. -
Moos' says:—According to the observations of Lucas, Politzer, and myself,
it has been proven that, by the application of the artificial membrane, the
intra-auricular pressure is increased. There is at the same time this advan-
tage, that in some cases in which the ossicles are still preserved, but are loose
in their articulation, which has resulted from an active, purulent inflammation
of the middle ear, the artificial membrane, by pressure, restores them to a
proper condition for the conduction of sound-waves.
| Ohrenkrankheiten, 1866, S. 275.
FUNCTION AND UTILITY OF ARTIFICIAL D R U M - MEMB RAN E. 979
T)alby' says:—The increased hearing may therefore be said to be produced
by approximating the articulations of the ossicles, or supplying their place
when these bones are partially wanting; which Dalby further states was in
substance the explanation offered by Dr. Yearsley.
Roosa” says:—The improvement to the hearing is probably due to the re-
storation of the interrupted continuity of the ossicula auditus to the fenestra
ovalis and the labyrinth. -
Hinton” says:—The question whether the artificial membrane operates by
closing the orifice in the membrana tympani, or by supporting the ossicula and
especially the stapes, is now decided in favor of the latter view. -
Allen" says:—The benefit is derived from support being given to the ossi-
cula, by which they are enabled to exercise that due pressure at the fenestra
ovalis which keeps the membrane of the fenestra rotunda in a condition sus-
ceptible of vibrations, and capable of transmitting them to the nerve expansion
in the labyrinth.
In response to inquiry, I have obtained, relative to this question of
conditions of the ear and function of the artificial membrane, these fur-
ther very interesting views. (I would state that I did not submit these
questions to many whose views would be highly esteemed, for reasons
which have already been assigned, and regret it as detracting from the
value and interest of this report. Three to whom the questions were
submitted, made no reply.)
Dr. Clarence J. Blake, of Boston, summarizes the conditions of the ear in
which the artificial membrane may be used, thus:–(1) Solution of continuity
of the membrana tympani, in which the artificial membrana tympani restores
a surface for the reception of the sound-waves, or, by closing a small opening,
prevents the simultaneous impact of the sound-waves upon the base of the
stapes and the remaining portion of the membrane, a condition which is shown
by experiments to result in interference;" (2) Thickening of the mucous
membrane of the tympanic cavity, associated with perforation of the mem-
brana tympani, the increased pressure given by the artificial membrane re-
sulting in the readier conduction of short sound-waves; (3) Destruction of
the membrana tympani, the artificial membrana tympani receiving the sound-
waves on its outer surface, and conveying them directly by contact to the
incus or stapes; (4) Loss of the incus in suppurative otitis media, the artifi-
cial membrane being made to press directly upon the stapes, thereby restoring
the degree of tension of the membrane of the fenestra ovalis. (“I have seen
in Politzer's clinic good results in such a case from the pressure induced by a
small cube of rubber-elastic, one millimetre in diameter, resting upon the
stapes and extending across the tympanic cavity.”)
Dr. D. B. St. John Roosa, of New York, states that, according to his experi-
ence, the artificial membrana tympani may be used where there is a partial or
complete loss of the natural membrana tympani, with a moderate amount of
Suppuration, or no suppuration at all, and with one or more of the ossicles
Žn situ. If there be much suppuration, the irritation of a foreign body, such as
an artificial drum-head, will always be apt to increase it. In a few rare cases
it is useful, where the natural membrane is entire but very much thinned by
atrophy. Its use should be limited to those cases where with the above con-
ditions there is a great impairment of hearing, i.e., inability to hear ordinary
conversation. . . . The improvement in hearing is effected primarily by pres-
' Diseases and Injuries of the Ear, 1873, p. 127.
* Treatise on Diseases of the Ear, 1873, p. 380.
* Aural Surgery, 1874, p. 189. .
* On Aural Catarrh and Curable Deafness, 1874, p. 370.
* C. H. Burnett; Weber-Liel, Fung. d. Memb, d. runden Fensters; Test with high
musical notes, Moos, Archiv f. Ophth. und Otol.; High Musical Tones, C. J. Blake;
Sprache und Ohr, O. Wolf.
980 tº SPEN CER,
sure upon the stapes, re-establishing the proper relations of that bone to the
fenestra ovalis, vestibule, and cochlea.
Dr. O. D. Pomeroy, of New York, says:—Any condition in which the base
of the stapes fails to exert the requisite pressure upon the oval window, and
consequently upon the waters of the labyrinth. The lesions resulting in this
condition are: (1) Perforation or loss of membrane ; (2) Flaccidity of the
membrane, either due to a cicatrix or to other causes whereby the membrane
fails to close down firmly upon the ossicles; (3) Loss of one or two of the
ossicles, the stapes being in situ; (4) Separation from any cause of the ossi-
cles from each other; (5) Partial luxation of the base of the stapes, or great
relaxation of its annular ligament. The discharge from the ear must be
moderate in quantity or absent. Polypi or granulations should be removed
or destroyed. The ear must bear the pressure of the membrane without the
production of either pain, tinnitus, vertigo, nausea, etc., increased discharge,
or irritation of the chorda tympani. .
Dr. Arthur Mathewson, of Brooklyn, says:—Like the natural membrana
tympani, the artificial serves to concentrate the force of the sound-waves
through the Ossicles on the nervous apparatus of the inner ear, focalizing these
waves, as it were, as rays of light are brought to a focus on the retina by the
refracting apparatus of the eye. In cases in which there is stiffening or anchy-
losis of the joints of the ossicles, so that they cannot transmit the sound-
waves, the artificial membrane only impairs the hearing.
Dr. Albert H. Buck, of New York, says:—As I comprehend the matter, the
artificial drum-membrane serves to intensify the sound-impulses. In the case
of Hassenstein’s membrane, I can readily understand how the vibration com-
municated to such a solid body, projecting as it does beyond the orifice of the
meatus, may be transmitted to the hammer, and so on to the labyrinth, with
a greater force or intensity than would have been the case had the same waves
of sound reached the auditory nerve without the intermediation of such a solid
body—the larger solid body offering a greater surface to the waves of sound
than does the hammer which is a smaller body. If there is a condition of
anchylosis, an entire membrana tympani would, it seems to me, be a much less
efficient intensifier of sound-impulses than would Hassenstein’s contrivance.
Hence, where there is anchylosis, it is quite possible that the total absence of .
the membrana tympani may be rather a benefit than otherwise ; for, in its
absence, the sound-impulses can strike directly against the foot-plate of the
stirrup (in other words, upon the fluid of the labyrinth) with greater force
than they could viá the chain of ossicles, the membrana tympani being intact.
The temporary benefit of artificial perforation, in such cases (of anchylosis
with entire membrane), may be explained in accordance with this view.
Dr. C. H. Burnett, of Philadelphia, in reply to the question “What is the
office of the artificial membrane; how is the improvement effected 7” says:–
This question is one not only of intense interest, but of the greatest impor-
tance, for upon its answer depends, as it seems to me, the gist of the entire
subject of application and usefulness of the false drum-head. Its office is
emphatically to restore the proper isolation of the ossicles of hearing. These
will not perform their normal functions if they are too tightly locked, or if
they are too loosely connected. Hence, in some cases, the false drum-head
would have to be adjusted so as to gently overcome the indrawing of the
malleus by the tensor tympani, while in other instances the benefit derived
from the false drum-head would be entirely due to pressure inward, since it
would thus overcome a too great relaxation of the joints of the ossicles, and
thus enable them to swing with each delicate wave of sound. The latter is
more easily accomplished, and perhaps is the more usual demand made on the
false drum-head. But, now and then, the more the false drum-head is made to
press on the remnants of the Sound-conducting parts, the less the patient
hears. In the cases of this kind which I have seen, the membrana tympani has
been largely destroyed, but the ossicles have been present, and their attach-
F UN CTION AND UTILITY OF A RTIFICIAL D R U M - ME M B R AN E. 981
ments normal, especially that of the tensor tympani to the malleus. Mani-
festly, here the bones have been already too much drawn inward, and pressing
down a pellet of cotton would but increase the defective isolation. If, how-
ever, in such cases the artificial membrana tympani be placed so as to gently
overcome the indrawing of the malleus, the entire chain of ossicles may be.
freed, and allowed once more to swing normally. This I have successfully
done by tucking the upper edge of the round or flattened pellet of cotton
behind the manubrium, not in front of it. The latter would be only an addi-
tional inward force, but the former adds outward force just enough to overcome
the retraction of the malleus. The base of such a false drum-head should rest
as nearly as possible along the line of insertion of the lower half of the mem-
brana tympani. In doing this, should some of the lower portion of the artifi-
cial membrane extend into the tympanum, as it almost surely will when the
membrana tympani is largely destroyed at its lower border, no harm comes of
it, if there be no discharge from the ear when the artificial drum-membrane is
inserted, and if the ear be examined by a competent person from time to time
in order to learn the condition of the parts where the cotton pellet lies. The
great objects to be gained in such cases of undue retraction of the malleus, and
consequently of the entire chain of ossicles, are : (1) a good support for the
base of the false membrana tympani; and (2) the adjustment of its upper edge
behind the lower end of the manubrium. Of course, large perforations
involving the lower half of the membrana tympani are supposed in what has
just been said. A small perforation does not as a rule cause as much deafness
as a large one, and in any event the artificial membrane used in the former is
to be laid over the perforation.
Prof. Schwartze, of Halle, says:—The indication for employment of the
artificial membrane exists only in a partial or total defect of the membrana
tympani, and it is contra-indicated by a subacute inflammation, or a profuse
Otorrhoea.
Prof. A. Lucae, of Berlin, writes:—The artificial membrane should not be
employed, and is of no value, in ancient perforations where the suppuration
has ceased, and where the edges of the perforation have cicatrized.
Prof. Politzer, in his communication to me, says:—It is important for the
action of the artificial membrane, as well the rubber disk as the pellet of cotton,
that it should be fastened on a solid or elastic stem, by which a certain pres-
sure is exercised upon the deeper parts. The rubber disk or the cotton pellet
which is fastened on a thread, will not produce so marked an effect, because
this pressure from without is not then exerted. -
Prof. Weber-Liel," in a preliminary communication, states that according to
his researches the band connecting the foot plate of the stapes with the edge
of the oval fenestra, described heretofore as the “ligamentum orbiculare baseds
Stapedis vestibulare,” should be considered rather as a circular membrane. It
is true that it appears on ordinary examination only as a very narrow band,
yet well prepared microscopic specimens, more than physical experiment on
fresh preparations, demonstrate that we have to deal with a relatively broad,
Žndependently vibrating, membranous band. On account of the peculiar posi-
tion and mode of union of the stapes with the edge of the oval window the
membrane generally going abruptly down to the edge of the stapes looking to-
ward the tympanum), it is only under certain conditions that we obtain a
demonstrative view. In well-prepared specimens, where the covering mucous
membrane of the tympanum has been previously removed, well-defined, radiating
fibres can be observed in the circular membrane. The elastic-ſibre layer of
Rüdinger, between the so-called “ligamentum orbiculare baseds staped is vesti-
bulare” and the “ligamentum baseds stapedis tympanicum,” constitutes the
real, very elastic attachment of the stapes-plate in the foramen ovale. In
illustration, there was presented, with this communication, a preparation of the
| Verhandlungen der physiologischen Gessellschaft zu Berlin. 3 Juni, 1876.
982 SPEN C E R,
human ear in which the wall of the vestibule opposite to the oval window had
been opened, the edge of the opening having been filed and widened to admit a
thin glass, which was made to close the opening hermetically, and through which
the circular membrane could be closely observed, enlarged 15–40 times. In the
external auditory canal there was loosely placed a glass tube, to which was
attached a piece of India-rubber tubing, through which sound-waves could be
introduced. At once, very low speaking, or singing high and low tones, into
the tube, produced plainly visible excursions of the light reflexes on the cir-
cular membrane, but none whatever on the stapes-plate. The light reflex ex-
cursions were very marked with stronger and lower sounds, but only very loud
singing into the tube produced the light reflex excursions on the stapes itself.
The tensor tympani and stapedius muscles appeared to effect the changes of
tension in the circular membrane. It was shown how, by pulling on the sta-
pedius muscle, the vibrating faculty of the circular membrane was at certain
points reduced or entirely checked. The counter-pressure of the labyrinth-
fluid was replaced in the preparation by air, which could be compressed by
means of a rubber balloon through a glass tube introduced into the closed
vestibule, a piece of rubber tubing connecting the distal end with the air bag.
I am indebted to this author for a personal communication, in which
he applies this newly discovered anatomical relation to the question we
are considering : “The stapes, regulating the intra-labyrinthine pressure,
exercises also an influence upon the circular membrane through the ope-
ration of the sound-waves and the tensor tympani and stapedius mus-
cles. If the normal tension of the membrana tympani and chain of
bones and muscles be impaired, in consequence of defect in the mem-
brana tympani, it is perhaps the pressure which is exercised by the
artificial membrane on the stapes to which the improvement in the hear-
ing can be referred. The intra-labyrinthine pressure and the tension of
the circular membrane may by this means be brought nearer to a
normal condition.” In connection with this interesting statement of
T’rof. Weber-Liel’s, I may refer to the experiments performed by Mach
and Kessel, conducted with a view to determining “whether a traction
upon the muscles of the tympanum will produce an alteration in the
consonance of the auditory apparatus for notes of various pitch,” and as
a result of which they state, “our conclusions are in unison with those
of former investigators. All observers agree that contraction of the
tensor tympani, whether produced artificially or by natural causes, will
render high notes more audible than low ones.” This phenomenon has
presented itself, I do not doubt, very many times to every gentleman
present, in the course of treatment of suppurative and non-suppurative
inflammations of the tympanum, there being at periods a marked im-
provement in the hearing of high tones, with no increase, or a positive
decrease, in the hearing of low tones.
We may now consider the contra-indicating conditions to the use of
the artificial membrane. After what has gone before, I shall consider
that a mere statement here will be sufficient, and will not be controverted
by any. In brief, then, the contra-indications to the employment of the
artificial membrane are found (1) in a profuse suppuration ; (2) in the
presence of any adventitious growth in the tympanum or external audi-
tory canal; (3) in acute disease; (4) where there is pain, or where there are
cerebral symptoms; (5) where the artificial membrane has been tried
and found to produce irritation ; and (6) in all cases where there does
not exist a degree of intelligence sufficient for the self-introduction and
| Versuche Über Accommodation des Ohres; Sitzb. der k. k. Akad. der Wiss., 1872.
FUNCTION AND UTILITY OF A RTIFICIAL D RUM-MEMB RAN E. 983
removal of the artificial membrane, or for the formation of a judgment
as to the indications for its continuance or discontinuance, and in cases
of young children. -
The forms of membrane, and I shall enumerate only those which have
met with some favor, and are in use among aurists to-day, are as follows:—
(1) Yearsley’s cotton-wool. (2) Toynbee's rubber disk. (3) Hassenstein's
(of Gotha) modification of Yearsley’s membrane, made by attaching it to
a pincette for its easier introduction and removal, and in order to supply
an increased pressure. (4) Lucae's modification of Toynbee's membrane,
consisting in the removal of the metallic button and wire, and in the
substitution of a fine rubber tube attached by a solution of gum to the
outer surface of the disk; the tube serves for its introduction by means
of a probe. (5) Politzer's artificial membrane, which is cut out of the
wall of a heavy India-rubber tube; it is from four to five lines long, and
should be one and a half or two lines thick; the upper end, through
which the wire of Toynbee's membrane is passed, is somewhat broader
than the lower. It is recommended in charity practice, for the readi-
ness with which it is made, and its comparative cheapness of cost.
Politzer has further modified Toynbee's artificial membrane by fastening
to the disk an artificial stirrup, to be used in cases where the head, neck,
and crura of the stapes have been destroyed, and only the foot-plate
remains in the oval window. The foot-plate must be susceptible of its
normal movements. (6) Gruber overcame the danger which is liable to
occur in the use of Toynbee's membrane, of the disk becoming separated
from the stem and being left behind in its attempted removal, by at-
taching a thread to the disk, and also to the ring which is formed in the
outer end of the wire, for its extrication in the event of such an acci-
dent. (7) Hartmann” has proposed an artificial membrane, to be made
of whalebone, six to seven centimetres long and one to two millimetres
broad, and as thin as possible. It is doubled upon itself to form a loop,
after it has been wrapped with cotton. It is recommended for the elas-
ticity of the pressure which it makes, for its easy introduction and re-
moval, and as a means of treating the cavity.” (8) Blake" recommends
the use of a disk of writing paper, to be employed only in a certain class
of cases; at the same time that it improves the hearing, the disk has its
chief value in its office as a therapeutic agent.
The conditions of the ear presenting the indications for the employ-
ment of the artificial membrane, which have been stated at such length,
occupying the greater part of the time allotted to this paper, with the
anatomical peculiarities of the location, constitute the argument upon
which is based the preference for Yearsley’s cotton-wool. Of all the
forms of membrane which may be committed into the hands of the
patient—and it should be kept in mind that this is its fate—this
form, in my experience, has proved to be the simplest of introduction,
the easiest of adaptation in the cavity, and much the least likely to pro-
duce irritation—which latter must be the constant fear of every intelli-
gent wearer of such a contrivance. In its employment, it will not be
forgotten that the artificial membrane (of whatever form) is a foreign
body; and that, in those cases in which it will produce the greatest
amount of improvement in the hearing, it will be liable to defeat what
* For description, see page 975.
* Archiv für Ohrenheilkunde, Band xi., Heft. 2.
* See page 985. * See page 985.
984 SPEN CER,
should be our first concern, the arrest of a process which endangers the
health of an individual, if not his existence, and compared to which the
improvement in the hearing is a matter of very secondary importance.
The high degree of deafness which so frequently obtains in chronic non-
suppurative inflammation of the middle ear, is comparatively of rare
occurrence, associated with suppuration in the cavity ; and where it
exists, we are apt to find more or less extensive destruction of the tym-
panal machinery, with the destructive process continuing. These are
the cases which when first presented necessarily excite some apprehen-
sion in our minds, and which require a guarded prognosis. They are
eases concerning which I have been led by sad experience to feel an
unusual solicitude; and when after a patient care of months, it may be,
such an ear has been recovered from this state of danger to a compara-
tively healthy condition, it is a question for the surgeon to decide,
“Have I a right to hazard this result?” When the continued use of
this mechanical aid to hearing has been determined upon—and circum-
stances at times will warrant such a decision—the question arises, What
form of membrane shall I employ 7 And I care not what the degree of
deafness, nor what the circumstances or condition of the patient making
it desirable to have the functional relief, the conclusion cannot be influ-
enced alone by the degree of improvement produced by this form of
membrane or that, but the surgeon must also consider his responsibility
in the case, and his duty to protect his patient, and he will put into his
hands that engine which will be the least calculated to do him harm.
If the rubber disk be used, it should be Lucas's, and never Toynbee's
with its metallic button.
I am further of the opinion that such a case should never pass entirely
from under observation, but that the patient should report himself
statedly for inspection to the aural surgeon. It is not without signifi-
cance that some of those of enlarged experience and of honor among us, if
they do not discountenance the use of the artificial membrane altogether,
at least may be said to endorse its use, in any form, very qualifiedly.
Among such are Luca and Schwartze, of Continental-European aurists,
and Buck, J. Orne Green, Knapp, Mathewson, and Prout, of those in
our own country.
Lucae says:—It is well known that in a continuing, chronic suppuration,
the artificial membrane improves the hearing in a high degree ; yet it irritates,
and retards the cure of the otorrhoea, so that it would appear more rational
to entirely abstain from its use, and principally to direct the attention to con-
trolling the suppurative process. I have, therefore, in my practice, restricted
myself in the use of this appliance to those very rare cases in which it effects
a marked improvement in the hearing, without at the same time producing
any irritation whatever.
Schwartze says:—As a general thing, I may state that, in my experience,
the artificial membrane is only in rare cases to be used as a means of improv-
ing the hearing. In most instances, the improvement is not so considerable
that the patient will bear the trouble and inconvenience which necessarily
attend wearing it; and, continued for a little while, it is soon thrown away.
J. Orne Green says:—I must say that my experience with them is not
brilliant; occasionally, in very rare cases, they have improved the hearing,
but even in these they are often not well borne. -
Knapp says:—My own experience with artificial drum-heads has been so
unfavorable that I hardly ever try them again.
FUN CTION AND UTILITY OF A RTIFICIAL D R U M - MEMB R A N E. 985
The functional value of the artificial membrane has been sufficiently
considered ; there remains something to be said of its therapeutical
uses, and I incline to the opinion that this is its office of greatest useful-
ness. It serves, in the first place, to protect the inflamed cavity from
the pernicious influences of an unkindly atmosphere, and from particles
of dust and soot ; and, introduced to the depth of the meatus, in more
or less profuse suppuration, may absorb the vitiated secretion, and act
as a slight irritant, where there remains a small perforation in the mem-
brane with a subsidence of the middle-ear trouble, to excite a further
reproduction of membrane and thus close the cavity. In the second
place, through this instrument, astringent solutions may be retained in
application to the cavity, often with great advantage. It is proper, how-
ever, to state here a precaution which may save others from an embar-
rassment to which I have been subjected. The cotton-wool should be
moistened merely, never Saturated, with the solution ; as the continuous
presence in the cavity and meatus of so much fluid might lead to the
development of a myringo-mycosis. Did time allow, I might report a
number of cases so treated. Prof. Politzer, in a letter, suggests a differ-
ent method of employing the cotton-wool with the medicated solution.
I shall give it in the connection in which he states it, as the whole sub-
ject is of interest.
The most important modification, since the year 1864, is that of Dr. Has-
senstein, of Gotha, who has contrived a pincette in which the cotton pellet is
fastened. It possesses advantages over Toynbee's artificial membrane in that
(1) its introduction is less disagreeable to the patient; (2) In speaking and
chewing, there is less often that disagreeable noise in the ear which accom-
panies the use of Toynbee's membrane; (3) It does not produce so much
irritation ; (4) The cotton takes up the secretion of the cavity; (5) By means
of the cotton, which has been saturated in a concentrated solution of sulphate
of zinc, Sugar of lead, nitrate of silver, or alum, and then dried, and moistened
again when it is to be used, a medicament can at the same time be retained in
contact with the diseased mucous membrane of the middle ear. . . . In the
same manner Dr. Arthur Hartmann's artificial membrane might be employed.
Dr. Clarence J. Blake informs me:–Lately, in cases of small perfora-
tions of the membrana tympani, the middle-ear trouble having subsided,
I have covered the perforation with a small disk of writing paper, moist-
ened ; the sizing of the paper is sufficient to secure its adherence, and in
some cases it has remained for several weeks; the slight irritation caused
by the paper favors closure of the perforation by cicatrization, and the
paper is then removed by the natural growth of the dermoid coat of the
membrana tympani. Dr. Blake kindly reports a case to illustrate the
effect of this disk of writing paper, taken from the Massachusetts Cha-
ritable Eye and Ear Infirmary’s Record, occurring in his service:—
CASE 2024, Vol. W.-Perforation of right membrana tympani from old otitis
media purulenta, discharge having ceased ; hearing for voice diminished, sound
of the voice being heard at six feet, but not understood readily on account of
loss of softer consonant sounds. Perforation in anterior segment, a little
more than two millimetres in diameter. Disk of common note paper moistened,
and applied over the perforation. Voice heard plainly, and conversation
understood at twelve feet (June 6, 1876).
* I have been in the habit of using, for making artificial membrane, a prepared cotton
from which the vegetable oil has been extracted: this substance answers weli for the pur-
pose, and is also a better vehicle than ordinary cotton for conveying medicated solutious
to the tympanum.
986 S PEN C E R,
July 1, 1876. Paper still in position, but has moved (by natural process of
repair) one millimetre backward and downward. I’erforation diminished in
size. -
July 18. Paper having been moved from over perforation, is reapplied,
with a repetition of the former favorable condition.
Finally, it is not easy to determine in what percentage of cases the
artificial membrane will prove of practical advantage, until it shall have
been tried in every case of perforation of the membrane, including cases
of one-sided deafness. We are ready to infer that the relative propor-
tion to the whole number of chronic suppurations would be exceedingly
small, where its use would be continued as a means of improving the
hearing. Of 261 cases of ear disease presented during the last six months,
taken apart from clinical cases, as affording opportunity for more careful
Observation, 34 have been cases of chronic suppuration of the middle ear
—the right ear being affected 11 times, the left ear 8, both ears 15. Count-
ing out all excepting the 15 cases of double-sided suppuration, for rea-
sons that will appear manifest, but five of these have presented the war-
rantable conditions for the employment of the artificial membrane, and
only one has continued the use of the artificial membrane after being
left with it for self-introduction.
Dr. Blake has placed me under further obligations to him by furnish-
ing these statistics:— -
The total number of cases of otitis media purulenta, treated at the Massa-
chusetts Charitable Eye and Ear Infirmary from Jan. I to August 5, 1876, was
267, divided as follows: Males 187, females 80; Right ear 95, Left 90 ; both
ears 82. In several of these cases, artificial drum-membranes were tested, no
record being made. I append notes of cases in which there was special record.
CASE 1928, Vol. V. Otitis media purulenta of both ears; destruction of
membrana tympani, only a rim remaining ; patient hears voice, except imme-
diately, with difficulty; cotton applied in both cases with great improvement
in hearing for voice.
CASE 1982, Vol. V. Otitis media purulenta; hearing for voice much dimin-
ished ; wall clock (60 feet) not heard at 6 feet. After introduction of cotton
drum, hearing for voice improved ; wall clock heard plainly at 20 feet; noises
in the street, unnoticed before, became very annoying. After remaining in
place with continued improvement in hearing for four days, drum removed to
allow of treatment of granular condition of tympanic mucous membrane.
CASE 208, Vol. VI. Destruction of left membrana tympani. Malleus drawn
in ward in contact with promontorium. Incudo-stapedial articulation visible.
Voice understood with difficulty at 3 feet. Cotton drum introduced, being so
moulded as to present a convex surface inward, pressing on the incudo-stape-
dial articulation, and a plane surface outward. Voice understood readily at
6 feet.
CONCLUSIONS.
I. Of the various forms of artificial drum-membrane in use, the cot-
ton pellet is preferable, for its greater simplicity and easier introduction,
for comparative safety in its employment, and for the greater uniformity
of its effect.
II. It has an advantage over all other forms of artificial drum-mem-
brane, in that, over and above the functional gain which may be derived
from it, there may be added its value as a means of treating the tym-
panum ; and this therapeutical use of the artificial membrane has a great
future in otology.
F U. N. CTION AN I) UTILITY OF A RTI FI C I A L I) R U M - M. E M B R A N E. 987
III. The continued use of the artificial drum-membrane, as a means of
improving the hearing, is indicated in rare conditions, which can only be
determined by the aural surgeon.
DISCUSSION ON DR. SPENCER's PAPER.
After the reading of the preceding paper, Dr. SAMUEL J. JoxEs, of Chicago,
said:—In some cases I have found the rubber disk of considerable service,
but latterly I have used the cotton pellet almost exclusively, occasionally
anointing it with cosmoline. Even in some cases of active suppuration, if the
secretion be carefully removed, the cotton drum-head may continue to be used
with advantage. This remark applies especially to the cases of those who must
continue to hear in order to attend to their daily work. Such cases, however,
should remain under the observation of the surgeon.
Dr. CHARLEs H. BURNETT, of Philadelphia, said:—I believe that putting the
cotton behind the malleus, when the perforation is large, is a great deal better
in some cases than pressing it on the malleus, for there are some cases of large
perforation in the drum-head in which deafness is the result of retraction of
the malleus. In such cases, the malleus being retracted, the rest of the bones
are pulled in, and the trouble is only increased if the artificial membrane pushes
the malleus in ward.
Dr. SPENCER said:—I beg to thank Dr. Burnett for his suggestion; it may
be the key to an explanation of the failure of the cotton pellet in some cases.
988
MODIFICATIONS OF THE METHODS OF TREATING CHRONIC
NON-SUPPURATIVE INFLAMMATION OF THE
EUSTACHIAN TUBE AND MIDDLE EAR.
BY
SAMUEL J. JONES, A.M., M.D.,
PROFESSOR OF OPHTH ALMOLOGY AND OTOLOGY IN THE CHICAGO MEDICAI, COLLEGE.
THE method of inflating the Eustachian tube and middle ear, intro-
duced to the medical profession by Politzer, possesses so many advantages
for that special purpose as to have been almost universally adopted in
the treatment of obstruction of the tubes, and of disease of the middle
ear. Experience, however, has shown that violence may be done by the
injudicious use of so large a rubber bag as that advised by Politzer.
More especially is this likely to occur when only one of the Eustachian
tubes is affected. The other tube being normally free, a greater amount
of force is exerted, on pressing the bag, by the air on the well ear, than can
be employed with safety, even though that air should not be medicated.
If, however, in those numerous cases where local stimulation, in addition,
is needed, medicated air be used, still greater disadvantage may result.
By this method of medication of the mucous membrane lining the air-
passages, a greater impression will be made on the naso-pharyngeal part
of it than on that portion lining the affected tube and middle ear,
although the latter portion of the membrane needs it most. If the large
bag be used, in connection with the Eustachian catheter, to introduce
either pure or medicated air into the middle ear, the size of the bag is
an inconvenient one, and often makes the procedure painful. The
amount of force usually employed with this large bag, in the treatment
of children, frequently alarms them, even if pain be not produced, and
renders it more difficult to treat them.
If the nasal douche be used to remove the hardened secretions often
found to be present in the naso-pharyngeal space, and obstructing the
mouths of the tubes, it is open to the objection that the saline solution
employed may be stronger than it would be safe to have enter the middle
ear, through the Eustachian tube, as it is likely to do if either the reser-
voir be placed too high, or the soft palate be removed from contact with
the posterior wall of the pharynx during the operation. Acute inflam-
mation of the middle ear, with occasional perforation of the membrana
tympani, has thus been produced. If the soft palate remain in contact
with the pharynx, that portion of its posterior aspect which is in contact,
and which is very often granular and covered with altered secretion, is
prevented by its position from being washed by the current as the other
parts of the membrane are, thus rendering the application only partial.
In the use of the Eustachian catheter, if hard rubber be the substance
of which that instrument is made, it necessitates a variety of shapes of
the catheter to meet the great variations found in nostrils. Unless the
proper size and right curve of the instrument be obtained, pain will be
produced, and failure to reach the tube will frequently result. Heating
IN FLAM M ATION OF THE EU STA CHI A N TUBE, ETC. 989
the catheter to give it the required curve, delays the operation, to avoid
which it is necessary to have a number of different catheters. If alloyed
silver catheters be used, they are too firm to have their curve readily
changed, and in consequence require the surgeon to keep on hand several
of them of different sizes and shapes. If Eustachian bougies be used to
open the tubes, their introduction is generally painful and attended with
Some risk, whilst the results obtained are too often uncertain and unsatis-
factory. -
With a view to avoid objections incident to the use of these different
instruments, I have been accustomed to substitute for the nasal douche a
steam atomizer (Fig. 1), using the vapor of some alkaline solution, as
Steam atomizer.
of the chlorate of potassium, or of borax, which the patient breathes in
through his mouth and expels through his nostrils—thus getting the
effect of the warmth, the moisture, and the alkali, to cleanse the mucous
membrane of its secretions, and to assist in removing the inflammation.
Having thus cleansed and prepared the mucous membrane for further
medication, a Eustachian catheter of pure silver (Fig. 2), readily adjust-
able to the curve required, is introduced. To this is attached, by means
of a small hard-rubber tip and an elastic tube, a small rubber bag (Fig. 3),
Figs. 2 and 3.
Eustachian catheter and valve-bag,
ith a valve such as is used in the local-anaesthesia apparatus. The
rdinary “ diagnostic tube” (“otoscope,” Toynbee) is then introduced into
he external meatus of the patient, and into that of the surgeon. Pres-
ure on the valve-bag forces air through the catheter into the middle ear,
f the Eustachian tube be open, as is readily recognized by the sound
roduced. This bag has the advantage of always filling in one direction,











990 J O N ES,
thus avoiding the drawing of mucus into the catheter. If the tube be
not open, a small hard-rubber syringe (Fig. 4), with its tip covered with
Hard-rubber syringe.
a piece of rubber tubing to adjust it to the expansion of the catheter, is
filled with a warm and slightly alkaline solution, with glycerine added,
and is inserted into the catheter. With this, the solution is forced into
the Eustachian tube, using the liquid as the mechanical means of distend-
ing the tube, instead of relying simply upon compressed air (as in the
methods of Valsalva and Politzer), or of using bougies.
Experience has shown that if the solution used be not of too irritating
a character, and if its temperature be nearly that of the blood, no inju-
rious effects follow its passage into the middle ear. On the contrary, it
assists, by dissolving them, in removing the secretions that have fre-
quently dried and remained accumulating in the middle ear and mastoid
cells.
Having thus opened the tube, and dissolved the dried secretion, air
impressed with iodine may be forced through the tube until the middle
ear, and even the mastoid cells, may be impressed by it. This can be
done by placing a few crystals of iodine between two pieces of sponge,
slightly moistened and inclosed in a hard-rubber bulb (Fig. 5), (such as
F=#||
Buttles's hard-rubber bulb.
Buttles's), attached to a catheter. Air is forced through the sponge by
means of the valve-bag above described (Fig. 6). When the lining of the
tube and the middle ear have thus been sufficiently medicated, the catheter
may be withdrawn, and a blunt nozzle attached to the bulb containing
the iodine. If this nozzle be placed in one nostril, the other one having
been closed by pressure, medicated air can be forced in, in the act of
swallowing water, as is pure air in Politzer's method—impressing the
whole membrane more thoroughly, by means of a smaller bag than that
used by Politzer, and with less attendant risk.
I3y the method here pursued, the surface is readily cleansed, and the





IN FLAM M ATION OF THE EU STA CHIAN TUBE, ETC. 991
requisite amount of stimulation of the affected parts may be easily and
painlessly obtained. Such cleansing and stimulation seem to be the basis
of the most successful treatment of this form of inflammation of the mid-
dle ear, and thus better results may be obtained than are usually ex-
pected in these cases.
The modifications proposed consist, therefore :—
I. In the substitution of the steam atomizer for the nasal douche, to
remove secretions from the naso-pharyngeal space and from the openings
of the Eustachian tubes, and to reduce inflammation.
II. In the substitution of pure silver catheters for those of alloyed sil-
ver, or of hard rubber.
III. In more frequent use of the Eustachian catheter as a means of
medicating the Eustachian tube and middle ear.
IV. In the substitution of a warm, slightly alkaline solution, forcibly
injected by means of a syringe through a catheter, to open the Eustachian
tubes in certain cases, instead of condensed air or bougies.
V. In the substitution of air, impressed with iodine, for irritating
liquids, as a topical application to the mucous membrane lining the naso-
pharyngeal space, the Eustachian tube, and the middle ear, this medi-
cated air to be introduced through the Eustachian catheter.
VI. In the substitution of a small rubber bag with a valve, designed to
inflate the Eustachian tubes, for the larger bag recommended by Politzer
for that purpose.

ON THE BEST MODE () F TESTING THE HEARING OF SCHOOL
CIIILDREN, AND OF PROVIDING FOR THE INSTRUCTION
OF PARTIALLY DEAF CHILDREN.
BY
CLARENCE J. BLAKE, M.D.,
INST RU ("TOR IN ()'I' () I., ()(; Y IN H A RV ARI) U. N. IV. F. KSITY.
ONE of the strongest arguments in evidence of the importance of the
subject expressed in the title of this paper, is the fact that, except in
individual cases, or where the loss of hearing is so great as to result in
deaf-mutism, no provision is made in our present school system for the
special instruction of those children whose infirmity, in this respect,
gives them, if anything, a larger claim upon the efforts of those to whom
is entrusted the laying of the foundation of that mental development
which is the basis of the prosperity of a people. To the attainment of
that proper degree of mental development which raises the man above
the animal, the sound mind in the sound body is necessary; and when
one of the channels for communication from without, is either wholly
or partially closed, there devolves upon those who have the furtherance
of this development in charge, the duty of compensating in one way or
another for the loss. How this may be best accomplished in the case in
question, is for us to consider.
In a work on the physical and mental education of deaf children, pub-
lished with the sanction and under the advice of Prof. Von Tröltsch, the
author says:" The generally received opinion that diminution of hearing
in children, in consequence of disease of the ear, is rare, is a mistaken
one ; indeed, in some localities, the cases of disease of the ear exceed in
number the cases of disease of the eye, and moreover they are apparently
on the increase; the steadily increasing demands upon the mental capacity,
accompanying the advances of the times, bring the defects of hearing more
and more prominently forward, because they show themselves to be a
decided hindrance to the better education of the child. The results, on
its later mental development, of the loss or diminution of hearing in a
child, are decided and permanent—affecting the understanding, the char-
acter, the self-confidence, and, at a later period, the ability of self-support:
mental tools the possession of which is invaluable, and the want of which
can never adequately be supplied. In this view, it is a matter of concern
that more attention has not been directed to the educational develop-
ment of partially deaf children.
An examination of a number of cases of partial deafness, occurring in
children under sixteen years of age, shows that, with the exception of a
majority of those cases in which the disease of the ear has been of a
character, or of a degree of intensity, sufficient to so far impair the
hearing as to be followed by deaf-mutism, the diseases of the ear ir
| Franciska Schaeling. Beiträge zu einer richtigen, leiblichen, und geistigen Erziehung
gehörkrauker Kinder. Thorn, 1872.
H E A R IN G O F SC H O O L CHILD RE N. 993
children are amenable to treatment, with more or less improvement in
hearing, and that the impairment of hearing varies considerably in dif-
ferent cases, and is moreover subject, in any one case, to variation during
the progress of the disease. In considering the subject of partial deaf-
ness, therefore, we have to deal at the outset with a factor in our problem
representing an unknown quantity; each individual case of partial deaf-
ness must be, as it were, a law to itself, as far as the compensatory advan-
tages to be accorded to it are concerned. To facilitate investigation,
however, two general divisions of the subject may be allowed. The first
will include those cases of partial deafness in which the loss of hearing
is so great as to interfere with the acquirement of articulation, though
not sufficient to permit the classification of the case under the head of
deaf-mutism. This division will include those cases in which the dimi-
nution of hearing is so decided as to interfere with the independent
acquirement of information through the medium of the hearing, and will
imply the necessity for special instruction. . The second division will
include a much wider range of cases, from those in which the hearing is
so slightly impaired as to permit of ordinary intercourse, downward
through varying degrees of impairment of hearing until the degree
belonging to the first division is reached.
Those whose cases come under the first division, form fortunately but a
small percentage of all the subjects of partial deafness among children;
and a consideration of their needs may be deferred, as secondary to the
subject immediately under consideration, and because moreover no pro-
vision has been very generally made for their instruction. For the in-
struction of those whose cases come under the second division, there is, as
far as I am aware, no provision made in our public schools, beyond the
individual and independent efforts of the teachers. The children who are
subjects of partial deafness are, however, sufficiently numerous to warrant
some special attention to the subject, with the view of determining the
best means for giving them equal educational advantages with their
more fortunate companions. To do this will require an examination into
the nature of the cause of their disability, and the establishment of rules
according to which the degree of impairment of hearing may be deter-
mined, that the character of the instruction may be varied accordingly.
An examination into the etiology of partial deafness, shows that the
diseases of the middle ear are its most frequent cause in children, and
furthermore that a great many cases of partial deafness are due either to
the subacute or chronic catarrhal inflammation of the middle ear, or to
the purulent inflammation accompanied by perforation of the membrana
tympani, which follows the simple acute inflammation, or occurs as one
of the sequelae of the exanthematous diseases of childhood. This general
rule is subject to certain differences, in differing classes of society;
among the wealthier classes, for instance, who perhaps merit our atten-
tion less in this connection, because their children are educated more
frequently in private than in public schools, the diseases of the ear
accompanied by partial deafness and more or less amenable to treatment,
in children under sixteen years of age, amount to but 7.8 per cent. of the
whole number of cases of ear disease in children and adults taken
together. Of this number, making the 7.8 per cent. of the whole, 76 per
cent. are traceable to the exanthematous diseases of childhood, especially
scarlet fever, and in 56 per cent. there is found an existing purulent
inflammation of the middle ear, requiring treatment, and causing a suf-
63
994 B L A K E ,
ficient degree of deafness to interfere with the patient’s participation in
the Ordinary school exercises, on equal terms with other children.
Among the middle and poorer classes, the proportion of diseases of
the ear in children is largely increased, and it is these classes which we
have particularly to consider, since they more generally avail themselves
of the advantages offered by public instruction. Out of 8715 cases of
disease of the ear, examined in patients of this category,” 2175, or 24.95
per cent., occurred in children under fourteen years of age. Of this
number, 2175 cases of disease of the ear accompanied by partial deafness,
1085, or 49.8 per cent., are recorded as examples of purulent inflamma-
tion of the middle ear; 113, or 10.5 per cent. of the cases of purulent
inflammation, being due to scarlet fever. As many as 514 cases, or 23.6
per cent. Of the cases of disease of the ear in children, are recorded as
examples of either acute or chronic catarrhal inflammation of the middle
ear. This brief analysis is sufficient to show the much greater preva-
lence of such diseases of the ear as are liable to induce partial deafness,
in the children belonging to those classes in society which depend for
their instruction on the advantages offered by our public schools. A
more minute analysis of the material offered, which would hardly be in
place here, affords interesting information as to the general causes and
the average course and results of diseases of the ear in children. It may
be remarked, however, that, in the analysis given, only those cases are
included in which the deafness was not so decided as to interfere with
the acquirement of articulation, or even with the use of the ear as a
medium for instruction. The number of cases of positive deaf-mutism,
and of cases in which, while there was a certain degree of hearing, it was
so slight as to render instruction in articulation necessary, was 107, or,
of all the cases in children examined, 4.9 per cent. The average age of
all the children examined was about nine years.
We see, therefore, that in a large majority of the cases of disease of
the ear occurring in children at an age when they should be profiting
by school instruction, the disease is accompanied by partial deafness, and
is moreover of a character to lead us to expect considerable variation in
the hearing during the progress of the disease, or during the ordinary
term of school life. This point is one which should be especially con-
sidered in coming to a conclusion as to the character of the instruction
to be provided in these cases; we have to deal not only with a different
factor, in the different degrees in which the hearing is diminished by
disease in different cases, but also with a possibly variable factor in any
individual case.
Admitting the necessity for making some provision for the wants of
children of this class in our public schools, and excluding, for the present,
those cases in which the deafness is of so high a grade that special
instruction is absolutely necessary, we have to consider the advisability
(1) of establishing separate classes in our schools for the instruction of
partially deaf children; or (2) of instituting such a system of inspection
as shall lead to a determination of the wants of individual cases, and
such a consideration thereof, on the part of the teacher, in addition to
the ordinary course of instruction, as will permit of education in mixed
classes, compensatory advantages being accorded in cases of partial deaf-
In 63SS.
| Aural Clinic, Massachusetts Charitable Eye and Ear Infirmary; Statistical Report,
Service of C. J. Blake.
FI E A R IN G O F S C H O O L C H II, D R E N .
Q
Q
5
The objections to the former course would seem to be—
(1) The encumbering of our school system with an additional depart.
ment for which especial provision would have to be made. Against this
objection it may be urged that initiatory steps have already been taken
toward the establishment of separate public schools for the education of
deaf-mutes, and the so-called semi-mutes, and that children suffering
from partial deafness could be transferred to such schools, thus making
use of a department already in process of establishment, and avoiding
the creation of another additional department for instruction of only
partially deaf children. While the instruction of semi-mutes in the
same school with deaf-mutes proper, has certain advantages which have
been successfully illustrated in the public schools established for that
purpose in Boston, and of which I shall speak hereafter, there are certain
aguments against this disposal of the question, and in favor of a different
provision for the needs of those partially deaf children who do not at
present, and, from what we know of the nature of the diseases which
caused their deafness, are but little likely to, in the future, deserve classi-
fication among semi-mutes. These arguments are included in the fur-
ther objections to the establishment of separate classes for instruction,
which are—
(2) The moral effect upon partially deaf children of making them, and
recognizing them as, a class by themselves, and the exaggerated sense of
their infirmity resulting from their being so set apart. The object of
the public-school education is to fit the children for the best use of their
mental powers in adult life, and to enable them to associate in the world
under circumstances which shall make their acquired knowledge best
available for their own and the general good ; and this object would be
in a measure defeated by the encouragement, in partially deaf children, of
those feelings with regard to their infirmity which are one of the chief
misfortunes of the deaf-mute. To set them apart in the manner referred
to, would be to permit an underestimate of their own powers, which,
though every effort to counteract it should be made, would necessarily
carry its in press into adult life.
(3) The loss of the beneficial association with hearing children, and of
a proper spirit of emulation ; for since these children are to go out into
the world, where they will be judged by the general standard of effort
and success, it is best that they should associate in the beginning with
those who are to be their companions or their opponents in the struggle
for existence, and that they should be urged rather themselves to coni-
pensate for their defect than to expect compensation at the hands of
others. More precisely, the association with hearing children helps
toward the overcoming of certain faults which are common in children
who are partially deaf. Partially deaf children are very apt to become
heedless and inattentive ; from not hearing occasionally, they get into
the habit of not expecting to hear, and make less mental effort to com-
bine such sounds of the voice, for instance, as they do hear, or to supply
the deficiency of those which escape them. The ultimate effect of this
habit, if un mental development, is very decided ; fºr,
in these cases of partial deafness, nature does not seem to have inade that
effort at compensation which is so strikingly illustrated in the quickened
perceptive powers of the deaf-mute. Again, many partially deaf children
are almost morbidly sensitive on the subject of their infirmity, and
of their implied inferiority : a feeling which, if permitted or encour-
aged, has a very unfortunate effect upon the child's efforts in its stu lies,
•o " " or, to ſl o +l
C{}}''GC { sti, O. : ] { } {}
996 B L A K E ,
and subsequently upon its efforts at the self-instruction and self-control
of adult life. The association with hearing children, and that degree of
participation in class exercises which is possible under certain favoring
conditions, tend to overcome the self-consciousness which is always more
or less of a barrier in the way of advancement.
(4) The final argument against consigning partially deaf children to a
special class or school, lies in the fact, already mentioned, that the imper-
fection of hearing is not a fixed factor in the problem. In the majority
of the cases included in the analysis given, the hearing was susceptible
of improvement, and in all of them was subject to temporary variations
during the progress of the disease or course of treatment.
The best fulfilment of the second course under consideration, education
in mixed classes, necessarily entails a determination of the degree of
physical disability of the pupil, for which compensation is to be made.
This may be accomplished in two ways, of which the best is by means of
a competent professional examination of each case of supposed or evident
deafness occurring in the pupils of, or those presented for admission to,
a public school. This course offers the advantage of determining with
accuracy, not only the degree of hearing, but also the character of the
disease which causes the deafness, the amenability of the case to treat-
ment, the probable course and duration of the disease, and its probable,
ultimate effect upon the hearing ; in very many cases, as may be judged
from the statistics given, the need of treatment would be detected where
otherwise it might have passed unnoticed. The establishment of the
office of medical supervisor of public schools, the position to be filled by
a qualified medical man who should devote his time to the duties of his
office, would cover this in addition to many more important needs in
connection with the hygiene of our public schools.
In default of this more thorough method of examination, the object,
as far as a determination of the degree of hearing is concerned, may be
accomplished by the teacher, to whom may be committed the task of
classification according to certain simple rules for testing the hearing,
applicable to all cases. The ordinary tests for the hearing, by means of
the watch and tuning-fork, or the use of other musical tones, are each of
precise value only when taken in connection with a competent examina-
tion into the condition of the diseased organ, and a careful consideration
of points of which only a professional observer is competent to judge.
Careful tests of the hearing by means of the voice, however, in connection
with one or other of the tests mentioned, would enable a competent
teacher to determine whether a subject of partial deafness could be left
to participate in the ordinary school-room exercises, in common with
other children, or whether it would be necessary to give the child spe-
cial attention.
|Following, for instance, the suggestions to be drawn from the obser-
vations of Oscar Wolf on the musical value of the vowel and consonant
sounds, and the effect which diseased conditions of the ear have upon
the perception of consonant and vowel sounds in combination, it is pos-
sible to arrange a series of test-words which may be used by teachers as
a standard test in schools.
Each teacher may be provided with a form for tabulation of cases,
which is to be preserved as a record of the degree of hearing power, ac-
companied by instructions as to the method of conducting the examina-
tion. These instructions should include a clear definition of the precau-
tions to be taken in order to arrive at a correct estimate of the hearing,
H E A R IN G O F SC HO O L C H II, D R E N . 997
the personal opinion of the teacher being required only in remarks upon
any other symptoms of disease of the ear, such as otorrhoea for instance,
which would seem to indicate the advisability of immediate treatment.
The watch and the tuning-fork, or the tones of a musical instrument, may
be employed as subsidiary tests, but the main reliance should be placed
on tests with the voice, for not only does the human voice, considered as
a musical instrument, fulfil certain conditions as a test not otherwise
attainable, but it is the voice of the teacher especially which the child
is required to hear, and for the accurate hearing of which it is necessary
that the child should be placed in such a position in the school-room as
shall serve to compensate for its diminished hearing. As a rule, there-
fore, the tests indicated should be repeated on the transference of a pupil
from one room, or one teacher, to another, for every human voice has its
peculiarities of pitch and quality, which give it, estimated as a test, a
hearing value of its own. These tests also may be repeated at intervals,
without proving a great addition to the labors of the teacher, for the
purpose of determining the average degree of hearing. º
The hearing distance for the voice having been determined, the point
in the school-room at which all the test-words are distinctly heard, should
determine the position of the seat to be assigned to the pupil, such prox-
imity to the teacher as shall enable the particularly deaf pupil to hear
the teacher's voice as readily as a pupil with perfect hearing at the ex-
treme limit of the room, being one of the compensatory advantages which
his diminished hearing demands. Furthermore, the attention of the
teacher should be directed to the necessity for giving such cases special
attention, in such manner as to supply the loss of parts in class exercises
which the pupil may have but imperfectly appreciated. A lack of
knowledge on the part of teachers of the great obstacle which partial
loss of hearing may present to a proper appreciation of school exercises,
and the establishment of a fixed standard of instruction to which all the
pupils in a class are required to conform, results in added labor on the
part of the partially deaf pupil, without the consideration which his
imperfect ability in this respect should command. -
Passing from the consideration of those cases of partial deafness which
may be provided for in the manner above proposed, we have to consider
the needs of that more unfortunate class whose hearing is so far impaired
as to render special instruction absolutely necessary. The objections
which were made to the separate instruction of the majority of partially
deaf children, do not apply here. One of the earliest and most unfortu-
nate consequences of extreme deafness, in children, is the impairment of
speech ; with the loss of hearing is lost the medium through which the
knowledge of speech is acquired, and the child gradually lapses into
the use of gestures (to proclaim its wants) and the production of inar-
ticulate sounds. To retain or to educate the power of speech, is, how-
ever, but one of the objects to be attained by special instruction ; some
means must be supplied which will compensate as far as possible for the
loss of hearing, and prove another medium through which the child
may receive the same education as that afforded hearing children in the
common School. The sense of sight may, in these cases, be called in aid,
and the child may be taught to hear, as it were, with the eyes.
Various systems for instruction in this so-called, visible speech, are in
operation, and their results, as far as I have been able to observe them,
are not merely encouraging, but eminently successful. Furthermore, as
every possible means of imparting instruction should be made available,
998 B L A K E ,
in addition to education in lip-reading and articulation, such hearing
as the child may possess should be utilized by the employment of arti-
ficial means, if necessary, for the readier conveyance of sound to the ear.
As a result of practical experience, and not merely upon theoretical
grounds, the use of the hearing-trumpet, of one kind or another accord-
ing to the requirements of the case, may be advised during school exer-
cises; indeed, in many cases, the use of such an instrument tends to
improve the hearing not merely during the time of its use, but generally,
the subjection of the ear to sound waves of larger amplitude either in-
creasing the vibratory power of the sound-conducting apparatus of the
middle ear, or acting as a stimulus to the auditory nerve. The proper
application of these auxiliaries to instruction, necessitates therefore the
formation of a separate class, for the benefit of which, as has been said,
the public deaf-mute school, which now forms an important part of the
Boston school system, and which must in time be engrafted upon the
public school system of other large centres, may be made available.
In the Boston school, the children are divided into two general classes,
those who are total deaf-mutes, and those who are semi-mutes. Children
in the latter class are instructed in articulation, for the purpose of over-
coming faults which always exist where the hearing is imperfect, and in
lip-reading, that they may learn to understand conversation from sight
as a substitute for hearing. Such hearing as remains to them is also
made useful in conveying ideas as to the formation of vocal compounds,
by means of an ear-trumpet, if necessary, or by speaking directly into
the ear. As the total deaf-mutes improve in articulation and lip-reading,
they are advanced to the class consisting of semi-mutes, partly because
the grade of instruction has become the same, and partly that they may
profit by the example of those more fortunate companions who have had
the advantage of having a little speech or a little hearing to start with.
On this plan, the Boston school has now been in operation for five years,
with increasing success and increasing evidence of its great value ; it
now provides for about sixty pupils, all of whom are instructed in lip-
reading and articulation, the method employed being the system of
visible speech introduced in this country by A. Graham Bell.
The conclusions drawn from a study of the subject of this paper, may
be summed up as follows:—
I. The frequency of partial deafness in children, during the period of
school life, renders it advisable to make some definite provision in our
public school system for compensatory instruction.
II. Since partial deafness is a comparative term, some provision should
be made for a proper determination of the degree of disability.
III. This may be best accomplished either by establishing a series of
speech-tests, to be used by the teachers, or by instituting competent me-
dical examination at the hands of a medical supervisor of schools; and
the creation of such an office in connection with our public school system
is strongly urged.
IV. Partially deaf children, whose hearing is not so defective as to
require special instruction in articulation and lip-reading, are better
taught in mixed classes with those who hear well, compensatory advan-
tages being allowed them according to their degree of disability.
V. Partially deaf children, whose hearing is so defective as to interfere
with the natural acquirement of articulation, and to render the ear of
little or no value as a medium for hearing, should be accorded the ad-
H E A H IN G O F SC H O O L C H II, D R E N . 999
vantages of special instruction, of which education in articulation and
lip-reading should form a part.
DISCUSSION ON DR. BLAKE's PAPER.
After the reading of the preceding paper, Dr. CHARLEs H. BURNETT, of
Philadelphia, said:—I would ask Dr. Blake if he has noticed, in the schools
visited by him, whether adult mutes have been taught to talk?
Dr. BLAKE said:—I have noticed, especially in the Northampton schools,
that pupils who have reached the age of sixteen years, for instance, are taught
to talk with very great difficulty. A deaf-mute taught in the sign language,
learns to think in a language different from ours. One sign may convey two or
three meanings, and its signification often depends upon the context. The
deaf-mute's arrangement of words in sentences resembles more closely that of
the French, than that of the English, language. The success of deaf-mutes in
the acquirement of articulation is sometimes very astonishing. The sound of
the voice is at first harsh, and articulation is imperfect. But modulation of
the voice is attained, in default of hearing, by the pupils learning to observe
the sensations produced by speaking in the throat, by which means they soon
learn to appreciate the difference between the rising and the falling inflection.
There have been instances in which English deaf-mutes have been taught with
such success that they have learned to speak French and German fluently, and
to sing harmoniously. -
1000
ON AURAL WERTIGO WITH WARIABLE HEARING.
BY
CHARLES H. BURNETT, M.D.,
AURAL SURGEON TO THE PRESBYTERIAN HOSPITAL, PHILADELPHIA.
VERTIGO from disease of the semicircular canals has been fully recog-
nized ever since the publication of Ménière’s papers on the subject.
Guided by the description of his case, and, more recently, by the inves-
tigations of Flourens and others respecting the physiology of the semi-
circular canals, the tendency among medical men has been to ascribe all
cases of acute aural vertigo, not directly traceable to some irritation in
the external auditory canal, to disease in the labyrinth, preference being
given to the semicircular canals as the seat of the direct lesion.
Without entering into a discussion respecting the precise location of
the lesion in labyrinthine vertigo, it can be comprehended why the deaf-
ness which is so marked a symptom of this disease, may be permanent.
In fact, if the direct lesion be in the labyrinth, as it undoubtedly is, in
true Ménière's disease, one cannot understand how the deafness can fail
to be permanent. In the affection known as Ménière's disease, called also
labyrinthine vertigo (Hinton), the chief symptoms are sudden tinnitus
aurium, vertigo, reeling, falling without loss of consciousness, nausea,
vomiting, and sudden, total, and permanent deafness in the affected ear.
The other symptoms may occur in paroxysms for longer or shorter periods.
Put there are on record a few cases, and doubtless many others have
occurred which have been recognized though not recorded in literature,
in which all the above-named symptoms have existed, excepting the
permanence of the deafness. Mr. Hinton records such cases, with the
statement that the recovery of the hearing was perfect, and then raises
the question “were they not caused by muscular spasm 7”
Especially noteworthy is that form of acute aural vertigo in which
the hearing diminishes during the paroxysm, improves during the inter-
val, and finally is restored when the paroxysms of tinnitus, vertigo, etc.,
cease to recur. In such cases, it is manifest that the direct lesion cannot
be in the labyrinth, and the question might be asked, “Are not such
cases due to a spasmodic affection of the muscles of the tympanic cavity?”
Future investigations may show that such cases are caused by undue
inward pressure of the stapes, which is brought about either by a tonic
contraction of the tensor tympani, so powerful as to overcome the equi-
librium normally existing between the latter and the stapedius, or by a
relaxation of the latter muscle, which permits the normal tensor tym-
pani to act without the antagonistic counterbalance of the stapedius. As
tending to answer in the affirmative the question which I have proposed,
. I would cite the following case:—
Mr. X., aged 41, single, a stock broker, was brought to my door in a car-
riage on May 8, 1875, apparently in collapse; upon approaching him, however,
I found him conscious, but very pale and weak, and his surface cold and
| Questions of Aural Surgery, pp. 261–262.
A U R A L V E R TIG O WITH W A RIA B L E H E A R IN G . 1001
clammy. I was asked to accompany him immediately to his home, and while
doing so learned from him that he had been suddenly attacked about an hour
before, while attending a meeting of the Board of Brokers, with sudden and
intense tinnitus aurium and vertigo, with entire inability to stand, and that
he had finally vomited, but that, during all the time of this most disagreeable
attack, his mind had been perfectly clear. I found his pulse about 75, but
very weak, and he stated that there was still some vertigo, but that the buzzing
in the ear had given place to a “stunned feeling” in the head, attended with a
boring sensation which seemed to start behind the auricle, and to extend inward
to the centre of the head. There was no complaint of altered hearing at this
time, but I found that the hearing of the watch was reduced to gº in. in the
affected ear. w
The patient was put to bed, and, as his surface was very cold, a little warm
brandy and water were given, and warmth was applied to his feet. In about
an hour, the vertigo became much less, the head was more comfortable, and
the face lost its intense pallor; pulse 80. The patient then stated that, four
or five weeks before, he had noticed occasional attacks of slight tinnitus in the
left ear; this was brought on or increased by cold air blowing on the ear. A
week or two afterwards, he observed some dizziness with the noises in the ear,
and also some confusion in hearing, especially during the playing of the organ
and the singing in church. The patient had had a good musical education,
and he stated that he heard all notes sharpened (heightened) in pitch, in the
left ear, which, of course, produced subjective discord with what he heard in
the other ear. This was also true for the tuning-fork, small “A,” which seemed
to him higher in pitch in the left or affected ear. As the tinnitus passed off,
however, notes appeared once more to have their true pitch.
With the cessation of the tinnitus, and with the return of the ability to hear
notes in their true pitch, in the affected ear, the hearing also improved for the
watch, rising from 6% in., during the attacks, to #3 in. as the paroxysms ceased.
This variation in the ability to hear the watch occurred not only once, but
repeatedly; and it was also observed that a mantel-clock, easily heard by the
patient across the room in the affected ear, when unattacked by the paroxysms,
was not heard during the latter. The left membrana tympani was more re-
tracted than the right. The Eustachian tubes were easily inflatable; the fauces
normal. There was a history of some stuffiness in the now affected ear, once
after sleeping all night upon the ground, when in the army during the war.
But beyond this, the patient knew of nothing out of the way in the ears.
The patient remained in bed four days: On the first day, it was found that
rest in a reclining posture relieved the tinnitus and vertigo, but on the second
day, a severe attack came on in bed, and lasted several hours. On the third
day, an attempt to rise brought back all the symptoms, which were finally
relieved by vomiting. On the fourth day, another severe and long attack
occurred. On the fifth day, the patient observed that the “stunned feeling”
in the left side of the head, alternated with the tinnitus ; the latter invariably
preceded the attacks of vertigo, beginning as a low and distant singing or
ringing, and increasing to a loud roaring, which culminated in the vertigo and
nausea. On the starth day, there was no attack. On the seventh, he felt very
much better until 11 A. M., when a severe paroxysm occurred ; as a rule the
attacks occurred in the afternoon or evening. On the eighth day, there was no
attack, but on the ninth there was a light one. Again, on the tenth day, there
was no attack, but at midnight of the eleventh, there was a very severe parox-
ysm of tinnitus and vertigo, which woke the patient up. Closing his eyes
ad always aggravated the vertigo, and he now found that the darkness of his
•oom greatly increased the dizziness. Being entirely alone, and unable to help
imself, he was obliged to call for a light in order to gain some relief from the
errible discomfort brought about by the vertigo. He felt as if his whole body
were being borne through space. Usually the apparent motion of surrounding
bjects, during the attacks, was around the patient from the right, over his












































1002 BURNETT,
head, to the left, under him and up again—that is, in a circle, the plane of
which correspended pretty closely with that of the superior semicircular canal,
and about at right angles with the antero-posterior diameter of the head.
The severe attack of vertigo on the eleventh day, extended into the twelfth
day, but there was no vomiting. On the thirteenth day, there were two attacks,
but no vomiting. On the fourteenth day, there were again two attacks, but
they were light, and there was no vomiting. On the fifteenth day, there was no
attack, but on the sia teenth day there was one very light and short paroxysm
of tinnitus aurium and vertigo. On the seventeenth day, there was no attack,
but on the eighteenth there was a very light one, which was the last the patient
had. The hearing now became normal.
Before these seizures came on, the patient had been under intense mental ex-
citement, and his general health had failed from the time of the financial panic of
1873 to the date of his first attack of vertigo. He had also been, in this weak-
ened and nervous condition, obliged by his business to endure the intense and
peculiar noise of the stock-brokers’ board, and also to strain his ears to hear,
and his vocal organs to perform his share of, the bidding which goes on in
such places.
The treatment consisted in general support, with the administration of good
food and some alcohol, together with large doses of bromide of potassium during
the persistence of the paroxysms. As the latter diminished in severity, iron
and quinine were given. On the sixth day of the disease, twenty grains of
bromide of potassium were given every hour, and this was continued until the
tenth day, when the patient took but ten grains every two hours. On the six-
teenth day, the bromide was taken every three hours, and kept up in this way
until the paroxysms had evidently ceased.
The patient went to Europe, made a short tour, and returned to business in
the autumn, about six months after his first attack of vertigo. There has been
no severe return ; this spring, when he was under considerable excitement once
more, he had a slight return of the tinnitus, and a slight tendency to vertigo,
but no sickness of stomach. A few days of rest, and from six to eight grains
of quinine daily, dissipated all these unpleasant warnings, and the patient has
been able to continue his attention to business.
This case of aural vertigo is especially interesting on account of the
variable hearing which was so prominent a symptom during the disease,
and also on account of the recovery of hearing which ensued when the
paroxysms of tinnitus, vertigo, nausea, etc., ceased to recur. In fact, these
features of the disease would tend to place it either in the list of those
of infrequent occurrence, or among those the true nature of which is
not often recognized, and hence undescribed. It is well known that the
prominent symptoms of aural vertigo, viz., sudden tinnitus, intense dizzi-
ness, alteration in the hearing, nausea, vomiting, and falling, without
loss of consciousness, may be caused by the irritation set up by the pres-
ence of a foreign body in the external auditory canal. But here the
cause is easily recognized and removed, and upon its removal the recovery
is complete. The same general symptoms are notoriously characteristic
of labyrinthine vertigo (Ménière's disease), but there the deafness is sud-
den, total, and permanent, though the paroxysms of vertigo may cease
to recur. -
I have lately seen two cases of tumor in the brain (the one proven post
mortem, the other diagnosed as such, but the patient still living), in
which the new growths produced symptoms very much like those usuall
attending labyrinthine vertigo. Still, there were points of differentia
diagnosis in these cases.
The subject of the first, a woman, suffered for many years with most of th
distressing symptoms of Ménière's disease, with the exception that she becam






























A U R AL VERTIGO WITH v A RIABLE HE ARING. 1003
slowly, entirely deaf, whereas the deafness in true, acute, labyrinthine vertigo
is sudden, intense, and permanent. In this case a post-mortem examination
revealed the presence of two tumors, one on each auditory nerve; on the right
side, the morbid growth, as large as a chestnut, seemed to have obliterated the
nerve, and extended into the porus acusticus internus, and apparently into the
labyrinth. The microscopic examination of this growth has not yet been made.
On the other side, the tumor, a smaller one, seemed to have simply grown in the
auditory nerve, between the brain and the internal auditory canal.
In the second case, that of a man, the presence of a tumor of the brain has been
diagnosed ; the patient has some of the symptoms of aural vertigo, but there
is permanent alteration of the gait, which is not characteristic of Ménière’s dis-
ease, nor of any form of aural vertigo originating in the tympanum or external
ear. Furthermore, the patient is not very hard of hearing (both ears are
affected, as they were in the first case), and, though he has constant tinnitus
and paroxysms of vertigo, he can always relieve the giddiness by sitting down.
While these cases may be classed under the head of aural vertigo, they are
manifestly not cases of primary labyrinthine disease.
The case of Mr. X., given above, presented all the marked symptoms
which are found in aural vertigo of the labyrinthine variety, excepting
the sudden, total, and permanent deafness; but this difference would
exclude it entirely from aural vertigo due to primary labyrinthine dis-
ease. The case certainly did not originate from irritation in the external
auditory canal, and that it could have had its origin in cerebral tumor,
is entirely out of the question, not only because such a supposition would
be unwarranted by the symptoms, but also because recovery finally
ensued. May it not be, however, classified as a case of aural vertigo of
the tympanic variety, in which the primary lesion lay most probably in
the muscular structures in the middle ear? As tending to cause such a
disturbance, I would in ention the intense strain on the vocal organs as
well as on the muscular accommodation of the tympanum, which neces-
sarily occurs among those who frequent the brokers’ board, where bid-
ding aloud and listening to bids go on.
In conclusion, I would suggest that, in future investigations of this
most interesting and important disease, it would be well to make “aural
vertigo” a general term ; then four varieties of that disease could very
easily be described, according to the anatomical situation of the cause,
for there might be (1) Aural vertigo from external irritation (in the ex-
ternal ear); (2) Aural vertigo from tympanic disease (Mr. X.'s case is an
example); (3) Aural vertigo from labyrinthine disease (Ménière's disease);
and (4) Aural vertigo from central irritation (cerebral tumors implicating
the auditory nerve). Such careful distinctions in diagnosis are ex-
tremely important, as aiding in prognosis—this being far more favorable
in the first two than in the other varieties.
1004
ON THE SEWERAL METHODS OF EDUCATING, AND ON THE
SELECTION OF PROPER SCHOOLS FOR, THE
DEAF AND DUMB.
BY
LAURENCE TURNBULL, M.D.,
FELLOW OF THE AMERICAN Association For THE ADVANCEMENT OF scIENCE: AURAL SURGEON
TO JEFFERSON COLLEGE HOSPITAL ; PHYSICIAN TO THE DEPARTMENT OF DISEASES
OF THE EYE AND EAR, HOWARD HOSPITAL, PHILADELPHIA.
THE lot of the uneducated and ignorant deaf-mute is sad indeed ; cut
off from intercourse with his fellow-man by loss of speech, and unable to
obtain instruction or amusement from such intercourse, or through books,
he is left to “Nature,” and is governed by naught but his animal passions.
and appetites. It is no wonder then that, when these latter are in full
development, he becomes allied to certain of the brute creation. From
my own dissections of the brain of the deaf-mute, as from those of many
careful observers, it is rendered probable that the deaf and dumb are
capable of receiving and retaining as great an amount of intellectual
knowledge as their hearing brothers or sisters, provided that adequate
instruction be made available through the eye.
As early as the fifteenth century, some effort was made to teach deaf.
mutes, but it is to the sixteenth century that is due the great honor of
having been the period of jubilee to the deaf and dumb ; and to the Abbé
de L’Epée was given the great gift of teaching deaf-mutes by a symbolic
language, so that they might know good from evil, have intercourse
with a select few of their fellow-men, and above all acquire such aspi-
rations after true knowledge as would fit them for a happy home here,
and for a better world above. Another devoted man, the Abbé Sicard,
who took up the clue already furnished by de L’Epée, adopted sign-lan-
guage, and enlarged, improved, and reduced it to a system. The knowl-
edge of this valuable method soon crossed the Atlantic, and its advocate,
the Rev. Thomas H. Gallaudet, D.D., founded the American Asylum at
Hartford, Conn. (1817), and, soon after (1820), M. Clerc (one of the favor-
ite pupils of Sicard), who came over with Dr. Gallaudet, organized the
Pennsylvania Institution for the Instruction of the Deaf and Dumb, in
Philadelphia. This institution has sent out, since its organization, 1700
pupils, well educated, and with a careful moral training which has been
of inestimable advantage to them and to the community at large. Ger-
many was not long after France in this philanthropic labor, for, in 1760,
Samuel Heinicke, a Saxon by birth, developed the “artificial method”
of instruction for deaf-mutes. The principal aim of this good man was
to improve the “French system,” and to endeavor to cultivate whatever
might remain of speech, by developing the latent power which exists in
all save a very few. In the early stage of this system, artificial signs
are absolutely necessary; but when these have been acquired, they are to
be employed only as a ladder to reach the higher department, where the
finger-alphabet and other artificial signs are no longer required. When
successfully taught by this system, pupils are enabled to think in the
E DU C A TI O N OF T) E A F A N ID ID U M B. 1005
idioms of the language of their country, to hold audible conversation,
and so understand much that is spoken to them, being thus rendered
practically less deaf, and actually less dumb.
Another advance which has been made in the further improvement of
the mode of instruction of the deaf-mute, comes from England, in the
system known as “Bell's Method of Visible Speech,” which, having re-
ceived but little attention in the country of its origin, was brought by its
author to the United States, where it has been received and adopted in
seven of our forty-eight institutions, and with the most gratifying re-
sults. I do not find fault with what has been done under the old me-
thods, but rather rejoice that so many thousands of deaf-mutes have
received the advantages of an education by means of the sign language,
aird of articulation taught by the German method. I would also state
that the United States have a “National College” at Washington, where
more advanced studies can be pursued, and where young deaf-mutes are
graduated with a standing and scholarship not inferior to that achieved
by the graduates of ordinary colleges. This institution bears to others
for the deaf and dumb, the same relation that colleges bear to schools
and academies. Many of the graduates of this college have received
appointments as teachers, while others are editors, authors, and writers,
or are found in the various government offices, in the exercise of duties
which they are quite capable of performing in an entirely satisfactory
manner. In our Centennial Exhibition will be found some admirable
pictures executed by deaf-mutes, as well as other products of their pencils
and pens. They are also capable handicraftsmen, and are to be found in
our shops and factories, as well as in the Industrial Homes founded in
this city for their special benefit.
Bell’s method or system of visible speech gives the pupil, by means of
drawings, etc., a knowledge of the concealed parts of the mouth and
throat, which are used in articulation, as also of the movements of the
various parts, so that the pupil is thus better able to gain conscious con-
trol over them. This method of writing any sounds that the pupils may
utter, serves to interest them in the practice of the elements and com-
binations, thus giving them great power over their organs of speech, and
obviating the necessity of informing them that a sound is wrong if it is
not the one which the teacher wishes to obtain. It is the practice of
those who teach this system to write all sounds in the visible speech-
symbols, and especially those that are essential in English speech. The
symbolizing of odd sounds also leads the pupil to think and study about
the parts of the mouth that produce them.
I shall now discuss the following questions: (1) What is the best me-
thod of classifying deaf children, and is it advisable to place them in
ordinary, or in special, schools 7 and (2) How many deaf-mutes are ca-
pable of receiving Bell’s method of instruction, and should the attempt
be made to instruct all deaf-mutes by articulation, or by the sign language
only 7 Not having heard Dr. Blake's paper, I shall attempt to answer
these questions from my own personal observations.
If a child can hear sufficiently well to understand the teacher when
near him, the ordinary School is, for him, decidedly better than a special
school. Children sometimes become deaf after having learned to talk
nd read ; such children may profitably attend an ordinary School, pro-
ided that the parents or teacher take time to explain the lessons; but
f this be not done, the child will often recite in a parrot-like manner,
without understanding what he has learned, and will go over a great deal




























1006 TURNBULL,
of ground with very little profit. This has been the experience of
teachers of deaf-mutes, even when the pupil has learned to read quite
well by observing the lips of the speaker. Congenital deaf-mutes, at-
tending an ordinary School, may learn to write, or rather to copy, and
may perhaps get some idea of numbers; but the teachers of such schools
do not know how to reach their pupils’ minds, even if they have the time
to teach them. As a rule, such children might as well be at play, except
that school occupies their time and their thoughts. Another advantage,
however, which is gained for the deaf-mute children, is in their mingling
as much as possible with those who hear.
If a child cannot profit by the instruction given in an ordinary school,
let him if possible have a private teacher, but not necessarily in his own
house, as he is not always subject to the best government there. If he
needs stimulating, it may be well to place him in a class with four or
five others of a suitable degree of advancement; and if this cannot be
done, he may be placed in a school or institution where the instruction
is especially adapted to the deaf.
If children are too deaf to profit by the common school, and yet have
sufficient hearing to have acquired speech through the ear, instructors of
the deaf are nearly or quite unanimous in the opinion that they should
be taught by articulation and lip-reading. The experience of the teachers
would lead them to say, “Let the attempt be made, if possible, to teach
every deaf child in this way.” Of 116 pupils in the “Clark Institution
for Deaf-Mutes,” three have been dismissed as incapable of learning arti-
culation and lip-reading, and one because she required more individual
instruction than could be given her. The latter, however, has since been
taught, so that speech and lip-reading are her means of communication
in her own home. Some of the remaining number of pupils (congenital
mutes) speak imperfectly, but in every instance well enough to be under-
stood in their own homes, while some of the indifferent speakers are
fairly successful in lip-reading, an acquisition as valuable as that of
speaking. Many congenital mutes speak so as to be understood by
strangers, and will probably be able to make speech and lip-reading a
successful means of communication throughout the world. Of the 116
pupils at the above-named institution, one-third are semi-mutes or semi-
deaf, although some of those so classed have not had hearing enough to
learn to talk.
My object in writing this brief paper has been : (1) To excite a greater
degree of interest, in physicians, for the deaf-mute, with an endeavor on
their part to prevent deafness, and so diminish the number of deaf-mutes;
(2) To induce a more conscientious study and treatment, by physicians,
of the ears of their patients, when the latter are attacked by scarlet or
typhoid fever, cerebro-spinal meningitis, or obstruction of the Eustachian
tubes as the result of measles, diphtheria, tonsillitis, or syphilis; (3) To
lead physicians to give the systems of instruction pursued in our various
institutions for the deaf and dumb, a certain amount of study, so as to be
able to recommend intelligently to patients, their relatives, or friends, the
best method for each individual case; and (4) To induce physicians to
recommend that there should be appointed by the governor of each State,
a commissioner, to collect, examine, and classify the deaf and dumb, so
that all who are found to possess any degree of hearing, or any remnant
of speech, may be taught articulation by the method of Bell, and that
those who are unable to profit by this system, may be taught the lan-
guage of signs, natural or acquired.
E I) U C A TI O N OF D E A F A N ID D U M B. 1007
To aid them in their arduous work, I have recommended to some of
our teachers of deaf-mutes, that their pupils should use mechanical appli-
ances for improving the hearing power. By speaking or singing differ-
ent vowels into one of these aids to hearing (tubes or trumpets), we can
determine how much hearing the pupil possesses, and, if he be able to
distinguish one vowel from another, a continued use of this mechanical
aid may ultimately enable him to utilize audition as an auxiliary to
vision. I have known very deaf persons, by the aid of this means alone,
to have had their hearing so much improved that they could distinguish
all ordinary sounds, and, by some effort, enter into conversation. An-
other important mechanical aid to persons who are deaf from diseases
in which the tympanic membrane is lost, in part or in whole, but in which
the inner small bone (the stapes) still remains, or in whose ears the bones
have become stiff or anchylosed, is the pellet of cotton, moistened and
applied near to the bones, or against the stapes, so as to bring the parts
in closer contact with external vibrations, and thus cause the sounds to
be transmitted to the auditory nerve.
In conclusion, I have added, chiefly from German authorities, the most
recent views on the subject of phonation, knowing how much interest
this subject is exciting in the minds of both physicians and teachers of
the deaf and dumb, at the present day. Some writers have endeavored
to prove that the brain molecules of the deaf and dumb differ from those
of persons who hear; but, as I have already stated, the brain is rarely
affected in those that are deaf, while, on the other hand, in many
instances of extensive disease of the brain, not involving the auditory
nerve, deafness has not resulted. Occasionally the spine is diseased, or
the nerves which, coming from that great centre, give power to the
tongue and larynx, thus rendering the deaf-mute unable to articulate, no
matter how much instruction he may receive. Section of the spinal
accessory, or of the inferior laryngeal nerve, entirely destroys the voice,
so that these may be termed the true vocal nerves. If, therefore, the
centre of phonation is situated in the spinal cord, it is plain that it can-
not be found in the brain ; anencephalous children have been known
to scream under the influence of external excitation or internal pain.
The centre of the memory for words, appears to reside in the brain, and
aftempts have been made to fix its seat in the anterior lobes, but the
observations made on this subject are as yet contradictory. Each centre
is independent of the other, for a cry may be easily uttered when articu-
lation is very difficult. Amnesia, or the loss of memory for words, there-
fore, must be distinguished from aphasia, or the loss of power to pronounce
then ; the patient suffering from aphasia can still write his thoughts,
while in amnesia he can only express himself by drawing a representa-
tion of the object to which he wishes to refer.
1008
ON BATHING, SWIMMING, AND DIVING, AS CAUSES OF
AURAL DISEASE.
- BY
LAURENCE TURNBULL, M.D.,
FELLOW OF THE AMERICAN Associ ATION FoR THE ADVANCEMENT OF SCIENCE ; AURAL SURGEON
TO JEFFERSON COLLEGE HOSPITAI, ; PHYSICIAN TO THE DEPARTMENT OF DISEASES
OF THE EYE AND EAR, HOWARD HOSPITAL, PHILADELPHIA.
SWIMMING and diving in cold water seem to me to be important and
frequent causes of disease of the external auditory canal and anterior
surface of the membrana tympani, as also of the middle ear, though bath-
ing in river or sea water is, when wisely and properly regulated, both
healthful and pleasant. The evils attending bathing and swimming in
cold water are the entrance of this cold fluid, not only into the external
meatus, but as far as the membrana tympani, causing inflammation of
the lower portion of the auditory canal, and of the anterior surface of the
tympanic membrane. But a still greater evil is from sudden deglutition,
during diving or swimming, by which—the mouth, nose, and pharynx
being filled with cold water, and the mouths of the Eustachian tubes
open—a portion of the water passes into the middle ear. . This result
rarely occurs in expert swimmers or divers, but is most common in begin-
ners, who suddenly, from cold, or the shock of the contact of the water,
breathe or swallow in a sobbing manner. I have, however, known it to
occur in old and experienced swimmers while plunging headforemost,
owing to the intense coldness of the water—the act of deglutition being
entirely involuntary.
If the water is not removed by placing the head to one side, and draw-
ing the external ear forcibly outwards, shaking the head at the same
time and opening the mouth, it is apt to cause inflammation, with the
formation of pus, followed by perforation of the membrana tympani; or
the inflammation, if neglected, may pass inwards to the cochlea and
labyrinth, and, implicating the brain, may terminate in death.
It is a well-recognized maxim among those who devote special atten-
tion to diseases of the ear, that no cold fluid should be allowed to enter
even the external auditory canal; still this important fact is not suffi-
ciently recognized by the profession at large. The entrance of warm water
into the ear is less objectionable, but even this is not quite free from dan-
ger, and has its disadvantages; and the water should in all cases contain
a few grains of a saline ingredient, like borax, soda, or common salt, when
employed in washing out the ear. The symptoms of water in the mid-
dle ear are, in the first stage, an uncomfortable sensation, followed by
earache or pain, which after a time becomes agonizing, and is accompa-
nied with great tenderness behind the auricle. In proof that water in
the ears is injurious, and causes deafness, I might cite a number of in-
stances, and it is a well-known fact that dogs which are thrown into
water become deaf.
Many cases of this form of disease, in its chronic stage, come under
treatment during all seasons, but acute cases, from swimming and diving,
occur during the summer months, and chiefly in boys from eight to six-
BATHING, S W IMM IN G, E.T.C., As CA USES OF A U R A L DISE ASE. 1009
teen years of age; a much smaller number occurring in the fall and win-
ter. If the acute form be promptly treated, entire recovery takes place;
but should the case not be seen until after the chill, it is always followed
by a discharge of shorter or longer duration. In cases not recognized,
the symptoms of violent headache, furious delirium, and coma, give the
physician the impression that disease of the brain is present, and the case
thus improperly treated terminates in death. The morbid condition in the
first stage consists in acute inflammation of the extremely delicate mucous
membrane lining the middle ear. This inflammation is followed by effu-
sion of fluid, and, after twenty-four hours, by the formation of pus; it is
in every instance attended by fever, with swelling and inflammation of
the nasopharyngeal space, and great pain. If this fluid or pus be removed
by incision into the membrana tympani, followed by the use of the air
douche, and injections of hot saline water, the patient recovers, and the
ear is saved. The patient is apt to remain deaf for several weeks, and
the local application of tincture of iodine, with or without some anodyne,
brushed around the back of the auricle, facilitates the removal of the in-
flammatory thickening. To diminish the discharge of pus, should it
continue, we may employ a powder of salicylic acid and starch, blown
into the meatus and after a time washed out, and reapplied twice a day,
until the discharge shall have ceased and the perforation have become
closed.
64
1011
SECTION ON SANITARY SCIENCE.
P R E S I D E N T OF T H E S E C T I O N .
STEPHEN SMITH, M.D.,
OF NEW YORK.
W I C E - P R E S I D E N T .
JOHN S. BILLINGS, M.D., U. S. A.,
OF WASH IN (; 'I' () N. g
S E C R. E. T. A. R. Y.
EZR.A. M. HUNT, M.D.,
of M ET tº CHEN, N E W J ERs Ey.
THE PRESENT CONDITION OF THE EVIDENCE CONCERNING
“DISEASE-GERMS.”
BY
THOMAS E. SATTERTHWAITE, M.D.,
OF NEW YOR IX.
THE object of this paper is to give a sketch of the prominent theories
now held as to the nature of disease-poisons. It seems hardly necessary
for me to say that the short space of time at my disposal will prevent me
from attempting to furnish either a detailed account, or even a review, of
the ample material that may be brought to bear upon these matters. I
desire, however, to state this clearly at the outset, because I am sure
that in the presence of the vast number of observations that have been
made, especially during the past few years, nothing short of a very
extended treatise could be made to fairly represent the whole subject.
Fortunately, my task is limited by the title of my paper, but I find
myself at the same time in the difficult position of one who is called
upon to define the proper limits of the subject, or, in other words, to
mark out the debatable ground.
In doing this, I have thought it desirable to direct the attention of
the Section chiefly to a certain number of important topics bearing upon
the subject, as in this way we can get a better idea of its present status,
and I have naturally included among the topics those with regard to
which I have had the most personal experience.
It is a matter of regret that I shall be obliged to omit many facts of
historical interest, as well as the names of well-known men, who, like
Pasteur, Sanderson, Salisbury, and others, have enriched the field by
original research. I shall also have to run the risk of appearing dog-
matic, in assuming that certain questions have virtually been settled, or
that others do not concern us, I shall thus take it for granted that the
minute, vegetable Organisins, called bacteria, exist pretty generally in
1012 SATTER THW AITE,
nature, both in and out of the body; and, following the acceptance of
this idea, that the question of spontaneous generation need not be intro-
duced into the present matter in hand.
Almost any one, who for the first time follows the discussions on these
subjects, encounters a little difficulty in the word germ, which is, per-
haps, not a happy one to have come into use as expressing that from
which a disease is derived. This, however, is its true meaning, and
neither indicates a vegetable nor an animal character, nor even that it is
living, though this latter motion is held by Beale." For even should a
disease-poison turn out to be a chemical substance, the term “germ” is
equally applicable to it, according to the proper definition of the word.
In fact, under this threefold character, we are called upon to study these
active principles, for about these three possibilities, of a vegetable, an
animal, or a chemical, character, are grouped the three prominent theories
that have been framed to explain the origin of infective diseases. These
theories, or hypotheses, as they might be more properly called, are (1)
the vegetable-germ, (2) the bioplasm, and (3) the physico-chemical,
theory. The infective diseases are such, in a general sense, as are either
propagated by direct contact, or through the medium of the air, various
gases, fluids, or common objects. Inquiries have mostly been directed
to such of these as are called septic, viz., erysipelas, pyaenia, septicæmia,
and puerperal fever, and to others known as contagious, miasmatic, and
the like, such as smallpox and typhoid fever.
I shall try to sketch these theories briefly :-
I. The “vegetable-germ theory” is the one that heretofore has
attracted more attention and interest than any other. Though we
have known it under this name for only a comparatively short time, it
is not of recent origin, and has in reality been recognized from very
early times in the history of medicine. It was at first, of course, merely
a hypothesis of the flimsiest character, though it soon came to be re-
garded as a possible one, when the microscope showed that both animal
and vegetable organisms, of exceedingly minute size, lived and grew in
the interior of the body.
More color was given to this theory by the labors of Schwann, Cag-
niard de Latour, and Kützing,” who found that in fermenting matters
there was a growth and multiplication of minute organisms, which they
regarded as vegetable; when at a later period Pasteur" asserted that these
particles were conditions essential to fermentation, then it came to be
assumed that the phenomena of disease, which in many respects resem-
bled them, might be due to an analogous cause. It was in this way that
the doctrine of vegetable germs as the cause of disease came to be re-
garded as having good & priori evidence in its favor. This belief was
further strengthened by Schönlein, who, in 1838, published his account
of the fungus plant found in Favus, which is now almost universally
believed to be caused by the deposit and development of the plant in the
diseased part. As further investigations were made, the silk-worm dis-
ease, and the potato-rot, or murrain, were also admitted to be caused by
growths of a similar nature.
More recently it has been held that a great many of the infective dis-
| Disease-Germs, p. 10. o -
* Schützenberger on Fermentations, pp. 36–7.
* Bastian ; Lancet, April 10, 1875, p. 502.
D IS E A S E - G E R M. S. 1013
eases have each a microphyte," or minute, microscopic plant, as its peculiar
active principle. These latter alleged discoveries have, however, been
received with marked opposition, many excellent authorities refusing to
accept these matters as definitely proved.
II. Other hypotheses had, therefore, to be brought forward, and promi-
ment among them was that of Beale,” who, admitting that particles of
minute size may produce disease, and in fact laying stress upon this point,
believes that the particles in question are degraded portions of the animal
body. Such particles he tells us have been seen by him, when using a
sufficiently powerful lens, and he assures us that they divide and sub-
divide under suitable conditions, and “as living matters alone divide.”
Rossº has a modification of the same idea, and Hutchinson* states,
with reference to certain diseases at least, such as gonorrhoea, purulent
ophthalmia, erysipelas, and phagedaena, that they are due to the conta-
gion of living cell-material, such as is called protoplasm, or bioplasm.
These tenets, with more or less modification, are sustained by those who
believe in the “bioplasm theory.”
III. Bastian deserves to rank as the ablest exponent of the remaining
theory, the “physico-chemical,” or “physical.” It is called a modifica-
tion of Liebig’s old theory, and, as now enunciated, holds that though
minute organisms may act as ferments, they do so by virtue of chemical
actions set up by them, while minute particles of the human body have
almost an equal capacity for setting up diseased action under suitable
circumstances. In either case, bacteria are apt to be engendered as cor-
relative products.”
It will be noticed that two of these theories are based upon the belief
that the origin of disease is due to minute particles, and that this belief
does not militate against the third theory, and is admitted as possible by
its advocates. This simplifies the matter before us very considerably,
and enables us to state at once that these poisons are particulate, or cer-
tainly that they are apt to be bound up with particles.” I will merely
add here that, in my experience, it may be possible that this has always
been the case; some of the particles or molecules, may, of course, be
almost immeasurably small. -
We may get a good idea of the controversial points by considering
first the arguments brought forward by those who support the vegetable-
germ theory, and then the answers or explanations of its opponents.
(1) I have already stated that after the publication of I’asteur's bril-
liant experiments in relation to fermentation and putrefaction, they
were regarded as affording good, d priori evidence of the truth of the
doctrine now under consideration. But it must be remembered that,
though sustained by the observations of many others, these views were
strenuously opposed by Willis, Stahl, Liebig, and others, chiefly of the
German school." There is little doubt now that these latter were in a
measure correct; in fact, Pasteur” has seen fit to modify some of his
earlier statements, for he quite recently has said that both alcoholic fer-
mentation and putrefaction may be initiated by the chemical processes
i Such as the diphtheria-micrococcus of Letzerich, the cholera-fungus of Hallier, and the
measles-fungus of Salisbury.
* Disease Germs. pp. 5 and 11. * British Medical Journal, May 27, 1876, p. 22.
* Ibid., April 24, 1875. p. 559. * Lancet, April 10, 1875.
* There is excellent evidence of this in all the diseases which are alluded to in this paper.
7 Schlitzenberger. p. 40.
S ſancet, April 10, 1875, p. 508; and Tribune Médicale, Avril 1, 1875, p. 321.
1014 SATTERT H WAITE,
taking place in the tissue-elements of certain fruits and vegetables, inde-
pendently of the minute organisms supposed to be necessary to the pro-
cess. Similar statements had previously been made by M.M. Le Chartier
and Bellamy, who found that, in modified forms of fermentation, inde-
pendent organisms were generally absent at first, though they often made
their appearance afterwards. Among the late contributors to this subject
is Dougall, who tells us that he has produced putrefaction without bacteria,
and has seen bacteria without putrefaction—in which latter statement
he can doubtless find many to accord with him.
Hiller” has also made statements to the same effect, for, having injected
fresh eggs with a fluid containing bacteria, but not putrid, the eggs
remained unaffected, which showed that bacteria might be present with-
out decomposition ensuing. These views have been further supported by
I)onné and Beauchamp.” They are interesting, as showing that there
has been, and still is, a diversity of opinion among scientific men as to
the rôle which organisms play in fermentation and putrefaction. I may
here add, also, that, in regard to the question of the ferment or cause of
the ammoniacal decomposition of the urine, or fermentation, as it has
been called, Pasteur" has stated definitely that it has not yet been demon-
strated mathematically that the little torula to which he called attention
several years ago, is the cause of the change, though he asserts that
whenever putrid urine is examined the little plant is found.
(2) Another argument, commonly urged by those who believe in the
vegetable-germ theory, is as follows: Almost all authorities admit that
minute organisms may be the sole and sufficient cause of diseases such
as scabies, favus, and the like, while many epidemic diseases among
plants and animals are similarly produced, so that it is reasonable to
suppose that vegetable organisms may be concerned in the production of
infective diseases, the origin and propagation of which are thus explained
with comparative ease. In reply, it is to be said that while no one
may be willing to deny these facts, and while the silk-worm disease and
potato-rot may be due to the vegetable particles that have been described ;
while various cereals may be affected with peculiar diseases, each exhibit-
ing a peculiar plant; and while the pollen of many grasses may be the
real cause of the hay-catarrh, or fever, as maintained by Blackley," yet,
that, on the other hand, it is certain that close observation in certain
other directions shows the number of diseases due to vegetable growths
to be really smaller than was formerly supposed. One has but to compare
the long series of skin-diseases which but a short time ago were put down
as caused by microphytes, with the modest list of five possible and three
probable organisms, which are mentioned by a recent authority in these
matters." I refer to the Achorion of Favus, the Tricophyton of Tinea,
and the Microsporon of Pityriasis versicolor.
The recent investigations of Lewis and Cunningham point in the same
direction. They make it appear probable that in the Fungus-foot of
India, the peculiar growth called Mycetoma is not necessary to the dis-
ease, as in some instances it has not been found, though the examinations
were doubtless conducted with skill and care." In the light of these and
similar experiences, it would appear that while we are now and then dis-
| British Medical Journal, April 24, 1875, p. 557.
* Centralblatt f der med. Wiss., Dec. 1874.
* Schützenberger, p. 225. * Loc. cit.
* Experimental Researches on Hay Fever, 1873. ° Piffard, Diseases of the Skin.
Lancet. January 22, 1876.
DISEASE-GERMs. 10 15
covering new plants or animals that act as disease-agents, we at the same
time sometimes find that the number of such alleged causes of disease
has been too large.
(3) It is further said that, in a number of the infective diseases, such
as smallpox, typhoid fever, etc., there is a constant ratio between the
intensity of the disease, in a given part, and the presence of bacteria ; SO
that, where the disease is most active, bacteria are most numerous. This,
indeed, is just what we should expect, in support of the vegetable-germ
theory, and it is a fact that few of its opponents are prepared to deny.
But it has long ago been shown by Schwann and others,' and more
recently by Tyndall,” that the air at times swarms with bacteria; and it
is also true that bacteria occur in the body in health, the mucous mem-
brane of the alimentary canal, from the mouth to the anus, having been
found peopled by myriads of them in active, independent motion.” These
facts have been so generally confirmed, that, as it may be remembered, I
assumed them at the outset. Now bacteria are also found in the heart
of the tissues, which is explained by the fact that they are taken up by
the absorbents, and carried about, while they have, in a certain number
of instances, been found in the blood of the lower animals, and some-
times in human blood.” Now, as long as this remains true, it is for
those who maintain this theory to show that there is a manifest differ-
ence between the bacteria which they believe to be disease-agents, and
those that we know are generally to be found in the tissues; for the
mere fact that bacteria are found in extraordinary quantity at any one
point, does not by any means indicate disease. In a large number of
experiments, performed by Dr. Curtis and myself, it was found that,
under certain circumstances not incompatible with ordinarily good
health, vast collections of bacteria were to be found upon the tongue.
Under these circumstances, it seems to me perfectly proper to believe
that bacteria occur in the diseases just named as correlative products,
and not as causes, of the disease. I may here venture to state that, as
far as diphtheria is concerned, and upon this matter I have made some
special study, I have never found any organisms connected with the
disease that could in any way be distinguished from those found at other
times in the body.” Of these experiments, I shall say more presently.
(4) Now, while it is further alleged that, in another class of diseases,
such as erysipelas and pyaemia, septicæmia, puerperal fever, and hospital
gangrene, there is always a numerical increase of bacteria at the points
involved, we may be allowed to state, in this case also, that, the presence
of bacteria in the body being allowed, their tendency to accumulate in
diseased portions does not necessarily show that they have any relation
with the cause of the disease; and when the question is further asked,
how may we distinguish the bacteria of such diseases from each other,
or from those of putrid infusions, I think that the same difficulty will
be found as in the case of the other infective diseases, before mentioned.
(5) An important question is often asked, viz., Can any strictly chemical
substance be a fever-producer, or do we know of any substance, whose
chemical nature we can express by symbols, that can produce fever ?
This is a question usually put to those who advocate the physico-chemical
| Beale and Sanderson. 2 Lancet, May 8, 1875.
* Bastian, however, seems inclined to believe that these organisms do not come from the
ai * Wagstaffe and others.
See Report on the Pathology of Diphtheria, in Report of the Bºard of Health of the
City of New York, for 1877.
º
1016 SATTERT H WAITE,
theory of disease. It may be impossible to answer it affirmatively, and
yet this by no means settles the matter. The minute chemistry of animal
poisons is far from being as yet in a satisfactory condition, but we can-
not therefore say that such substances may not at some time be found.
Weir Mitchell," of Philadelphia, in his most extensive researches on the
poison of the rattlesnake, assures us that the poison is an albuminoid
body (which he calls crotaline), which is not precipitated by boiling, but
is by alcohol. Prince Bonaparte seems to have found, also, that the
venom of the viper contains a similar, albuminoid substance, which he
has called echidnime. Hiller” also believes that, in glycerine, he has found
a material that has the power of extracting certain chemical poisons in
putrid and septic matters. We see, therefore, that a certain definiteness
has been reached in our estimation of a few active principles, and it is
possible that when this field has been more actively worked by the
chemist, we may find those other matters which the microscope has
failed to analyze, and which yet may react in a definite way, so as to
show individual characteristics. It is also reasonable to suppose that
chemical combinations of more or less complexity may be formed in the
body, under the influence of peculiar processes, or of the presence of viru-
lent matter, and then, in either case, may communicate like qualities to
other ordinary matter of the body ; for the venom of serpents is certainly
formed out of the normal tissue-elements. In the case of chemical com-
pounds, they may increase to an indefinite amount when placed in suit-
able liquids, where the proper constituents are present.
(6) It is also maintained, by the vegetable-germ theorists, that the
extraordinary capacity which disease-poisons have of retaining their
vitality, is a strong argument in favor of their being bacteria, which
resist various reagents, and exposure to extreme degrees of heat and
cold, and which may remain dormant for long periods of time, without
losing their capacity for reproduction. It is known, however, that the
poison of the rattlesnake resists boiling, and is not rendered less virulent
by alcohol; and Fayrerº has asserted that this latter quality belongs to
the poison of the cobra; but both boiling and alcohol prevent the multi-
plication of bacteria, according to the testimony of so large a majority of
observers that this point has seemed to me sufficiently settled. Whether
or not minute particles of human tissue are capable of living long after
separation from the body, is still a question before us, and not one that
can just yet be summarily dismissed, as some would imply.” But if it
should prove true that the little particles of living matter soon lose their
capacity for reproduction, it does not follow that they have lost their
power of acting in such a way as to communicate qualities to, or set up
actions in, other particles. This is advocated by one who believes in the
physico-chemical theory.
(7) Again, it is frequently urged by those who believe in the vege-
table-germ theory, that the bacteria of certain diseases will induce like
diseases in other persons or animals, when inoculated. This may be true
in the case of individuals, though there is testimony against, as well as
for, this assertion.”
I may here state that the results of my experiments and of those of Dr.
Curtis, in regard to diphtheria, have failed to show that the inoculation
of the bacteria of diphtheritic membranes upon animals produce any
Smithsonian Contribution, p. 46. * Centralblatt f. Chir., 14, 15, 1876.
* Edinburgh Medical Journal, 1868 et seq. * Sanderson.
* Compare the statements of Wolff, Küssner, and others.
D IS E A S E - G E R M. S. 1017
other lesions than those of bacteria artificially reared or obtained from
our own mouths. Hiller proposed to himself the following questions:
whether (1) bacteria had the property of exciting inflammation, when
inoculated 2 or (2) if in the blood did they produce fever ? or (3) multi-
ply 7 or (4) have the capacity of penetrating living organisms? IIe expe-
rimented on animals, using the bacteria taken from different kinds of
decomposing substances. The temperature rose, but not above 2° Fahr.;
on the third day, the bacteria at the point of inoculation were shrivelled,
and on the eighth day they had disappeared. Even when introduced
into the living blood, they soon ceased to be recognized, though in blood
exposed to the air they multiplied rapidly. In this connection, the expe-
riment which Hiller made upon himself, the results of which he exhibited
at last year’s meeting of the German Surgical Society, deserves more than
a passing notice.” IIe allowed himself to be punctured in eight places
with bacteria, which he had isolated by a method of his own. When
these punctures were exhibited at the Congress, six days afterwards, they
had nearly healed, no traces of redness, inflammation, or pustule, remain-
ing. He also showed another place where he had been subcutaneously
inoculated three days before with a fluid containing bacteria. There had
been local oedema, occurring six hours afterwards, but it had disappeared
in forty-eight hours, and on the day in which he made his communica-
tion to the Society his general condition was excellent, his appetite was
good, and he had no fever.
My own experiments on animals agree in a certain number of instances
with those of Hiller. When the bacteria were filtered out of Cohn’s
nutrient fluid,” in which they are known to grow with exceeding rapidity,
and were inoculated in the thighs of rabbits, the organisms ceased to be
visible after the fourteenth day, though there was usually a marked
deposit of a pasty material at the point of inoculation. The same thing
'as observed when inoculations were made with tongue-scrapings, or
with diphtheritic membrane; the bacteria Soon ceased to multiply,
though the time at which the process stopped was variable ; they became
bloated and distorted, so that it was hard to make them out ; after three
weeks, they were rarely seen at all, though the focus of disease remained
extensive, the animals quite often dying at a later date with symptoms
of constitutional infection. Still, in all of these experiments it is not
probable that the bacteria were ever completely isolated, for even when
Cohn's fluid was used, where the only organic substance was the tar-
trate, fermentation took place, and some of the products of fermentation,
perhaps in the form of minute particles, may have attached themselves
to the bacteria which then may have been carriers of the poison—itself a
chemical product. And yet I have, in repeated instances, seen fluids
inoculated upon rabbits, where the microscope showed bacteria in con-
siderable numbers, though no trace of a lesion was observed.
We have now to consider a topic of great importance to us, in further
defining our subject, and this is the classification of the organisms that
are now called bacteria, to which class the vegetable-germ theorists,
almost without exception, refer the agency of disease. Their name does
not by any means imply that they are all rod-shaped, though the word
bacterium means a little rod, but rather that they belong to a class of which
! Allg. med, central Ztg., 1, 2, 1874. 2 Archiv f. klin. Chirurgie, 1875.
* Tartrate of ammonium, 1 gramme: phosphate of potassium, sulphate of magnesium,
each. 5 decigrammes; phosphate of calcium, 5 centigrammes; distilled water, 100 cubic
ce Int] net res.
1018 SATTER THWAITE,
the rod-shaped bodies are common types. Various classifications have
been given of them, those of Billroth and Cohn having met with special
favor, and each of these being tolerably complete. I will venture to say,
however, that no elaborate classification appears to be necessary for these
bodies, judging at least from our present knowledge of them, so that I
shall describe them by common terms, which can be as well understood
by those who are not familiar with these matters as by those who have
carefully studied them. Simple as the classification will be, it is per-
haps convenient rather than accurate, for while it seems to me to cover
the whole ground, it may be questioned whether it does not do more ;
i. e., give a reality to some forms the existence of which is in doubt.
First we have (a) the very minute, round bodies, varying in size from
those which are described as having a diameter so small that they can
barely be seen by the ordinary high powers of the microscope, up to those
which have a diameter of about 37% go of an inch; these are the Micro-
cocci of Cohn, and the Microbacteria of Billroth ; then we have (b) the
little, oblong, or slightly oval, bodies that have a length of about one-
third the diameter of a lymphoid corpuscle, and a breadth of about 34 on
of an inch; they occur singly, or in chains of two or more elements;
thirdly, there are (c) the little chains which often appear to be made up
of minute spheroids; fourthly (d), the globular masses that appear to be
made up of spherical bodies (Zoogloea of Cohn, Colonies of Hallier, Glia-
coccos of Billroth); and fifthly (e), the filamentous bodies which are so
often seen to glide about with an undulating or serpentine movement
across the field of the microscope (Spirilla of Cohn).
I use the term bacteria for all these forms, and yet, as I have already
said, objection may be made to this classification. It is held by some
that the round particles known as micrococci, are nothing but either the
rod-bacteria, seen end-wise, or merely particles of dead granular matter,
or perhaps particles from the living protoplasm of cells. It is probably
true that many mistakes of this kind have been made, and yet I should
feel disinclined to believe that there are no round bacterial bodies, coming
within the range already given, for it has seemed to me that the chains
just described are composed of minute spheroids. As for the filamentous
bodies known as spirilla, they are also thought by some to be composed
of spheres. These bodies when single, or in segments, have two states,
one of activity and one of rest ; but mere absence of motion does not
necessarily indicate that they have ceased to live, for under changed con-
ditions they again resume their motions and multiply. All small sphe-
roids have a motion within a limited area, but it is difficult, if not impos-
sible, to distinguish in them that motion which is called “independent”—
which is inherent in them as living particles, and is not caused by external
circumstances. It has long been known that the mere fact of motion, in
such particles, does not indicate life ; for all particles are apt to show a
kind of motion, which is greater in very fluid media, and less in dense
media. These well-known facts, however, do not seem to be sufficiently
prominent in the minds of some who have written on these subjects.
Real motion in such bodies may be certainly recognized, when they
move against or across currents, and do not merely show irregular rota-
tion or vibration in a limited area. The rod-bacteria, chains, and long
filaments, or spirilla, just described, have clearly this sort of motion,
under certain conditions of life. The spirilla often dart across the field
of the microscope, stop suddenly, and then dart back, or off in some new
direction. Various micro-chemical methods have been devised for assist-
D IS E A SE - G E R M S . 1 019
ing the eye in detecting them. Among those that have claimed the
most attention, are the methods of Letzerich, Eberth, and Hiller, all of
which are more or less useful. Detzerich" employs a watery solution of
iodine, which imparts to the rods and chains a deep-brown color; but
Hiller has shown that this method is unreliable, from the fact that
granular iodine is deposited, and that there are no means, probably, of dis.
tinguishing the iodine particles from the so-called spherical bacteria, or
micrococci, etc., if such be present. The mere size of such atoms gives
no criterion for determining their character, for, according to Cohn, the
distinguished botanist, they vary in size within exceedingly wide limits.
My own experience in using this method has inclined me to coincide
entirely with Hiller.
Eberth's test consists in boiling the suspected bodies in alcohol, or in
caustic alkalies, by which process the rods, chains, etc., are unaffected ;
but this method is objectionable from the fact that if we wish to get rid
of all the oil, which resists these reagents a long while, the suspected
tissue is itself apt to be destroyed.
The best method, in my experience, has been that of Hiller.” I have
found the following modification of it to answer well: Make a ten per
cent. watery solution of caustic potassa, in which the tissue to be ex-
amined is then immersed for an hour and a half, then washed in distilled
water, and finally plunged into a mixture of tincture of iodine and dis-
tilled water, 1–25; after remaining in this menstruum for fifteen minutes,
the substance assumes a brownish or deep-yellow color. The fatty
matters are more or less dissolved, excepting, in some cases, the larger
oil drops, but the bacteria retain the color more or less deeply. Such of
the round, oily particles as remain after this treatment, can usually be
distinguished from bacteria, by the fact that they refract the light
strongly, while bacteria have a dull, lack-lustre appearance.
Sometimes we are called upon to decide as to the character of the dark
substances that exist in cells, to determine whether they are bacteria or
not. I at one time adopted a modification of this plan. In an instance
where a rabbit had shown signs of constitutional disturbance after inocu-
lation with putrid matter, I examined some of the blood on the second
day after removal from the body, when bacteria were very plentiful, and
when most of the white blood-corpuscles had disappeared, while those
that remained were enlarged and granular. I added liquor sodae in
excess to a small amount of the blood, allowing it to act for one and a
half hours. At that time the white corpuscles had swollen and were
generally dissolved, liberating a large number of granules. Ten of these
were kept in view, and moved about in all directions, turning and twist-
ing ; at one time they arranged themselves in a cluster, and then again
separated, and formed a chain. During this time, the bacteria of rod-
form had become more and more invisible; while these particular bodies,
on the other hand, had become brighter and brighter. During all this
time there was little or no change in a number of oil drops that were
scattered about the field. Here, then, we have an instance of liquor sodas
having afforded us a means of differential diagnosis, in an optical manner,
between bacterial bodies and certain particles that took the chain-form,
and that came from the interior of white blood-corpuscles.
One of the most important reasons for putting little reliance on exact
measurements as to the size and form of bacteria, is that these charac-
7 5.
! Virchow's Archiv. lxii. 3, 1875. * Virchow's Archiv. lxii., Jan. 18
1020 SATTER T H WAITE,
teristics are probably apt to change under varying conditions. Bastian
tells us that if we take an ordinary organic infusion, and expose it to a
warm temperature, it will show rod-bacteria. If we add a drop of
acetic acid, we will get bacteria of larger size; adding a few drops
more, the changes take place less rapidly, and the organisms, instead of
multiplying as they did before, now grow continuously into filaments.
This ground is said to be held by Trécul," of Paris, and is favored by
Beale;” my own experience is not sufficient to justify me in forming an
opinion on this point. I may here add one point, viz., that I have seen
no reason to believe that there is anything like a genetical relation be-
tween bacteria and the mould or sugar fungus.
I have already stated that my experience agrees with that of Chauveau
and Sanderson, that the virulent principle is particulate, in certain in-
stances at any rate. It is quite clear that very virulent fluids may be
rendered quite harmless by passing them through a clay filter; this I
have had repeated opportunities for observing, as far as relates to inocu-
lation with putrid infusions, or with diphtheritic matter ; and yet when
we come to the question, are these poisomous particles bacteria 2 we know
that by successive filtrations, as through paper, where the bacteria of
distinctive forms are separated and removed, the fluid may still be poi-
sonous. Granules are often observed in such fluids; are they spherical
bacteria, or the spores of these or others 2
We must remember, however, that rod- and chain-bacteria may be
introduced in large numbers into the system without producing any
lesion. When they appear to have been isolated, as in Cohn's fluid,
this, as I have stated, is perhaps really not the case, but some organic
compound may have attached itself to the vegetations, and thus have
conveyed the septic influence.
Various efforts have at times been made to determine whether or not
the poisonous matter is albuminoid. Chauveau, Onimus,” and Sanderson,"
have worked in this direction. Sanderson and Onimus tried dialysis,
and Chauveau diffusion. The former, in investigating the cause of the
cattle plague, passed the virulent fluids through parchment-paper; the
dialysate was wholly harmless, while the liquid that did not pass was
poisonous. As the question with Sanderson was whether the contagia
were crystalline or colloid, he decided in favor of the latter possibility.
Onimus concluded that the matters were albuminoid from experi-
ments conducted in much the same method. But there were in both
sets of experiments, possibilities of error, arising from the fact that it
was not certain whether albuminoid substances did not actually pass
through the membranes, which it is now known that they will do, when
certain quantities of the phosphates or carbonates happen to be present."
It would, therefore, be erroneous to conclude that the poison remaining
behind the filter was necessarily albuminoid, when it was uncertain
whether the harmless filtrate did not also contain albumen.
Chauveau appears to have shown, by his experiments, that it is ex-
tremely unlikely that the poison in vaccine virus is due to a soluble,
albuminoid substance. His method will be briefly noticed. He took
raccine lymph, collected from the arm, and placed it in a test-tube
standing in an upright position. The introduction of the lymph into
| Lancet, May 15, 1875, p. 684. * Disease Germs, p. 37.
3 London Medical Record, November 19, 1873.
* Twelfth Report of the Medical Officer of the Privy Council, 1869, p. 233.
* Graham, Proc. Royal Society, 1861, vol. ii. p. 243. I have not been able to refer to
this paper.
D IS E A S E - G. E. R. M. S. 1021
the test-tube was effected with such care that the liquid did not touch
the sides of the glass in the act of filling. Water, to the depth of a few
lines, was then added with similar precautions, and the whole was
allowed to stand for twenty-four hours. Although no membrane was
used, yet it is said that when proper care was exercised, the liquids did not
mix, except in the immediate neighborhood of the surface of junction.
All the soluble constituents of the vaccine matter passed upwards into
the water. At the end of twenty-four hours, the most superficial layer
was removed by dipping into it the end of a fine capillary tube. This
supernatant liquid was then examined microscopically, and tested for
albumen. Now albumen, though held to have the least diffusibility of
chemical compounds, was found in the water, the inference being that
no other soluble chemical matter had been left behind. This upper
stratum was used upon heifers and children, but without success, while
the lower stratum produced the vaccine disease. Chauveau had pre-
viously employed a method called subsidence, in which, by adding ten
volumes of water, he had found that the leucocytes were separated.
These did not produce the disease, but the stratum that produced infec-
tion contained minute, microscopic granules, and it was therefore con-
cluded that the disease was produced by them. Sanderson corroborated
these conclusions in the great majority of his attempts, though he expe-
rienced some difficulty in the required manipulations, which need a good
deal of delicacy.
Colin' asserts that he has been unable to “diffuse,” as Chauveau claims
to have done, and intimates that the method is faulty, and that no such
real diffusion takes place; Chauveau, however, insists that the granules,
even when washed with immense quantities of water, retain their
virulent quality, and compares them in this respect to the spermatic
elements of seminal fluid. The supernatant liquid which is not poison-
ous, responds to the test for albumen by heat and nitric acid. In farcy,
Chauveau finds that the granules are as poisonous as the pus itself.
According to Panum’s” experiments, the virulent substance of putrid
infusions is not destroyed by boiling, and is soluble in water, but not in
alcohol; which qualities make him surmise that it may arise from the
decomposition of albumen, or may perhaps be secreted from the bacteria,
though he feels uncertain as to what the nature of the poison really is.
In prosecuting this line of inquiry, I have performed a number of
experiments in co-operation with Dr. Edward Curtis, Professor of Materia
Medica in the College of Physicans and Surgeons, New York, whose
name I have previously mentioned in connection with other topics. The
following questions were some of those that presented themselves for
solution :-(1) Is the poisonous matter in putrid infusions destroyed by
boiling and evaporation to dryness? (2) Is it soluble in alcohol, or not ?
(3) Is it soluble in water, after boiling in water and in absolute alcohol?
(4) If there are granules in the fluid which prove poisonous, will they
breed bacteria Ž
The liquid employed in these experiments was obtained from an infu-
sion of a calf's liver, that had been allowed to become putrid; the liquids
and solids used, were inserted into the muscular tissue of rabbits, and
examined at varying times thereafter.” The following conclusions seemed
in my opinion to be warranted:—
| La France Médicale, Fév. 26, 1876. 2 Virchow's Archiv, lx. 3 and 4, 1874.
* Many of these experiments have already been reported. In fact, this entire paper
embodies views which were published in 1875. Medical Record, Dec. 18 and 25, 1875.
1022 s ATTER T H WAITE,
(1) Putrid matter, when introduced into the system, is capable of pro-
ducing a well-marked train of symptoms, which are extraordinarily like
those of ordinary sepsis.
(2) The poisonous quality does not reside in the absolutely clear liquid,
when entirely freed from granules. This was shown by porous clay.
The apparatus used in these experiments was devised by Dr. Curtis, and
consisted of a porous-clay cylinder or cup, over the bottom of which was
drawn a bit of rubber tubing, which was thick, and made to grasp the
cylinder firmly ; in the opposite end of this tubing was fitted a cork,
through which a glass tube passed, so as to connect the chamber beneath
the cylinder with the interior of a small glass jar that could be exhausted
of air by means of a common exhausting syringe. When the liquid to
be filtered was placed in the porous cylinder, and the air was removed
from the glass jar, the liquid passed through the cylinder, and stood in
beads or drops on its bottom, from which it was collected in small quan-
tity without much difficulty.
(3) The poison is sometimes separated by coarse methods of filtration,
such as by common filtering paper. When Cohn's fluid was passed
through the equivalent of 25 thicknesses of ordinary filtering paper, it
produced no lesion, and yet Cohn's fluid, unfiltered, and ordinary putrid
infusions, produced about the same lesion.
(4) Continued boiling and evaporation to dryness does not destroy the
poison.
(5) Continued boiling, and evaporation to dryness, and boiling with
absolute alcohol, does not destroy the poison.
(6) The dry alcoholic extract, freed from alcohol by evaporation with
heat, is poisonous.
(7) My experience with regard to the albuminoid character of the
poison, has not made the matter clear to me, for while in these cases the
dry alcoholic precipitate, after continued boiling, was poisonous (and it
contained the albuminoid substances), yet the liquid alcoholic extract in
one case produced a lesion, and in another did not. In my first account
of these experiments, the results were stated as above, but in a subse-
quent series of experiments, the liquid alcoholic extract produced exten-
'sive lesions in two cases in which it was tried. In other words, when
the albuminoid deposit produced by both boiling and alcohol was separated,
and water afterwards added, the virulent matter appeared to reside both
in the precipitate and supernatant fluid. These experiments do not,
therefore, decide anything as to the albuminoid character of the poison.
(8) It further seemed to be shown of putrid matters which, after being
filtered several times, were boiled to dryness, then boiled with absolute
alcohol, and again dried and extracted with water, that the ordinary
paper filtrate was poisonous.
(9) On examining this watery liquid, it was found to contain granules,
and yet, when these granules were placed in vacuum-tubes, they in several
instances failed to show any development of bacteria under such circum-
stances as favored the growth of bacteria. The suspected solution was
put away in bent tubes, with suitable precautions, and while similarly
arranged tubes that had been contaminated with the barest trace of bac-
teria, were found turbid from the production of these bodies seventy-two
hours afterwards, the suspected liquids were perfectly clear, with one
exception, where there was a slight pellicle on the surface. It is true
| Loc. cit,
D IS E A S E - G E R M. S. 1023
that, after a variable time, several tubes became contaminated, and yet
others remained clear for months, and one for nearly a year, and as length
of nozzle and fineness of neck are necessary conditions for success in the
experiment, and as those thus provided held out best, it is fair to suppose
that with the others some error was committed in carrying out the
experiment, and that thus the bacteria of the air had in some way gained
an entrance. That this is possible we have already seen.
It is proper now to stop here, and note that the granules have been
very frequently noticed in the poisons of infectious disease; they seem
destined to play an important part in the discussions now pending on
the subject. There can be no question that in most of the diseases
that are assumed to have a definite vegetable form as their immediate
cause (for this is certainly the way in which the relation has been stated
over and over again by the vegetable-germ theorists), authors have given
the most conflicting accounts of the organisms, and we may fairly say
that, with the exception of relapsing fever, not a single form has been
accepted by any considerable number of germ-theorists as the agent, par
eaccellence, of the disease. We have observed that, according to Chauveau,
Sanderson, and Beale, certain granules appear to be associated with the
origin of disease, and that this fact has been the point of departure of
both the vegetable-germ theorists and the bioplasm theorists, while it
is not incompatible with the physico-chemical theory. Let us examine
these points a little more closely.
It is clear that if the vacuum-tube experiments be of value, they show
that the particles observed are not the spores of bacteria. What evi-
dence is there that the matter in question is organic and pertaining to
the body ? It is quite clear that, to the eye, using the ordinary powers
of the microscope, these particles cannot be distinguished from one
another with certainty. Beale, however, assures us that by using
extremely high powers, such as the 3's or the s”, he has seen them at
times dividing, and at others increasing in size, and that he has colored
them with carmine. Some of these may, he says, be no more than
To gº on of an inch in diameter. In diseased conditions of the body, he
believes that such particles may increase enormously. Belief in this
doctrine is, of course, inconsistent with the old cell-doctrine, by which
this body was regarded as the ultimate morphological element of the
system ; and yet we may safely say that this old theory is not by any
means what Schleiden and Schwann once held.
It does not appear to be necessary that a cell should have an envelop-
ing wall, inclosing a softer material in which is a nucleus. Max Schultze
showed that many important cells possessed no cell-wall, and that some
might not have a nucleus. Our notions, therefore, have been greatly modi-
fied in these respects, and a living cell is now held to be merely a mass of
glutinous, viscid matter, which is endowed with peculiar qualities, called
vital, such as amoeboid motion, molecular motion, and the like. As to
the nature of this viscid substance, there is hardly much uniformity of
opinion, as yet ; some holding it to be formless and structureless, while
others believe that it consists of networks, and others again, as Beale,
that it is made up of minute spheres, closely packed together, and that
these spheres may in turn be made up of other spheres. I hardly think,
however, that microscopists are ready to agree upon any staining matter
that is fitted to distinguish protoplasm or bioplasm in all cases, and these
' Disease Germs, p. 246.
1024 SATTER TH WAITE,
statements of Beale must, therefore, be accepted with caution. Even if
the particles be large, it is not certain that carmine will differentiate
them. It has, to be sure, a preference for animal tissues, and yet it will
also stain various other substances, if they remain long enough in the
staining fluids. While, therefore, it is conceivable that the ultimate
living elements of the body reside in particles which go to make up cells,
we have no sure means of recognizing them, and of deciding positively
that they are animal, and not vegetable, or whether or not they belong
to that ill-defined class called granular matter. If, however, we believe
that such minute portions of the body are the agents of disease, then we
have to assume that they have a capacity for life which is remarkable:
that, in fact, they can be subjected to extremes of heat and cold, or to
the action of various acids and alkalies, and that they can be separated
for months, and perhaps years, from the body, without losing their active
qualities—all of which does not comport with the opinions commonly
held about living animal matter.
The name “physico-chemical,” as applied to the theory which is thus
designated, is objectionable, as it dates back to the old-fashioned notions
of Liebig, when the ideas held on these and kindred subjects were quite
different from those of the present day. Tiebig' held that the ferment
was a portion of organic matter, which, itself unstable, was capable of
communicating molecular movement (chemical change) to certain sub-
stances. Bastian, the exponent of the modified doctrine, holds, as already
stated, that “living organisms, though they may act as ferments, act in
this capacity merely by virtue of the chemical changes which the carry-
ing away their growth necessitates, and that other chemical changes,
taking place during the decay of organic matter, may make fragments
of it (in the dead state) almost equally capable of initiating fermentative
changes in suitable media.”
This statement would appear to show that the friends of the theory are
not altogether willing to deny to bacteria and allied forms, an influence in
the cause of disease, but that they regard them as perhaps remote factors,
the important one being the chemical change exerted by the growth of
the microphytes, while, at the same time, dead organic matter may have
a similar power. This theory is, therefore, properly a chemical one, and
admits of two possibilities; either, on the one hand, that the cause of
disease operates through chemical changes under the influence of minute
organisms, or on the other hand, that it so operates under the influence
of dead portions of the body. The former hypothesis is unlikely, because
the virulence of diseases can sometimes be shown to be independent of
bacteria; the latter one, however, is by no means impossible, though
we know but little in its favor. If we assume that there is a logical
connection between the processes of fermentation and disease, and decline
to accept the hypothesis that minute organisms have that absolute rôle
that has been given them, we may believe, with Hiller and others, that
the ferment is a chemical substance. This is the view held by Bert with
relation to vaccine virus, which he subjected to conditions under which
life appeared to be impossible.
Under such an hypothesis, there is formed in the tissues, in certain dis-
eases, a material which is able to resist various reagents (heat and cold, and
the like), and which, when transferred to another organism, may occasion
the formation of like compounds, just as the sulphate of sodium, instanced
by Bastian, when placed in a liquid having the necessary ingredients for
* Lancet, April 10, 1875.
D IS E A S E - G E R MIS. 1025
forming it, will increase in amount.' Now we actually know that the
poisons of the cobra and of the rattlesnake, which are elaborated from
healthy tissues, are capable of being subjected to conditions that are
incompatible with 1 in its common acceptance. The poison of the
cobra may be diluted ‘h water, ammonia, or alcohol, without having
its deadly qualities affected, whi) according to Weir Mitchell,” the poi-
son of the rattlesnake can be boiled or frozen, or subjected to the action
of strong sulphuric or muriatic acid, ammonia, chlorine water, iodine,
soda or potassa, and yet, as far as the matter has not burned, its virulence
be unaffected. These qualities mind one strongly of the poison in
putrid matters, where, according to my own and Panum's experiments,
neither ordinary boiling in water, nor in absolute alcohol, nor evaporation
to dryness, destroys its active qualities.
Let us glance, in conclusion, at the leading opinions at present enter-
tained in regard to those of the infective diseases that have been most
thoroughly studied with reference to the materies morbi. I shall refer
merely to cholera, vaccinia, the carbuncular diseases of man and ani-
mals, typhoid and relapsing fevers, and diphtheria, in regard to which
the most specific descriptions have been furnished of the organisms sup-
posed to be concerned in their production.
The investigations which were occasioned by the cholera epidemic of
1849, appear to have been the first in which attention was called to cer-
tain particles, alleged to be the cause of the disease. These particles were
called the cholera-fungus.” In 1867, Hallier" published a work in which
he described the supposed ferment, the cholera micrococcus, a granular
mass that by cultivation underwent a great variety of changes in form.
Cohn" and many others followed with descriptions of the fungus. It is
safe to say, however, that there has been no general agreement between
the most prominent writers on this subject as to the specific form of the
supposed contagium. In the Congressional report of the epidemic of
1873, in the United States, we find it stated" that no microscopic changes
peculiar to cholera were found in the discharges, though high powers of
the microscope were used ; this being in agreement with the statement of
Macnamara, who used a one-seventieth inch lens. Molecular matter was
always seen by these observers, and it is stated in the report that from this
molecular matter in the vibrionic stage of decomposition, and not from the
vibriones themselves, the dejecta of cholera patients are capable of setting
up a morbid action in the intestinal canal of those who receive them."
Among the most recent and complete experiments on this point are
those of Lewis and Cunningham.” They injected 36 dogs, through the
veins, with choleraic dejections. In 15 cases they obtained positive re-
sults: that is, death was evidently due to the matter injected. In 17 of
the cases this matter had been kept for ten minutes at a temperature of
212° Fahr. In the remaining 19 cases it had not been exposed to heat.
In the 17 cases the mortality was 47 per cent. ; in the 19 others it was
only 36 per cent. It was thus found that a continued temperature of
212° appeared to have no influence in abating the virulence of the mat-
ter, for, when it was boiled, the mortality was even a little greater than
in the other cases. These observers also believed that bacteria could not
2
! Bastian, Joc. cit.
9 Budd and others.
* Biologie der Pflanzen.
7 Ibid., p. 43.
Smithsonian Contribution, p. 46.
1)as Cholera-Contagium.
&eport, etc., p. 36.
Journal of Anatomy and Physiology.
s54
65
1026 SATTER TH WAITE,
be the cause of cholera, and in fact they found similar forms in the
lesions produced by inoculation of various other substances, such as so-
lutions of ordinary faeces, or urine."
About ten years ago, it was noticed that vaccine virus contained minute
spheroids, and they were described in 1867–1868.” Cohn called them
Microsphaerae vacciniae, and described them as small, colorless cells, some-
times in rosary-like chains of eight or more links, and sometimes clustered
together. Sanderson thought that they were “filamentous, not jointed,
but branching, and giving off from their extremities microspheres or
conidia, much after the fashion of the penicillium.” Having been favored
by Dr. F. P. Foster, Director of the Vaccine Department of the New
York Dispensary, with an opportunity of inoculating calves, I performed
the following experiment in relation to this matter. Having prepared
a solution of salicylic acid, with sodium phosphate as a solvent, I com-
bined it with equal parts of vaccine virus taken immediately from fresh
vesicles, and having allowed the two to remain in contact a minute, they
were inoculated in my presence, on a calf, in the usual way. Now this
proportion of salicylic acid (sºn) had been shown by previous experi-
ment to be able to prevent the development of bacteria for from twelve to
twenty-five days, and yet in this instance regular vesicles appeared at the
proper time in nearly all the inoculated points. I cannot but think,
therefore, that this experiment offers strong evidence against the theory
that vegetable germs have to do with the cause of disease.
The name Carbuncular Điseases, which the French employ synony-
mously with the German word Anthrax, has proved to be a convenient
form for a rather remarkable group of contagious diseases, which have
a certain connection with one another, and which include malignant
pustule, splenic fever, and the disease called “mycosis intestinalis.” The
post-mortem appearances in all these diseases are remarkably similar.
Balls of rounded particles are said to be found in the affected parts, and
rod-shaped bacteria in the circulating blood ; the spleen is enlarged ; there
are hemorrhagic infarctions of the intestine, causing sloughing of the
mucous membrane, exudation and infiltration of serum, and enlargement
of the glands near the points involved. In such cases a pustule often
appears, and hence the name Malignant Pustule; and yet it may not be
necessary to the disease, which often proves fatal without it. Now, in
these diseases, Pollender and Davaine” observed minute rods, which Da-
vaine called bacteridia, and which he said were always motionless; and
he has made such extensive studies of them that his opinions have be-
come well known. He regarded them as necessary causes of the diseases
in question, and as essentially different from what he called the bacteridia
of decomposition, which were really what we know as the bacteria of
putrid matters. His views have, however, not always met with accep-
tance, and notably have been opposed by Bouley," Gaillard, and others,
who assert that the blood may be infectious without the presence of rods.
Bodinger, who is now regarded as one of the foremost German authori-
ties, states that he also has produced the disease in question in a similar
way, but that in such cases there have always been spherical bacteria
present. We may justly ask, in view of what has already been cited
whether spherical bacteria were really present, and whether the particles
he describes may not have been other solid particles?
| Tribune Médicale, 369, 1875. * Virchow's Archiy, 4), 42, 1867–8.
* Davaine in 1850, and Pollender several years previously.
* Cyclopædia of Practical Medicine, vol. iii. p. 377.
D IS E A S E - G E R M S . 102.7
Among the most recent and best recorded accounts of the vegetable
organisms connected with typhoid fever, are those of Klein,' of London.
He declares that he has found peculiar bodies, in this disease, at or near
Peyer's patches. These bodies were carried along the lymphatics or
blood vessels of the mucous membrane; in color they were often yellowish-
brown, and in size varied from one-fourth to three times the size of a
human, red blood-corpuscle. It will be noted that if we accept these
views, we are carried away from the subject of bacteria towards that of
the other vegetable organisms, called torulae, which in my opinion have
not been shown to have any genetical relation with bacteria. These
views of Klein are comparatively new, and as yet I have failed to find
any confirmation of them.
In regard to relapsing fever, the microphytes are pictured with more
vividness than in any other disease. In 1872, Obermeier, of Berlin, gave
an account of certain bodies, long and filamentous in form, which were
found in the blood during the rise of the fever, disappearing with its
fall, and reappearing during the relapse. These observations have been
very largely confirmed, but, on the other hand, Laptschinski made fre-
quent searches for these bodies, but never found them, though he did
observe an enormous increase in the number of the white blood-corpuscles,
which were unusually granular; when the fever decreased, the number
of the white blood-corpuscles diminished. Recently, IIeydenreich,” of
Moscow, examined the blood in sixty-four cases, and he asserts that he
found the spirillum in every instance, and that it was the same as the
Spirochaete plicabilis, of Ehrenberg, which this observer discovered in
water. In most cases these bacteria were found at the beginning of the
febrile exacerbation, sometimes even preceding it. Before the fall of the
temperature, the bacteria generally disappeared. On the other hand, we
are told by Motschutkoffsky,” of Odessa, that the blood of relapsing-fever
patients was readily and successfully inoculated upon healthy human
subjects, though not on animals. The blood was only poisonous when it
was taken during a febrile exacerbation, but it made no difference
whether it contained spirilla or not.
In the matter of diphtheria, I may speak with more confidence, as my
personal experience in this department of the subject is larger than in
any other. The relation of bacteria to diphtheria has been made most
prominent by the writings of Oertel, IIueter, and others; and, in con-
junction with Dr. Edward Curtis, I have made some extended re-
searches on the subject. Oertel, and others of the German school,
plainly ascribe to the micrococcus found in diphtheria, the cause of the
disease; at least I can understand them to imply nothing else. In the
first instance, it must be said that the real presence of bacteria in diph-
theritic membrane is usually a matter of ready proof. They exist in
collections on the surface of the membrane, and often in it, as well as in
the secretions of the pharynx, trachea, nasal passages, etc. They are to
be found in masses, or separate, and usually may be distinguished as rod-
shaped. It is true that they often appear as spheres, but this appearance
is apt to be deceptive, for, when they are accumulated together, they are
often arranged in extremely regular order, and they then give this pecu-
liar appearance. To show that in such cases they are rods, is not a
matter of much difficulty : Press the cover against the slide, and the
Report of the Medical Officer of the Privy Council, 1875.
* St. Petersburger med. Wochenschrift, 1. 1876.
* Centralblatt, and St. Louis Medical and Surgical Journal. May, 1876.
102. S
SATTER THWAITE, DISE ASE - G E R Ms.
more prominent rods will be pressed down, showing their peculiar shape.
Another source of deception is the fact that these bacteria are apt to
move about with a gyratory motion, with extremity directed towards
the observer. Watching such a particle carefully, it may sometimes be
seen to turn and expose its side, and then we may see that it is nothing
but the ordinary rod-bacterium. When we have to do with other parti-
cles, then indeed it is well to give diagnostic points by which we may
distinguish them from ordinary granular matter, such as fragments of
tissue, minute oil particles, pigmentary matter, etc. I feel confident,
however, from repeated examinations, that no particles have been de-
scribed by Oertel as micrococci, that can be positively shown to be pre-
sent in diphtheria alone. On the contrary, both Dr. Curtis and myself
have repeatedly examined the accumulations in our own mouths, and
have there seen the forms which are described as belonging to diphtheria.
And yet diphtheritic membrane is very poisonous, and fatal when
inoculated in the muscles of rabbits, as I have had repeated opportunities
of observing. I may here state that Oertel’s descriptions are the most
elaborate and, perhaps, the most clearly given of any writer's on the
experimental pathology of diphtheria; as far, however, as my experience
has gone, it has in most instances failed to verify them. In inoculating
the corneae of rabbits, in a number of instances, no lesion followed, be-
yond an ordinary keratitis, and none of the rabbits died ; in fact they all
recovered quickly. The fresh diphtheritic membrane, when inoculated,
was very fatal, the tendency to death being extremely common about
the end of the second day. Of 27 rabbits inoculated with the solid mem-
brane, or an aqueous infusion of it, 20 died, and 12 at about the end of
the second day, or between the second and third.
Now the membrane when thoroughly boiled, was equally fatal in two
cases, and yet boiling is said by most excellent authorities to destroy
bacteria. In fact, this is a matter of general belief. Furthermore, bac-
teria were shown to decrease rather than increase, when introduced into
the system, so that certainly after two or three weeks they had either
become distorted, so as to be hardly recognized, or they had altogether
disappeared. When very strong solutions of salicylic acid, combined with
phosphate of sodium as a solvent, were made up into a paste with diph-
theritic membrane, and inoculated in the thighs of rabbits, they produced
a fatal disease, though the lesions were not as extensive as when diph-
theritic membrane alone was used ; and yet, in my experience, salicylic
acid in the proportion of g ºn has, as before mentioned, prevented the
development of bacteria for from twelve to twenty-five days. 's,
I believe that I have now given a tolerably fair account of the most
prominent views entertained on the matter of disease-germs, and think
that I am warranted in submitting the following conclusions with regard
to the present status of the question :--
I. That, as far as inquiry has been made as to the nature of the active
principles in infective diseases, it is probable that in a certain number
the matter is particulate, or molecular in form.
II. That in regard to the causes of septicæmia, pyaemia, puerperal
fever, erysipelas, and hospital gangrene, and those of cholera, vaccine-
disease, the carbuncular diseases of men and animals, typhoid and
relapsing fevers, and diphtheria, there is not satisfactory proof that they
are necessarily connected with minute vegetable organisms.
III. That the real nature of these causes is still uncertain.
1029
WITAL STATISTICS OF BUENOS AYRES.
BY
G. RAWSON, M.D.,
OF BU ENOS AYRFS.
A BRIEF review of the vital statistics of Buenos Ayres may perhaps
awaken some interest in the International Medical Congress now assen-
bled in Philadelphia, not only as adding to the data accumulated from
day to day as elements of Sanitary Science, but as presenting circum-
stances peculiar to that Argentine city itself.
Buenos Ayres, next to Rio de Janeiro the most populous city in South
America, has grown with extreme rapidity, having tripled its population
within the last twenty-five years, mainly owing to the vast tide of
emigration from European shores. But, even in the event of a dimi-
mution of the influx of immigrants, and a corresponding reduction of the
rate of increase, it is almost certain that Buenos Ayres will, at the close
of the present century, have upward of half a million inhabitants. Situ-
ated in latitude 35° south, with a genial climate, it is exempt from the
extremes of temperature so common in other localities; and, were it not
for the modifying influences exercised upon its sanitary condition by the
increase of population, and by the circumstances usually attending that
increase—when not overruled by strict observance of the admonitions of
science—it would be as healthy a city as its name (good air) would seem
to imply.
3ut the death-rate in Buenos Ayres attains proportions by no means
atisfactory ; and the recent epidemics, particularly the yellow-fever
scourge of 1871, show that much has to be done before the city can
regain that salubrity reasonably to be expected from its situation and
soil, and from the prevailing winds and other climatic conditions with
which it is favored by Nature. Epidemics are warnings to mankind—
warnings all the louder in proportion to the severity of the visitation;
and Buenos Ayres has learned from her recent sufferings the lesson to be
desired. Works, both above and beneath the surface, are now in prose-
cution for the sanitary improvement of the city, by means of a system
of drainage and underground disinfection which will cost twenty mil-
lions of dollars (eight millions have already been expended), and which,
when completed, will be one of the most efficient in the world.
I3esides, the population of the city is, to a great extent, composed of
foreign elements permanently incorporated therein and constantly in-
creasing. In this respect Buenos Ayres bears a striking analogy to many
cities in the United States, and, like these, presents a series of phenomena
peculiar to this species of social evolution, as revealed in its vital statis-
tics. The analogy here referred to I shall endeavor to point out in the
course of the present essay.
Population of Buenos Ayres.—It is necessary, first of all, to determine
he population of Buenos Ayres, and its component elements; but the
ccurate accomplishment of this is difficult, owing to the long intervals
jetween the censuses, and the rapid increase of the number of inhabi-












1030 R AWSON,
tants. The mode of development in cities of the New World is in
general so irregular that, in measuring their growth, it will not suffice
merely to determine the difference between the numbers of births and
deaths. The increase resulting from that tardy process is insignificant
when compared with that derived from immigration, and with that
which is due to the irresistible attraction which populous centres exercise
at all times upon neighboring towns. This species of attraction is, from
causes peculiar to the Argentine Republic, more powerful in Buenos
Ayres than in other American cities of similar growth. In 1871, for
example, the number of victims of the disastrous yellow-fever epidemic
exceeded that of the births in the same year by 13,206: but the equi-
librium of the population was more than re-established by the influx of
emigrants from Europe, and from the surrounding provinces and repub-
lics. By comparing the total number of births during the period from
1858 to 1872 with the total number of deaths during the same period, in-
cluding, of course, the victims of the cholera of 1867 and 1868 and those
of the yellow fever of 1871, we observe an excess in the deaths, of 1778.
Hence, if Buenos Ayres had depended solely upon its own resources for
its growth, its population, instead of increasing, would have diminished.
But the ravages of this frightful mortality were more than compensated
for by immigration, and the remarkable growth of the city pursued its
course without any apparent interruption.
The progress becomes more and more marked, dating from 1852. In
the absence of Official data, it is scarcely possible to estimate the popula-
tion of Buenos Ayres in that year, which was marked by a political
event of transcendent importance—the downfall of the dictatorship by
which the nation had been oppressed and depopulated for the space of
twenty years. Numerous emigrants returning to their homes after a
prolonged proscription; the establishment of liberty, political and civil;
the opening the navigable rivers to the vessels of all nations; the dis-
covery of riches susceptible of being developed advantageously in the
Argentine Republic by the hand of man ; and the facilities offered by
both the government and the people to foreigners desiring to take up
their residence there, induced a stream of European immigrants, which
continued uninterruptedly for a number of years. Dating from the be-
gimming of the influx of foreigners, the rapid growth of the population
became evident, and about that time the greatest increase took place.
Nevertheless, no census of the city was taken until 1855, nor was a
second effected until 1869, the year of the general census of the republic.
According to the terms of the constitution, the general census will in
future be taken every ten years.
The two censuses referred to are, therefore, the only available data on
which to base my computations; those for other years must, of necessity,
be only approximate. In the census of 1855, the total population of the
city was set down at 91,548, and in the general census of 1869, at 177,787.
Hence, the mean annual rate of increase during the period embraced be-
tween these two extremes would be 4.8 per cºnt., always supposing the
progression to have been uniform. Now, by äpplying the same system
of reckoning to the previous years, that is to say, from 1852, and to the
successive years down to 1875, the population of Buenos Ayres would be
as in the annexed table in the years therein expressed:—
1851, by calculation . - e -> & - . 76,000 inhabitants.
1855, according to census . tº & * º . 91,548 ( &
1869, 4 & { % - º - * - . 177,787 ( &
1875, by calculation . º e - e º . 230,000 & K
VIT A L S T A TIS TI C S OF B U E N O S A. Y. R. E. S. 1031
On reviewing the foregoing statement of the increase of the popula-
tion, two objections are apparent, and I must now endeavor to explain
them. They are: first, the epidemic of 1871, which would appear to
have checked for the time being the numerical advancement of the
population; and, second, the perceptibly decreased immigration in the
last two years, 1874 and 1875.
Buenos Ayres is not only the chief port, but also, by reason of its
position, the natural centre of all movement in the republic. It is the
point of disembarkment for the immigrant on his arrival, and of re-em-
barkment for those who return to Europe. Passengers, whether immi-
grants or not, coming from Montevideo, likewise land at Buenos Ayres;
and there they go on shipboard again when leaving to go back. There,
too, is the rendezvous of all craft navigating the tributary streams of
the Rio de la Plata. Hence, the movement of passengers throughout
the year may at all times be readily ascertained, and the balance to the
credit or debit of Buenos Ayres accurately determined by comparison of
the arrivals and departures. The communications by land are extremely
limited, and confined to the rural districts of Buenos Ayres and the .
neighboring provinces. It is generally admitted that more than two-
thirds of all immigrants to the republic, come whence they may, remain
in Buenos Ayres city, the remainder being distributed through the sur-
rounding country. The following table shows the movement of passen-
gers for the port of Buenos Ayres in the years 1864–72:—
JBalance
Years. Arrivals. Departures. reinaining.
1864. . º º © e & . 20,307 16,745 12,562
1865 . º º º º e . 30,556 24,434 6,132
1866 . * º 4- © * . 40,132 20,658 19,474
1867 . º e & º & . 42,729 21,154 21,575
1868 . o © º - e . 56,354 25,342 31,012
| S69 . e tº - º e . 73,045 29.99() 43,055
187 () . . . . . . . 81,166 33,450 47,716
IST | . - e º - º . 49,741 28,468 21,273
1872 . & e -> e se . 70,991 36,756 34,235
As seen in the foregoing table, in 1870, the year immediately follow-
ing the general census, the balance in favor of the population reached
the highest point so far known, as far as the arrival and departure of
passengers were concerned. That year was an auspicious one for the
city. Immediately after the termination of the Paraguayan war, a vast
accumulation of capital was effected, credit facilities were opened up, en-
couragement was offered to such as desired to embark in new industrial
enterprises, and important public works were undertaken, such, for in-
stance, as city railroad lines: and the result of all these favorable cir-
cumstances was the attraction to, and permanent establishment in, Buenos
Ayres, of a vast number of people from foreign countries and from the
other provinces of the republic. The influx of strangers at that time
amounted to two-thirds of the balance of 47,716 mentioned in the table,
that is to say, over 30,000 new inhabitants, which is equivalent to three
and one-fourth times the usual rate of increase. Such an excessive aug-
mentation of numbers, at a time when the city was not suitably prepared
to receive them, or to afford them necessary accommodation, gave rise
to an accumulation altogether incompatible with the general good health,
and contributed, beyond all doubt, to the awful severity of the epidemic
of 1871, by which more than 12,000 foreigners were carried off.
The yellow fever committed its ravages in the midst of an overcrowded
city. But, notwithstanding the great mortality, there still remained,
1032 R AWSON,
with a surplus for the following year, a mass of inhabitants greater than
would have been obtained by calculation, adopting the established an-
nual rate of increase, and to which should be added the number of the
immigrants of 1871 who settled in the city. These remarks may serve
to meet the first objection above alluded to.
As for the second, suffice it to state that, in 1872, the tide of immi-
gration again began to flow, and foreigners arrived in such numbers as
to leave a balance of 34,235; and that in 1873 immigration reached the
highest figure ever attained in South America, leaving a balance much
more favorable still than that of the year immediately preceding ; I
deeply regret that I have not at hand the official returns to offer in sup-
port of this statement. In 1874 and 1875, by local causes easily ex-
plained, and others of a general character which have produced and still
produce such grave perturbation in commercial and industrial circles
throughout the world, immigration to Buenos Ayres was considerably
diminished, while emigration was increased in a proportionate degree.
There has, nevertheless, been no instance as yet, even at the worst, of
the departures having exceeded, or even equalled, the arrivals; a balance,
however small, still exists in favor of the latter. Now, taking into con-
sideration the excessive accumulation which occurred in the two years
immediately preceding the crisis, the same reasoning may apply to 1874
and 1875 as we have already applied to 1871, with the favorable differ-
ence in the case of the two former years that they were marked by no
such catastrophe as the epidemic of the latter, to exercise a depressing
influence upon the population. Hence, the adoption here of the mean
annual rate which served us in estimating the number of inhabitants
for the earlier periods, would seem perfectly justifiable; and we may,
without any fear of exaggeration, set down the population of Buenos
Ayres in 1875 at 230,000.
This population is spread over an area of 1620 hectares (or 6 square
miles approximately), or a mean of 70 square metres (= 833 Square yards)
to each individual. Of course, the distribution is not always uniform.
There are many districts much more densely populated than others, and
the tenement-houses, though disseminated through all the districts, are
in themselves centres of accumulation, pernicious alike to the physical
and moral well-being of the community. The streets are for the most
part narrow, barely eleven metres in width ; and the public squares are
few and of inconsiderable dimensions. Within the last few years, a vast
system of horse-railways has been introduced, with an aggregate length
of seventy miles, by means of which cheap mode of conveyance a certain
degree of expansion is afforded to the inhabitants. It may here be ob-
served that, with the exception of Philadelphia, Buenos Ayres has, in
proportion to its population, a greater extent of horse-car lines than any
other city in the world.
From this short history of the development of the population of Buenos
Ayres, it may be presumed that it is largely composed of foreign ele-
ments. Indeed, the census of 1869 shows that, in that year, foreigners
cónstituted almost one-half of the total number of inhabitants. -
Total population tº & * @ e © 177,787
Argentines d tº e * . 89,666
Foreigners & tº * * † . 88,121 -
*** * -177,787
Doubtless the proportion of foreigners has increased in a marked degree
since that time, and, in the absence of precise data, I calculate that their
number in 1875 exceeded that of the natives as follows:—
VITAL STATISTICS OF BU E N O S A. Y. R. E. S. 1033
Total population . § © & { } e tº tº . 230,000
Argentines g * e * . 105,000
Foreigners e * & § . 125,000
9 — 230,000
But, in order to give an idea of this foreign mixture, and commence
the study of the vital statistics upon a more solid basis, I shall here tran-
scribe a page from the census returns of 1869, with all the details and
particulars, to which we may have occasion to refer.
Table showing the Population of the City of Buenos Ayres, in 1869,
Arranged according to Nationality, Age, and Sea.

To 1 year 2 to 5 6 to 10 11 to 15 16 to 20 21 to 30
Nationality. -
M. F. M. F. M. F. MI. T. M. F. Mſ. F.
Independent America :-
Argentines... . . . . . . . . . . . . . 3,704 3,565 | 6,672 7,136 7,070 7,668 5,56S 6,858 || 3,022 || 5,811 4,262 8,240
Bolivians.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 . . . . . . 2 1. 1 9 3 26|| || 13
Brazilians . . . . . . . . . . . . . . . . 3 I 15 26 32 25 34 24 54 46 123 60
Chilians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I I 5 4 9 I3 46 30 96 32
North Americans. . . . . . . . . . . . . . . . . I 2 6 7 6 I j 8 47 13 239 20
Uruguayans . . . . . . . . . . . . . . 48 25 | 150 | 129 266 221 || 414 || 325 | 620 449 | 1,003 770
Paraguayans... . . . . . . . * * * * I 2 15 11 43 37 6S 25 64 17 117 33
Peruvians . . . . . . . . . . . . . . . . 1 |... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 . . . . . . . 4 3 13 2
From other parts of America. . . . . . . . . . . . . * * * * * * * * * * 2 l l 3 2 4 4 15 15
Europe:—
Austrians. . . . . . . . . . . . . . . . . ' ' e º e º s e ] e s e o 'º e i e º s e º º 2 3 l 3 4 46 2 241 17
Germans. . . . . . . . . . . . . . . . . . 2 I 21 17 29 27 27 32 SS 72 596 234
Belgians. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1 3 |... . . . 4 2 4 8 38 16
Spaniards. . . . . . . . . . . . . . . . . 15 16 87 90 151 158 471 305 | 1,604 496 || 3,706| 1,035
French. . . . . . . . . . . . . . . . . . . . 26 12 97 109 | 168 172 302 242 919 585 2,810, 1,524
English. . . . . . . . . . . . . . . . . . . 9 2 28 20 45 || 46 71 || --67 192 || 132 – 809––368
Italians. . . . . . . . . . . . . . . . . . . 82 75 559 524 954 818 1,881 | 1,026 2.670 | 1,629 || 9,490. 4,063
Portuguese . . . . . . . . . . . . . . . I I 2 . . . . . . 5 4 6 3 39 4 274 20
Swiss. . . . . . . . . . . . . . . . . . . . . 2 5 11. 11 20 I3 35 23 112 60 417 114
From other European countries 2 2 2 7 6 5 29 7 190 38 538 63
Africans . . . . . . . . . . . . . . . . . . . . . . . . . . . . l 2 1 4 |... . . . 4 3 9 5 48 13
Asiatics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 . . . . . . . . . . . . 2 | . . . . . . 31. . . . . .
Not classified. . . . . . . . . . . . . . . . . . . . . . . . 2 |... . . . . . . . . . . . . . . . . . . . . . 2 l 8 . . . . . . 6|... . . .
Totals. . . . . . . . . . . . 3,896 || 3,711 || 7,666 8,094 | 8,812 || 9,209 || 8,949 || 8,971 9,753 || 9,407 |24,870|16,652
31 to 40 41 to 50 51 to 60 . 61 to 70 71 to 80 81 to 90
Nationality.
M. F. M. F. M. F. M. F. M. F. M. F.
Independent America :-
Argentines. . . . . . . . . . . . . . . . 2,909 5,543. 2,043 3,712 1,343 2,089 612 987 223 425 43 110
Bolivians. . . . . . . . . . . . . . . . . II 2 4 |. . . . . . 8 . . . . . . 1 3 |... . . . 2 |. . . . . . . . . . . .
Brazilians . . . . . . . . . . . . . . . . 93 37 54 23 32 15 13 2 2 . . . . . . . . . . . . 3
Chilians. . . . . . . . . . . . . . . . . . 65 23 (51 21 21 14 11 3 4 l 2 2
North Americans... . . . . . . . 128 11 57 7 21 2 S 3 2 . . . . . . . . . . . . . . . . . . .
Uruguayans . . . . . . . . . . . . e 423| 361| 164 225 94 | 1.42 49 56 14 25 3 7
Paraguayans . . . . . . . . . . . . . 78 11 32 7 12 10 3 3 4 |... . . . . . . . . . . . . . . .
Peruvians. . . . . . . . . . . . . . . . 7 6 4 9 7 2 3 3 2 . . . . . . . . . . . . . . . . . .
From other parts of America... 13 7 5 2 4 2 1 l 1 . . . . . . . . . . . . 2
Europe:—
Austrians. . . . . . . . . . . . . . . . . 109 11 44 IN II 3 7 2 2 | . . . . . . . . . . . . . . . . . . .
Germans. . . . . . . . . . . . . . . . . . 431 160} 17:5 79 53 2S 33 19 5 4 1 . . . . . .
Belgians. . . . . . . . . . . . . . . . . . 39 14 17 4 à 2 4 . . . . . . . . . . . . . . . . . . s is a s ºf e i e s a s a s
Spaniards . . . . . . . . . . . . . . . . 2,478 718, 1,237 || 410 || 496 || 179 167 76 59 25 I2 4
French . . . . . . . . . . . . . . . . . . . 2,229| 1,051 1,320 671 || 490 251 193 113 60 27 9 6
English. . . . . . . . . . . . . . . . . . . 453; 166|| 257 125 | 101 59 64 31 23 7 1 3
Italians . . . . . . . . . . . . . . . . . . 7,428 2,612; 3,852 1,387 | 1,34 636 45S 230 | 127 56 29 15
Portuguese . . . . . . . . . . . . . . . 141 11 10.5 10 SO 7 38 3 14 3 5 - . . . . .
SWiss. . . . . . . . . . . . . . . . . . . . . 262 72| I].S 36 33 12 13 2 6 2 1 | . . . . . .
From other European countries 29S 62. 146 26 46 29 13 6 9 4 2 . . . . . .
Africans . . . . . * * * * * * * * * * * * * * * * * 34 14 39 24 40 39 27 45 31 40 20 24
Asiatics. . . . . . . . . . . . . . . . . . . . . . . 2 . . . . . . 3 2 I. I 1 1 : . . . . . . 3 . . . . . . I
Not classified. . . . . . . . . . . . . . . . . 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 . . . . . . . . . . . . . . . . . . . . . . . .
Totals..... tº a # tº e º 6 17,635; 10,892; 9,727 6,781 4,241 3,522 1,719, 1,590 588 624 | 12S 177
t : ; ! §


1034 R AWSON,
91 to 100 º Age unknown Recapitulation
Nationality. | - |
| M. F. M. F. M. F. M. F Total.
Independent Annerica :— i : r
Argentitles . . . . . . . . . . . . . . . . 1() 20 3 2 2 * * e ºs e ∈ E * * * 37,486 52,175 S9,661
Boliviºlis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . * * * * * * * * * d = e º e a s = * * * 60 27 S7
Brazilians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.5 2(;2 717
Chilians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ! I . . . . . . . . . . . . . . . . . . . . . . . . . . | 3] 2 144 456
North Almericans... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . | 5.26 77 603
Trns u:Xàtis . . . . . . . . . . . . . . . . . . . . 2 1 1 . . . . . . . . . . ". . . . . . . . . . 3,249 2,738 5.9S7
Paraguayans . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . ‘. . . . . . . . . . . . . . . . . . . . 437 J 56 593
Peru Viºl is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ' ' - - - - - - - - - i. . . . . . . . . . 43 2.) 6S
From other parts of America. . . . . . . . . . . . . . . ........... is . . . . . . . . . '.......... 47 3S S.5
Europe :-
Austrians. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 33 . . . . . . . . . . 499 43 542
'**'s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,461 57 S 2,039
Belgians . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‘. . . . . . . . . . 1 16 47 163
Spaniards . . . . . . . . . . . . . . . . . 2 . . . . . . | 1 | . . . . . . . . . . . . . . . . ". . . . . . . . . . 10,486 3,512 13.99S
French . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 . . . . . . . . . . . . . . . . 14 S.625 4,777 13.40.2
English . . . . . . . . . . . . . . . . . . ............…....... j 1 2.0.54 1,027 3.081
| tillians . . . . . . . . . . . . . . . . . . 4 2 1 . . . . . . 5 J. 2S,SS3 13,074 41,957
Portuguese . . . . . . . . . . . . . . . l 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 711 67 77.8
Swiss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • - - - - - - - - - . . . . . . . . . . 1,030 3.0 I,380
From other European countries 2 . . . . . . 2 | . . . . . . | 33 . . . . . . . . . . 1,315 347 1,662
}
Africans . . . . . . . . . . . . . . . . . . . . . . | 2 7 3 3 . . . . . . . . . . . . . . . . . . . . . 263 210 482
-Asiatics. . . . . . . . . . . . . . . . . . . . . . . | * * * * * * * * * * * * * r * * * * * * | * g º e º e º 'º e º 8 ° º a s º e º is sº tº º is is a 4 12 {} 21
Not classified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 |... . . . . . . . 21 4 25
Totals. . . . . . . . . . . . 2] 41 14 6 75 I6 98,091 70,696 177,787
Attention is at once attracted by the numerical relation of the pre-
dominant elements in the native and foreign populations respectively.
It should be borne in mind that, among immigrants to Buenos Ayres, the
male element is far in excess of the female, and that for reasons as obvious
as they are natural. The pioneers of emigration are always robust men
in the prime of life ; and not until prolonged experience has proved the
certainty of happy results, do the women and families set out to share
the fortunes of the fathers and brothers who have left their native homes.
Immigration to the United States has now assumed a character of perma-
mency and stability induced by satisfactory experiments extending over
more than half a century; nor is it to be wondered at that immigrants arrive
on the shores of the Union in a state of almost complete family organiza-
tion, or, at least, that 45 per cent. of them are females of all ages. And it
is a noteworthy fact that the distribution of female immigrants through-
out the country is, according to the census of 1870, in direct ratio to the
age of the States. In Maine, New York, and Massachusetts, for instance,
the female foreign population is equal to, or often in excess of, the male ;
while in the new States and in the Territories, the number of females in
the foreign population is small as compared to that of the males, save in
the single Territory of Utah, where, for well-known reasons, the reverse
is the rule.
The population of Buenos Ayres in 1869 comprised:—
Males of all ages and nationalities 98,091
Females - § { § { 79,696
Total . § e & . 177,787
The Argentine branch of the population, of all ages, comprised, in the
same year: males, 37,486 ; females, 52,175 ; or an excess of 14,689 females.
In the foreign branch, including all ages and nationalities, there were:
males, 60,605; females, 27,521 ; or an excess of 33,084 males, which
not only compensated for the deficiency of males in the Argentine popu-
lation, but constituted an excess of 18,395 males in the total number of
inhabitants.
VIT A L S T A TISTICS OF BU E N O S A. Y. R. E. S. 1035
In regard to age, children under five years numbered 23,367, of whom
2290 had been born in foreign countries. In New York, the number of
children of that age, so interesting in the study of vital statistics, is equal
to 11.8 per cent. of the whole population, while in Buenos Ayres it con-
stitutes only 13.1 per cent. From the age of five to fifteen, the proportion
of foreign-born children gradually increases, which is likewise observed
to be the case in New York, as shown by the report of the Commissioners
of Emigration for 1875, in which children not over twelve years of age
represented 21 per cent. of the 84,000 immigrants who arrived at that
port in the year mentioned. The period ranging from sixteen to sixty
years, is that in which the numerical superiority of the foreign popula-
tion is most marked in Buenos Ayres; and the same phenomenon is
observed in New York, though without the strange proportions charac-
teristic of the former city. This is the period of life in which full physi-
cal and moral development are attained—plenitude of power for labor, for
reproduction, and even for organic resistance of the permanent influences
which menace health and existence. In this triple point of view, the
foreign population is certainly superior wherever it presents, as it does in
Buenos Ayres, such an evident majority of individuals in the age of vigor
and strength.
Marriages.—The following table shows the number of marriages that
took place in each of the seven years from 1867 to 1873. I have taken
care to compare the numbers with the population in the respective years,
calculating the latter according to the established rate of increase, in
Order to ascertain the number of persons per thousand married in each
year:—
Number of
Years. Marriages. persons ina rried
per | () ()().
1867 * § & * & & & e . 1530 10.()
1868 ſº & º g º ſº e & . I 7 ()3 2().2
1869 g e © º e † t; g . 1858 2().9
| S7 () p te e e & * & & . 1916 20.5
1871 tº e e g e º e e . 1896 19.4
1872 g º * ſº * & gº gº . 21.93 21.4
1873 * e * º & iº e * . 2291 21.3
Mean number of persons married per 1000 during 7 years . 2().39
From this table it appears that the number of marriages increased
gradually, save in the year 1871, in which there was a decrease of 20 as
compared with the figures of the year immediately preceding, due to the
perturbation caused by the great epidemic. In the succeeding years the
increase was again visible, as was also that of the population. It is like-
wise to be observed that the proportion per thousand varied very little,
and may be set down at an average of 20, though the mean for the seven
years was 20.39. Figures in statistics assume greater importance when
compared with others of like nature. Here, as in other branches of the
present report, I prefer to make the comparison with the city of New
York, not only because I have ready access to the Official documents
relating to the vital statistics of that populous city, but also on account
of a certain analogy which I find it to bear to Buenos Ayres in the
department which now engages my attention. The number of marriages
in New York in each of the same seven years, as given in the reports of
vital statistics published by the Board of Health, and for which I am
indebted to the courtesy of Dr. Nagle, will be seen in the subjoined
y
table. I should add that, in computing the rate per 1000 of persons who
1036 RAW SON,
married, I have estimated the population before and after the census of
1870, according to the rate of increase—say 2.1 per cent.—adopted by
the official authorities:–
Persons married
Years. Marriages. per 1000.
I S67 te s e * e lº ſº e . 7144 16.14
| S68 & e tº ſº is * * e . 69.2(; 15.33
1869 * & tº e & & & g . 8695 18.44
1870 e & t te e te tº & . 7985 14.71
1ST | tº # º g e g º {e . 86.46 18.07
1872 e e & * & * *: e . 9()()8 18.52
1ST 3 * > * * & º tº e e . SSS7 17.72
Average . e te º tº e te & e 16.99
This mean annual rate may be regarded as somewhat below the truth
for New York, inasmuch as the Registrar-General, in the course of his
reports, complains of the culpable negligence of some of the persons
required by law to have marriages registered in the proper office. At all
events, the data I have adopted as the basis of my calculations are of
official origin, and they show the increase in the number of marriages
to be not uniform, as likewise the proportion per 1000. This variability
or lack of uniformity I am at a loss to account for, nor am I aware to
what causes, social or economical, it should be attributed. I shall add,
by way of comparison, a list of the marriages in nine American cities in
the year 1872, observing that the population of the city of New York
has been increased in the proportion corresponding to two years after the
CéllSUlS.
lS72.
Number per
1000 of ersons
Cities. Marriages. lmarried.
New York . º º º e & & . 9()()S 1S. 52
Boston . e tº te º * * e . 37.62 28.38
Philadelphia . & * º e & e . 6496 19.28
Richmond e ſº g º e e † . 567 18.90
Providence . ſº e e g e g . 943 26.46
Pittsburg e & º & e e tº . 1143 26.56
Albany & * e * * * º . (51.3 16.14
Newark . e tº & * e º & , 1241 23.62
Jersey City . & & st * * º 677 lă.7.
Buenos Ayres g o e * o e 21.93 21.04
In view of the heterogenous composition of the population, it is im-
portant in a statistical point of view to inquire into the nationality of
the consorts. The results of observation in this respect are, in Buenos
Ayres, as follows:—
Marriages according to the Nationality of the Consorts.
Argentines. Foreigners.
1869 Males . . . . . 444 Males . . . . . . 1414
Females . . . . 719 I'emales . . . . . 1139
1163 2.5:53
IS70 ſ Males . . . . . 519 Males . . . . . . 1397
‘’” UFemales . . . . 770 Females . . . . . 1146
1289 2:543
1871 ( Males . . . . . 478 Males . . . . . . 1418
* “ U Females 737 Females . . . . . 1159
VIT A L STAT IS TI C S OF BU E N O S A. Y. R. E. S. 1037
|S72 Males . . . . . 485 Males | 70S
" . Females . . . . 722 Females . . . . . 1471
12()7 3| 70
1873 ſ \ſales . . . . . 41s Males . . . . . . Isis
! Females . . . . 758 Females . . . . . 1533
1176 3406
In these five years, the number of foreigners who married is seen to
exceed by far that of the Argentines. And if, for the sake of greater
accuracy, we take the year 1869, bearing in mind that the foreign and
the Argentine elements were then almost equal, the different nationality
of the persons who married can only be explained by special comparison
of the foreign element in relation to age and sex. Thus, the number of
Argentines who contracted marriage in the year referred to was 1163,
and that of the foreigners of both sexes, 2553—that is to say, about 2.19
of the latter to 1 of the former. It will also be noticed that the number
of Argentine males was in still greater disproportion to that of the
foreign males, namely 444 to 1414, or as 1 to 3.18. Still another com-
parison with one of the foreign nationalities: The Italian population is
set down in the census at 41,957, against 89,661 Argentines. Now, the
number of Italians who married in the course of that year reached 1304,
and that of the Argentines 1163, of both sexes, while the Italian males
amounted to 704, and the Argentines to only 444. A similar dispropor-
tion is noticed in New York in a series of years. Let us take, for
example, the year 1873:—
Natives. Toreigners.
Males . . . . . 2688 Males . . . . . . 6,183
Females 353() Females . . . . . 5,341
6.218 11,524
Here the natives stand in the proportion of 1 to 1.8 of both sexes, the
proportion of native males being even smaller–1 to 2.3. The same
observation may be made in New York with reference to the German
nationality, as that I have just made with respect to the Italians in
Buenos Ayres. The German population, according to the census,
amounted to 151,216, the native having been 523,198. Meantime, while
but 6218 native Americans of both sexes contracted matrimony, the
number of Germans who married was 6340. And, in order to render
the analogy still more marked, let us mention that the American males
who entered into wedlock numbered only 2688, and the Germans 3416.
Births.--The same uniformity of progression appears in the births. It
may also be stated with certainty that the number of births follows the
increase of the population, preserving with it a uniform proportion, which
proves that the registration has been carefully attended to, and that my
estimate of the population before and after the census is neither exces-
sive nor deficient. Although I have the registers from 1855 down to
1873, I only adopt in the following table those relating to the five years
commencing with that of the census, and consequently including the
Inn hanºr, v v ear 1871 : —
• * * ** f : ['J J * * * =* *-* tº sº. g
*-*. A.
Years. Population. Births. Rate per 100ſ).
1869 177.7 - 7 Ö944 39.3
1870 185,320 7 561 40.5
1ST I 105,262 7 j-19 3.S. 6
1S 72 204.634 S()7 S 39.4
1873 214,456 Sjj9 39.9
Mean annual rate per 1000 39.5
1038 R AWSON,
Continuing the comparison with the vital movement in New York, I
transcribe from the official documents the number of births during the
same five years, in relation to the population calculated according to its
annual growth :—
Years. Births. Rate per 1000.
1869 . . . e º & º º e . 13,947 15.17
1870 . e e e t º - e . 14,524 15.41
1871 . e º - ſº te 0. e . 20,821 21.64
1872 . e o º e º º º . 22,068 22.45
1873 . . . . . . . . . 22,683 22.61
Mean annual rate per 1000 . º t e e . 19.45
The different rates in the first two years as compared to the others
may perhaps, in the absence of a visible specific cause, be attributed to
a defective system for the registry of births. But, even taking the
proportion of 22.61 per 1000, which is the maximum, it is far from the
mean annual rate in Buenos Ayres. The accompanying table will show
the proportion of births in a few cities of Europe and America, and will
serve to demonstrate how variable that proportion is in different nations,
though not on account of difference of race, but from other and complex
causes which must, sooner or later, come within the range of sanitary
SClé]] C62 –
Cities. Birth S in 1873. Tate per 1000.
Brussels . e º * o e e º 6,200 33.51
Ilondon o e © º e e -> . 121,100 36.05
Bordeaux . & º e º e º º 5,036 25.95
Berlin º e º º e e e . 36,281 38.19
})ublin s s © & e t & g 9,031 28.70
Milan & o {e é e e & º 9,091 33.52
Mexico º © © e te & e © 9,273 41.21
Boston º t tº e º © e & 9,688 35.07
Brooklyn . º e º e º º e 5,027 11.54
Philadelphia . e e te º e . 17,811 23.74
& 4 (1874) . º º e e . 19,387 24,07
Chicago º º te 9,718 24, 29
In some American cities the proportion of births is so low, as observed
by the Board of Health of Philadelphia in its reports, as only to be ac-
counted for by defective registration. If such be the case, the necessity
of reform is evident in this very important department of statistics.
The matrimonial statistics with respect to the nationality of the con-
sorts, would seem to promise a like proportion in the births with respect
to the nationality of the parents. I shall confine my examples in the fol-
lowing tables to births of children whose parents were either both Argen-
times or both foreigners, omitting cases of parents of mixed nationalities,
and cases without any specification.
Births.
'parents both Parents both
Years. Argentines. foreigners. Proportion,
1869 . e º º * . 1512 3314 1 to 2.0
1870 º º º º e . 1403 3881 | 2.7
1871 * * e º * . 1564 4019 | “ 2.4
1872 º e e º º . 1580 4451 I “ 2.8
1873 - te . 1543 4.738 I “ 3.0
The proportion of children of foreign parents to children of Argentine
parents, increased from 2 to 1 in 1869 to 3 to 1 in 1873, it being worthy
of remark that the augmentation coincided with the most extensive
immigration. Here, again, I meet the same analogies as before between
I3uenos Ayres and New York, as set forth in the subjoined table, in which
W IT A L STATIS TI C S OF B U E N O S A. Y.T. E. S. 1039
are included only births of children of American parents and children of
foreign parents.
Births.
Years. American parents. Foreign parents. Proportion.
1869 . ſº e tº * . 2457 9,080 1 to 3.7
187 () . º & tº g . 2553 9.282 I “ 3.6
1871 . e & e º . 2631 14,144 I “ 3.8
1872 . tº o º * . 37:21 14,829 I “ 3.9
1873 e & g . 3827 15,353 I “ 4.0
In New York, the excess of births of children of foreign parents, as
compared with those of children of American parents, is more remarkable,
inasmuch as it reached the proportion of 4 to 1 in 1873. This extraordi-
nary proportion is far in excess of that suggested by the number of
marriages according to nationalities, and indicates that the fecundity
of these different classes of persons is affected by other causes, as proved
by the two following facts: (1) That the predominance of males over
females is greater among children of foreign than among those of Ameri-
can parents, and (2) That, according to the curious observations contained
in the tables of statistics published by the New York Board of IIealth
from 1870 to 1873, among American mothers whose children were regis-
tered in those years,
35 had had up to that time g gº ſº e . 12 children each.
17 & & & $ * { € $ * e e e t 13 { % { {
9 & & ( & { { * { & o tº & e 14 & 4 { %
5 * & é & { { * { e e * te ſº 15 { { & &
2 { % & 4 & 4 & e º * & * 16 & 4 { %
1. & 4 { % € $ “ g & te { } . 18 * { { %
69
And among foreign mothers there were counted
215 with . g g e º tº * . 12 children each.
119 “ . e tº wº e tº te * . 13 { * & 4
57 “ . g . . g . & º . 14 { { { %
17 “ . o ſº º * † º º . 15 $ 8 * *
12 “ . e © g * * * tº . 16 § { § {
1]. “ . e tº e & tº G : ; . 17 & & & 4
4 “ . & e º ſº o & te . 18 § { * *
I “ . g tº - t e g sº . 19 § { & Š
436
making a total of 436 fecund foreign mothers, and only 69 American,
the fecundity of the latter appearing, too, in a less degree than that of
the former. -
Mortality.—I have now reached the most painful portion of my review.
In regard to the sanitary condition of Buenos Ayres, I must state facts
plainly as I apprehend them to exist, not merely because science should
be in possession of the whole truth, but also because the truth may serve
a useful end in stimulating the praiseworthy efforts now being made to
remedy the evils which menace the public health in that city.
Annual reports of the vital statistics of Buenos Ayres have only been
published within the last few years, and always so late as to have lost
much of their interest when they have reached the eyes of the few per-
sons who consult them. The public is for the most part ignorant of the
number of deaths that have occurred during the year, and is altogether
unaware of the proportion existing between the mortality and the popu-
lation, so that the belief still prevails that the city is very healthy. From
time to time such epidemics have appeared as smallpox, Scarlatina, or
1040 RAWSON,
measles, often carrying away large numbers of people; but such visita-
tions have been regarded as temporary exacerbations of mortality, which,
once past, would give place to returning health and all its attendant bless-
ings. In 1858, a yellow-fever epidemic, confined within the narrow limits
of a single ward of the city, killed from three to four hundred victims.
As the same disease had raged to a fearful extent the previous year at
the neighboring city of Montevideo, its appearance in Buenos Ayres pro-
duced a profound impression of terror, and caused a large number of the
inhabitants to flee to the rural districts; but the epidemic having proved
of short duration, and its effects somewhat limited, it was believed that
the sanitary condition of the city was so perfect as to prevent the spread-
ing of the horrible malady, and a general complaint arose against the
quarantine department for want of vigilance in allowing the introduction
of an exotic disease. In spite of the frequent returns of smallpox, Scarla-
tina, and typhoid fever, and the mortality caused by the tetamus infantum
(popularly called the “seven days’ sickness”), and other diseases common
among children, the idea of the salubrity of the city still prevailed in the
public mind.
In 1867, Asiatic cholera made its first appearance, and the following
year it returned, extending its ravages through the surrounding country
and most of the provinces of the interior. Much greater, indeed, would
have been the alarm in Buenos Ayres, if timely publicity had been given
to the disastrous effects of the warnings from Nature, who in no instance
allows any violation of her laws to pass with impunity. Much greater,
I say, would have been the alarm, for the people would then have been
made aware that the number of deaths in 1867 had reached 8029, or 49.9
per 1000 of the entire population, and 38.9 per 1000 in 1868. As it was,
however, the evil was productive of some good results: works were under-
taken for supplying the city with running water, and the cleaning of the
streets, and other sanitary details coming within the province of the
municipal police, were more regularly and efficiently performed.
The year 1869 was a peculiarly favorable one for determining the real
sanitary condition of the city, there being no epidemic just then in
Duenos Ayres, and the general health being, to all appearance, perfectly
satisfactory. The census of the population was taken in the year just
mentioned, and that was the juncture fixed upon for inquiring into the
real nature of the city as a habitable centre, and examining the status of
its account current between life and death, always bearing in mind that,
after the disappearance of severe epidemics, the relative death-rate de-
creases in a sensible degree. Now, had a report of the vital statistics
then been drawn up and published, it would have exhibited a mortality
of 5982 for the year last referred to, or 33 per 1000 of the inhabitants who
had just been numbered, and would have shown that, with such a usual
rate, Buenos Ayres could not appear to advantage beside other civilized
cities, in which latter—even including the most populous of Europe and
America—the mean annual death-rate is, with very few and marked
exceptions, much lower. Then would the existence have become evident
of permanent causes, the removal of which was indispensable in order to
the improvement of the public health. It would also have been dis-
covered that those causes tended to heighten the severity of epidemics,
and that something more was necessary than merely defending the
entrance to the city against the invasion of pestilence (even could such
defence, which is rarely the case, be rendered efficacious), namely, the
purification of the city itself, in order to render it salubrious under all
VITAL STATISTICS OF BU E N O S A. Y. R. E. S. 1041
circumstances, and to weaken the virulence of disease in the event of
extraordinary visitations. -
In 1870, peace and prosperity reigned undisturbed in the city, the
general health seemed good, immigrants, in hitherto unprecedented
numbers, were flocking in, labor was abundant and well remunerated,
and capital easily obtained, and commerce and industry were more active
than ever before. Buenos Ayres was all contentment, and looked with
evident satisfaction upon its visible growth ; and the very possibility of
another epidemic was forgotten by the people, who supposed the entrance
to their city well guarded by vigilant sentinels. Indeed, the death-rate
for that year was 1.5 per 1000 lower than that of the year immediately
preceding, though still far above the usual rate in other cities between
which and Buenos Ayres comparison was allowable. The situation
remained unchanged until the early days of 1871, when some cases of
yellow fever were reported in the southern extremity of the town. How
had the enemy entered, and who was to blame for the neglect? Investi-
gation was idle; the yellow fever, the terrible yellow fever, was in their
midst, and the frightened inhabitants anxiously occupied themselves
with the thought: what is likely to be the severity, and what the
extent, of the visitation ? All, families and individuals, who could do so,
left the city in search of a refuge from death that stared them in the
face. The pestilence, in the mean time, spread apace, and gained in
intensity as it spread. It attained its maximum severity in April, and
thenceforward gradually subsided until the end of May or beginning of
June, when the last cases occurred. The epidemic had extended through-
out the entire city. Its ravages were truly awful; 106.5 of every 1000
inhabitants died in that year, including in the population those who
were saved by withdrawing to the rural districts—some 60,000 persons.
Such mortality was beyond all imagination: one out of every nine in-
habitants is a death-rate unprecedented in the civilized world in the
nineteenth century; nor is it possible to describe the feelings of anguish
and terror which it left in the breasts of the survivors. It then became
deplorably evident that the hygienic condition of Buenos Ayres was
unfavorable in the extreme, and that the prompt investigation and
removal of the causes of the evil, at any sacrifice, were matters of the
utmost urgency. Under the promptings and counsel of Science and
experience, works of Sanitary improvement were at once commenced,
and on their completion we shall be in possession of that salubrity which
is so much to be desired, and which is always the reward of man’s efforts
to secure it. The lesson has been a severe one. -
It is only within the past few years that the beneficial results of
Sanitary Sciences have been experienced, even in Europe itself. To know
that many diseases are avoidable, inasmuch as their determining causes
are known and may be suppressed, is the first step, and comes within the
province of science. The will and the means necessary for the removal
of those causes are to be applied by the people, through their municipal
or political organization. The world has been very tardy in learning to
know itself in this respect, and is still slow in reaching the ultimate
consequences. It is not, therefore, to be wondered at that Buenos Ayres
should have been so ignorant, and still more neglectful than ignorant, of
the interests of the public health. Its very rapid growth warrants the
presumption that its sociological evolution may possibly partake of a
somewhat tumultuous character. Political agitations on the one hand,
apt on occasions to assume convulsive forms; inward satisfaction at
66
1042 - RAwson,
conscious advancement on the other, with the accumulation of stimuli
developed in a feverish and progressive society, and the complete con-
centration of power, individual and collective, in pursuit of the more
material and tangible ends of human energy, have been so many in-
fluences tending to divert, and which have in reality diverted, the minds
of men from those other interests, more radical and enduring if we will,
but less peremptory than the first, because their sphere is not measured
by common vision, and because a catastrophe is at times required to
bring them to the public attention. -
Although the foregoing reflections do not strictly form a part of the
principal object of the present review, they bear so close a relation to it
that I cannot forbear including them, they having been suggested to me
in the course of my statistical inquiries. It also appears to me proper
to mention, in this place, the chief causes of the increased mortality,
though they differ in no respect from those which—in all cities where
the laws of hygiene are imperfectly observed—contribute to augment
the number of deaths. - -
In Buenos Ayres, as in all Spanish towns, the streets are narrow, and
they present, together with the few, small, public squares, an area of very
inconsiderable extent. It is to be remembered that the proportion of
the municipal area to each inhabitant, as mentioned in a preceding page
—70 metres—is the average proportion, there being many parts of the
city sparsely populated ; and it is likewise to be borne in mind that in
most houses considerable space is devoted to extensive court-yards, etc.
As the population increases, these relative advantages grow less, and
they will become altogether null at no far distant day, unless prudent
forethought lead to the enlarging of the squares, and the converting
them into health-giving parks, and the widening some of the streets into
vast and spacious avenues.
In the course of the past twenty-four years, about two-thirds of the city
have been rebuilt, but without any attempt having been made to improve
that opportunity by adopting a methodical system of widening, save only
in the new streets of the suburbs. A grave error was committed in
using the filth of the town for the purpose of filling up and levelling some
of the streets, which were immediately paved over. The filth thus em-
ployed consisted of a heterogeneous mass principally made up of the
refuse from the dwellings, that is to say, animal and vegetable matter
united with dust and other substances, comprising house and street
sweepings. Such a sediment is destined to be decomposed by putrid
fermentation, and gives place to the generation of mephitic gases, which
escape through the porous surface stratum, and, mingling with the air
breathed by the inhabitants, constitute an inexhaustible source of poison
for the atmosphere. Indeed, it has been observed that the people dwell-
ing in the wards here described, have been relatively the principal suf.
ferers during epidemics, and that some portions of these districts are
rarely exempt from typhoid fever, especially in the spring and summer
Sé8 SOIlS. -
The water formerly used in Buenos Ayres, both for drinking and gene-
ral household purposes, was derived from three sources; the rich had
rain-water, preserved in impermeable tanks or cisterns, and the remain-
der of the population took well-water and the river-water sold in the
streets, which was commonly brought from the portion of the river La
Plata contiguous to the town, and was certainly contaminated by the
VITAL STATISTICS OF B U E N O S A. Y. R. E. S. 1043
fluvial population of the port, and by the liquid animal matter flowing
down from the slaughter-houses situated on the borders of the Riachuelo,
some two miles south of the centre of the city. With the exception of
the cistern water, for the most part good, the water chiefly used was
necessarily bad, as may be presumed from the nature of the sources from
which it was derived. Since 1868, steps have been taken for supplying
the town with running water proceeding from a more suitable portion of
the river, towards the north of the city; but the supply thus obtained is
extremely limited, nor is the source from which it is taken altogether
free from objection yet. The extensive works at present in process of
execution will accomplish a radical improvement in this respect.
The system of privies was primitive in the extreme. The receptacles
of the excrementitious matters were common cesspools, usually sunk
below the level of the subterranean water. In the soil, eminently porous
in that region, a deposit of putrescible matter was maintained for years,
dissolved more and more by the subterranean water, whose level has a
mean alternate rise and fall of about six feet from the dry to the wet
season. Hence, the process of absorption was rapid ; and not only the
gases generated by fermentation, but the liquids in which the decomposed
organic matter was held in solution impregnated the soil, vitiated the
water of the wells, and sent to the surface mephitic emanations incompa-
tible with the good health of the people who breathed an atmosphere
thus poisoned. In 1868 a new system of impermeable privies was insti-
tuted; but it has not yet become sufficiently general in its application,
and since 1871 the plan has been put into practice of emptying and
cleaning the privies by a pneumatic mechanism similar to that so suc-
cessfully applied in France. The works of drainage and sewerage, so
actively prosecuted at the present time, are destined to radically remove
this infection, which experience has demonstrated to be one of the most
fruitful causes of disease and death.
Before closing this tedious enumeration, I must add that there existed
two other foci of infection in Buenos Ayres. One of these was an immense
heap of refuse, made up of animal and vegetable matter in full course of
decomposition, which was accumulated some three miles southwest from
the centre of the city, and from which the noxious gases were carried to
the town by the atmospheric currents, and mainly by the wind called el
pampero, blowing in that direction from the pampas, and reputed as the
most healthful in the region. The quantity of filth gathered in that
place was enormous; in 1873, three hundred tons of the pestiferous mix-
ture were carried off daily, and in 1875, three hundred and ninety tons.
Since 1873, the evil effects of the accumulation have been sensibly modi-
fied by the simple and most efficient means adopted of burning the
unclean matter.
Two miles southward from the centre of the town runs the Riachuelo,
which empties into the Rio de la Plata. Here the loading and unloading
of the coasting and other light craft are mainly effected; and on the
banks of the Riachuelo stood for many years the slaughter-houses and
fat-boiling establishments, which represented the two principal industries
of the province, and in which as many as half a million of cattle were
slaughtered annually, and more than two millions of sheep and mares, and
the various parts of their carcasses were prepared for commerce. All the
liquid and much of the solid refuse matter proceeding from these estab-
lishments were thrown into the Riachuelo. The mass of infection thus
1044 RAWSON,
collected may easily be imagined, as may the consequent contamination
of the waters by the fermentation of the organic matter, from which arose
stifling gases to corrupt the air shortly to be breathed by the inhabitants
of the town. So extensive were the interests connected with the ancient
and remunerative industry allowed by our legislators to be carried on in
the manner described, that, notwithstanding oft-repeated warnings of
the grave objections offered by the nuisance, all the terror and desolation
of 1871 were necessary to bring about its abrupt suppression. Many
proprietors, no doubt, suffered materially by the measure; but the bene-
ficial results to the public health were incalculable. The diminution of
the typhoid fever since the removal of the saladeros, etc., affords an
evident proof of the wisdom of the step.
Is it, then, astonishing that, under so many unfavorable circumstances,
mortality should have been so great in Buenos Ayres 7 If the people
had been informed of the number of deaths from year to year, and the
relation between that number and the number of inhabitants, they would
have seen that, during the years 1854–1872, the death-rate was never
less than 31 per 1000, without counting the great epidemics; they would
have understood that the severity of the cholera and yellow fever which
decimated their ranks was intimately connected with causes within
their midst, calculated to encourage the development of contagious
maladies; and they would have investigated the nature of those causes,
would have found them where all modern societies have found them, and
would have energetically set about their removal. They would thus have
avoided much grief and many losses of greater moment than the expendi-
ture would have involved. There is no doubt that, if the public health
be persistently and intelligently cared for, and past and future experience
in this respect be profited by, the rate of mortality will in a few years
descend to the level of that of London, the metropolis of the world, as
it is called on account of its gigantic proportions. The climate of
London is not better than that of Buenos Ayres; nor are the waters of
the Lea or the Thames comparable, either for purity or abundance, to
the sweet and crystalline streams of the Paraná and Uruguay, which
unite to form the Plata; nor is the food used in England more healthy
or nutritious than that used in the Platine city ; nor is the soil of the
former more extensive or more fertile than that which the latter can
offer to the present and to future generations. If, in our endeavors to
improve our own condition, we use the same enlightened determination
which England uses, and which secures for her the respect and admira-
tion of all beholders, we shall accomplish what she has accomplished,
namely, the reduction of the death-rate in her large cities from 50 per
1000, near the close of the last century, to 22 per 1000, which has been
the mean rate during the last few years.
Det us now see what statistics say in their austere language. Takin
a series of fourteen years, from 1861 to 1875, exclusive of 1874, for which
I have as yet no returns, but inclusive of 1867 and 1868 with their
great cholera epidemic, and 1871 with its yellow fever, the mean annual
mortality is found to be 38.9 per 1000. If we leave out the years
marked by epidemics, the mean annual rate of the eleven remaining
years will be 31.3. But I prefer to present these data in tabular form,
for the sake of clearness, and in order that the maximum and minimum
mortality in the years referred to may be readily perceived.
VIT A L STAT IS TI C S OF B U E N O S A. Y. R. E. S. 1045
Estimated Rate per
Years. population. Mortality. 1000.
1861 * tº g g º . 121,280 3,410 28. I
1862 & * e g & . 127,101 4,313 33.8
1863 e º g e tº . 133,200 4,539 34.0
1864 tº * , g & * . 139,593 4,378 31.3
1865 * > * * & 4. . 146,292 5,857 40.0
| 866 e * & ë g . 153,313 5, 111 33.3
1867 e g º * e . 160,671 8,029 49.9
1868 º & º g º . 168,382 6,564 38.9
1869 * * iº º gº . 177,787 5,982 33.6
1ST0 g & g g e . 186.320 5,886 31.5
1871 º e & & g . 195,262 20,748 106.2
1872 * sº e e e . 204,634 5,671 27.7
1873 e gº & g & . 214,453 5,891 27.4
1875 e & * g & . 230,000 6,751 29.3
Mean annual rafe . : c • - * se º . 38.9
Mean annual rate, leaving out the years marked by epidemics 31.3
In the foregoing table are included three years of dreadful epidemics.
It is beyond doubt that, although the importation of contagious maladies
is almost always accidental, the extent to which they spread and the
severity of their character are always to be imputed to the sanitary con-
dition of the population, and to the same account is the increased mor-
tality to be charged. The year 1865 likewise figures in the table with a
death-rate of 40 per 1000, owing to the fact that the soldiers wounded
in the first battles of the Paraguayan war, fought on Argentine territory
invaded by the enemy, were brought to Buenos Ayres, and considerably
increased the number of deaths registered in the city. Deaths occa-
sioned by war should also appear in vital statistics: they are losses of life;
and, sooth to say, the cause to which they are due is among the most
easily avoidable. With these observations, the mean annual rate for the
period we have chosen may readily be estimated. If we leave out the
epidemic years and the first year of the Paraguayan war, the mean
annual rate of the ten remaining years will be 31 per 1000.
Let us see the state of things in New York during the same period.
As will be observed in the subjoined table, I have adopted the figures of
the census returns of 1860 and 1870, and computed the population of the
intervening years by applying the mean annual rate of increase corres-
ponding to 1.5 per centum. For the years following 1870, I have, for
reasons already hinted in this paper, adopted 2.1 per cent., the mean
annual rate of increase admitted by the Board of Iſealth. The State
census of 1865 has always been regarded as too low ; and such must be
the case, for, by comparing the population as set down in that census
with the mortality for that year, the death-rate would be 35.4, which is
inadmissible, as being out of proportion with the rates of the previous
and succeeding years.
| Commencement of the Paraguayan war.
1046 R.A.W S ON,
Rate per
Years. T'opulation, Deaths. I () ()().
1861 . & º * * . S.25,873 24,525 2S,4
1862 . e * g & . S3S,2{}() 23, 15() 27.6
| S (53 . & 3. º g . 8:5(), S3; 26,617 31.2
1864 S(; 3,625 25,702 20.9
1S (; ) ST 6, 57 ( 25,767 29.3
| S(){} . & e * g . SS!) . 726 26,815 30.1
1867 . º & * & . 94)3,071 23, 1.59 25.6
| S(jS . ſº g s * . 91 (5,641 24,889 27.1
| S{}{} . & t; :* g . 930,337 25.1 (3.7 27. ()
IST () . +: ſº o 9 . 942,292 27, 175 2S.S
187 | . $ e g § . 962,079 26,976 2S. ()
| S72 . e & & e . 982.282 32,647 33.2
| S73 . g g t * . 1,002,909 29, ()S-4 28.9
1874 . * * # 9. . 1,023,960 28,727 2S.()
IST 5 . ge tº ge * . 1,045,467 30,709 29.3
Mean annual rate of mortality per 1000 . & tº {º . 28.8
In comparing the two tables, I have only to observe that the death-
rate for the years 1872 and 1873, in Buenos Ayres, is lower than that for
the same years and the year 1874 in New York, while that for 1875 is
precisely the same in both cities; that the number of still-born infants is
included in the total of deaths in Buenos Ayres, but not in that of the
deaths in New York, according to the usual custom in the United States
and England ; and finally, that, of the total number of deaths figuring
opposite the year 1875 in the Buenos Ayres table, 1041 were caused by
smallpox.
Comparative Table of the Rate of Mortality in some American and
European Cities in the Year 1873.
Citio S. Rate. Cities. Rate,
New York . . . . 28.9 London . . . . . 22.8
Thiladelphia. . . . . 19.6 Liverpool . . . . . 25.8
Chicago . . . . . 23.8 Edinburgh . . . . 21.9
Boston . . . . . . 28.4 Paris . . . . . . 23.0
Cincinnati . . . . 22.8 3Ordeaux . . . . . 26.7
Buffalo . . . . . . 13.7 Berlin . . . . . . 27.8
St. Louis . . . . . 19.4 Vienna . . . . . . 35.2
New Orleans . . . . 37.5 Valparaiso . . . . 50.0
Cleveland . . . . . 19.2 Buenos Ayres . . . 27.4
The statistics of mortality in Buenos Ayres are taken with commen-
dable numerical accuracy; but that alone is not sufficient when those
statistics are to form a part of the general vital statistics, for in the
tables of these a methodical and scientific classification is required. The
classification in Buenos Ayres is defective. The deaths are registered
according to the medical certificates, in which is expressed the cause of
death ; but the diagnosis is not submitted to the criterion of any compe-
tent authority; nor are any fixed rules observed in the preparation of
the tables. The municipal employés, in their turn, but so long after date
as to preclude the possibility of adequate revision and correction, copy
down in alphabetical order the diseases mentioned in the physicians’
certificates; so that statistics thus compiled leave much to be wished for,
in a scientific point of view. The establishment of a uniform system of
classification for all countries would be desirable, as much enhancing the
advantages to be derived from comparative statistical studies. The classi-
fication proposed by Dr. Farr, and approved by the International Statis-
tical Congress in Paris, in 1855, is the one commonly followed in the
United States and England; but it has not been adopted in France and
W IT AL STATISTICS OF BU E N O S A. Y. R. E. S. 104.7
many other nations, nor is it uniformly observed even in the United
States. In the reports of the Chicago Board of Health, which I have
before me, I find the diseases arranged in alphabetical order, without any
regard to their special character. - -
The publication of the complete statistics of Buenos Ayres would,
therefore, be of no practical interest; and so I shall select the latest of a
series of reports in my possession—that for 1875—and transcribe there-
from such portions as are necessary. Of the 6751 deaths registered during
that year, the prevailing causes were as follows:—
Smallpox . º & tº e e tº g & g ... 1041
Phthisis t • * e º º & * o e . 858
Tetanus infantum º º ſº * * e 3 tº . 445
Typhoid fever . e & ſº & gº wº tº & . 140
Meningitis . * & tº & º & * º º . 355
Pneumonia. o § º e & & & gº e . 38.2
Organic affections of the circulatory system & g * . 389
Diphtheria tº † & e © tº g g * ... 101
Diarrhoea . t i- e g e tº ſº tº * . 296
The mortality according to sexes was as follows:—
Males . o § tº e * * tº * gº tº . 384L
Females & tº & . * gº w ſº g te . 2889
Not specified * * tº {} ſº g o g ſº g 21
Total . . . & g g * te e * . 6751
According to ages: —
Up to 5 years (including 189 still-born) o e ſº iº . 3521
Up to 100 years . te iº & & g o ſº * . 3072
Not specified & g o ſº g g tº º g . 158
Total . * t te e g tº g tº g . 6751
According to nationalities:—
Argentines . . . . . . . . . . . 5102
Foreigners . * . . . & te e d g e . 1649
Total . . g º & 6751
Smallpox stands for 15.4 per cent. of the mortality of the year. Few
cities present so large a number; and this is precisely the disease the
ravages of which may be most effectually prevented. If vaccination
were made obligatory in all cases and by all means, and due care taken
to be sure of the efficacy of the virus by frequent renewal, the deaths
from smallpox might be reduced to one-tenth of the number figuring in
the table; particularly when the hygienic condition of the city should have
been improved by the overground and underground sanitary works now
in progress. The appearance of smallpox is no longer an accident, but
an event of ordinary occurrence; the extent of its ravages is variable,
but the disease never fails to come, as proved by the following table:—
In 1869 the number of deaths by smallpox was . g g . I83
“ 1870 & & § { & 4 & 6 © * g . 195
4 * 1871 * { & & { { { % g te g & 1656
“ 1872 s & & 5 $ $ * { * tº gº . 836
£ & 1873 & 4 & 4 & & § { * * º * 76
“ 1874 & & & 3 & 4 4 & tº * tº . 525
** 1875 & 4 & 4 * * * g ſº sº ... 1041
Total . gº * & • * . 4512
Giving a mean annual rate of 644 during the seven years mentioned.
Such figures as these need no comment, nor even comparison with those
of American and European cities or regions.
1048 - RAWSON,
The next item of importance is that of 858 deaths from pulmonary
consumption, representing 12.7 per cent. of the total mortality. The
death-rate caused by phthisis has sensibly augmented in six years, as
will be seen in the following table —
Deaths Rate per cent. of
Years. from the total
phthisis. mortality.
1869 . * * tº º * is & * . 370 6.1
1870 . * gº e º g * & * . 274. 4.6
1871 . . . . & º & © & . . . 495 2.4!
1872 . * * g * § tº & & . 597 10.5
1873 . º te • e ū g ſº & . 755 12.8
1875 . gº & © * g te e {º . 858 12.7
This progressive increase of tuberculosis, at a time when cases of zymotic
disease are tending to diminish in number, save only smallpox, which is
due to a specific cause, can only be accounted for by an increase of damp-
ness in the soil underlying the city, in combination with the other causes
of insalubrity already mentioned, and which have as yet been but slightly
modified. Dr. Buchanan observed the effects of the drainage-works in
twenty-five cities in England, and reported that in all of them the gene-
ral mortality had decreased, particularly that determined by typhoid fever
and diarrhoea; but that in those which had been supplied with thorough
sewerage, without an equally effective system of underground drainage,
neither pulmonary consumption nor catarrhal affections had undergone
any diminution. The immediate effect of subterranean drainage is to
dry the ground, thus allowing the air to penetrate into the latter and
take the place of the water throughout the thickness of dried earth, and
there hasten the oxygenation of the infectious substances held in solu-
tion, and thereby establish a healthy condition of the soil. Besides, this
drying process exercises a powerful influence upon the atmospheric strata
immediately contiguous to the ground and forming the air breathed by
the inhabitants. It has been observed as an invariable rule, easily ex-
plained by physical laws, that fogs disappear or are diminished in a re-
markable degree in cities and elsewhere where the ground has been dried
by drainage. From the two foregoing facts it may be deduced that the
increase of tuberculosis corresponds to the increase of underground hu-
midity in conjunction with other depressing influences; and that if we
desire to put a limit to this grave malady, all the more to be feared from
its hereditary character, it is necessary that a most perfect system of
underground drainage should form a part of the works now in process
of execution, not only to prevent the invasion of new masses of water,
but to dry up that now contained in the ground, and so remove the
existing infection. - -
Buenos Ayres is not, indeed, the city which offers the greatest mor-
tality from pulmonary consumption. This disease has always been pro-
portionately more destructive in New York. The statistics of fifty-five
years demonstrate that, down to 1853, it caused from 16 to 21 per cent.
of the total mortality of that city; but that since that time it has
diminished in severity, as may be seen by the subjoined table, corre-
sponding to that above given for Buenos Ayres:—
The year of the great yellow-fever epidemic,
W IT A L STATISTICS OF BU E N O S A. Y. R. E. S., 1049
Daaths Rate per cent. of
Years. from the total
phthisis. mortality.
1869 * & & t e g tº & . 3364 13.37
187() * ſº wº † tº e ge g . 4030 14.82
1871 * e e tº g o tº § . 4186 15.52
1872 © * te g te ſº g º . 4274 13.09
1873 . . e tº * & º {...} º . 4134 14.21
1874 e g wº * * g º g . 4034 14.04
1875 * e tº e {º º ū . 4172 13.78
Nor is New York the least favored city in this respect in the United
States or Europe, as may be seen from the following table:—
Rate per cent. Rate per cent.
Cities. of deaths Cities. of deaths
from phthisis. from phthisis.
Poston . . . . . 15.17 St. Louis . . . . . . 8.78
Philadelphia. . . . 14.28 13altimore . . . . . 14.55
Portland . . . . 25.03 London . . . . . 11.70
Cincinnati . . . . 11.64 Paris . . . . . . 18.90
Cleveland . . . . 7.76 Tome . . . . . . 11.00
Chicago . . . . 6.68 Naples . . . . . 15.24
Next in order of numerical importance, on our list of causes of mortality,
stands tetanus infantum or trismus nascentium, the number of victims to
which was 445 in the year referred to, or 6.5 per cent. of the total mor-
tality. The peculiar tendency of the soil of Buenos Ayres to determine
such a considerable number of cases of tetanus infantum, vulgarly called
the “seven days' sickness,” and in England the “nine days’ sickness,” is a
circumstance deserving experimental and scientific inquiry. This species
of tetanus is regarded as traumatic, and as proceeding from the section
of the umbilical cord: it may set in during the process of cicatrization.
That this is not the only determining cause, is proved by the existence
of the disease in the endemic form in the city and province of Buenos
Ayres, and, to a certain degree, in the other littoral provinces. That it
is dependent upon the impurity of the surrounding atmosphere and the
want of care bestowed upon new-born infants, is demonstrated by its
almost total disappearance among families comfortably situated in clean
and well-ventilated houses; while the chief ravages of the affection
occur among the poor, particularly in houses overcrowded with people
who either know not how, or are unable, to give their infants that care
which is required by their tender years. At all events, the mortality
from tetanus infantum lias been on the decrease for a number of years,
owing to the improved condition of the general hygienic police, for I
have no doubt of the existence of a zymotic element in the production
of the disease.
Deaths from Rate per cent.
Years. tetanus of the total
infantum. mortality.
1869 . º * © & ſº tº * ſº . 630 10.5
1870 . tº tº g • - * tº § . 689 11.7
1871 . * º tº * ſº & e e . 470 2.21
1872 . g * * & s {º * e . 558 9.8
"1873 . . . . . . . . . . 620 10.5
1875 . * } © e $ º º tº g . 445 6.5
It is not here possible to establish a comparison with other cities, the
tetanus of new-born infants either not being mentioned at all in their
statistical reports, or only figuring therein for an extremely small pro-
portion of the total mortality. One exception I should, however, make:
! Year of the yellow fever.
1050 RAW SON,
the city of Havana, where 388 of the 83.90 deaths which occurred in
1875, were caused by tetanus infantum, being 4.6 per cent. of the whole
mortality. -
Typhoid fever was represented in 1875 by 128 deaths. The number
of deaths by this disease was 600 in 1869; but it has been gradually
decreasing since the suppression of the Saladeros in 1871, and the de-
struction of the filth in 1872 and 1873. This, like the other zymotic
diseases, is subordinate to the infection of the soil and air, and will pre-
vail in inverse ratio to the progress of the sanitary works now in course
of execution.
I shall devote no special remarks to the other causes of death enume-
rated in the table, partly because they are common diseases, and again
because the sanitary improvements will exercise a certain influence upon
them. After a brief examination of the subject of mortality among
children in Buenos Ayres, I shall proceed to consider the relation in
which the various nationalities appear before the law of death.
The number of children under five years of age who died in 1875, was
3521, including still-born infants, or 52.1 per cent. of the total mortality
for the twelvemonth. More than one-half of the deaths in Buenos Ayres
are of children under the age of five, which proportion is at once extremely
large and afflicting, especially as it seems to increase from year to year,
as set forth in the annexed table :-
Years. No. of deaths Rate per cent. of the
among children. total mortality.
1869 . & e t e e º tº 2534 42.2
1870 . § * ſº g © º º 2690 45.7
1871 . e º * e e e º 3591 17.3
1872 . º º ſº © & g & 2649 45.7
1873 . g tº * º & e º 2891 49.0
1875 . e e & e e 3521 5.2.1
Let us compare this table with the following one for New York during
the same number of years:—
Years. No. of deaths Rate per cent. of the
among children. total mortality.
1870 . e º e º e . . 12,971 48.0
1871 . º § e º º -> . 13,333 49.0
1872 . º g e e e º - 16,188 49.5
1873 . te * º e º tº {-> 14,182 48.7
1874 . e • e & g º e 13,956 48.9
1875 . g º º o º g o 14,839 48.3
From the comparison it would appear that the relative mortality
among children was greater in New York than in Buenos Ayres. But
in both cities it is very much greater than in localities the hygienic
condition of which is more favorable to general health ; while, on the
contrary, wherever that general condition is less favorable, infant mor-
tality represents a still higher proportion.
Where a full-grown adult may be able to brave morbific influences
with impunity, a tender infant will succumb. The mephitism of cities,
resulting at once from accumulation, imperfect circulation of air, defec-
tive light, and the gases from decayed organic matter which pervade
the atmosphere, menaces the health of all; notwithstanding which, the
great majority of adults survives, thanks to fully developed vigor and a
confirmed habit of organism, inured, as it were, to these adverse circum-
stances. But the infant, just emerged from the maternal cloister, igno-
rant of the circumstances in the midst of which it lives, unaccustomed
to the struggle, breathing that impure air from twenty-six to thirty
VITAL STATISTICS OF BU E N O S A. Y. R. E.S. 1051
times each minute, with extremely permeable membranes, and the rapid
processes of assimilation required by the progressive development of its
organs; the infant, in a word, feeble, inert, and defencelessly exposed to
the poisonous air, without knowledge of the evil, and even helpless to
avail itself of its locomotory mechanism to enable it to avoid danger
under the guidance of instinct, droops, and is prostrated by disease
and death. And all this without taking into account the baleful effects
of hereditary transmission, by which those tender organisms are unfitted
for life, poisoned as they are before birth by virulent infections, which at
best doom to a miserable existence the beings who receive them with
the blood of their progenitors.
These simple reflections, dictated by common sense, serve to illustrate
the incontestable fact that, under whatever hygienic conditions, even
the most satisfactory, life is surrounded by most dangers when in its
dawn, and that deaths will be more numerous during that period than
at any other time with which it may be compared ; but the same reflec-
tions serve also to illustrate another phenomenon less generally known,
namely, that, in proportion to the development of toxic influences in a
community, not only will the general mortality be enhanced, but the
relative mortality among children will be increased in a still higher
degree. This unchanging fact, proved by statistics and never contra-
dicted by experience, points to the conclusion that the proportion of the
infant mortality to the total mortality in each community may be taken
as a reliable human necrometer, and that from it may be deduced the
Sanitary condition of that community, even without an absolute knowl-
edge of the population at a given moment.
Supposing, for instance, that New York should succeed in reducing its
mortality from 29.3 per 1000, as it was in 1875, to the London rate of 21
per 1000 (which, it seems to me, would be perfectly attainable in a few
years, if the remedies pointed out by science were resolutely applied),
the aggregate mortality would be 21,954, instead of 30,709, and the in-
fant mortality, which reached 14,839, would not only be reduced, in pro-
portion to the total, to 10,604, but (the rate per cent., instead of 48.3,
being only 40, as it is approximately in very.healthy cities) would not
rise above 8781, thereby saving more than six thousand children annually
who are now sacrificed by the fatal circumstances under which they are
born to await death. And, if the same reckoning were applied to
Buenos Ayres, the mortality in 1875 would have been 4830, instead of
6751, and the corresponding infant mortality would have reached but
1932, and 1589 infant lives would have been spared.
The vital statistics of Buenos Ayres show that, of 6751 who died in
that city in 1875, 5102 were Argentines, or 75.5 per cent. of the total
number who perished. With the exception of 1871, in which year the
number of foreigners who died was greater than that of natives, the latter
stand in the death-returns for from 70 to 75 per cent. Indeed, the excep-
tion mentioned is to be explained by the fact that 60,000 persons, almost
exclusively Argentines, fled and took refuge in the rural districts, while
the foreigners (workingmen with their families) remained, for the most
part, in the infected town, and bore the brunt of the pestilence. For the
sake of clearness, I give the subjoined table, in which are set forth the
mortality among Argentines and foreigners, and the death-rate of the
former in relation to the total mortality in the city during a period of
six years:—
1052 - R AWSON,
Tercentage of
Years. Argentin; es. Foreigners. Argentine deaths.
1869 g g § g & . 4203 1,779 7 ().2
1ST () * © § & g . 4587 1,299 77.0
1871 & g g & te . 8()S2 12,666 38.9
1872 . . . . . . 4121 1,550 72.6
1873 . . . . . . 4319 1,572 73.3
1875 :- & * & & . 5102 1,649 7 5.5
If we examine the figures corresponding to 1869, which, taken as they
are from the census-returns of that year, present the advantage of being
accurate, and bear in mind that the native and foreign elements were
then almost equal (89,661 Argentines, 88,126 foreigners), we shall observe
that the mortality among the former was at the rate of 46.9 per 1000,
and that among the latter 20.1, And, if we take into consideration that
the proportion of the foreign to the native element has increased from
year to year, the marked inequality in the relative proportions of mor-
tality in the two groups will become at once perceptible. The gravity
of such an alarming state of affairs as shown by statistics is somewhat
attenuated by the fact that, among the number of deaths of Argentines,
is included the total mortality of children up to five years of age.
Deducting the latter from the death-returns of the same year, 1869,
which, as has been seen, is likewise the least unfavorable for the Argen-
times, and counting as adults (in as far as probabilities of life are con-
cerned) all individuals of upward of five years of age, we shall have:—
Argentines . & & g e e tº. * . 4203.
Children. e e * 9 t y e & . 2534
| 669
F,-,-,-, , , , , , , , , i.e. - - O
I, Oregnér's º º g $3 * <> & º g § J
that is is to say, a slightly greater mortality among foreign adults. It
is, however, to be observed that, of the 23,367 children (up to 5 years)
shown by the census, 2290 were born out of the republic. The portion
of these among the children who died in that year, and who were natu-
rally registered acording to their respective nationalities, forms a part of
the 1779 foreigners of the death-returns, and hence cannot be deducted
from the total of the Argentine infant mortality. If 9.8 per cent, of
the infant population, up to five years, is made up of foreign children,
it is fair to suppose that at least 9 per cent. Of the infant mortality
belonged to that category, in whicn case the approximate result would
be :—
Total of deaths among children . e & º . 2534.
Nine per cent. of foreign children 22S
Number of Argentine children * e & * . 2306
which deducted from the total Argentine mortality, would leave, instead 4
of 1669, a remainder of 1897, a number much higher than that of the
deaths among foreigners. -
Before proceeding any further with the review of the sad details sug-
gested by the foregoing results, let us compare these with those of the
corresponding table for New York, as follows:—
Mortality.
Years. r— $ —y Percentage of
Americans. Foreigners. Almericans.
1868 . . . . . . 16,805 8,084 67.5
1870 . * & * e . 17,471 9,714 64.2
1871 . & & © © . 17,470 9,566 64.7
1872 . º º g g . 21,448 11,199 65.6
1873 . g & º g . 19,135 9,949 65.7
W IT AL STATISTICS OF BU E N O S A. Y. R. E. S. 1053
Taking the year of the census, in which the poptilation was composed
of 523,198 Americans and 419,094 foreigners, the mortality among the
former was 33.3 per 1000, and among the latter 23.1 per 1000. If the
children be also deducted, for the same reason as in the case of Buenos
Ayres, the balance of the adult mortality is in favor of the native popu-
lation, in the proportion of 4671 deaths of adult Americans and 9714 of
foreigners, regarding as adults, as usual in my calculations, all the in-
habitants of more than five years of age. It is necessary here to make two
observations concerning these comparative results. The first has refer-
ence to the difference as regards ages, between Buenos Ayres and New
York, whence it appears that the inhabitants under five years of age
constitute, in the first city, 13.1 per cent. of the total population, as may
be seen by the census returns, while in the second they represent but 11.8
per cent., and, consequently, that the mass of inhabitants among whom
death makes its most abundant harvest is relatively larger in Buenos
Ayres. The second is contained in the following words of Dr. Elisha
Harris, recorder of vital statistics of the New York Board of Health :
“We next notice that more than half of the total population which is
over five years of age is of foreign birth, and that families, the heads of
which are of foreign birth, constitute the chief portion of the tenement
population, as shown by the returns of census-takers in the different
wards.” . . . “Vigorous as the better portion of foreign residents
are, the rate of mortality in their children is excessive.” These state-
ments go to show that the mortality among foreigners of over five years
of age, who live under such depressing circumstances, as also among their
young children, must be greater than that among the native population,
by whom other advantages are enjoyed.
There is in all this something more radical and serious than mere
numbers. In order to attenuate the gravity of the vital statistics, the
argument of the mortality among children is at all times adduced, and
their number deducted from that of the deaths among natives, thereby
proving that, from the age of five years upward, the vital energy to
resist disease and death is no greater in foreigners than in natives. I do
not wish to discuss this point, respecting which much might be said in
view of the lessons of history and of the biological sciences; but I must
say something upon the subject of the element with which it is asserted
that the balance against the native population is closed. Considered in
its relation to social mechanics, a child is assuredly not a power, but a
resistance ; not a force, but a burden; and, according to this incomplete
and fallacious theory, the death of a child would only be a loss in the
breasts of those who mourned him, and not for the producing capacity of
society, especially if replaced by a vigorous adult, come whence he might.
Such a doctrine, gondemned by our natural feelings, by justice, and by
philanthropy, is also in opposition to the dictates of sound reason and
statistics. Socially, the child is the moral bond and the hope of the
family; politically, he is the citizen of the future. The citizen who has
been born and grows up in the land of his fathers, not only assimilates
the materials of his organism in the continued process of rapid renova-
tion, but takes in, in that atmosphere, the constituent elements of his
disposition, and thus becomes by progressive education, by the contem-
plation of vicissitudes and of the struggles of manhood, and by the innate
love of all belonging to him, the surest guaranty of the firmness of the
institutions under whose influence and in whose mould he has been
formed. It is, then, the duty of well-constituted Societies to bestow
1054 R AWSON,
attention upon their children in view of the double interest just referred
to, and, if for nothing else, for the purpose of preserving the largest
number possible for the battles of collective life. ! #.
If the mortality among Argentines in Buenos Ayres, and among
Americans in New York, should become enhanced, or even retain its
present proportions, it would be difficult to foretell how far the respec-
tive nationalities may become weakened as a ruling power in society,
and how, little by little, that loss of influence may be felt in the customs
of the people and the integrity of the institutions. In my opinion this
danger is neither imaginary nor remote, and the only means I can dis-
cover by which it may be averted (and I have long studied the subject)
is, by the energetic improvement of the sanitary conditions of states,
cities, and towns; the reduction of mortality to its lowest possible ex-
pression (18 per 1000, for instance); and the perfecting of the systems
of education, popular, moral, and physical. From what we have already
seen concerning the susceptibility of favorable or adverse influences in
infancy, if mortality be lessened, those most benefited thereby will be
the children; while society, by the preservation of a larger number of
these, will secure the organic advantages which I have mentioned.
Statistics have also a voice in the question. The city of New York,
during the seven years ending in 1873, had a mean annual death-rate
of 29 per 1000, while the rate of births for that period was very low.
Taking the figures as they stand in the register, the number of deaths
and births was as follows:—
Deaths during the seven years . e - e . 189,385
Births “ ( & & 4 “ . * 119,226
Difference against the population . . . . 70,159
which is equivalent to a loss of more than 10,000 per annum. So that
if such losses were not compensated, and even exceeded, by immigration,
the population would go on gradually decreasing. I should here mention
that, according to official reports, the registry of births is so defective
as to warrant the assumption that not more than 75 per cent. of the real
number is recorded. Even accepting this hypothetical suggestion, and
supposing no omissions to have occurred in the death-registers, we should
have :— - *
Deaths gº tº tº º º © e e . 189,385
Births - & tº & º © tº © . 158,968
30,417
which would still leave a considerable loss for the population. And, in
order to avail ourselves of these figures, let us suppose the mortality in
New York to be reduced to 21 per 1000; in which case we should have
the following results:—
Deaths • tº & w & g d g . 140,692
Births º e º g - e º e . 158,968
18,276
leaving a balance of 18,276 in favor of the population, in place of a real
loss, as it has been sustaining ; and this without taking into account the
positive fact, based on experience, that the number of births increases
with the improvement of the sanitary condition of the city. It is like-
wise to be borne in mind, respecting children, that mortality among
them decreases much more rapidly with an improved healthy condition
VITAL STATISTICS OF BU E N O S A. Y. R. E. S. 1055
of the city than among adults; so that, if, of the hypothetical number
of deaths (140,692), 40 per cent. had been of children, the mortality of
the latter would have been 56,276, instead of the 93,677 who died during
the seven years, thereby constituting an economy of 37,401 infant lives,
or as many fathers or mothers of families in the course of a few years.
During the same seven years, Buenos Ayres had 51,207 births and
58,771 deaths, including the three epidemics (1867, 1868, and 1871), or a
loss of 7564 inhabitants. By reducing the annual death-rate to 21 per
1000, the mortality would have been 27,455 in the seven years, and the
difference in favor of the population 23,752. I am not examining chi-
meras, but realities; death and life are recorded in official statistics, and
the improvements which I hold as possible are graven in imperishable
monuments, in the form of sanitary works, in those American and
European communities which have struggled gloriously with death, and
have conquered it.
Wherever there is death there is sickness. It is generally admitted,
and to a certain extent proved by statistics, that the sickness-rate of a
city or town is approximately two sick persons throughout the year to
each death per annum. Hence, to ascertain the number of days of sick-
ness suffered by the population, taken collectively, the permanent factor
730 (365 × 2) is multiplied by the number of deaths during the year: so
that when the mortality is considerable, the number of sick persons is
also considerable in like proportion—which is perfectly reasonable, inas-
much as sickness and death proceed from the same causes acting, in a
given locality, upon each and all of the inhabitants. In 1875 the mor-
tality of New York was 30,709; and, if, as has been admitted, there
were two sick persons for each death constantly throughout every day
in the year, the number above given should be multiplied by 730, and
the product, 22,417,590, would be the number of days of sickness suffered
by the population collectively, which is equal to 21.4 days for each
inhabitant.
One day of sickness signifies one day's labor lost for those at an age
for working and producing. The number of these is easily computed
when we know that, according to the census of 1870, there were in the
city 350,556 persons engaged in all occupations, that is to say, 37.1 per
cent. of the total population; and, by applying this percentage to the
population in 1875, we ascertain that as many as 387,769 persons were
working, each one of whom lost by sickness 21.4 days of work in the course
of the year, and all of them collectively 8,298,566 days. The remuneration
for work varying considerably, according to the nature of the occupation
and individual capacity, it is not easy to adopt a uniform standard ; so
I shall take the lowest rate said, by the Commissioners of Emigration,
to have prevailed in 1875 for persons working by the day, namely, $1 to
$1.50, preferring the first, in order to avoid all appearance of exagge-
ration. The value of the labor lost would amount, at the rate of $1 per
day, to $8,298,566. The expenses occasioned by sickness are incident to
the whole population; and the number of days’ sickness, for population
collectively, as above reckoned, was 22,417,590. The approximate amount
of such expenses may be ascertained by means of the data furnished by
the hospitals, and according to which each patient costs about $2 per
day. Now, reducing those expenses by one-half (say to $1 instead of
$2), and including therein the outlay for professional attendance, medi-
cines, regimen, and nursing, for the inhabitants of all classes, the aggre-
ate cost would be $22,417,590, corresponding to the number of days of
sickness.






































1056 RAW S ON,
I shall not present in the pecuniary form the depressing influence
which morbific causes exercise upon the capacity, physical and moral, of
those individuals who, by reason of their vital energy, can resist the
effects of such causes and preserve their health. To eliminate and
brevail over a pathological agent, implies a waste of organic force in the
process, and so much less force in the physical and moral aptness applied
to production. Mems sama in corpore sano. It is enough to mention this
last branch of the subject, the pecuniary value of which cannot be esti-
mated.
Those who die during the working age have an independent value as
capital irrecoverably lost. Not only the days of sickness, or the days of
the year, are here lost, but the very instrument of production itself for
the future. In the United States, an adult innigrant is estimated as
representing a capital of $1000 incorporated in the national wealth: now
8580 adults, approximately, died in 1875, in the city of New York,
figuring consequently for an aggregate of $8,580,000.
With these numbers, every figure of which I have carefully calculated
according to data, either official or of acknowledged scientific authority,
the losses in the account of the public health for 1875 may be posted in
the ledger of the city of New York, as follows:—
Work lost . & * & * & e . $8,298,566
Loss, expenses incurred by sickness . º . 22,417,590
Loss, adult lives . & 9 e sº * . 8,580,000
$39,296,156
These losses cannot be avoided, but they may be considerably dimin-
ished. If the mortality had been 21 per 1000, instead of 29 per 1000,
each of the items of the account would have been reduced in the same
proportion ; the aggregate would only have been $28,452,216, and there
would have been an economy of $10,838,840.
That amount of money saved would be equal to the interest of a capi-
tal of $150,000,000 at seven per cent. And let it be asked of the dis-
tinguished Dr. Chandler, President of the Board of Health, or of the most
skilled and experienced Sanitary Engineers, either of this country or
of Europe, if that capital, or one-half thereof, intelligently invested in
sanitary improvements in the city of New York, would not be sufficient
to place that city on the level of London in point of salubrity. I am as
certain that the reply would be in the affirmative as I am that never
could money be invested in a more remunerative speculation.
As for the causes of the evil, and its remedy, there is a set of books
which contains their explanation, and which is worth a whole library.
The Reports of the New York Board of Health enumerate those causes,
accompanied by eloquent suggestions of remedies, from year to year,
supported by the authority of science and study. If the reading of those
Reports were rendered popular, the influences which make an imperial
metropolis an unhealthy city, in the eyes of the laws of hygiene, would
be recognized ; people would then know in what mortiferous conditions
live one-half of the population, and how those conditions may be mate-
rially improved, and what are the existing defects in the system of
drainage and sewerage, and the danger of those defects being enhanced,
to the still greater detriment of the public health; the relations of
meteorological phenomena to the mortality of the city would be discov-
ered ; and for each and every one of those evil influences would be found
a certain remedy, suggested by experience both at home and abroad, or
VITAL st ATISTICs of BU ENOS AYRES. 105.7
the means of attenuating such influences as were not immediately depend-
ent upon the hand of man. The recommendations of the board of health,
once put into action, with the amplifications required by successive
developments, would be sufficient to reduce, within the space of five
years, the mortality of New York from 29 per 1000 to 21 per 1000, and
thus secure all the benefits, physical and moral, to be gained by such a
triumph. .
It is for the interest of all, both poor and rich, natives and foreigners,
to aid in the realization of sanitary improvements, which are peremp-
torily urgent for the present and necessary for coming generations. And it
must be remembered that the cost of their execution is enhanced by every
day’s delay. One of those omnipotent movements of opinion which in
a strong-minded people are commonly attended by prodigious results,
would lead to the immediate and complete solution of the grand problem.
Nor does this subject concern alone Buenos Ayres, in that far-distant
region of America, nor New York, in this part of the continent: it is a
subject which affects the interests of whole nationalities. New York,
in 1790, had 33,000 inhabitants; eighty years later, with a million of
souls, it is the third city of the Christian world, and is marching onward
to become the first, at the close of the second centennial of the United
States. Philadelphia competes with Berlin and Vienna; on the banks
of the Mississippi is rising up St. Louis, another city which would
monopolize the admiration of all who beheld it, were it not that on the
margin of Lake Michigan, Chicago rears her head in pride before the
astonished gaze of natives and foreigners—Chicago, the new born city,
which now contains half a million of human beings. What, in the course
of time, will become of these grand centres of civilization, and of many
others as yet without a name : The problem of their destiny is in their
own hands, and Sanitary Science should be the chief light to guide them.
The tendency to centralization, with its advantages and inconveniences,
is inherent in human nature, and not to be controlled. In 1860, there
were in the United States 18 per cent. of the total population in cities
of 8000 inhabitants and upwards; and in 1875 the aggregate population
of the cities of 8000 and upwards amounted to 10,116,000, or 24 per cent.
of the total population, this last being estimated at 42,000,000. And
this in spite of the agricultural interests which should tend to dissemi-
nate the population over the entire length and breadth of the land; spite
of the rivers and lakes, canals and railways, the aggregate length of which
would reach three times round the terrestrial globe; spite of all these
facilities for cheap and rapid transit for people and industrial products,
whithersoever called by the necessity of the market.
In the Argentine Republic, this instinctive force of centralization is still
more marked than in the United States, and that for reasons, economical
and geographical, which are readily perceived. The growth of the lit-
toral towns is proportionately much more rapid than that of the towns in
the interior, and particularly that of Buenos Ayres, where the agglo-
meration is altogether incommensurate with that observed elsewhere in
the country. This is not a suitable time to inquire into the sociological
and political consequences of this natural inequality; but, in treating of
the life of cities and of the statistics of Buenos Ayres, to the latter are
applicable such considerations as that species of agroupment may suggest.
As for the causes of the excessive mortality of Buenos Ayres, they have
now been briefly enumerated, as have also the measures undertaken for
their removal. -
67
1058 RAW SON, VITAL STATISTICS OF BU EN Os AY REs.
For the rest, in the sanitary condition of cities, whatever be their
population, it is incumbent, not only upon them, in as far as their cir-
cumscribed capacity may extend, to assume the responsibility of the
present evil and of its future aggravation, but upon each and all of the
inhabitants: all have to take part in the continued struggle in defence
of life, as well individually as in municipalities, legislatures, and con-
gresses. I know not whether the illustrious Cobden and Peel concerned
themselves little or much with matters of public hygiene, but I do know
that the liberal commercial legislation established by them in England,
has served to improve the condition of the poor of that nation, by ren-
dering their existence less burdensome through the lower prices of
articles of food, and has contributed effectually to lessen the number of
deaths and of those diseases which are induced by want.
In closing this paper, T feel it my duty to apologize for the liberty
which I have taken of instituting comparisons with the vital movement
of New York, without the authority of prolonged personal observation.
On one hand, I should say that the Argentimes ever look to this part of
the world for example and stimulus; and on the other, that I have
noticed such close anthropological analogies between what I have seen
during my short stay in New York and that which has long been the
object of my study in Buenos Ayres, that I have not been able to resist
the desire of establishing a few comparisons, even at the risk of arriving
at defective or inaccurate conclusions.
1059
THE GENERAL SUBJECT OF QUARANTINE, WITH
PARTICULAR REFERENCE T() CHOLERA
AND YELLOW FEVER.
BY
JOHN M. WOODWORTII, A.M., M.D.,
SUPERY ISING SU R GEON-G ENERAL, UNITED STATES MERC ANTILE MARINE-HOSPITAL SERVICE.
THE earliest recorded measures instituted to prevent the spread of
disease were adopted by Moses, who made regulations concerning the
leprosy, in which he not only provided for the isolation of the infected
people, but held the suspected for observation and cleansing. In the
fourteenth century, certain restrictions were placed upon vessels arriving
at Venice and Genoa, in Italy, to prevent the introduction of the plague,
but it was not until the fifteenth century that quarantine was generally
established.
The early system of quarantine was not based upon scientific facts or
experience, but appears to have been an outgrowth of that peculiar
period (noted for ignorance and superstition) known as the “dark ages.”
The name “quarantine” fairly indicates the hypothetical extravagance
which held sway at its birth. As out of the forty days’ fast in the wilder-
ness grew Lent, the period of abstinence instituted for the purification of
the soul, so the process of purifying ships and passengers from so called
contagion was made to cover forty days, and this process was termed
quarantine." In the measures blindly enforced to protect seaports from
infection, not only was commerce crippled, and property needlessly sacri-
ficed, but the comforts and rights of the suspected were entirely ignored.
They were not only compelled to undergo a tedious, and worse than
useless, period of observation, but, by the very process of sequestration,
they were exposed to tenfold greater danger from fomites that might
chance to be in the ship. Many of the senseless and inhuman practices
which grew up under the name of quarantine, have by degrees, and from
time to time, been discontinued, and yet—so hard is it to cut loose from
the influence of tradition—not a little of the fog and delusion associated
with the term “quarantine” in the past continues to the present day, espe-
cially in the countries where quarantine was first established.
As the visits of the plague became less frequent and less severe, yellow
fever and cholera commenced their migrations. These diseases gave a
new interest to quarantine, which had previously been confined in its
operations to the old world, but by these diseases was extended to the
new. To the quarantine of ships, and of those who travelled by them,
was added the “cordon sanitaire” against cholera, in the hope of prevent-
ing its march by land. This last measure has been enforced in Europe
with the utmost rigor, and, though utterly futile in its results, appears
Charles Caldwell, M.D., on Quarantine, 1837.
1060 woo Dwor.TH,
not to have been entirely abandoned in some localities even during the
prevalence of the last recorded epidemic of this destroyer."
In America, quarantine was first established in 1758, at New York,
against yellow fever. Though I shall have occasion, further on, to speak
of the administration of quarantine at New York, it serves to mark the
progress and application of experience in this direction to note here some
of the changes which have taken place at that port. In 1811, we find
that vessels arriving from infected districts were detained thirty days at
quarantine, and passengers and crews twenty days after the occurrence
of the last case of yellow fever. In 1830, healthy persons arriving in
vessels from infected localities were permitted to proceed to the city, but
without their baggage. Notwithstanding that many pernicious restric-
tions still stand upon the statute-books of the State, the enforcement of
them is left to the medical officer, whose opinion is more and more recog-
nized. It is now found practicable not to detain either healthy passen-
gers or infected vessels. This arises from the generally accepted princi-
ple, that healthy individuals do not convey the morbific poison of cholera
or of yellow fever, but that the poison finds lodgment in confined clothing,
and especially in the vessels themselves, under favoring conditions. To
detain an infected vessel has been found to increase the virulence of the
poison. Accordingly, the ship's cargo is promptly transferred to lighters
in the bay, freely exposed to light and air, and the vessel, after thorough
disinfection, is allowed to proceed. In strong contrast with the foregoing,
is the practice pursued at Pensacola, on the Gulf Coast. In May, 1874,
upon the arrival of yellow fever at quarantine, the City Council of Pen-
sacola passed an ordinance which is here given in full:——
“Saturday, May 30, 1874.—Board met, pursuant to call from Mayor. The
object of the call having been stated, on motion it was resolved that all ves-
sels arriving at this port from infected ports shall be compelled to remain
in quarantine until frost; or said vessel shall be allowed to depart from this
port at any time during quarantine, at the option of the commander or captain
of said vessel; but in no case shall any such vessel be permitted to load, take in,
or discharge, cargo, within the limits of the quarantine station during the exist-
ence of quarantine; nor shall any person being on board any such vessel be
allowed to visit the city during quarantine.
“Resolved further, that the Mayor be requested, and he is hereby fully autho-
rized and empowered, to employ a good and sufficient armed guard, with a good
and sufficient boat, to patrol during the night on an established line between the
quarantine station and this city; and that the Mayor be requested to instruct
said guard to prevent all communication whatever, by boat or otherwise, be-
tween said station and this city, and to use sufficient force to attain that end,
should it be necessary to fire into the person or persons attempting to violate
said quarantine.
“Attest: M. P. DE RIoBoo, Clerk.”
The results of these widely different methods may be stated in a few
words: During each of the past five years, and more, a number of infected
vessels arrived at the New York quarantine station. Many cases of yel-
low fever were treated in Quarantine Hospital, but in no instance did
the disease spread to the city, or affect a single attendant on the sick. At
Pensacola, in 1874, the infected ships were anchored near the quarantine
| Dr. Milroy, in an article in the British and Foreign Medico-Chirurgical Review, No.
lxxxiii., states that “in 1867 military Cordons were drawn around the infected districts in
Montenegro, and persons who dared to cross them were shot. The horrors of famine were
thus added to those of pestilence.”
QUARANTINE. 1061
station. Communication from the infected vessels and from quarantine
was had by night with the land; and when, under the fostering condi-
tions for propagation, the yellow-fever poison had gained sufficient viru-
lence, the disease spread to the city and the naval station near by, the
quarantine medical officer himself falling a victim to the system which
he had blindly endeavored to carry out. -
In passing to a brief notice of quarantine regulations at two other
ports of the United States, it is proper to mention the fact that the con-
trol of quarantine in this country is not assumed by the general govern-
ment, but that it is established and enforced by each seaboard State, or
municipality, for itself. The only exception occurred during the war of
the rebellion, when the commanding general of the Union armies, upon
the recommendation of the Surgeon General of the Army, directed (1) that
all vessels arriving from ports infected with cholera, but having had no
case during their passage, should be quarantined for fifteen days and
thoroughly fumigated, and (2) that all vessels having had cholera on
board during their passage, should be quarantined for fifteen days after
the termination of the last case, and thoroughly fumigated. -
The quarantine regulations at the port of New Orleans, in 1822, autho-
rized the health officer, in his discretion, to continue quarantine indefi-
nitely, but provided that infected vessels should be detained not less than
fifteen days after the recovery of the sick, and purification of the vessel.
Healthy vessels from healthy ports were detained five days, and “ves-
sels from any port of Europe, arriving between the first of May and the
first of November, bringing more than twenty passengers, were not, how-
ever healthy, permitted to come within three leagues of the city, until
after the first of November in any year.” A committee on quarantine
for the State House of Representatives of Louisiana, reported that “dur-
ing the last year [1822], notwithstanding the strictest compliance with these
laws, our expectations were frustrated at the very moment when we
thought we could indulge the hope of the most complete success.” Under
the present laws in force at the New Orleans quarantine, vessels hailing
from ports infected with yellow fever are allowed to pass to the city after
ten days from the date of leaving an infected locality, and in this period
is included the time consumed in the passage. The Spanish bark Valpa-
raiso, which introduced yellow fever into the United States in 1873,
arrived at the quarantine station below the city of New Orleans on the
24th of June, eight days out from Havana. She completed the two
remaining days of quarantine required by law, and having been twice
fumigated with chlorine, and carbolic acid having been used in her pumps,
she proceeded to the city, where the mate was attacked on board on the
fourth of July, and died. Eight days subsequently, the mate of a steam-
boat, laid up for repairs at the same wharf, was also attacked, and died.
The first case of the cholera epidemic of 1873, in the United States,
occurred at New Orleans in the month of February, when quarantine is
not enforced. The man who first died of the disease had resided two
months in New Orleans, and at the time of the attack was engaged in
disch & wº ro-3 ** Arº are ſº yº tº gº. £-own º T iverpool vessel
15ul i a 1 31 11:3 vall 3V 11 v1.11 a L 1 v ∈ 1 Juvi esse 1.
Under revised quarantine laws adopted in South Carolina in 1869,
healthy vessels arriving at the port of Charleston, in that State, from
infected ports, are detained from fifteen to twenty days, and thoroughly
History of Quarantine in Louisiana, from 1821 to 1846. By B. Dowler, M.D., New
York Journal of Medicine, 1846, p. 160.
1062 woo Dwo RT II,
cleansed. If no case of disease be developed, the vessel is allowed to
proceed to the city. If, however, cases of disease have occurred on the
passage, the vessel is subjected to a quarantine of thirty" days, or longer:
all sick are promptly removed to the lazaretto, and the vessel is disinfected
as before. Under the careful enforcement of these rules, no case of yellow
fever has entered the city, notwithstanding that the disease has been
brought to quarantine every summer, except in 1871. In the latter year,
when no recognized case arrived by ships, the disease broke out in the city.
Turning from the diversity of opinion, practice, and results of quaran-
time, in this country, we observe a most rigid quarantine enforced by
countries bordering on the Mediterranean, while England has, during
late years, maintained the free pratique of her ports. Because England,
from her climatic conditions, comparative isolation, and wise measures of
internal sanitation, is able to maintain this advanced position, it does
not follow that the seaports of the continent can with impunity conform
to her example. In India, the endemic home of cholera, quarantine has
proved unavailing, and thence, from the standpoint of some observers in
that country, it is argued that measures to contravene the progress of
cholera are useless. Were quarantine to be established in the West
Indies against yellow fever, it would require no prophetic foresight to
predict the result. The conventions of Paris, Constantinople, and Vienna
have happily done much to harmonize the conflict of opinion which has
prevailed in reference to the particular system which should be applied
in quarantine. This system, however, must necessarily be modified by
the geographical position and climate of the countries concerned.
To ascertain, as nearly as possible, what precautions are necessary, and
what restrictions superfluous, in the administration of quarantine, the
next step will be to consider the characteristics of cholera and of yellow-
fever propagation, in order to determine as nearly as may be the prophy-
lactic value of Port Samitation, a term which most definitely expresses
the practical measures indicated by experience.
Cholera.-Amongst the many views respecting cholera, it is generally
admitted that the endemnic home of the disease is India, especially the
valley and delta of the Ganges, and that it is caused by a specific poison
capable of reproduction or multiplication. Whether the endemic exist-
ence of cholera in India is due to peculiarities of air, temperature, soil,
or water, or to the filth of uncleanly masses of people, is not determined :
but it is undoubtedly true that each and all of these influence the pro-
pagation of the poison, and the spread of the disease outside of India.
Some of the apparently well-established facts respecting cholera in India
are: (1) That it only prevails epidemically at intervals, usually of
several years; (2) that since its first migration around the world, it has
not passed the border of its endemic home to prevail epidemically in
other countries, except at times when the disease has shown unusual
virulence and diffusion in India ; (3) that the number of persons attacked
in the same town or city, during different epidemics, varies considerably,
even where the surrounding conditions are apparently equally favorable
to the spread of the disease; (4) that it is possible to flee from it,” show-
ing that a locality or place is the centre or focus of infection ; (5) that
Dr. Lebby, the Health Oſſicer at Charleston, has recently informed me that, at the last
session of the legislature of South Carolina, the period of quarantine was reduced to fifteen
days.
* The mountains of Lebanon have always proved a safe retreat for the inhabitants of
the cholera-stricken cities of Syria.
Q U. A R A NT IN E. 1063
recent improvements in the sanitary condition of jails in India have
rendered them almost exempt from visitation by cholera, many escaping
entirely, and very few of those attacked suffering with severity ; and
(6) that attendants upon the sick, in cholera hospitals removed from
infected localities, do not suffer more than any other class, and usually
enjoy entire immunity.
Dr. Cunningham maintains that the spread of cholera does not depend
in any degree upon the use of drinking water polluted by cholera evacua-
tions. Over against this statement is to be placed the fact that the mor-
tality rate from cholera has greatly diminished in Calcutta,” since the
introduction into that city of water less liable to contamination than
formerly.” The fact that those attacked by cholera, and those who
escape, in any given locality, drink from the same wells or other source
of water supply, is not proof positive that the cholera poison may not
be conveyed through the medium of drinking water, while the condition
of individual susceptibility remains as an undisputed factor in the devel-
opment of the disease. Many undoubtedly receive the poison who do
not suffer from it. Proof does not exist of cholera arising from impure
water, uncontaminated with cholera dejections, but the cholera poison is
unquestionably intensified in its action, or the susceptibility of individu-
als increased, or both, by the use of drinking water containing organic
impurities. Experience outside of India” abundantly proves that the
cholera-principle is portable; that it is carried by ships, and in clothing
and baggage, when excluded from the light and air. The spread of
epidemic cholera is characterized by localization in particular places,
ships, or houses, which then become centres of infection. The activity
of these foci of infection, as well as the intensity or fatality of the dis-
ease, appear to depend upon certain causes associated with the aggrega-
tion of human beings, and the attendant evils of impure air, impure
water, and filth. When these are present, a mild case of cholera serves
to kindle an epidemic as readily as a spark from the hunter's flint may
kindle a fire in the dry, rank grass of a Western prairie; and the pro-
gress, controlling influences, and results, of both sparks, are not dissimilar.
Individuals, infected with the disease, who travel during the period of
incubation, may, under favoring conditions, set up new foci of infection
at the places where they are attacked. These “favoring conditions”
are both individual and local, and, when either are absent, the cholera
germ may slumber, or may lose its reproductive power altogether. The
non-receptivity of certain localities, and of individuals, has long been
recognized, and is undoubtedly due to good sanitary conditions.
There is strong reason for believing that cholera dejections, which
appear to be harmless in their fresh state, become actively poisonous
Report of the Cholera Epidemic of 1872, in Northern India; by J. M. Cunningham,
M.D., Sanitary Commissioner with the Government in India.
* British and Foreign Medico-Chirurgical Review, July, 1872, p. 56.
* Prof. von Pettenkofer states that whole towns in Germany, which were ravaged by
cholera during former visitations, have been entirely free from the disease during late
epidemics, and that this result has been brought about by thorough and efficient drainage.
and by purification of the water supply.
* Both Dr. Cunningham and Dr. Bryson maintain that cholera is not spread by traffic
or human intercourse. The difficulties in the way of proving or disproving the portability
of the cholera-principle in a country where the disease originates, are too apparent to give
any weight to this negation. The causes or vehicles which spread a disease, not contagious
in the sense in which smallpox and typhus are contagious, can only be determined, if deter.
milled at all, Outside of the endemic home of the disease.
1064 Woo Dwo RTH,
with the commencement of fermentation or decomposition. Acid disin-
fectants interrupt or prevent altogether the fermenting process, thereby
destroying the poison. In like manner, the acid secretions of a healthy
stomach are believed to neutralize or render innoxious a certain amount
of the cholera-principle. The almost universal testimony is that good
sanitary conditions lessen the influence of the attack, restrain its dis-
semination, and frequently ward off the disease entirely. Dr. Harris
has remarked, in referring to cholera in New York, in 1866, “interpret
it as we may, the events in the experience of that visitation of cholera
demonstrated the practicability of dealing with the transportable and
exotic, or germinal, factor of the pestilence as an enemy to be held in
restraint, and its propagating attribute to be destroyed—a pestilence to
be stamped out by definite hygienic measures.” There is abundant proof
that the specific poison of the first cholera epidemic in the United States,
and of succeeding epidemics, down to the last one, was introduced by
ships from Europe, and the testimony of European observers furnishes
conclusive evidence that the disease was imported into that country
from India. The last epidemic of cholera in this country has differed
from previous epidemics, in that direct connection between the initial
cases and an imported germ has not been established,” but the fact re-
mains that nearly two thousand emigrants from cholera-infected districts
of Europe arrived in New Orleans during the month of the outbreak
and that immediately preceding.” It may be stated, as a general fact,
that each period of epidemic prevalence of cholera in America has been
associated with a similar period in Europe.
The morbific principle of cholera has from time to time shown a dis-
position to permanent lodgment by surviving the winter seasons of
Europe” and America. In the epidemic of 1854, in this country, the
disease spread to the Pacific coast, and was several times re-imported
from Central America to the port of New York; but the generative
principle of each epidemic has finally died out, and each succeeding
epidemic has depended upon fresh importations from India." Emigrants
from infected districts have always been a prolific cause of intensifying
and spreading the disease. “It is a matter of common experience to find
that at times, when the disease is only of occasional or sporadic occur-
rence in Calcutta, emigrant ships leaving the port are scenes of severe
outbreaks.” The readiness with which a vessel takes on the character-
istics of a crowded community or city, and becomes a centre of infection,
will be more readily appreciated, and the measures to prevent the spread
of cholera by ships more wisely directed and applied, when it is con-
sidered that a ship is but a town afloat. The ill-ventilated hold and
| Reports and Papers of the American Public-Health Association, vol. i. p. 346.
* There occurred, in 1873, three later outbreaks at widely remote points in the United
States, which were due to poison imported in personal baggage packed in the infected dis-
tricts of Sweden, Holland, and Russia. Surgeon Ely McClellan, U.S.A., in his Report on
the Cholera Epidemic of 1873, in the United States.
* Dr. McClellan, op. cit.
* Drs. Pelikan and Arkhangelsky have shown that cholera was present in Eastern Europe
from 1847 to 1856, and again from 1865 to 1873, though evincing a feeble activity during
much of the time.
* Prof. von Pettenkofer maintains that “it is a fact independent of all theory, which has
been observed in every epidemic of cholera, in every place, and on every occasion, that the
attacks in each individual house terminate on the average within twelve or fourteen days.”
Cholera, How to Prevent and Resist it. By Dr. Max von Pettenkofer. Translated by
Dr. Hime, 1875.
* Calcutta Review, 1869.
QUAR ANTIN E. 1065 •
foul bilges are the counterpart of the filthy sewers and cesspools of a
filthy city.
Yellow Fever.—Yellow fever is a disease produced by an invisible
poison, capable of self-multiplication outside of the human organism.
This something—the germ or miasm which has hitherto eluded micro-
scopical demonstration—is a product of the tropics. It shows a disposi-
tion not to spread in high, salubrious lands, but exhibits a preference
for low regions, especially the filthy portions of cities. Filth and high
temperature are as truly its concomitants as cleanliness and cold are op-
posed to its lodgment or propagation. In this country, yellow fever
has prevailed in most of the Atlantic and Gulf cities, and in many of
the towns along the Mississippi River." In some instances it has been
carried inland with people fleeing from infected localities, but it has
never shown a disposition to spread epidemically at points remote from
the continuous water-roads of commerce. The cities of the great lakes
have always been exempt from the disease.
In considering the morbific cause of the disease, we are necessarily
restricted to an examination of its characteristics or comportment, exhi-
bited in different places and under different conditions. We are, how-
ever, met at the outset with the difficulty and uncertainty of distinguish-
ing between yellow fever and the pernicious malarial fevers of the Gulf
coast. The cases that end fatally furnish reasonable certainty of the diag-
nosis given, but the milder cases that recover scarcely escape from doubt.
This uncertainty in determining the nature of mild cases, divides the
profession on the question of the endemic lodgment of the disease on
the Gulf coast, and serves to complicate the question of quarantine.
Whether the disease was endemic in the intertropical islands of America,
before it was brought from Africa, is uncertain ; but there is no doubt
now of its permanent lodgment in the West India Islands. The fact
that the island of Key West, off the southern extremity of Florida, is
in daily communication with IIavana, makes it extremely difficult to
determine the question of importation at that particular point. The
weight of evidence, however, is against the assumption of an indigenous
origin of the disease in the border lands of the Gulf, but it is probably
true that the poison has there been preserved through the winter in
formites, though it is believed that the United States is not affected epi-
demically except by the imported germ. The germ is transmissible. It
is capable of being transported in the personal effects of passengers and
sailors, but the damp, filthy holds and bilge water of ships are its favorite
lurking places, where, if confined, it multiplies and increases in virulence
to such an extent as not only to affect those on board, but even to exert
its pernicious influence in the direction of the currents of air to a con-
siderable distance. A vessel anchored at a wharf in Havana, or other
infected place, appears to become, for the time being, a part of the in-
fected region; and in sailing to a distant port, the ship transports the
poison as surely as could be done by transplanting a section of the infected
island of Cuba itself, were this possible.
Yellow fever is not communicated from the sick to the well, the sick
being dangerous only as possible carriers of the poison-germ or miasm;
hence all persons from an infected district may safely be considered as
| Greensville Dowell, M.D., of Galveston, states in his forthcoming work on the History
of Yellow Fever Epidemics, etc., in the State of Texas, that “yellow fever has spread to
228 cities and towns, and in 28 States in the United States, appearing 741 times, and caus.
ing 65,311 deaths.” -
1066 WooDw or TH,
harmless when the period of incubation, which lasts from two to six
days, has passed. This simplifies the question of quarantine, and indi-
cates the direction of preventive measures to the vessel and cargo, or to
the locality, if the poison have found lodgment on shore.
We have come now to the question of practice, and to the consideration
of the methods which should be pursued to secure the greatest protection
to the public health against cholera and yellow fever, with the least restric-
tion upon commerce. We may differ on the questions of the nature and
modes of propagation of cholera and yellow fever, but it is believed that
all meet on the common ground of prophylactic measures, and will
accept the proposition of General Sanitation—applied to the endemic
abodes of cholera and yellow fever, to ships, and to exposed countries—
as the surest means of stamping out these diseases. The general question
of preventive measures, is one intimately associated with that of higher
civilization. Every improvement in India, in matters of drainage, in
securing pure drinking water, and in personal cleanliness of the people,
will tend to lessen the ravages of cholera there, and to diminish the
chances of its spread abroad. In the West Indies, the harbor of Havana
is most frequented by commercial people, and is the most prolific source
of yellow fever.
In a recent personal letter to myself, Dr. Peters has expressed the
opinion in reference to Havana, which he had just visited, that “an
international public sentiment should be created against the filthy and
careless ways of the authorities, which cause so much suffering and death
among the mercantile and public navies of the whole world. The harbor
is small and landlocked ; all the drainage and sewage of the city go
into it, and very little gets out of it.” Dr. Peters suggests that a canal
could be made at the head of the harbor, to the ocean, allowing the tide-
water to sweep through the whole harbor, and thus remove its unhealth-
fulness. A vessel exposed to the influences of an infected harbor may
not be able to escape, but the danger can be greatly lessened by enforcing
strict cleanliness of the men and vessel. The bilge should be changed
every day with sea-water, until the pumps bring clear water. The men
should be compelled to bathe and change their flannels daily, when their
work is done, and should not be allowed to sleep on the open deck, or
in the lower part of the vessel. The same precautions should be con-
tinued through the voyage from a yellow-fever port. Ventilation should
be freely encouraged, and no confined air allowed in any part of the
vessel, if it be possible to prevent it. There is an example of a ship
trading between New York and Havana, on which these precautions
have been strictly enforced for a period of twelve years, and not a single
case of yellow fever has occurred on board." The proprietors of a line of
steam-vessels, trading and carrying passengers between West India ports
and New Orleans, employed an experienced person on each vessel, during
last year, to supervise its sanitary condition and to disinfect it after the
discharge of each cargo, with a similar result.”
I have already described the manner in which a ship becomes infected
with cholera, and, as cleanliness is the great end to be attained, and
maintained, on shipboard, the general preventive measures against this
disease are not unlike those suggested against yellow fever. If, how-
ever, one or more persons are seized with cholera on board a vessel, they
Communicated by Dr. Vanderpoel. * Communicated by Dr. C. B. White.
Q U A R ANTIN E. 1067
should be separated from the well passengers and crew ; their stools
should be disinfected with a solution of sulphate of iron, and at once
thrown into the sea ; and all soiled clothing should be burned or thrown
overboard. But if cases occur after the first four or five days out from
port, it is safe to conclude that the vessel is the source of infection.
Any suspected baggage should then be disinfected, and, for ten or twelve
days, all water used on board should be boiled before being served out."
Bxperience teaches that a cholera-infected house, or ship, ceases to impart
the disease after about twelve days, unless a new crop of the poison be
introduced. An outbreak of cholera on shipboard can certainly be
stamped out, and it is possible to do so during the passage of a steamship
from Europe to America.
The foregoing suggestions can be carried out by any master who
possesses sufficient intelligence to navigate a vessel, and it is believed
that by imparting such definite information to seafaring men, commerce
will be relieved from most of the restrictions reasonably imposed by
quarantine. The unreasonable hindrances imposed by quarantine can
only be corrected by cutting loose from senseless traditions and theories.
It is unreasonable, as it is impracticable, to apply a theoretically uniform
quarantine to all places, without reference to climate, the relations of
surrounding countries, or the natural history of the disease to be com-
bated. The question should be settled, separately and practically for
each country or place, by taking into account the liability to infection
of the port of destination, the period of incubation of the disease, the
length of time consumed in the passage, and the measures enforced by
the vessel en route. True quarantine measures should commence as soon
as the vessel has left an infected port, and, if commercial people find
that their well directed efforts are recognized by the port health-authori-
ties, a strong incentive to rigid cleanliness will be thereby at once estab-
lished, infectious diseases will be measurably restricted in their course,
and the problem of quarantine will be made comparatively easy of solu-
tion. The practice of medical inspection and sanitation, as adopted and
now carried out by Dr. Vanderpoel, at the port of New York, expresses
the practical application of our present knowledge of cholera and yellow
fever, as found applicable at that port.
If, upon arrival from an infected port, it be found that a vessel is clean,
and that no case of sickness has occurred on board during her voyage, any
detention of passengers and crew beyond the time required to thoroughly
air and disinfect their baggage and dunnage, is believed to be unnecessary,
provided that the period of incubation of the disease has passed during
the voyage. If cases of yellow fever have occurred during the passage,
the passengers and crew are removed from the vessel; the sick, if any,
placed in hospital, and the well detained in a comfortable, healthy place,
until five or six days after the occurrence of the last case, when they are
allowed to proceed to the city. Meantime the vessel is at once subjected
to a thorough airing and fumigation, and the cargo transferred to open
lighters in the bay, by men kept for the purpose. During the utiloading,
the vessel is daily fumigated, and, when the transfer is completed, every
available part is cleansed with water, and, after a thorough disinfection
and fumigation, the vessel is returned to commerce. It is not found
practicable to lay down arbitrary rules in regard to vessels on which
cholera has occurred. Each vessel is judged by the particular features
| Plan recommended by Macnamara.
1068 WooDW OF TH,
which belong to it. If prompt and energetic measures be enforced at
the first appearance of the disease, its spread can be cut short, as before
stated, and when this has occurred on vessels coming from Europe, it
has been found practicable to allow the vessels, passengers, and crew to
proceed to the city with only such delay as has been required to defi-
nitely ascertain the facts, and to perform disinfection. A vessel arriving,
however, with cholera on board, the same precautionary measures are
carried out as are enforced on the arrival of ships with yellow fever, and
eight days after the occurrence of the last case, the passengers are allowed
to leave. While the foregoing measures are necessary at New York,
England wisely confines her supervision of cholera, from without, to the
removal and care of the sick, and the cleansing of the vessel. It would
be futile for England to quarantine against ports of the continent, with
which she is in daily communication. Mr. Simon has truly said that
“contraband of quarantine, like ordinary smuggling, is developed so
soon as the inducements for it are considerable.” Yellow fever is less
liable to find lodgment in England than in Spain and Portugal, or in
New York.
As it is the custom for many emigrants, bound for America from
the continent of Europe, to embark at Liverpool or other healthy ports,
when cholera prevails on the continent, this country is exposed to the
introduction of the disease through the personal effects of such emi-
grants, sailing on healthy vessels from healthy ports. In a recent report
to Congress, I called attention to the necessity for “prompt and authori-
tative information to threatened ports [of the United States] of the ship-
ment of passengers or goods from a cholera-infected district,” and sug-
gested that the consular officers of the government should be instructed
to place themselves in communication with the health-authorities of
their respective localities, and to advise promptly, by cable, of the out-
break of cholera, and the sailing and destination of any vessels carrying
passengers and goods from infected districts. By this plan (which the
Honorable Secretary of State deems it practicable to carry into effect, if
Congress provide the necessary means) the thorough disinfection of in-
fected articles would be insured, and the danger from this source of
infection would be lessened.
In considering the value and practice of disinfection, the fact should be
kept in view that disinfectants are not as much needed as is cleanliness;
where the latter prevails, the former are not required. It is when there
is not time to get rid of filth, or when the poison has found lodgment,
that disinfectants are applicable, and then their application should be
thorough. The value of the several disinfectants is recognized, but their
use on ships depends chiefly upon the manner of application. Ordinary
fumigation cannot be relied upon to destroy the poison of an infected
vessel, without removing the cargo, as has been exemplified in many
instances, notably in the case of the bark Valparaiso, before cited. Dr.
Perry' has devised an apparatus, which he used successfully at the New
Orleans quarantine, in 1874, whereby either sulphurous-acid gas, carbolic-
acid vapor, or heated air, can be forced into a ship through flexible
rubber pipes, by means of blowers propelled by steam, all hatches and
other openings in the ship having been first securely closed. Whether
1 Effectual External Sanitary Regulations without Delay to Commerce. By A. W.
Perry, M.D., of New Orleans. American Public-Health Association's Reports and Papers
vol. i. p. 437.







































QUARANTINE. 1069
this process, in which are employed from thirty to one hundred pounds of
sulphur, for a single vessel, will always prove effectual without removing
the ship's cargo, remains to be determined by further trial.
It must be admitted that the germs of infectious diseases may elude
the most vigilant sanitary supervision of shipping which can be devised;
hence the importance of municipal co-operation, to the end that all
exposed cities may, through wisely directed sanitary measures, be ren-
dered less susceptible of infection. The value of sanitary supervision of
ocean-travel and traffic, and of preventive measures at home, is more
and more recognized by civilized nations, and the enlightened and
vigorous prosecution of these means gives hope of rendering exposed
countries less liable to infection; but the repeated battles against cholera
and yellow fever should awaken an international spirit, and a determi-
nation to carry the war upon these diseases to their endemic homes, and to
there instruct the people, and if need be compel them, to employ rational
means of prevention.
From what has preceded, the following conclusions appear to be justi-
fied:— -
I. The supervision of ocean-travel ought to be directed to securing
good sanitary conditions for vessels at all times, out of as well as in port.
II. A system of Port-Sanitation should be adopted and administered
for each country or place, separately, and should be modified in particu-
lar cases by taking into account the liability of the port to infection, the
period of incubation of the disease, the length of time consumed in the
voyage, and the measures enforced by the vessel en route.
III. In some countries, the detention of passengers and crews of ships
hailing from infected ports is warranted, but for such time only as is
necessary to complete the period of incubation of cholera or of yellow fever,
counting from the date of departure from an infected port, or of landing
from an infected vessel; in no instance should passengers or sailors be
held for observation on board an infected vessel, and such vessel should
not be detained beyond the period required for inspection, and for
thorough disinfection and cleansing.
IV. Recognizing the fact that the morbific causes of infectious dis-
eases may sometimes elude the most vigilant sanitary supervision of
shipping, the importance of wisely directed internal sanitary measures
can scarcely be overestimated.
V. As far as America is concerned, it is desirable that prompt and
authoritative information should be had of the shipment of passengers
or goods from districts infected with cholera or yellow fever, thereby
insuring the thorough disinfection of infected articles. -
VI. The endemic homes of cholera and yellow fever are the fields
which give the greatest promise of satisfactory results to well-directed
and energetic sanitary measures, and to this end an international senti-
ment should be awakened, so strong as to compel the careless and offend-
ing people to employ rational means of prevention.
DISCUSSION ON DR. WooDWORTH's PAPER.
After the reading of the preceding paper, Dr. A. S. BALDWIN, of Jackson-
ville, Florida, said:—In the port where I have lived for the last thirty years,
there has been no visitation of yellow fever as an epidemic. Isolated cases
1070 WOODW ORTH,
have presented themselves, but there has been no spread. In one instance, the
disease was brought in the contents of a valise. A gentleman, a resident of
that section of country, had been visiting in Havana, and in the course of his
rambles had passed through the Yellow-Fever Hospital. In a valise, which
he had opened two or three times on the way, the disease was carried, and
affected a nephew and niece who met him on his return. The niece recovered,
but the nephew died, and a post-mortem examination showed the liver to be of
a boxwood color. No other case of yellow fever followed from that outbreak.
In 1857, a disease broke out in Jacksonville, supposed to be yellow fever, but
it could not be traced to any foreign cause, and it differed somewhat in its
symptoms. During the summer a marsh had been cut off, and a railroad depot
erected thereon. This was in June. On the 20th of August, an individual
living near the marsh was affected with a fever ; on the 20th of September,
the disease was still existing in that neighborhood, and had occasioned much
alarm, 100 deaths having resulted. But the fever was as unlike the cases of
yellow fever which have been brought to Jacksonville, as typhoid fever is unlike
typhus.
Dr. IIENRY FIARTsIIoRNE, of Haverford College, Pennsylvania, said:—If we
believe that yellow fever is not personally communicable, there should be no
detention of the sick at quarantine. In regard to cholera, the fact mentioned
in the paper that persons escape by fleeing from the disease, is a proof that it
is not more communicable than yellow fever. Efforts to disinfect the stools
of patients have motoriously failed to arrest the disease, while local sanitary
regulations have in this country prevented its spread. Quarantine and deten-
tion have caused many deaths on infected vessels. What is wanted, is to do
away with personal detention at quarantine, and to see that sanitation is
enforced at sea and in port. A comparison has shown that rigid restrictions
have failed in Pensacola, while, in New York, less rigid restrictions have been
attended with better results.
Dr. S. O AKLEY WANDERPOEL, of New York, said:—There are three distinct
schools of belief, as to quarantine: One relies wholly upon a certain amount
of detention, and with another, everything depends on cleanliness, following
out the English hygienic system by which quarantine has been done away with.
I think that the modern school is the best, which employs a combination of
moderate detention and sanitation. I am willing to go as far as any one in
praise of local sanitation, but there is a necessity for the detention of ves-
sels coming from infected ports. I say too that yellow fever is not conta-
gious, from person to person, but I think that persons should be detained
until the period of incubation of the disease has passed. In New York there
is no quarantine, that is to say, no forty days' detention, as the name implies;
there may be a delay of a couple of days, but the period of incubation must
be allowed to elapse before passengers' baggage and clothing are permitted to
go into the city. There have been several instances in France in which disease
has been carried away to the country in clothing. A Savannah steamer came
into New York Harbor last Sunday morning. The crew and passengers were
perfectly well, and the vessel had not been lying in that portion of the town in
which the epidemic was raging, but I held the vessel twenty-four hours, to
make up the five days out. I do not call that a quarantine. Quarantine has
killed more persons than it has saved. The epidemic in New York, in 1856,
was caused by the Health Officers placing a vessel with its cargo off Long
Island. Exposed to the Sun, and lying there for twenty days, it became a
pest-ship, and soon from 150 to 200 vessels were strung along the Long Island
coast, all infected. Clothing and offal were thrown overboard from these, and
people living within two or three miles of the coast suffered. In relation to
cholera, I believe that if the dejections can be disposed of immediately, the risk
of contagion can be prevented. There is a period of from one and a half to
two hours, in which the dejections are inert ; after that, fermentation sets in,
and they become contagious. As far as I have been able to study the subject,
Q U. A R A N TIN E. 1071
cholera can be traced along the lines of travel. Even with the same atmos-
pheric conditions, five or ten miles from the line of travel, the disease is not
found. There are seasons in which epidemics are intense, and others in which,
if proper sanitary precautions be taken, cholera, though breaking out with
great virulence, will last only a week or ten days.
Dr. J. G. KERR, of San Francisco, said:—In the cities of China there are no
municipal governments, and no arrangements are made for cleaning the streets.
The filth which accumulates remains in the streets until carried off by natural
processes, or carted off by scavengers. Some streets are filled the whole year
with filth. I witnessed two epidemics of cholera in China, but they did not
seem to be influenced by the filth, nor confined to the filthy sections. Why is
this, when so much stress is placed in America and in Europe on cleanliness 2
My own opinion is, that it is due to the absence of underground sewerage.
In the cities of China there is no system of underground drainage, and the
gases which form are not confined. Epidemics there are not worse than here.
The poisons which propagate these are fostered by the arrangement of drain-
age here, and fermentation in sewers is as much to blame as anything else.
In China, where no attention is paid to drainage, there is no confinement of
gases, and no concentration of influences which produce disease. My observa-
tions were confirmed by a physician of the British Army, who, during the
Chinese war of 1856–1857, visited cities where the accumulations of filth were
obnoxious to strangers.
Dr. HARTSHORNE said:—It can be easily seen that scattered ſilth is not as
poisonous as when it is concentrated, but the fact still remains that filth is one
of the factors of disease. If it be true that the period of incubation of cholera
is short, yet I have known cases in which cholera has appeared when a vessel
has been two weeks at sea. The morbific agent which produces cholera has
met a vessel out at sea, and though the ship has been detained in quarantine,
yet in all that time the disease has not passed to the cabin-passengers, showing
that it is connected with local conditions and migratory causes.
Dr. VANDERPOEL said:—I agree with Dr. Hartshorne that cholera has ap-
peared in vessels hailing from perfectly healthy ports, but inquiry has shown
that the steerage-passengers, among whom the disease has broken out, did not
belong to the port from which they started. For instance, most emigrants to
this country start from Liverpool, yet they belong to Poland and other places.
These outbreaks on vessels have thus been traced to sections in which the dis-
ease has been raging. In the clothing of these emigrants, there is undoubtedly
a large quantity of soiled linen, which, as is well known, carries the disease.
The fact of the vessel coming from a healthy port does not show that every
one on board belongs to the healthy port. I can account for what Dr. Harts-
horne has related, by the baggage being closed until the vessel has got out to
sea; case after case has been traced to trunks. That is one reason why the dis-
ease does not go among the cabin-passengers; steerage-passengers generally
keep their baggage about them, while cabin-passengers have their trunks stored
in the hold, and there they remain until the end of the voyage. Besides, the
cabin-passengers are more cleanly, which is another point in favor of Dr. Harts-
horne's idea of sanitation.
Dr. EZR.A. M. HUNT, of Metuchen, New Jersey, said:—I remember a case in
which a lady visited a hospital, and three weeks afterwards wore the same silk
dress which she had worn while at the hospital. Scarlet fever broke out im-
mediately afterwards. As to filth, we have never yet had it proved to origi-
nate cholera. We understand that filth is a nest for disease, some of which
it does, and some of which it does not, originate; and this is a good reason why
we should get rid of it. The fact that it does not originate cholera and yellow
fever, does not weaken the importance of not letting their contagia get into
the filth. To prevent the spread of these diseases, we must stop baggage and
disinfect vessels, and stop passengers too, if necessary, but not keep them on
the ships.
1072.
A UNIVERSAL PHARMACOPOEIA.
BY
EDWARD R. SQUIBB, M.D.,
OF BROOKLYN.
THE idea of an International or Universal Pharmacopoeia, though by no
means new, has within a few years past come before the medical and
pharmaceutical professions with more than ordinary prominence, and
much has been written on the subject. The rate of progress in the art
of medicine in its utility to mankind, depends largely upon accumulated
experience; experience is the result of research and observation; and the
value of an observation is in direct proportion to its accuracy and com-
pleteness. That classification and comparison of observations, the result
of which is experience in the art, depends largely for its value upon the
uniformity of the conditions under which the observations are made, and
hence the present strong tendency to control and to formulate the condi-
tions under which experience accumulates, so that a larger proportion of
it may take the rank of absolute knowledge. For example, we know, as the
result of observation which has passed through the stage of experience to
become absolute knowledge, that opium relieves pain. This reaction be-
tween opium and pain involves two distinct series of phenomena, or is con-
ditioned from two separate bases: First, the cause, nature, and quantity of
pain, and this concerns the pathologist; and, second, the cause, nature,
and quantity of the opium appropriate to the reaction, and this concerns
the therapeutist. Pain is universal. Opium has, through knowledge,
become almost universal. To formulate and condition the opium for this
reaction upon the best results of general experience in the past, so that
future experience may accumulate under uniform conditions of the medi-
cinal agent—and may accumulate universally to the same single end,
namely, advanced knowledge for universal good—is the object sought
for in a Universal Pharmacopoeia.
Some such train of reasoning as this, having for its basis, at least, the
establishment of a universal standard of strength, composition, and
quality, for medicinal agents, so that by accuracy in the agents the results
of their use all over the world may be compared with accuracy, and thus
more rapidly convert empirical experience into knowledge, has been
generally advanced in support of the design. And it may be said that
the same line of argument, and the same necessities which made National
Pharmacopoeias first useful, and then indispensable, must, with the
advance of civilization, apply with equal force to produce an International
Pharmacopoeia. Thus the advantages to be expected from a Universal
Pharmacopoeia are so great and so easily shown, and the arguments for
it are so forcible, that up to this time all writers upon the subject, as far
as seen, in all nations, have been on one side of the question. And yet,
although ranged on the same side of the question, I have, by thoughtful
consideration of the subject, gradually reached the conclusion that the
design is premature, and for the present age impracticable, for the follow-
ing principal reasons:—
A U. N. IV E R S A. L. PH A R M A C O PCEIA. . 1073
(1) The difficulties of constructing a Universal Pharmacopoeia, which
would be universal in any true sense, would probably be at present insur-
mountable, because, as in other international designs of a similar char-
acter, the present national standards are so very different that they could
not be made to harmonize without radical changes, which the standard
of medical education of the age is not high enough to admit; and because
each prominent nation would at once seek to make its own pharmacopoeia
the basis to which others should be changed, as the condition upon which
it would share in the undertaking, just as is done at present in the
attempts to unify the coinage of different nations. And if a Universal
Pharmacopoeia should be constructed, with one or more prominent nations
Omitted from active co-operation, it would be but a sham, and would in
the end be productive of more harm than good, since anything of the kind
which might not be thorough and sound, would not stand, nor be authori-
tative, and would but add to the present confusion. The complete idea
of a Universal Pharmacopoeia is, of course, that it should take the place
of all national pharmacopoeias, and render these unnecessary, so that they
should be abandoned. But short of this, there seems to be a popular
idea which aims to embrace in the design only the making of the prepa-
rations, or the compound medicaments whether chemical or galenical, of
a uniform strength and character, leaving the national pharmacopoeias
to be as necessary as ever, but to be in accord in regard to the strength.
and quality of the agents of certain classes of remedies which have been
long and commonly used in different nations by the same or similar
names. For example, colocynth is used under the same name in all the
national pharmacopoeias, but its preparations and compounds in the dif.
ferent pharmacopoeias, under the same or similar names, contain it in
very different proportions. To have such preparations and compounds of
the same strength, and to have them designated by the same name every-
where—and this only—leaving the national pharmacopoeias as they are
with such exceptions of common accord, seems to be the less complete
idea of a Universal Pharmacopoeia aimed at by some writers. But this
really involves no less difficulties than the complete idea, nor are the dif-
ficulties of a different character, nor more easily overcome. For the
primary substance itself must be uniformly defined or described, or other-
wise it may vary so much in different countries and markets as to make
its preparations and compounds as different and as variable from that cause
as they would be from different proportions. And all primary substances
and chemicals would require the same definition and description in order
to secure their uniformity in use. Hence the difficulties in making a Uni-
versal Pharmacopoeia seem to be insurmountable in the present age. But
let it be assumed that a proper commission or council could be had, and
that the great amount of time and labor needful had been given to the
work, and that it had been harmoniously completed to the entire satis-
faction of all nations; even then, unlike coinage, and weights and mea-
sures, it could not be considered as either established or completed, since
in order to carry out the idea, and preserve its utility, it would have to
be revised at short intervals, and the commission would have to be recon-
structed from time to time, or would have to be permanent.
(2) To have a Universal Pharmacopoeia, involves the idea of universal
applicability. Could it be made universally applicable, or universally
useful? In civilized countries the civilization is not uniform in degree,
and between nations there is a still wider difference in this respect. All
the normals of different nations differ, that is, geographic position,
68
1074 SQUIBB, A UNIVERSAL PII AR M A COP (EIA.
climate, race, food, clothing, manners, habits, etc., make nations differ so
much that their health and their diseases are not the same either in cause,
course, or result, and are therefore not subject to uniformity in manage-
Thent. Or treatment.
(3) Again, the standard and degree of medical education is anything
but uniform throughout the world, and therefore a uniform code for its
use might not be generally applicable, any more than a universal grammar
would be applicable to popular use in all languages.
(4) Finally, all modern progress in the medical art points unmistakably
to singleness and simplicity in medicinal agents, and in their application.
The older and more complex formulas are rapidly passing out of use, and
single substances of more or less known physiological power, and of defi-
mite constitution, are as rapidly taking their place in the only true and
permanent interest of the art ; because upon such medication only can
much accuracy of observation be claimed. Then, just in proportion to
the progress in this direction, does a Universal Pharmacopoeia become
less necessary and less useful. And by means of this progress, the idea
of a Universal I’harmacopoeia becomes year by year more easily carried
Out, because simple substances of definite constitution and established
character and power are perhaps alone applicable to universal uses, and
because such are easily defined, described, and controlled.
These apparent difficulties in the way of a Universal Pharmacopoeia
are presented with hesitation, because the offering them may be construed
into opposition to a design for improving the means whereby precision of
observation and of result is to be looked for. The suggestions are made,
however, in no such spirit, but simply to present a few points which may
serve to awaken thoughtful attention to that side of the question which
has not hitherto been sufficiently considered.
THE RELATIONS OF THE PHARMACIST TO THE MEDICAL
PROFESSION.
BY
EZR.A. M. HUNT, M.D.,
OF METUCHEN, N. J.
THE relation of Pharmacy to Practical Medicine is not merely collate-
ral, but to the extremest degree radical and essential. All the command-
ments that form the decalogue of the physician find their summation in
two avowed purposes. One is thoroughly to make out the disease, and
the other is thoroughly to make out the remedy. Anatomy, physiology,
and pathology, mean little to us professionally and practically, unless
thereby we establish standards for the normal and abnormal, and by com-
parisons and observations are able to arrive at a diagnosis. Diagnosis
means but little unless it defines, and differentiates, and knows, in order
to guide to correct treatment. TSut treatment is as impossible without
accurate pharmacy, as is diagnosis without accurate physiology. Indeed,
the term diagnosis is as applicable to Materia Medica as to Disease. It
is just as indispensable to know through and through a medicine, as it
is to know thoroughly a disease. If there is failure at all either in the
one or in the other, we have, as far as ignorance can accomplish it, an
absolute failure resulting, just as if both were alike defective. A polished
steel bar on One side, elaborately finished and laid, and a tarred cable-
rope on the other, never yet made a railroad track. None the better will
there be efficiency in conducting onward this great science of ours, with
elaborated diagnosis on one side, and a smeared pharmaceutics on the
other.
I am quite aware that in what may be called popular medical feeling,
diagnosis of a disease outranks diagnosis of a remedy. There are a glow
and an enthusiasm about anatomy, histology, physiology, and pathology,
because of the subjects themselves, and of the accuracy of classification
of which they admit, but which has not as yet its parallel in the corre-
sponding department. A human being is so much grander a thing than
a poppy-seed, that it is much more attractive to pry into the cells and
functions of the one than into those of the other. The old story of the
Frenchman, who in his hospital rounds thrilled his pupils by his accurate
demarcations between healthy and diseased action, is still pertinent.
When asked the remedy, he turned away with a shrug, as if that was
a matter in which he had no concern. Until with equal identification
and elaboration he had indicated this, he might be anatomist, histologist,
physiologist, and pathologist ; but he could not be a physician.
The anatomy, histology, physiology, and pathology of the Materia
Medica must be studied individually and accurately, just as we study the
subject Man. If, in a certain sense, the one is to be investigated as if the
question of treatment would never occur, so the other may be studied as
if the drugs concerned were never to be employed as remedies. Such at
least may be the tendency of the naturalist, in either department. But
1076 II UNT,
he must know that his studies, as thus pursued, are merely preliminary
or collateral. His relations to medical practice (when he stops here) are
only those of the botanist, geologist, chemist, or comparative anatomist.
Our practice, our profession, our art, has as its sole object our ability to
make such an adjustment between the individual, corporeal man, and the
substances found in nature outside of him, as will promote his healthful-
ness. This, and this only, is the practice of medicine.
Therapeutics, since it is the application of remedies to the cure of dis-
ease, is almost a definition of the art of medicine. Dunglison defines a
therapeutist as “a practitioner of medicine.” Watts is only a little
more general when he says, “Medicine is justly distributed into pro-
phylactic, or the art of preserving health, and therapeutic, or the art of
restoring it.” Tet it then be axiomatic with us that none but a thera-
peutist is a physician. The knowledge of the remedy in all its accuracy
and in all its effects, is as essential as the knowledge of disease. It is
the conjunction that marks the inflowing tidal-wave of medical knowl-
edge, and that bears with it the skilful practitioner. So fundamental
and essential is the concurrence of these conditions of medical art, and so
palpable the proposition even upon its mere bare statement, that we can
scarcely account for the existing contrast and discrepancy between the
prominence given to the study of disease, and that tendered to the study
of remedies. Handfield Jones wrote to me some time since, in a private
letter, “a more perfect knowledge of the action of remedies is the great
desideratum of the day.”
A recent prize essay of the New York State Medical Society (1862)
had this as its motto: “I’hysiology has become a science by well-con-
ducted experiments that have illustrated facts. Can therapeutics claim
to be a science while so many of its votaries are content with assertions,
without experimental facts to support them 7” We must at least affirm
that unless therapeutics be a science, physiology cannot make the prac-
tice of medicine an art. This necessitates as a basic condition, not only
of success but of all experimental investigation, a certified reliability in
the articles by which our therapy is tested and applied. What we need
just now, is the most accurate assemblage and classification of experimen-
tal and experiential facts as to medicines themselves, and the greatest
safeguards as to purity and uniformity, in order that with scientific
exactness we may trace and record their actions. Accurate study and
adjustment here are very difficult to secure, as is almost everything of
value in our art. But only thus can that exactness of result be obtained
which will make real treatment not only possible but actual.
I have said thus much as to the general significance of therapeutics,
and its essential foundations, in order to magnify and emphasize this
fundamental condition of the progress of rational and practical medicine.
Our definiteness must begin with definiteness as to the disease which
we have to treat, and definiteness as to the medicines which we propose to
use. To this end, uniformity of preparation and reliability of dispensa-
tion must accompany a definite knowledge of what we have a right to
expect from the quantity of each article named in Our prescriptions.
How absurd that we should seek for and watch the action of a prepa-
ration, and expect and record salutary results from its use, unless the
preparation itself be of an indisputable character. Thus it needs no
argument to prove that the relation of what is called Pharmacy to the
Practice of Medicine is vital. It has so to do with the essence of the
tling, it is so much the centre and substance of our professional science
R E LAT I O N S OF PH A R M A C Y TO ME DIC IN E. 1077
and art, that it is an accessory before the fact. It will not do to assign it
to a territory adjacent to that of the medical profession. Such border
land is always doubtful land. As well might I recognize my right foot
or my right hand as an acquaintance: my only real prospect of material
success is to recognize and have them a part of my integral self. Nay,
the case is even stronger: it is wearing one of the vital organs outside of
the body, to put the framers and formers of our remedies totally without
the pale of our profession. Their department must have fundamentally
the surveillance of the medical profession, and this can only be secured
by its being within the adjudication of the faculty. Other assurances of
competency may be occasional and accidental, but only this can be reli-
able, when the two branches of science are so closely connected. When
seeking aid in our diagnosis, we consistently go to him who, while be-
longing to our profession, may have made of one department a specialty.
When he puts himself outside the pale of the profession, or is so put by
circumstances, whatever his boasted attainments, we recognize that it is
not for our interests, and still less for the interests of medical science, that
we should avail ourselves of his assistance. Yet for aid in the depart-
ment of therapeutics, that other arm of the profession, a very great part
of our dependence is upon those who are outside. The relation is a purely
commercial one, and tempts to demoralization. No profession can ever
put so much of its practice, of its essentials, so totally outside of itself.
and yet conserve its best interests as a science or an art. The effect
always will be to enfeeble the practitioner as to his knowledge of reme-
dies, so that he will not even know how to adjudge competency, or to
verify the assurance of reliability and accuracy, while another effect will
be to make the dispenser a mere tradesman. -
The first step in remedying this evil must be to hold pharmacy to
accountability and reliability, by making it a part of the profession of
medicine. It must be a specialty, like every other medical specialty,
having its foundation in a thorough medical education. It must, like
ophthalmology and gynaecology, be made a specialty, only because it may
not be practicable for each practitioner to attend to every department of
medicine, and in order that by giving more time for study greater accu-
racy may thereby be attained.
It is a noticeable fact, in the history of medicine, that this was just the
position that pharmacy formerly occupied. It was made a specialty not
that it might be a trade, adjunct and accessory to, yet outside of, medical
art, but because it was so fundamental and essential as to require con-
centrated study within the field of our calling. Even the English
method at the present day shows how thoroughly the Apothecary’s busi-
ness was identified with the medical profession. It was so fundamental
and integral as to give name to the practitioner.
The results of the separation which has occurred are so patent as to be
undeniable, and so degrading as to be notorious. The average American
dispenser is a dry-grocer, who avails himself of the patronage of the
medical profession in order the more to thrive as a merchant of drugs,
dye-stuffs, prescriptions, wares, patent medicines, fancy articles, liquors,
and manifold incidentals too numerous for cataloguing. The price-cur-
rent, for instance, of a prominent New York drug house, in over two
hundred pages, has only about forty devoted to drugs, and only one-half
of these are used medicinally. Not a few bear testimony that their
largest transactions are in patent nostrums, in which many of thern have
a proprietary interest. The retailers differ very in uch as to their stock in
107S H U NT,
trade according to locality; and in that part of their business which is
pushed into prominence we know of but few who follow what from the
medical, professional stand-point would be considered in accordance with
the rules of ethics. Under the elegant college-building of one of the best
of American medical schools, the pharmacist posts his own cure for neu-
ralgia, and prepares his own specifies for diarrhoea, and is at the same
time well patronized by the profession with prescriptions.
As the word from which “apothecary” is derived, means a repository
or storehouse, and as “drug” is a general name for commodities employed
for the purposes of medicine, dyeing, tanning, and other uses, these deal-
ers may be excused for their employment of the terms, and may become
general storekeepers. We do not object that honorable men should pur-
sue as a legitimate business the sale of this combination of commodities,
which the law permits. Our claim is that the preparation of medicines,
and the dispensing of the same by physician’s prescriptions, should not
by the physician be tolerated under such an arrangement. Medical prac-
tice is demoralized by such association, and an incubus is thus put upon
the real advancement of therapeutical knowledge among practitioners.
The only question before the wholesale dealer, is how to carry on his
trade to the best pecuniary advantage. If he acquire any pharmaceu-
tical knowledge at all, it is not in the interests of legitimate practice, but
that he may associate this with the other branches of the trade. We
know of a leading house which pays a practising physician to acquaint
it with the tastes of the profession, and to inform it of what is most likely
to please. The laxness of the retailers, if not quite so outspoken, is often
no less real. Prescribing pharmacists abound. The prescriptions of phy-
sicians are used with freedom, and are repeated indefinitely without the
knowledge of the prescriber. If in some stores the patent-medicine
notices are not so prominent, the article is nevertheless kept in stock, and
large sales of it are made.
We are aware that there are three classes of pharmacists: Those of the
first, and by far the most numerous class, do all in their power to gene-
ralize their business, having not the least regard for the physician, except
as a customer, and availing themselves with equal suavity of Jacob
Townsend and of Austin Flint. Those of the second class desire the
patronage of the profession more than they do a general business; they
have a faint perception of the higher sphere of therapeutics, and so foster
a prescription business, while feeling themselves necessitated to keep all
things required in the general trade. We theoretically add a third class,
of those who deal only in pharmaceutical preparations, and who dispense
medicines within such bounds as a profession can recognize. But we add
this class simply because many of the best of our pharmacists wish that
it existed, and that they belonged to it. It is quite plain that while de-
ploring the present state of things they do not see any way to improve it.
At the last meeting of the American Pharmaceutical Association, Pro-
fessor Maisch spoke of the innmense traffic in patent medicines. The
Association professed to be opposed to the sale of these articles, but it
is added “the efforts of pharmacists in this direction would amount to
nothing, as long as patent medicines are called for by the public.”
Nothing could more plainly show the present status of the business.
We might just as well say that the physician is compelled to prescribe
patent medicines because they are popular with the public. It is merely
the forced admission that the pharmacist does each day that which is
antagonistic to the principle of individual prescription for each case.
R E L A TI O N S OF PH A R M A C Y TO ME DIC IN E . 1070
And we do not notice any gain in the adaptation of the drug business to
professional ethics. A recent New York authority" says that in that
city “the sign, “Physician's prescriptions accurately prepared,’ is flanked
on all sides by cure-all pills, wonderful lotions, and infallible pain-killers.”
This is even more literally true in all the smaller cities and villages
through the land. I have purposely examined some of the leading so-
called pharmacies between New York and Philadelphia, and have found
the evil magnified beyond expression. I do not suppose that it will ever
be possible to break up these bric-a-brac shops, or prevent the mongrel
sale. Public demand will cause a place of supply. Stores will ever con-
tinue to exist, at which, under the name of “apothecary,” stationery and
innocent toys, perfumery and cosmetics, soda water and liquors, blacking
and garden-seeds, soaps and paints, window glass and putty, and all varie-
ties of patent medicines will continue to be vended. Let the drug-grocer
go on, and be recognized as such in his business, but let not such be the
place to which we resort for the compounding of our prescriptions. If we
give recognition to such establishments, we must not be critical because
these bazaars are the points of departure from regularity in medical prae-
tice. Quasi-elixirs and counter-doctors’ prescriptions are the inevitable
results of such afflictions. Worse still, the public is educated into low
views of our art, and among physicians themselves the relations of thera-
peutics to practice are distorted. Manifold preparations are smuggled
into professional use, which would not get there under proper medical
supervision, and such pharmacy is in turn the progeny and the progenitor
of lax therapeutics.
We are not to expect that any radical reform will originate with the
apothecaries themselves. Their relations to our profession being merely of
a business kind, there are not sufficient motives for change amid the vari-
ous mercantile interests pointing in other directions. We are told of late,
on the best of authority,” that there is danger that the United States
Pharmacopoeia itself will go over “to the commercial interests of phar-
macy.” Prof. Remington, in his address before the Philadelphia College
of Pharmacy, March 14, 1876, in view of the present degraded tendencies
of pharmaceutists, says: “Do you regard your avocation as a profes-
sion, or as a mere business calling : . . . What shall it be Profession
or trade, pharmacy or black art, pharmacopoeia or price current 7” The
very character of the business decides that question for us, and decides
too its reflex influence on medical science and practice. Definite and
damaging results must flow to us from such untoward channels of com-
munication with the populace. It is not surprising that the vender of
patent medicines should himself become a compounder and prescriber,
and that those whom we send for prescriptions should be beguiled by the
beautiful signs, or influenced by the advertisements of nostrums, with
which they meet.
For all this condition of things I hold the medical profession, in a great
degree, responsible. I do not complain of the American druggist that,
placed by the consent and really by the action of the medical profession
outside its guild, he should accept the situation and assume his relations
to that profession to be merely commercial. I will not blame the College
of Pharmacy of the city of New York,” whose business it is to educate
successful venders of drugs, that its Code of Ethics says that the “ne-
cessities of the times” warrant the keeping of patent medicines, although
! Medical Record. * E. R. Squibb, Ibid., July, 1876, p. 691.
3 Ibid., Oct. 30, 1875.
1080 HUNT,
it declares their sale to be “not a legitimate part of our business custom.”
But I do complain that Our profession, by complicity with this system,
aids and abets a calling which, by its very construction and methods of
practice, compromises that profession, militates against scientific medi-
cine, lowers our own estimate of therapeutics, and tends to remove the
care of our curative forces outside the domain of our professional jurisdic-
tion. The medical profession in New York City regards it as so improper
for a licensed practitioner to carry on the business of a retail druggist,
that it excludes such an one from medical societies, and will not place
his maine in its register. If a physician cannot keep a modern pharmacy,
as certainly he cannot consistently with proper professional feeling, I do
not quite see how he can suitably patronize one. It would be well if
it were practicable for every physician to refuse to send prescriptions to
be compounded by any save those duly licensed in medicine, and who,
having chosen this as their specialty, were bound in ethical propriety not
to prescribe, to sell and to compound only in recognized pharmacy, and
to hold themselves in the same relative position as a part of our profes-
sion, as do others who pursue a particular branch.
If, to-day, ten pharmacists in such cities as New York and Philadel-
phia could be brought into this direct association with the profession,
it would be a gain for pharmacy and therapeutics of the most reforma-
tory and indisputable character. Such a relation, existing between one
or more of our leading manufacturers and the medical profession, is an
elevation of the whole domain of therapeutics, not because of their per-
sonal attainments merely, but because they are thus held thoroughly
responsible to those high therapeutic demands which are alike in the real
interests of each department. When we bring the same conditions to
bear on the retail dispenser, we shall have Our greatest security for the
purity and adaptability of medicines. All hope of reform from outside
is Utopian, because the Organic relation is wrong, and must first of all
be righted. -
A method of this kind needs only to be initiated by such a medical
school as that of ILarvard, by such a State Society as that of New York,
or by such a school of pharmacy as that of Philadelphia, in order to
make of it an ultimate success. Enough of the better class of physicians
would rally to the support of those of their own number who should thus
thoroughly identify themselves with the interests of the profession in
one of its specialties. Many a pharmacist, sighing for deliverance from
his present mongrel trade, would gladly accept his place in our profession,
and in this branch of it would contribute to its welfare. All chemical
and microscopical examinations, and various similar aids which the
general practitioner now seeks and pays for, might naturally be committed
to this branch of the profession, as well as much that is now appropriated
by the instrument-maker. Place the dispensary in its natural relation,
in charge of a member of the medical profession by choice assigned to
that department, and Society would be shielded from exposure to irre-
sponsible remedies, and from the temptation to self-medication to which,
by the present system, it is constantly and cordially invited.
The pharmacist, within the fold where he legitimately belonged, would
Dave the status demanded by therapeutics, and would thereby become
directly interested with other physicians in the advance of our art.
There would be hosts of apothecaries on the outskirts, just as now there
are hosts of irregular practitioners on the outskirts of the legitimate
profession, but they would recognize themselves as belonging to the open
R E L A TI O N S OF PHI A R M A C Y TO ME I) IC IN E . 1081
frontier and the outside common. The line of demarcation would be
so pronounced, and the professional recognition so honorable, that the
real pharmacist and the real physician would alike rejoice. Therapeu-
tics, adjusting the relation between diagnosis and cure, has the right to
claim such a union. It already takes every one of us by the hand, and
shows us that it is not meet that we should divorce from us that which
forms an integral part of our profession, and which is incident to our very
life-success. Instead of leaving the pharmacist outside, let us invite him
within the boundaries of legitimate practice, and let him become imbued
with the esprit de corps which belongs to a noble profession.
I am importunate in this regard, because I feel that the present me-
thod of supply, or the medium of communication between ourselves and
Our patients, as far as remedial agency is concerned, is essentially de-
fective. If it were a mere criticism as to feasibility of method, or as to
expediency of convenient or financial management, it could be passed
by ; but the whole success of treatment, and therefore the welfare of
both patient and practitioner, are alike involved. The medicine or thing
prescribed is the result and means of conveyance of expressed skill—
the deliberate verdict on a case more or less critical. It is entitled to
the most assuring safeguard which the profession itself can furnish.
This safeguard cannot be furnished by adjunct relations. We cannot
afford to leave the work of preparing our remedies to the manipulation
of an outside corps. Identify pharmacy as fully with the profession as
any other legitimately followed medical specialty, and we at once throw
around it a cordon of protection and give an assurance of reform. Such
vastness of uncertainty as is at present distributed from the drug-shops of
our land, and very much under our prescribing, must be abolished ; and
this can only be done by reinstating pharmacy as part and parcel of our
calling.
This is peculiarly essential to medical progress, because for the next
quarter of a century the most crucial questions of practical medicine
will centre in therapeutics. The two great preliminaries for our progress
are (1) to have physicians record clinical and experimental results most
exactly, and to tabulate in extended classifications the symptoms of dis-
ease, and (2) so to acquaint us with the physiological effects of medicines,
and their effects in the various kinds and stages of disease, as to enable
us in like manner to tabulate remedies. To do this, we must be assured
of the precise quality, quantity, and precision of combination, of articles
used, so that sources of error shall be indisputably eliminated. All of
us who have examined and compared various specimens of medicines,
know how much this means, and how much uncertainty is introduced
into all chemical records by unreliable preparations. Never shall we be
able to exclude this disturbing factor, confusing all statistics, until the
prevalent system of dispensing medicines is changed, and until the phar-
macist takes his place as a member of Our profession, glad to be held
strictly responsible to its ethics, and finding it to his interest to practise
his specialty in the interests of every other department.
The following conclusions are offered as being warranted by what has
gone before:–
I. The interests of society and of the medical profession render it de-
sirable that the furnishing of medicines should be surrounded with
greater safeguards.
II. There are reasons why pharmacy should be regarded as a specialty
within the general bounds of the medical profession.
1083
SECTION ON MENTAL DISEASES.
P. R. E S I D F N T OF T H E S E (; T I O N .
JOHN P. GRAY, M.D., LL.D.,
OF UTICA, NEW YORK.
VI C E - P R E S I D E N T S .
E. GRISSOM, M.D., ISAAC RAY, M.D.,
OF NORTH CAROLINA. OF PHILADELPHIA.
S F. C. R. E. T. A. R. Y.
WALTER KEMPSTER, M.D.,
of os HKosH, WISCONS1 N.
THE MICROSCOPIO STUDY OF THE BRAIN.
BY - -
WALTER KEMPSTER, M.D.,
PHYSICIAN AND SUPERINTENDENT OF THE NORTHERN HOSPITAL FOR THE INSANE, OSHKos H,
- WISCONSIN.
THE microscopic examination of the tissues of the brain has added so
much that is new to the departments of anatomy, physiology, and
pathology, that each demands more time for its consideration than can
be given to it now. The microscopic pathology of the brain, as found
in insanity, having engaged my attention more particularly, I shall
devote myself wholly to this department of the subject.
Changes in the Meninges.—Insanity, in its various forms, is found to
involve all the cerebral tissues. Of the membranes investing the cerebral
mass, the dura mater is the least liable to general histological change,
general paresis being the only disease in which it is found to be uni-
formly altered. The alterations consist of thickening of the tissue, the
increase in thickness depending upon the formation of a new membrane,
apparently due to a disease of the epithelium lining the dura mater;
new vessels are formed in the membrane, generally tortuous and irregular.
In the more advanced stages of the disease, minute hemorrhagic points
are found scattered over the under surface, depending upon rupture of
some of the most tender capillaries. This state of the membrane must
e sought for particularly, as no great departure from the normal stan-
ard is observed without the aid of a lens, the most characteristic change
eing the presence of a delicate, pink tinge, not found ordinarily in the
ormal state. Transverse sections of the tissue, carefully prepared, will
how this condition very perfectly; or the new membrane may be torn
rom the dura mater, though it cannot then be so well studied. The
arge hemorrhagic clots found sometimes over the brain surface, in general
aresis, occur between the dura mater and this new membrane, the latter
















1084 KEMPSTER,
separating the clot from the subjacent tissues, and forming a delicate
film which, being stained by the blood, is often overlooked, and is re-
moved when the membrane is torn away from the clot. Not unfre-
quently the dura mater is found thickened in localized patches in other
forms of mental alienation, the increase of thickness appearing then to
depend upon an inflammatory condition which does not differ essentially
in appearance from that found in ordinary inflammation.
The arachnoid and pia mater are nearly always found diseased in all
forms of insanity, the most prominent changes being found in the vas-
cular system, and consisting of deviations in the course, size, and struc-
ture of the capillaries. The membranes are usually semi-opaque, and in
some cases thickened, and in thickening of the arachnoid, granules and
the products of inflammation are found upon its external surface. The
deviations in the course of the vessels, consist of increased tortuosity ;
the deviations in size, of aneurismal enlargement; and the deviations in
structure, of hypertrophy and degenerative processes.
In removing the pia mater from the convolutions, before the brain has
been placed in any hardening agent, portions of the external layer of
gray matter often adhere to the membrane, and patches of gray matter,
varying in size from that of a pin's head to the entire width of a convo-
lution, may be removed with it. In the parts so removed, it is common
to find changes of structure, having their origin in abnormal deposits on
the vessels, in minute hemorrhages, dependent upon rupture of vessels,
or in passive exudation, preparing the way for inflammatory changes, and
for softening and destruction of adjacent nerve-tissue.
The pia mater is composed of two layers, and in diseased states these
layers are easily demonstrated. Occasionally we find a hemorrhagic
point between the layers, in which case the layer on each side becomes
thickened by inflammatory changes; the thickening of the membrane
arrests the circulation in the contiguous parts, sometimes completely
shutting off the blood-supply to that part of the convolution which is
covered by the membrane, and, the twigs conveying the blood to the
external layers of gray matter being first closed, causes local softening of
the gray matter. The change here alluded to is often found in cases
of general paresis, although it is also found in other forms of mental
disease of an acute type. When the hemorrhage occurs between the
pia mater and the convolution, secondary changes do not appear to follow
so frequently. Occasionally, changes occur in the pia mater which do
not depend on hemorrhagic points; the simple thickening of the mem-
brane from inflammatory processes may cut off the blood-supply, and
necro-biosis of the tissue beneath then results. . *
New material is sometimes found on the external layer of the pia mater,
increasing the thickness of the membrane three or fourfold, and being
always the result of inflammatory processes. It is rare to find extensive
lesions in either the arachnoid or pia mater, without both membranes
being involved, though the pia mater is probably the first affected; this
is especially noticeable when pus has been formed, the pia mater being
then seriously diseased and thickened by deposits of plastic material upon
its surface.
JBloodvessels.—The most constant lesions observed in the cerebral tissue
of those who die insane, are connected with the circulatory apparatus;
and the first of these to be described, because probably laying the foun-
dation for other lesions, is engorgement of the arterioles and capillaries.
It will be remembered that the coats of the cerebral vessels are in their
M I C R O S CO PIC STU D Y O F T H E B R A I N. 1085
normal state more inelastic than those of other vessels, and that their
lumen is considerably larger than that of vessels of the same size else-
where. In the earlier stages of insanity, there is often fulness of the
cerebral vessels, resulting either from rapidity of the heart’s action, which
forcibly dilates the capillaries for a considerable length of time, or from
stasis of blood, depending upon disease of the vaso-motor apparatus. If
this fulness is relieved in a short time, the capillary resumes its ordinary
calibre, but the second distension is more easily effected than the first,
and the vessel is then less liable to resume its normal size. The process,
if frequently repeated, leaves the capillary in a state of permanent dis-
tension. The vessel is then irregular in form, being larger above a bifur-
cation than below, and presents the appearance of having been stuffed.
If the engorgement has been of long standing, changes in the coats of
the vessel and in the adjoining brain-tissue will be seen. The change
which occurs in the vessels is a fatty degeneration of the muscular coats,
or of the cells constituting the walls of the finer capillaries.
The first change noticed in the coats of the larger vessels is the collec-
tion of numbers of fine granules, apparently lying on the wall of the
vessel, or developed within its muscular coat; these are grouped together,
the granular deposit varying in size according to the stage of the de-
generative process. In the walls of the smaller capillaries, each cell
maintains its contour at first, but is slightly increased in size. Granules
are then formed near the nucleus, gradually encroaching upon the
plasma of the cell, which in time becomes a mass of granules; the
nucleus becomes involved in the same granular change, and finally dis-
appears. In the arterioles the degenerative process continues until the
evidences of muscular fibre disappear, and till the vessel looks like a
mass of granular material, through which its outline can sometimes be
dimly traced. A remarkable instance of infarction and secondary change,
illustrating the fact that these conditions may occur in utero, was found
in the brain of an infant who died in an epileptic convulsion immediately
after birth. The mother had for years been epileptic, and during preg-
nancy had had repeated epileptic seizures, followed by paroxysms of
violence. In the third left anterior convolution of this infant’s brain,
cysts were found, with fusiform dilatations of the vessels, and fatty de-
generation of the walls and cells of the vessels and capillaries. One
vessel occupied a place in a large cyst, wherein abundant evidences of
new material, the product of inflammation, existed, and where absorp-
tion must have occurred.
A change which appears to depend upon Over distension and subse-
quent relaxation is tortuosity and kinking ; the deviation in direction
ranges from a simple wavy course to the formation of a complete loop,
as though a knot had been tied in the vessel. The tortuous vessel is
not confined to any particular form of mental alienation, but exists in
all forms in which distension and subsequent relaxation have occurred,
and has been noted in acute mania, melancholia, dementia, and general
paresis. I have not found the tortuous vessels in the brains of the lower
animals, nor in the cerebral tissue of those who have died sane, except
in the brain of a man executed for murder, and who had been insane
some years before.
A condition that has given rise to considerable discussion in the de-
partment of cerebral pathology, is the existence of what have been called
the “perivascular canals,” in which the blood vessels are found, and the
“hyaline membrane” or “perivascular sheath,” which surrounds the
1086 KEMPSTER,
vessel. The canal and sheath are not easily demonstrated in the normal
brain, but in the diseased tissue they are readily observed. The mem-
brane or sheath, as it is called, does not always envelop the vessel closely,
but sometimes hangs loosely about it, and, where the vessel bifurcates,
forms a triangular sac. Sometimes the sheath is found closely applied to
the brain-tissue, this condition occurring where there has been excessive
engorgement a short time prior to death, the sheath having been dis-
tended, and the brain-tissue crowded back. After death, the vessel
recedes somewhat, leaving the membrane attached to the nerve-tissue,
and the vessel itself adhering to one portion of the membrane ; trans-
verse sections show the vessel apparently lying in a tunnel, which is
composed of the enveloping sheath applied to the wall of nerve-tissue.
The vessel, partially distended with blood, is found in the canal, and
tortuous vessels are sometimes found lying in comparatively straight
canals.
The various conditions of the perivascular canal are best studied in
fresh specimens, as we can thus acquire a better idea of the parts as
they actually exist, all hardening agents causing some contraction of the
tissue. Injected specimens, especially those of diseased cerebral tissue,
will aid materially in studying these interesting conditions, but for tracing
the ramifications of the canal, the hardened tissue answers best.
Lymph cells are found in the canal, in the fresh tissue, while smaller
granular bodies glide over each other as pressure is made on the covering
glass; it is the opinion of some Continental observers that these canals
convey the products of waste from the cerebral tissue into a lymph
space in the pia mater, an opinion which appears to be based upon good
reasons, for the perivascular canal can be traced into the space between
the layers of the pia mater. In all cases in which engorgement has
existed for some time, crystals of haematoidine are found both upon the
walls of the vessel, and also in the perivascular sheath. This deposit
varies considerably in extent, sometimes occurring only at the bifurcation
of the vessels (where it is always most abundant), and at other times
completely incrusting the coat of the vessel, and thickly deposited upon
the sheath. Another' deposit which is found upon the vessel, much
smaller than the crystals of haematoidine, appears as minute specks of a
fatty character, varying in size from Tºwn to a n'on of an inch in diame-
ter; these are yellowish-brown in color, and under high powers appear
crystalline, but they are not easily dissolved, nor are they affected in
any way by staining fluids.
As a result of the excessive engorgement of the vessels, we have fusi-
form enlargements and miliary aneurisms. Fusiform enlargements
appear to depend upon degeneration of the coats of the vessels, which
sometimes rupture, when the blood is poured out into the perivascular
canals, the hemorrhage being limited by the sheath ; these limited
hemorrhages are found only in the course of the smaller capillaries,
where the force of the blood-current is not sufficient to burst the sheath
after escaping from the vessel. This is not a frequent occurrence, but
has been observed a sufficient number of times to make it noteworthy.
These fusiform enlargements often extend to a bifurcation, the vesse
again enlarging beyond until the next branch is reached, and so on t
the finer capillaries. In all cases of fusiform enlargement, fatty meta
morphosis, in varying degree, has been found. Miliary aneurisms ar
not as frequent as fusiform enlargements, but are more striking in ap
pearance ; they are larger, ranging from go to 's of an inch in diameter
2 5
























MI C R O S CO PIC STU D Y O F T H E B R A IN . 1087
and can sometimes be seen without the aid of a lens. The vessels upon
which these aneurisms occur, do not appear to be as seriously diseased
as those in which fusiform enlargements are found, but the aneurisms, too,
depend upon morbid changes in the vessels' coats: degeneration of the
walls (the peri-arteritis of Charcot), together with engorgement, appear to
determine their existence in a certain number of cases, but other factors
are concerned in their formation, as the aneurisms are not found in all
cases of degeneration even though evidences of engorgement also exist.
They are found in all parts of the brain-tissue, and in the mem-
branes. I have found them in the gray matter of the spinal cord ; in
one notable case, the sac was situated near the origin of the first cervical
I) e l’VG.
IIypertrophy and fatty degeneration of the capillaries are frequently
noted in cases of protracted engorgement, this abnormal condition at
times existing to such an extent as to destroy the vessel, the mass form-
ing a nidus around which changes in the structure of the nerve-tissue
occur. Occlusion of the capillaries sometimes results from stasis follow-
ing engorgement, the minute thrombi being formed when the circulation
is impeded. If the circulation of a bat’s wing be arrested for a time,
certain of the blood-corpuscles are seen to adhere together, forming
minute thrombi. The agglomerated corpuscles are moved along with the
current until they pass into a vessel of small calibre, where they finally
lodge, generally at a bifurcation. The blood beyond the thrombus in
the plugged capillary becomes stationary, and a clot results, secondary
degenerative changes being then induced. In One case of acute mania,
recently examined, these minute thrombi were found in great numbers,
completely depriving large areas of the brain of their blood supply. The
vessels beyond the plug are in some cases found empty, but in others
distended with coagula, the adjacent brain-tissue being deeply stained
with the coloring matter of the blood. When we recall for a moment
the great vascularity of the brain, the effect of closure of the vessels
must be regarded as a fruitful source of abnormal cerebral action, inde-
pendent of the results which follow as a consequence of the deprivation
of nutrition.
In cases of insanity of long duration, or where there has been serious
disorganization of brain-tissue, a growth sometimes appears near the
capillaries, projecting beyond the sheath into the brain-tissue; the growth
is ovoid, one end being connected to the capillary. These growths are
Sometimes arranged in pairs, six or eight deep, the largest pair being at
one end of the mass, and each pair being smaller than the preceding.
They sometimes appear to surround the vessel, the outline of which
appears distinctly in the mass. The edges of these growths are not
sharp, and they do not have an investing membrane. The mass is granu-
lar, of a grayish-white color, and is not affected by carmine staining.
There are no nuclei apparent, and although the nerve-tissue is destroyed
wherever these growths occur, none of the débris caused by destruction
of nerve-tissue can be found in or about them. They are not fatty, and
there are no crystals of haematoidine upon them, but these may be seen
in abundance upon the vessel. Gold and palladium staining color the
growths slightly ; Osmic acid also colors them, but not as deeply as it
does the surrounding tissue. This microscopic mass is to be distinguished
from amyloid degeneration, and from the deposits found in syphilitic cases.
The fact that these bodies have been found in the vicinity of capillaries,
or in the course of obliterated vessels, has led me to infer that they are
1088 KEMPSTER,
dependent upon lesions of the circulatory apparatus. I have not observed
them near the larger cerebral vessels. They are not aneurismal, and do
not appear to have any direct connection with the vascular system.
Miliary hemorrhages are found frequently in cases in which aneurisms
do not exist, the amount of blood extravasated depending upon the size
of the vessel. Miliary hemorrhages vary in size from one-eighth to one-
thirtieth of an inch, or even smaller. The hemorrhage is usually limited,
but occasionally it involves large areas and produces characteristic symp-
toms. One point in connection with hemorrhage, not due to the rupture
of aneurismal sacs, I have not seen noticed by any writer, and that is the
tendency to extravasation of blood into the gray matter. This form of
bleeding I have usually found confined to the posterior convolutions. A
section through a convolution thus involved, shows that all the vessels
are more or less diseased, and that the hemorrhage has taken place from
all of the vessels in the vicinity, and apparently at about the same time ;
the smaller capillaries show small clots, which may at first be mistaken
for aneurisms, but careful inspection will reveal the difference.
In these cases it is quite difficult to determine just where the capil-
lary is ruptured, the closest scrutiny with the highest powers of the
microscope sometimes failing to disclose the opening. It may be that
the degenerated vessels permit a passive hemorrhage, the blood slowly
transuding through the softened walls. This form of bleeding is not
infrequent; I have found it in all forms of insanity consequent upon
engorgement, but especially in those cases of dementia which some
writers have denominated “acute.” The hemorrhage is not always
confined exclusively to the cortical substance of the brain, but is much
more frequently found there than elsewhere, and is more extensive than
in the white matter. The results are the same as in other forms of
hemorrhage; absorption slowly occurs, and cysts are formed, or local
softening takes place. Nearly always the remains of a vessel may be
found in or near the cyst. In the convolutions of the brain of the infant,
already alluded to, numerous cysts were found, in some of which the
vessels were apparently intact, but enveloped with granular débris. The
microscopic appearances of the circulatory apparatus indicate that in a
certain proportion of cases the initiatory processes of disease have their
origin in the capillaries or arterioles.
Nerve-fibres.—The nerve-fibres undergo changes which must seriously
interfere with their normal functions, independently of the diseased
tissues around them. The most common changes are hypertrophy and
atrophy. Hypertrophy, though not frequent, is found in certain cases,
and appears to depend upon increased growth of all the parts of the fibre.
The tubular membrane, or sheath of Schwann, grows more rapidly than
the other tissues, and is proportionately thicker than in its normal state.
The fibres must be examined as soon after death as possible, and should
not be placed in any fluid, as the outlines change rapidly after being
immersed. In hypertrophied fibres, the tubular membrane sometimes
appears to be formed of several delicate layers of tissue, presenting a wavy
appearance. The myeline is increased in quantity, and is granular.
The axis-cylinder contrasts strongly with the dark tubular membrane,
and presents a molecular appearance.
The most remarkable hypertrophy of nerve-fibres that I have ever seen,
was found in the cerebral tissue of a person aged forty-seven, who had
been maniacal for a year. The brain tissues, generally, were diseased
the vascular system presenting the enlarged appearances already de























MIC R O S CO PIC STU D Y OF TH E B R A IN . 1089
scribed, and the coats of the capillaries having in many places undergone
fatty changes. Twenty measurements of nerve-fibres were made soon
after the patient’s death, giving results as follows: one field contained
a number of fibres 3 g of an inch in diameter; several fields showed
fibres of an average diameter of 3 kg of an inch ; others again of a ºn of
an inch ; while in one instance the entire field was covered with fibres
ranging from +}s to sºn of an inch. The largest fibres were found
arranged in parallel bands. The same group of fibres, measured at dif-
ferent places, gave the same general results, the fibres ranging from sº
to +4 g of an inch in diameter. The portions measured were taken from
different parts of the brain, and there was no great difference observed
in the several fields as to size. Atrophy of the nerve-fibres from pressure
of adjacent growths, or from prolonged capillary engorgement, is of
common occurrence in cases of chronic insanity, particularly in elderly
people ; SO considerable is this atrophy, at times, that it is difficult to
distinguish the tubular membrane, nothing but the axis-cylinder being
clearly marked.
Changes in the Neuroglia.—Since Virchow first demonstrated the neu-
roglia, several forms of disease have been described which are attributed
to morbid changes of this tissue. The most common form of change has
been called sclerosis, to which name several affixes have been given;
thus there are disseminated sclerosis, multiple cerebral sclerosis, and
insular Sclerosis. The varieties above enumerated can be seen without
the aid of a lens, and they are believed to depend upon an increased
growth of the neuroglia. This hyperplasia of the connective tissue, as
it is sometimes called, plays an important part in several forms of
nervous disease not necessarily involving the mental status of the indi-
vidual affected.
Certain changes in the appearance of the cerebral tissues, which have
recently been brought to the attention of neuro-pathologists, have been
described under the name of Miliary Sclerosis. In this form of disease,
it is usual to find, scattered about the field of the microscope, a number
of white spots, situated in the white matter of the convolution. These
spots are not stained by carmine, and contrast sharply with the sur-
rounding tinted tissue; they vary in size from sºr to gº of an inch in
diameter; they are generally round, with well-defined margins; and the
adjacent tissue has the appearance of having been pushed back, as though
the new growth had formed rapidly. These spots are granular in ap-
pearance, and on some, connective-tissue fibres can be seen. They are
found in the white matter of the convolutions, in the corpora striata, the
optic thalami, the medulla oblongata, and the spinal cord; some are found
between the gray and the white matter, and some in the gray matter
itself. The nerve-fibres appear to bend around the spots in some places,
or they may terminate in them. This is particularly noticeable in the
medulla oblongata, where it is common to find the nerve-fibres either
bending around, or frayed out in, the spots. Occasionally one of the
spots forms about a capillary, which it destroys, in and beyond the mass.
Some of the spots are ovoid in form, and, when so shaped, the long
iameter corresponds to the axis of the nerve-fibres; again they are
ometimes found lobulated, the lobes generally being of unequal size,
out apparently developed from a central point; some of the spots have a
elicate greenish tinge, and this tint is the same whether the tissue has
een previously hardened in spirits, or in other agents.
These spots have been found in the fresh tissue; in one case, an entire










































69
1090 KEMPSTER,
section of the medulla, made soon after death, showed the tissue studded
with them ; and subsequent sections made from the medulla, after it
had been hardened, showed the same general appearance as in the fresh
state. The spots are best studied, however, in hardened tissue that has
been stained with carmine or with chloride of gold; when the latter
substance is used, the spots are slightly colored, but not uniformly
stained to the centre, except in the smallest masses; chloride of palla-
dium colors then brown, and a solution of osmic acid turns them dark
brown or black. When placed in a solution of osmic acid, they can
be seen to change color immediately, before the adjacent nerve-tissue
changes; three or four minutes’ immersion in a one per-cent. Solution
suffices to render them black, and when thus stained the spots appear
more granular than when stained with other agents.
There are several varieties of this form of degeneration, each one pre-
senting distinct characteristics; sometimes the spots are decidedly fibrous
in appearance, the fine stroma of delicate fibres being distinctly visible
when examined with a one-tenth objective. In other cases they are
amorphous, or but slightly granular, and with no apparent nucleus.
The margins of some of the smaller granular spots are clear and distinct,
while the margins of the larger spots in the same section may be irregu-
lar and apparently interlaced with the surrounding tissue. In the
fibrous masses, the fibres do not run in one direction, but interlace with
each other at all angles. The fibrous spots occur sometimes in tracts
affected with gray degeneration, which would seem to indicate that the
two forms of disease are separate and distinct. In one well-marked case
of gray degeneration, affecting the medulla, pons, and cord, in an epilep-
tic, the degenerated masses were found in several sections to be situated
directly in the tissues affected by the gray degeneration. It was ob-
served that where sclerosis did exist, the spot was distinctly fibrous;
where sclerosis did not exist, the spot was not fibrous, but presented the
slightly granular aspect already described. In the case alluded to there
were large patches, ſº inch in diameter, in the sclerous portion, while
in the tissue not affected by gray degeneration there were granular
masses rºotſ inch in diameter; some of these smaller patches were
lobulated, and lºad well-defined edges. As above stated, none of the
masses had nuclei, and no characteristic granular spot could be dis-
covered which could be regarded as a nucleus; nor could any of the
detritus of broken-down nerve-tissue be found in the masses, excepting
where sclerosis or gray degeneration had previously existed. No trace
of resemblance could be observed between the diseased spots and the
normal tissue, even in the most recent cases, and before chemical agents
had been employed to prepare the tissue for preservation.
Another form of disease, found quite frequently in certain cases,
has been called Colloid Degeneration; the name does not appear satis-
factory, for, except in color, the diseased parts do not resemble colloid
growths, nor do they respond to the reagents which are known to affect
colloid tissue. The so-called “colloid growths” of the brain are much
smaller than the unasses above described, ranging from s , , to 4 ºut of an
inch in diameter; they are more numerous than the patches of iniliary
sclerosis, have well-defined margins, and are more even in appearance an
smoother than the miliary spots. They occur altogether in the whit
matter, which in certain places is filled with them.
In cases of insanity complicated with syphilis, growths of anothe
form have been noticed ; these are as large as the miliary spots, bu























MIC R O S CO PIC STU D Y O F THE B R A.I.N. 1091
not as distinct, the margins shading off into the surrounding tissue.
They are more decidedly granular, or rather cellular, in structure, the
cells having nuclei, and there being a fibrillar stroma. Still another
form of growth has a distinct margin, but the mass appears to be sur-
rounded by a dense membrane, arranged in layers, the interior of the
spot appearing smooth and slightly molecular, but without a nucleus.
Five distinct forms of growth have been recognized, and subjected to
such tests as experience has dictated, each presenting peculiar and dis-
tinct reactions with the agents employed, and each having an affinity
for certain special staining materials; though osmic acid, in varying
degrees of intensity, stained all the sections subjected to it, with such
differences, however, as to leave little doubt that they were unlike each
other in structure. It should be stated that these tissues were sub-
jected to tests for cerebrin and lecithin, and to the most delicate tests
for albuminates; and that the substance which the larger spots (miliary
sclerosis) most resembled, and of which the test gave the most decided,
characteristic reaction, was cerebrin; but that the reactions noted at the
time were not sufficiently certain to warrant the assumption that this
material entered largely into their composition. The smaller masses did
not give the same reaction, and we are left without certain knowledge as
to their true structure. It should also be stated that comparative exami-
nations have been made of the central nerve-structure of the lower
animals, as well as of the central nerve-tissue of persons who died sane,
and who were suddenly deprived of life by accident. In nearly every
instance, the tissues were placed, part in alcohol and part in chromic
acid, or other hardening agent, but the results were substantially the
same as far as the diseased portions were concerned.
The masses of degeneration are found most frequently in the anterior
portions of the cerebrum, in the white matter of the convolutions; next
in the medulla, pons, and cord; and less frequently in the cerebel-
lum. In some cases, they are most numerous in the upper part of the
medulla, and it has been observed that while they are sometimes very
numerous about the region of the olivary bodies, there are comparatively
few in the olivary bodies themselves. These masses are frequently found
in the lateral columns of the cord, sometimes encroaching upon and
almost obliterating the central canal, for a considerable distance; and in
these cases the epithelium liming the canal is altered in structure, and often-
times its outline cannot be seen. In attempting to follow the course of
nerve-roots, these spots are sometimes found encroaching upon them,
fraying out the fibres, and destroying the continuity of the root itself.
In cases in which the roots of the nerves of special sense are seriously
interfered with, hallucinations referable to the nerves affected are observed
among the symptoms during life.
Nerve-cells of the Cortez.-The nerve-cells are subject to changes in
structure and form, being in some cases hypertrophied, in others atro-
phied, and in others again in some stage of granular degeneration, or of
igmentation. Changes in the nerve cells are quite constant. There is
not a particular change for each form of mental disturbance, nor do I
egard this as important, but the change in the structure of the cells is
o my mind of the highest significance. While it has not been shown
hat the nerve-cells are directly concerned in mental processes, yet the
ajority of writers consider that intellectual vigor is dependent upon
he normal state of the nerve-cells, and that these are immediately con-
rned in all our mental operations; and when it is found, in a large



































1092 REMPSTER,
number of cases, that degeneration of the nerve-cells is concomitant
with impairment of intellect, it is fair to assume that mental integrity
depends upon their being in a normal state. Granular changes in the
cells are the most frequent in all forms of insanity, the degree of disor-
ganization appearing to depend to some extent upon the violence of the
disease; the most complete metamorphosis of cell-structure is sometimes
found in acute cases which have run a rapid course. This form), of
degeneration has been denominated fatty, but the cells do not always
show the reactions incident to this condition ; the chemistry of the sub-
ject is, however, as yet crude, and the tests employed cannot be relied
upon when such delicate tissues as nerve-cells are involved.
In the initial stage of granular degeneration, a few yellowish specks
appear scattered about in the substance of the cell, at first not affecting
the nucleus. These specks increase in number as the change progresses,
until the entire body of the cell, including the nucleus, becomes involved,
and the cell wall partakes of the same change ; ultimately the cell loses its
contour, and is converted into a mass of granules, the polar prolongations
having previously become atrophied and indistinct. In atrophy, the
whole cell appears shrivelled, and its investing membrane is shrunken.
The poles become considerably shorter, and appear to lose some of their
substance, and the whole cell and its appendages seem to be surrounded
by a clear space. This atrophic change sometimes continues until the
cells lose their characteristic appearance, and the poles disappear. The
large pyramidal cells are sometimes found in a condition of hypertrophy,
but it is not a frequent occurrence, nor is it usual to find hypertrophied
cells in all the convolutions ; they appear most frequently in the parietal
convolutions, and seem to depend upon some local cause. The atrophie
and granular changes are nearly always general, as far as the pyramidal
cells are concerned. These large cells are often seriously affected, while
the smaller cells do not present the same form of change in so distinct a
manner. In cases of dementia of long standing, the large pyramidal cells
are affected by the granular change, more generally, I think, than in any
other distinct type of mental disease. In general paresis, the large cells
are also granular, but are less shrivelled, and contain pigment granules.
When the nutrition of the brain-tissue has been interfered with by
thrombi plugging the capillaries, the nerve-cells in the parts deprived of
blood have been found atrophied and granular, and in these cases the
lesion is localized, appearing only in those parts of the convolutions which
are deprived of nutriment. That the same form of degeneration may
be found in mania and melancholia, for instance, does not militate
against the inference that both forms of alienation may arise from the
same cause, the external expressions of the disease depending upon some
other circumstances. Whatever may be the function of the cells, it
cannot be properly performed when they are affected by a destructive
process which transforms a part or all of their substance into a material
so wholly unlike the normal structure that the characteristic features o
the cell are entirely lost, and its attachments to the surrounding nerve
fibres severed.
That part of our subject which relates to the pathological states whic
are characteristic of certain forms of insanity, must be approached wit
caution, as it is yet a comparatively new field ; but it is the practica
result which is expected to follow from a study of the morbid condition
of the brain, and it must eventually play an important part in dete
































MIC R O S CO PIC STU D Y O F THE B R A IN . 1093
mining the therapeutics of mental diseases. To illustrate this subject,
I have selected typical cases from the well-pronounced forms of insanity,
and will briefly describe the pathological conditions found in each.
Acute Mania.-In one case of acute mania, death having taken place on
the tenth day after the earliest manifestations of insanity, the capillaries
were found in the first stage of fatty degeneration ; the granules were
situated along the inner walls of the vessels, and also between the vessels
and their sheaths; and many of the capillaries which were undergoing
this change were found plugged by minute thrombi. The perivascular
canals were not seriously dilated, and the adjacent brain-tissue had not
undergone atrophic change. The nerve-fibres were not impaired; small
spots of degeneration were seen, but they were few in number, not more
than six or eight being seen in a section; they were a nºn of an inch in
diameter, and were molecular, but with no nuclei; the margins were
distinct. Sections stained with carmine presented the same general
appearance; the perivascular sheaths were more distinct, and the con-
trast between the patches of degeneration and the nerve-tissue was greater;
the patches were slightly tinged with the coloring matter. The pyra-
midal cells were clearly defined, and larger than in the normal state; in
these enlarged cells fine molecular material was found in the plasma. In
the parts of the convolution which had been deprived of blood by thrombi,
the cells were more seriously impaired, the molecular matter in the body
of the cells being more abundant, and some of the cells being atrophied.
In a case of puerperal mania, in which death occurred six weeks from
the first manifestation of the disease, the pyramidal cells were found
slightly enlarged, and molecular material was deposited in the plasma.
The cells were not well stained, apparently repelling the coloring fluid,
and the outlines were a little indistinct. The capillaries were under-
going the first stage of fatty change, and many were found plugged;
there was also slight engorgement. The white matter was studded with
spots of degeneration, ranging from fºod to 3 o'nn of an inch in diameter;
these spots had no nuclei, and were not stained by the carmine.
In a third case, in which the acute symptoms were prominent for six
months before death, the changes were much more evident. The pyra-
midal nerve-cells were decidedly granular and atrophied, the walls appear-
ing shrivelled, and the poles having undergone atrophic change; the
masses of degeneration were larger, ranging from Tºwn to sºn of an inch
in diameter; they were characterized by a distinct margin, and were
round, while their structure was molecular. Their cut surface appeared
concave; they were not stained by carmine, and presented a yellow tinge.
Some large masses were found in the cortex; these were g’s of an inch
in diameter, and were lobulated, and without nuclei; they were un-
stained, and were found near capillaries.
Melancholia.-In typical cases of melancholia of short duration, the
lesions observed in the early stages were the appearance of fatty granules
in the walls of the vessels, with slight hypertrophy of the muscular coats,
and some irregularity in the course of the affected vessels. The peri-
vascular sheaths were slightly distended, sufficiently so to show a de-
parture from the normal state, and to indicate that at some period the
vessels had been engorged. The masses of degeneration were confined
to the white matter, and ranged from 3 o'ow to 3 o'an of an inch in diameter;
they were molecular and without nuclei. The pyramidal cells were
cloudy, slightly granular, but with distinct nuclei; the polar prolonga-
tions were unchanged. A notable feature was that the cells were
1094 KEMPSTER,
surrounded by clear spaces, although the bodies of the cells were not appa-
rently atrophied. These spaces were more distinctly marked in recent,
than in prolonged, cases of melancholia, in which latter the capillaries
were found engorged, tortuous, and unsymmetrical. The canals and
sheaths were well shown, the former being much enlarged. Crystals of
haematoidine were found in quantities about the bifurcations, and in
many cases there were miliary hemorrhages. The neuroglia was pro-
liferating, the extremely fine fibres appearing coarse, so that its ramifi-
cations could be easily followed. The pyramidal cells were distinctly
granular, and some were much hypertrophied. The small spots of degene-
ration were found in large numbers, unstained by carmine, and without
nuclei.
Chronic Mania.-The microscopic appearances of brain-tissue varied
somewhat in these cases, but certain changes were quite constant. The
evidences of engorgement were marked, the coats of the vessels being
extensively hypertrophied, and the remains of vessels being outlined in
parts of the tissue. The perivascular canals were large, often dilated to
six or eight times the calibre of the vessels. The sheaths were fibrous,
and large quantities of minute crystalline material were found deposited
upon them, this being noted even upon some of the finer capillaries.
Crystals of haematoidine were also found in greater abundance than in
some acute forms of disease. The large pyramidal cells were extensively
degenerated, the shrunken atrophied cells, and the granular masses into
which the cells are sometimes changed, being quite common ; the nuclei
were less distinctly seen than in other forms of disease, and the polar
prolongations were impaired. It was in cases of prolonged insanity that
the hypertrophied nerve-fibres were found, although these were not com-
mon, atrophied nerve-fibres being more frequently met with. The
masses of degeneration were large, often g’s of an inch in diameter, and
could easily be detected without a lens, in carmine-stained sections.
Dementia.-In cases of long standing dementia, intense engorgement
of the cerebral vessels was a prominent feature. Fusiform enlargements,
miliary aneurisms, and miliary hemorrhages, were all frequently observed
in this form of disease. The nerve-tissue adjacent to the vessels was
stained with the coloring matter of the blood, and numerous small cysts,
indicative of old miliary hemorrhages, were found in the gray matter.
In a case of dementia of long standing, miliary hemorrhages were abun-
dant in the gray matter of the parietal convolutions, and the cysts of
former hemorrhages were numerous. The nerve-cells were granular, and
sometimes enlarged ; the nuclei and nucleoli indistinct; and granular
masses often occupied the positions of the nerve-cells. In these cases, the
granular cells appeared to have undergone disintegration, the molecules
spreading over a considerable space, and free oil-globules being found
1063, l'.
General Paresis.-The cases of general paresis presented some features
in common with those of dementia. The lesions in the membranes have
already been described ; well-marked cases had extensive fatty degenera-
tion of the capillary walls, and tortuosity of the vessels; crystals of
haematoidine were found in great abundance, and the minute crystalline
granules encrusted the walls of the vessels and the perivascular sheaths.
The nerve-cells were shrunken and granular ; the nuclei indistinct, or
completely obscured ; and the polar prolongations not to be seen. There
was a marked increase of connective-tissue elements. In the cortical
substance, in several cases, a number of stellate, crystalline bodies were
MIC R O S CO PIC STU D Y O F T H E B R A IN . 1095
found ; these varied from a cºrn to stºod of an inch in diameter, and
had distinct, black nuclei. The masses of degeneration were lobu-
lated, and were not as numerous as in other forms of insanity; they
were usually attached to the walls of vessels, which were shrunken, and
were often found close to the gray matter. The nerve-fibres were atro-
phied, and the appearance of the tissue was indicative of active degene-
rative processes. In the spinal cord there were frequent departures from
the normal state, involving the membranes, which were in many cases
affected like the membranes of the brain ; the nerve-fibres of the poste-
rior columns of the cord were atrophied in the advanced stages, and there
was an increased growth of connective tissue.
Insanity of Epilepsy.—In insanity following epilepsy, the nerve cells
were found pigmented to some extent, particularly in the medulla and
upper part of the spinal cord. The cells of the posterior convolutions of the
brain were similarly affected, the bodies of the cells being pigmented and
atrophied, while the prolongations were not so seriously affected. Small
cysts were found in some cases, and masses of degeneration appeared in
the medulla in great numbers, the masses being of the largest size, cellu-
lar in structure, and with a fine fibrillar matrix. Changes in the nerve-
fibres of the spinal cord were not infrequent ; gray degeneration in its
various stages was quite common, and longitudinal sections showed
atrophied nerve-fibres, and increased growth of connective tissue.
There are, of course, broad divergences from the above described con-
ditions, the great range of diversity being in the various states of the
neuroglia and the masses of degeneration. We know very little about
the physiology of cerebral connective-tissue, and still less of the influ-
ences which affect its integrity. The spots may all be due to an abnor-
mal state of this tissue, but up to this time I have not been able to
demonstrate this point satisfactorily. It does not seem probable that the
various changes can be due to different stages of the same disease. In
the cerebral tissue in one case, there was gray degeneration of the col-
umns of Turck; and in this degenerated tissue, patches of so-called
miliary sclerosis were found, and, at its side, the smaller masses which
have been described under the name of colloid degeneration. In the
patches of gray degeneration, connective-tissue fibres were abundant; in
the masses of sclerosis situated in the degenerated columns, the spots were
composed of cells imbedded in a fibrous matrix; and in the adjoining
tissue were found the small spots with distinct margins and molecular
structure. The patches of gray degeneration were deeply stained with
gold, the masses of sclerosis much less so, and the molecular spots not at
all. In unstained sections, the differences were as marked as in those
which were stained. The polariscope and tourmalines gave evidence
that the formations were not all of the same structure, and aided mate-
rially in determining the differences of the several forms of disease; none
of the spots, when under the polariscope, gave the black cross and ring
of amyloid bodies.
From a study of these varying conditions, the conviction has forced
itself upon me that the degenerations are not always the result of pro-
liferation of the neuroglia, but that in some instances they follow slow
inflammatory processes, resulting in degeneration of portions of the
nerve-tissue, and causing atrophy of nerve-fibre by direct pressure. It is
noteworthy that in all cases in which well-formed spots of degeneration
were found, of whatever type, there was an inflammatory condition of
the meninges, and an exudation of serous fluid into the sub-arachnoid
space, and into the lateral ventricles.
1096 KEMPSTER, MIC Rosco PIC STUDY of THE BRAIN.
These observations are based upon an examination of one hundred and
fifteen cases, embodying all common forms of mental alienation ; and
while they do not cover the entire ground, the principle microscopic
lesions observed have been given. It need hardly be said that one of
the results of this investigation, has been to place me among the ranks
of those who believe in the somatic origin of insanity; and, further, I
believe that the only successful method of arriving at a definite know-
ledge of the pathology of insanity, is to be found in a study of the patho-
logical histology of the cerebral tissues. We must appeal to the micro-
scope for an explanation of those mysterious phenomena which, under
the name of insanity, have so long baffled the Philosopher, Theologian,
and Physician. The mysteries will yield to the careful student of Mi-
croscopic Pathology. *
[Thirty-six photo-micrographs, illustrating the various pathological alterations of brain-
tissue described in the paper, were then exhibited by means of the lantern.]
DISCUSSION ON T)R. KEMPSTER’s PAPER.
After the reading of the preceding paper, Dr. ISAAC RAY, of Philadelphia,
said:—I cannot see a paper of so much importance pass entirely without note
or comment. Dr. Kempster deserves great commendation for his labors on the
microscopic anatomy of the brain, and there can be no doubt that in this direc-
tion is the way to successful inquiry into the pathology of insanity. In the
case of two persons dying of mental disease under apparently very similar
conditions, we may find in the brain of One every possible lesion, and in that
of the other, nothing at all. It is somewhat the fashion to sneer at these
microscopic investigations, but however indifferent we may consider the results
so far, it can scarcely be denied that it is to them that we are to look for further
light on this obscure subject. It is foolish to taunt us with our inability to
find a delusion packed away in some congeries of cells, or to see a crazy pro-
ject stamped at full length on a slice of gray matter, but, certainly, if we learn
from the microscope something of the initiatory steps in the morbid process—
if we are made sure that in every case there is a dilatation of some cells, or a
plugging of some vessels—we have made a substantial advance in our know-
ledge. Very few of us, I suppose, feel competent to discuss such a paper as
this, and all may not be prepared to accept the conclusions of the writer, but,
none the less, it ought to receive our most careful study.
. The President, Dr. JoHN P. GRAY, of Utica, said:—I am glad to hear the
remarks of Dr. Ray on the value of the microscope in the study of insanity.
In the institution at Utica, where I inaugurated this work in the asylums of
this country, though we have been engaged in these investigations for a num-
ber of years, I consider that we are only in our infancy in regard to the devel-
opment of this subject. I do not understand Dr. Kempster to claim that the
lesions which he has mentioned are constant and peculiar to, or only found in,
certain forms of insanity ; and indeed such a claim could not be sustained.
Winslow remarked, a long time ago, that insanity was due to a peculiar inflam-
matory process. A recent article in the British and Foreign Medico-Chirur-
gical Review, on the other hand, in referring to the investigations at Utica,
said that we were no nearer to the discovery of the cause of insanity, or to an
explanation of its phenomena, through these researches, than our predecessors
were through their methods. And it is maintained by good authority that
similar morbid changes are found in other diseases of the brain. What we are en-
deavoring to do by microscopic investigation, is to determine the exact character
and extent of the morbid lesions in insanity, and we think that photographic
illustrations and illuminated sections of tissues, such as Dr. Kempster has here
thrown upon canvas, are valuable methods of demonstrating these lesions.
And all this should tend to stimulate further investigation.
1097
THE RESPONSIBILITY OF THE INSANE FOR THEIR
CRIMINAL ACTS.
BY
ISAAC RAY, M.D.,
OF PHILADELPHIA.
TTow far insanity should be received in excuse for crime, is a question
on which, as we all know, there still exists much diversity of opinion.
Notwithstanding that the study of metaphysics has, of late years, engaged
the attention of some of the profoundest thinkers of the time; notwith-
standing that better opportunities for the study of insanity have been
afforded by the modern practice of gathering its subjects into large
receptacles for care and custody; and notwithstanding that cases for
legal adjudication in the courts of justice have been increasing with re-
markable rapidity, we are yet, apparently, as far as ever from well-settled
conclusions respecting the exculpatory effects of mental disease. Among
lawyers and among physicians; among men of science and culture as
well as among men who pretend to neither; among men of extreme con-
servatism as well as among those who are never satisfied with the
present—in each and all of these classes, we find, on this subject, most
diverse and even opposite views. This we may be inclined to regard as
unwarrantable under the circumstances, proceeding as it does from neglect
or careless use of the information at our disposal, yet, considering the part
which passion, prejudice, and illogical reasoning, have in the formation
of all opinions, it is neither strange nor extraordinary.
In the history of English jurisprudence, insanity, as an excuse for
crime, Scarcely made its appearance until within a comparatively recent
period. Towards the middle of the seventeenth century, it may have
been recognized as such in some of its grosser forms. With that better
understanding of mental phenomena, and that milder treatment of
human infirmity, which began to be visible in the literature and science
of a somewhat later period, insanity became an unquestionable element
both of moral and of legal irresponsibility. Lord Hale undertook to
define, with some show of precision, the exact extent of its influence upon
the mental movements, and consequently of its effect in impairing the
responsibility of its subjects. In this attempt he was guided, unques-
tionably, by the best medical opinions of his time, as he found them in
books, and in the discourse of eminent members of the medical profession.
As the result of his inquiries, he came to the conclusion that insanity in
its milder forms was not necessarily incompatible with responsibility for
crime, while he freely admitted that in its severest manifestations it was
an ample excuse for any criminal acts that might be committed under its
influence. And ever since, his successors on the English bench have been
seeking for some tests whereby these two grades of the disease might be
distinguished, the one from the other, but always with very indifferent
success; although, moved by that spirit of humanity which has been
steadily infusing itself into the English law, their instructions in par-
1098 RAY,
ticular cases have become more and more frequently correct. The tests
which have been promulgated from time to time, not being founded on
any correct knowledge of insanity, have each and all proved unsatisfactory
when scrutinized under the light of practical observation; but, notwith-
standing, they are still put forth occasionally as the law of the land.
The discredit into which they have fallen, has somewhat, but not in a
corresponding degree, widened the application of the plea of insanity in
criminal cases, while it seems also to have given rise to some extent to
the very opposite condition, the now prevalent distrust of the plea being
supported by reasons which, though far from being new, have recently
become endowed with a significance quite unwarranted by what we know
of mental operations under the influence of disease. They are no less
satisfactory, however, to that large class of people who having taken
their opinions from one another, with but little knowledge of the subject
itself, find it convenient to allege some plausible grounds for their belief.
In the light derived from a good deal of intimate intercourse with the
insane, and from the study of various authors who have written on the
subject, I propose to examine the reasons now most often given for with-
drawing that exemption from punishment which, in a greater or less
degree, the insane have hitherto experienced. I am not so sanguine as
to suppose that any efforts of this kind will turn the current of opinion
now setting against these unfortunate victims of disease, but the solitary
inquirer, sincerely seeking for the truth, should not be obliged to seek
i il V &ti il.
Much, if not most, of the present feeling on this subject may be traced
to the legal profession, by which the plea of insanity has never been
very cordially received. To lawyers, it seems like an intrusive element
having no proper place in our legal system, but which, nevertheless, can-
not be kept out of it. It implies, as we all know, a scientific fact to be
examined, and its significance determined, by the rules and in the spirit
of modern scientific investigation. This is a task completely outside of
the domain of law. The lawyer has had no scientific training, and his
knowledge of physical, and especially of medical, science, is only that
which floats on the surface of the current thought. The more that is
learned about insanity, the more difficult does he find it, for lack of such
training, to determine its exact relations to crime. Even when told that
the insane, generally, know right from wrong, what is lawful and what
is unlawful, and recognize the distinction between vice and virtue, he is
still unable to see what element of crime is wanting in their criminal
acts. Iſe looks at them, not from the scientific, but from the legal, or,
more properly speaking, the metaphysical, point of view.
When a person commits a criminal act, knowing that crime is wrong
and”forbidden by the laws of God and man, incited to it, perhaps, by a
rational motive—to gratify some passion, or to avenge some injury—
evincing design and contrivance in the execution of it, the lawyer is con-
strained to believe, as a strictly logical sequence, that such a person
should be punished. In such an act, not a single ingredient of crime, as
he has studied his books, is wanting. A person, he says, who imagines
that another, sitting opposite to him at table, is making faces at him, is
led to this belief by some morbid condition of the perceptive organs, for
which he is not to blame, certainly, but which furnishes no excuse for
shooting his imaginary foe, because he knows as well as he ever did that
killing or maiming another is wrong and unlawful. Besides, he acted
deliberately, he had malice in his heart, and, as the old indictments used
R E SPO N SIBILITY OF THE IN S.A. N. E. 1099
to have it, he was moved by the evil instigation of the devil. What then
was wanting to render him responsible 7 Nothing, certainly, if we leave
out of the account those springs of action, no less real and potent, which
are introduced into the mental mechanism by disease, and ignore entirely
some faculties of the mind, as necessary for determining and regulating
the conduct as those which are recognized. He can find no excuse in
his philosophy for one who slays the dearest objects of his affection, while
admitting the wrong and deploring the necessity which obliges him to do
it, simply because he has but a faint apprehension of the mental faculties
chiefly concerned in the act, and scarcely any apprehension at all of how
they are affected by disease. In short, of the two classes of faculties
or manifestations that make up the mind, one, considered as the subject
of disease, is altogether ignored, while the operation of the other under
stress of disease is greatly misunderstood.
And thus it is that in their theories respecting the responsibility of the
insane, the lawyers, in their imperfect understanding of the nature and
operations of the mind, commit two serious mistakes; one is that, where
the mental affection is too obvious to be overlooked, they measure and
define the scope of its influence in an arbitrary manner, unsupported
entirely by the facts of psychological science; while the other, as just inti-
mated, consists in regarding the affectional faculties—the sentiments, emo-
tions, and passions—as without any part in the play of disease, or with
so little that it may be safely ignored. The first mistake may be wit.
nessed in the rule propounded many years ago by Hoffbauer, a German
jurist of great repute, that an insane person may be excused for any act
prompted by a delusion, only as far as the act would have been excusable
had the belief been a reality instead of a delusion. That is to say, if an
insane person imagined that another was approaching him with intent
to take his life, he might kill him, and be excused on the plea of insanity;
but if he only imagined that this person was making faces at him, or
had been following him from one place to another, he should not be so
excused, because had the offence been real instead of imaginary, it would
not have justified the killing. Never has there occurred a more re-
markable instance of this mistake than that presented by the English
law-lords, in 1843, on the occasion of the trial of McNaughton, for kill-
ing the secretary of Sir Robert Peel. McNaughton was possessed by the
delusion that he was pursued by enemies who, though unknown and un-
seen, completely destroyed his peace. In fact, he was laboring under
what is now called the mania of persecution. He had somehow connected
Sir Robert Peel with this conspiracy, and concluded to shoot him ; but
mistook his secretary for him, and killed the latter instead of the prime
minister. He was acquitted on the ground of insanity, but the public
rebelled so strongly against the verdict that the matter was brought
before Parliament, which instructed the law-judges, twelve in number,
to confer together and decide what the rule should be in cases of this
kind. They agreed upon the rule put forth by Hoffbauer, as above
described, and accordingly it was announced authoritatively as the law
of the land.
We may well be astonished that a rule which is to decide the question
of life or death for all coming time, should evince the grossest ignorance
of the mental operations when affected by disease, and should be put
forth, too, by a body of men who might be supposed to be more correctly
informed. The rule, be it observed, implies mental disorder, and conse-
quent irresponsibility, the extent of which, however, is limited in an
1100 RAY,
arbitrary manner, with no reference at all to the pathological condition.
It means that if a person imagine that enemies are waylaying him at
every turn, he may not be accountable for that belief, because it has in-
truded itself into his mind without any will of his own; but that, it being
there, he is accountable, to some extent at least, for what he thinks and
does about it. He is required to act respecting it very much as if he
were perfectly same—killing his fancied enemy if he apprehends from him
a murderous assault, as a matter of self-defence, but resorting to the
courts for redress, if his enemy has only assailed his reputation, or is
preventing him from obtaining certain estates. That there is any ground
for such limitation, no one can admit who has been much conversant with
the insane. Indeed, the fallacy of the principle in question is obvious
enough without any experience of this kind. Everybody knows that
the man who imagines that his legs have turned to glass, goes about as
usual, instead of keeping still and thus making his conduct consistent
with his belief.
How a principle so plainly and completely contradicted by the facts of
science, should have obtained the currency that it has, is not easily ex-
plained. In England, this, as well as some other mistakes on this subject,
may, possibly, be attributed to a famous dictum of Locke, who said that
madmen reasoned correctly from false premises. Locke knew as little
about insanity as the English law-judges, otherwise he would have known
—what the humblest servant in a hospital for the insane knows—that
the insane may wander at every step of their reasoning, from premises
to conclusion. It is no more than might have been expected, that one
who insanely believes that his neighbor has been telling bad stories about
him, should also believe himself justified in taking that neighbor's life.
The confusion of ideas, so flagrant and so common in discussions upon
this subject, is well illustrated by the fact that the judge who presided
at the trial of McNaughton, and who approved of his acquittal, subse-
quently joined the other judges in declaring Hoffbauer’s rule to be the
law of the land. Under this rule, McNaughton should have been con-
victed, for, crazy as he was, he certainly apprehended no personal harm
from Sir Robert Peel. Another instance of this confusion of thought
was exhibited by one from whose multifarious knowledge and keen
Sagacity something better might have been expected. Lord Brougham
said in Parliament, on one occasion, that he could conceive of “a person
whom Deity might not deem accountable, but who might be perfectly
accountable to human laws.” In other words, a mental disorder which
would render a criminal act excusable in the eyes of God, might be
entirely ignored in the judgments of men. In this statement Lord
IBrougham did not merely mean to declare—what nobody would deny—
that man, with his limited apprehension, might fail to discern mental
disturbances that would be perfectly obvious to the eye of Omniscience;
he meant to assert the doctrine that a kind and degree of mental disorder,
equally obvious to God and man, might lead one to excuse, and the other
to punish, any criminal act that might be committed under its influence.
How such a monstrous conclusion could be reached, except in defiance
of all reason and religion, is not very obvious. We can account for it
only on the supposition that, to the mind of the thorough-bred lawyer, it
seemed imperative that the legal theory of guilt and responsibility should
be upheld at all hazards. For certainly the act in question had in it all
the elements of crime, and, of course, the doer of it must be punished,
even though God undoubtedly were ready and willing to excuse him.
R E S P O N S I B II, IT Y O F T H E IN S.A. N. E. 1101
The other mistake pervading the theory of the law respecting the
responsibility of the insane, is to leave out of the account altogether the
moral faculties of Our nature—the sentiments, passions, and emotions.
Here again is another of those inconsistencies which abound in the eur-
rent reasonings on this subject. While every one admits that in these
faculties are the great springs of human conduct, that they incite men to
good or to evil, and furnish the motives and impulses by which they are
governed, the idea that they, or rather the cerebral organism with which
they are connected, may become diseased as well as the reflective facul-
ties, is regarded as preposterous and of dangerous tendency. And yet we
have the same proof of the one fact that we have of the other. The con-
ditions of health and disease are precisely the same in both. Tºoth are
manifested by the same material organ, the brain, by far the larger portion
of which, according to the most prevalent opinion, is given to the moral
powers. Disease in any part of the brain must necessarily be followed
by derangement of its appropriate function, so that it is in the order of
nature that when a certain part of the brain is diseased, there will be
some disorder of the affectional faculties. How this conclusion can be
denied by any one who believes that disease of the brain may produce
loss of memory, of judgment, of attention, and of mental application, is
not very obvious. The only possible explanation of this curious incoln-
sistency is that disease of the moral faculties so often resembles manifes-
tations of moral depravity, that it has been mistaken for the latter,
especially by those who are not accustomed to regard this subject from a
physiological point of view—their notions, as far as they imply any ex-
ercise of thought, being founded solely on metaphysical considerations.
And here we see the influence of that school of mental philosophy in
which our predecessors were trained. We may safely say, I think, that
had IIerbert Spencer, and Bain, and Morell, lived and written in the
days of John Locke, the popular motions respecting insanity would not
now be precisely what they are. Under their teaching, the affectional
faculties would have held their rightful place in the mental economy,
and would have played as necessary a part in its operations as that of
the others in completing the grand result implied in a thinking, social,
responsible being. Until they are regarded in this way, we need not
expect much improvement in the law of insanity. The tests of respon-
sibility will continue to be what they now are—confined exclusively to
the action of the reflective powers. The question will continue to be,
did he know right from wrong 2—did he know that the act was coin-
trary to the laws of God and man —did he evince forethought and
contrivance in executing it 7–ignoring the equally important questions,
could he see the moral complexion of the act in its true colors 2–had he
the power, unaffected by disease, to pursue the right and avoid the
wrong; to resist the natural impulses to wrong-doing by the superior
force of conscience? Responsibility implies the integrity of all the men-
tal powers, moral as well as intellectual. If the mental movement is
disturbed by the intrusion of a foreign element, it is immaterial at what
precise point this element enters. To suppose otherwise, is as absurd as
it would be to suppose that a delicate piece of mechanism could be
deranged only at a certain point.
As a consequence of this confusion of ideas, there has occurred a lack
of uniforinity in the practical application of the rules of law, which,
considering the momentous issue involved, suggests no very comfortable
reflections. The court may be satisfied of the irresponsibility of the
1102 RAY,
prisoner, while, under a strict construction of the rules, he must be
regarded as guilty; or the jury may prefer to found their verdict on
the matters of fact disclosed in the evidence, rather than on the rules of
law laid down by the court. And such must always be the case as long
as the matter of insanity is treated as a question of law rather than as a
question of fact, for here is the source of much of the error that has been
committed on this subject. It is especially visible in the current doc-
trine—as current now almost as it was in the time of Lord Hale—in
regard to the exculpatory effect of what is called partial insanity. In
some forms of disease, the patient does not seem to be entirely bereft of
reason. On some subjects he converses with no lack of correctness or
propriety ; some business he transacts with his customary shrewdness ;
and many people meet him in the ordinary intercourse of life without
suspecting any aberration of mind. It is not questioned that he still is,
in some degree, a rational creature. And certainly it is not surprising
that the world should be slow to admit such a mental condition as an
absolute excuse for crime. If the person have been entirely rational for
Some purposes, or in some relations, why may not this circle of rationality
have embraced the act for which he is tried ? This is a fair question,
undoubtedly, and is entitled to a respectful answer. What we complain
of, is that, instead of being answered in the light of that knowledge of
the workings of the insane mind which is derived from long, clinical
observation of the disease, the question is supposed, in actual practice,
O carry its answer with it. The logic runs thus: the act may have
been the product of the reason left untouched by disease; therefore it
was. We insist that the fact should be proved, and we claim in the
interest of true science, as well as of humanity, that the burden of proof
lies with the side that denies the influence of the alleged disability.
The existence of insanity in never so small degree being shown, it is for
the other side to show that it had no part nor lot in bringing about the
criminal act. Now we do not deny that this is ever possible, but we do
say that in most, if not all, cases, we are positively unable to fix the
limits of the operation of disease, and to say that the act in question was
not the offspring of disease. No man pretends to discern all the springs
and turns of thought even in the rudest same mind, and it certainly is no
easier when the subject of observation is thrown out of its ordinary
courses by a disturbing force. We know enough, however, on this sub-
ject, to be convinced that, very often, thoughts apparently the most
remote and disconnected from one another, are found, on further re-
search, to be closely associated, and thus to lead to conduct otherwise
most strange and mysterious. He must have been a superficial or care-
less observer of insanity, who has not often discovered the most violent
acts to be the outcome of a wild and tortuous succession of thoughts.
To say that we see no logical connection between the mental condition
as obviously manifested, and the criminal act, is simply a confession of
ignorance, not a display of knowledge.
In contending that in criminal prosecutions, when insanity is pleaded
in defence, the burden of proof should fall upon the side that resists it,
we are only following the rule most used in civil cases. There, the ex-
istence of insanity having been shown, it is incumbent on the party
wishing to establish the act in question, to prove that the person had
recovered, or that the act was performed quite independently of, and was
untainted by, disease. If a will be in dispute, and the testator be shown
to have labored under some unquestionable delusion or weakness of mind,
RES PO N SIBILITY OF THE IN S.A. N. E. 1103
the presumption is that the will is rendered invalid by the mental affec-
tion, and it is left for those who would establish it to prove the contrary,
and the rule is the same in reference to contracts. It goes further even,
for many a contract has been voided which displayed no indication of
unsoundness, and which could not be traced to undue influence. There
is not the slightest reason for this difference, in the nature of mental
disease. Its agency in the occurrence of crime is as far beyond all our
resources of detection, as it is in the making of a will or contract. If any
difference is to be admitted, it should be the other way, inasmuch as an
issue of life or death is a far more Serious matter than one of property
alone. -
There is nothing in the popular conception of insanity so common or
with so little foundation in the nature of things, as the idea that the
extent of the malign influence exerted by insanity on the mind, can be
accurately measured by the external appearance and deportment as viewed
by the casual observer. It is supposed that a person who can converse
sensibly, behave properly, and transact business, cannot be so insane as
to be irresponsible for his criminal acts. In every trial where insanity is
pleaded in defence, this idea is generally the main stay of the prosecu-
tion. A host of witnesses is summoned, who testify to perfect soundness
of mind. One had frequently met the defendant, passed the time of day
with him, and talked about the weather; another had employed him in
some ordinary trust or duty; another had had some business-transactions
with him, selling him, perhaps, some little necessaries of life, or paying
him a trifle of debt or interest; another had met him mingling with
company at a watering-place, or at some social gathering; and these
persons, one and all, declare that they witnessed nothing strange or un-
natural in his looks, discourse, or deportment; and those who had busi-
ness-dealings with him, and especially if they got a good bargain out of
him, declare him to have been uncommonly shrewd. This evidence,
though entirely negative, is none the less effective with most of those
who hear it. Its force is scarcely weakened by the statement, which
they may admit in general terms, that insanity often leaves some opera-
tions of the mind untouched, and thus escapes the notice of the casual
observer. And yet this trait of insanity would seem to be too common
to be so disregarded in actual practice, for every hospital report, every
newspaper that we take up, bears witness to its frequency.
In the normal condition, nothing, under ordinary circumstances, is
dearer to a man than his life. To preserve it is one of the most power-
ful instincts of his nature, and, if in certain exigencies he willingly part
with it, it is for the rational purpose of securing what seems to him a
greater good, or of avoiding a present, real, unequivocal evil. And yet
a large proportion of Suicides are committed by persons urged by no ap-
parent motives, in the possession of every outward circumstance calcu
lated to make life desirable, and giving no indication whatever of mental
disturbance. Up to the last moment, they may have transacted business,
conversed sensibly with friends, and in all the relations of life conducted
themselves with their customary propriety. Yet who will venture to
say that, notwithstanding all these apparent indications of good mental
health, suicide, committed under the circumstances just mentioned, does
not signify a kind and degree of insanity as destructive of moral free-
dom and responsibility as the most demonstrative forms of the disease?
It is also a well known fact that many of those persons who attempt un-
successfully to commit suicide, while appearing to the casual observer
1104 RAY,
entirely sane, subsequently have only the most dim and uncertain con-
sciousness of the attempt. Now, there is no reason to doubt that homi-
cide, and perhaps some other criminal acts, may be committed in a similar
state of mind—evincing just as much coolness, deliberation, and contri-
vance, and just as complete an absence of all the demonstrative signs of
mental disease. It is not creditable to the intelligence of our time, that
the apparent correctness and propriety of the person in the common
relations of life, should be regarded as incompatible with the presence of
insanity, or, at least, with any such insanity as should exempt him from
responsibility.
Unquestionably, during the present century, the tendency of public
sentiment, following, no doubt, that of the clinical study of mental dis-
eases, has been to enlarge the exculpatory effects of the latter. Now and
then there have been signs of reaction, never stronger, probably, than at
this present moment. To men whose opinions are formed by the current
prejudices around them, rather than by any careful study of facts, it
seems as if the plea of insanity had been making crime a little too easy,
and that a wholesome check to this facility would be found in punishing
the insane like other criminals. The argument by which this doctrine
is generally supported is that many of the insane know right from wrong,
that they are governed by motives, and may restrain their passions. The
facts implied in the argument, we willingly admit, for nobody denies
that many of the actions of many of the insane are rationally considered
and rationally performed. Nobody denies that their conduct may be
determined by the hope of reward or the fear of harm. One patient
strives hard to obtain a privilege or a favor, while another is deterred
from an assault upon a fellow-patient by remembering the threshing he
got in a former encounter. The same man who believes that he is coming
to want, and destroys himself and family to save them from misery, may
refrain, if he please, from exposing his person, from soiling his clothes
or from assaulting his neighbor. Why then should he not be punished
for offences that are not inspired by his disease ? To those much con-
versant with the insane, the reasons against it are obvious and conclu-
sive. The more that one learns of insanity, the more inscrutable are the
movements of the mind affected by it, and the less confidence is felt in
any attempt to discern exactly their connections, and to say which can
be safely attributed to sanity and which to insanity. If this be so, under
the daily and hourly observation of a skilful inquirer, what confidence
can be placed in any positive conclusions founded on the testimony of
those who have seen the accused at remote periods, who know nothing
of insanity beyond what is learnt by the casual sight, now and then, of
a person reputed to be crazy, and who are unable by lack of culture to
convey to others the impressions thus made on their own minds. If any
one could tell us—physician or philosopher, court, counsel, or jury—by
what means, with the slightest approach to certainty, we might make
the distinction between the working of the same and that of the insane
element, we would not object to the proposed rule. At any rate, let the
burden of proof rest on the party which alleges that the criminal act
was prompted not at all by the presence of disease.
There is another reason for not punishing the insane, which, feeble as
it may be to the common mind, is conclusive to the close observer of
mental disease. Admitting, as we do, that much of the daily life of the
insane shows no trace of disease, we are none the less sure that the
presence of disease, however limited it may appear, is generally incom-
RESPONSIBILITY OF THE INS AN E. 1105
patible with the most correct and vigorous exercise of all the faculties
of the mind. It impairs the freedom of the will; it blunts the sense of
right and wrong, of the good and true; it weakens the power of self-
control, and diminishes the normal amount of restraint upon the ap-
petites and passions. No one engaged in the service of a hospital can
have failed to observe how fiercely the passions of the patients are excited
by little provocations that would scarcely have ruffled their tempers
before; how disproportioned to the Offence is the measure of their reta-
liation; how grossly exaggerated are every feeling and impulse awakened
by the ordinary experiences of life; how often native propriety of man-
ner and delicacy of sentiment are replaced by a rude demeanor, and by
a coarse, reckless disregard of the rights and feelings of others. Even
when the criminal act seems most clearly beyond the range of the morbid
influence, there is always reason to suspect, if not to positively believe,
that it would not have been committed except for this enfeeblement of
the power of self-control, or this blunting of the moral perceptions.
Such being the fact, it shows how groundless is the doctrine, some-
what countenanced just now, of a limited responsibility, as applied to
the partially insane, according to which they are always to be punished
for their criminal acts, though in a less degree than they would be if
unquestionably sane. I need only allude to the doctrine, as its unsound-
ness has been sufficiently shown by the views already expressed. A
moment's reflection must convince any one that no device of legislation
could make the application of it in practice otherwise than absurd. The
idea of a court or jury constructing a scale of insanity according to its
severity, and graduating the measure of punishment thereby, is simply
ridiculous, and would be rendered still more so by any attempt to apply
it to a given case.
Recently, we have seen the revival of a doctrine, never much in vogue,
however, that the insane should be punished in order to deter them, by
force of example, from breaking the laws. In support of this view,
instances are related of insane persons, who, when talking over the
criminal acts of others understood to be insane, have said to each other
with much self-complacency, that, being insane, they would not be
punished. In this belief, they would naturally use no self-control, and
would feel free to break every law on the statute-book. Unquestionably
the insane know very well that they may not be punished for their offences,
as they know a great many other things. They are able to reason cor-
rectly on the subject, as they do on many other subjects. The fact is not
extraordinary, nor has it recently come to light, and, considered in con-
nection with other facts, it implies no responsibility. The truth is, that
very few of the insane believe that they are insane ; consequently, immu-
nity from punishment does not present itself to them as an inducement
to commit crime, nor to relax in the slightest degree their control over
their passions. While they perceive well enough the abstract nature of
crime, they cannot see it as applied to any particular act in their own
cases. They are outside of the range of such application, and are a law
to themselves. Some are urged by a necessity, which they cannot resist,
even knowing that they do wrong, and knowing the usual consequences.
Some are prompted by strange suggestions: the voice of an unearthly
presence, a terror that overrides every thought of consequences, or a spur
of Savage ferocity unmingled with the slightest sense of humanity.
These people act without reference to law or gospel, under motives and
impulses as remote from their natural dispositions and principles as the
70
1106 RAY,
poles are asunder. The fact that persons reputed to be insane had suf.
fered the usual penalty for their crimes, would have no more restraining
influence than blows or threats in hushing the cries of a new-born infant.
No human law can be more imperative than that higher law within him
which impels many an insane man to some act of violence, and no con-
sideration of justice or pity can come in to lighten the stroke provoked
by the trivial offence of a neighbor. Indeed, this idea of the insane
being deterred from criminal conduct by penal laws, is utterly destitute
of foundation, and we challenge its advocates to produce a single instance
in point.
In order to make this idea practically efficient as a means of restraint,
some steps would be required to give it an authoritative character, for
unless the insane were somehow convinced of their responsibility, clearly
and fully, of course it could have no restraining power. There would
seem to be an insuperable difficulty in the way of making this idea im-
mediately effective. If left to the courts, the most that could be expected
would be now and then a decision declaring insanity to be no excuse for
criminal acts. And supposing these occasions to become more and more
frequent, until the rule should generally prevail, there still would be a
considerable period of doubt and uncertainty as to the actual state of
the law. The case could be properly met, if at all, only by an act of the
legislature, and, in the present state of public sentiment, nothing is less
likely to happen than an act making insanity, of whatever kind or de-
gree, no excuse for crime. If, however, the legislature, without going
to this extent, should undertake to specify what forms of the disease
should or should not have this effect, as it has in some European countries,
the result would be a lamentable failure, producing only confusion and
distrust. Our motions of the actual limits within which the operation
of any form of insanity is confined, are too vague for such a purpose, and
the imperfection of our momenclature would prevent any approach to
uniformity of meaning. And thus we stand: The legislature is indis-
posed to act, and the rules adopted by the courts are irrelevant, inade-
quate, and conflicting. Nor from this unsatisfactory condition of the
law can we expect any relief, until the whole question of insanity shall
be regarded as a question of fact, not of law, as at present; and, thus
regarded, shall be taken altogether from the court, and, like other mat-
ters of fact, be given to the jury, which would be governed by the weight
of evidence and the individual convictions of the jurors. This course is
virtually taken by juries, even now, and it is held up as a flagrant in-
stance of our scandalous indulgence of crime, that many a verdict of
“not guilty, by reason of insanity,” is rendered, in spite of the instruc-
tions of the court.
I cannot leave the subject without adverting to an argument in favor
of punishing the insane like others, on which unusual stress has been laid
in some recent trials. It is represented that in our hospitals for the insane,
the discipline is maintained by the use of rewards and punishments.
This, implies that the patients are deterred from wrong-doing by the
understanding that it will be followed by punishment, and the inference
is drawn that the same motive would operate in the same way outside,
as well as inside, of a hospital. If the statement on which this reason-
ing is founded were strictly true, it should be taken in connection wit
the other well-known fact, that many of the insane are not deterred fro
violence or any other wrong by fear of any consequences whatever
Neither threats nor blows, nor death itself, can turn them from their chose


































R. E S P O N S I BII, IT Y O F T H E IN S.A. N. E. 1107
course. And thus arises the difficulty which has already presented itself
in another shape, that of determining to which of these two classes the
accused may belong. By what kind of evidence are we to be convinced
that the prisoner at the bar would have refrained from committing the
offence for which he is on trial, had he believed that he would be
punished 2
I}ut we are really not reduced to this dilemma. The idea that the
inmates of our hospitals are punished for their delinquencies, is false—
entirely without foundation in fact. They are deprived of a privilege or
of an indulgence, which they have shown themselves unable to use with-
out harm to themselves or others—an inability which may have been as
much beyond their control as the usual manifestations of bodily suf-
fering. Such deprivations, as well as rewards for good behavior, are
used as a means of trying and strengthening the power of self-control—
a power which in the insane is confessedly weak. Its exact degree of
weakness or strength, no one much acquainted with them will undertake
to measure; and who then can measure it for the purpose of apportioning
the proper amount of judicial punishment : So far is it from being true
that the patients in our hospitals are punished for any reason whatever,
that the attendants are prohibited from returning a blow, or retaliating
for insults or injuries, on pain of dismissal; and yet, when provoked by
serious assaults, they might often say with truth, “he knew better; he
knew he was doing wrong ; and a little summary punishment will help
to make him do better in the future.” But if to punish the insane be
good law in a court of justice, why should it not be in a hospital? We
would have it distinctly understood that it is not good law in the latter,
not because there is never a case in which punishment might prove a
powerful help to improvement, but because no insight short of Omnis-
cience can ever know for certain which are such cases. It may be urged,
perhaps, that exception should be made of cases in which it is shown by
satisfactory evidence that the accused had often been deterred from
wrong-doing by the fear of punishment. The statement is quite too
vague to serve as the ground of a general rule; and besides, it is open to
the objection of showing a negative rather than a positive state of facts.
What a man refrains from doing under certain circumstances, is no safe
measure of the extent of his self-control under other and very different
circumstances.
That there has been, of late years, much practical disregard of the rules
of law, on the part of juries, must be admitted ; but the course of judicial
decisions and verdicts within a very recent period, shows how grievously
potent they still are. About two years ago, one Fordham, a patient in
an asylum for the insane, murdered an attendant. It appeared in evi-
dence that he was an epileptic, quarrelsome, and often violent; that he
had quarrelled with the attendant, and had declared that he would have
revenge. He was tried, and convicted of murder. The court, Mr. Jus-
tice Denman, charged the jury that the mere fact that the prisoner was
laboring under a delusion as to his treatment in the asylum, as no doubt
he was, was not sufficient excuse in law. “If a man killed another,”
said he, “while under a delusion that he himself was about to be killed,
and that he was acting in self-defence, he would not be punishable; but
if a man did so for some supposed injury to his character or fortune, then
he would be responsible.” Sentence of death was passed in the usual form,
but the punishment was afterwards commuted to penal servitude for life.
Some three or four years ago, Mr. Lutwidge, one of the members of the
1108 R A Y,
Board of Lunacy, while passing through a hospital which he was visiting
officially, was assaulted by a patient, who inflicted upon him a wound
from which he soon died. The patient’s insanity was unquestioned,
though he had not been supposed to be dangerous. In speaking of the
case, in their annual report, the twenty-eighth, the Board say that the
man “was quite responsible for his actions.” Since this case occurred a
man named Blamfield has been tried for murdering a fellow workman.
The act was done suddenly, without apparent premeditation or provoca-
tion. Blam field had been a patient in a lunatic asylum, from which he
had been discharged, uncured, some months before. The medical super-
“intendent of the hospital testified that, while in his charge, Blam field
had had a fear of punishment for misconduct, and had been governed
by this feeling. He, therefore, considered him responsible for his acts.
The man was convicted of murder, and sentenced to be hanged ; but his
punishment was subsequently commuted.
Such are the more prominent difficulties now in the way of making
the plea of insanity in criminal cases as effective as it should be. The
question may naturally be asked: How can these difficulties be most
readily removed, and the law be administered in conformity with the
truths of science? It is scarcely within my purpose to speak upon this
point, but it may not come amiss to indicate very generally the direction
from which reform may come.
Let me say, in the first place, that if courts are to continue to measure
the exculpatory effects of insanity by certain arbitrary tests, they are
bound to avail themselves, as did Lord Hale, of all the existing medical
knowledge on this subject. Instead of repeating, one after another, rules
and distinctions, of which the sole claims to respect consist in the fact of
their having been uttered before, it is their duty to learn as much as
possible of the nature of insanity from the only true source of knowledge
—the practical observation of the insane. Legal knowledge is, for the
most part, so technical that the decisions of the courts on most matters
are received by the public in faith, nothing doubting ; but on this subject,
the public will have an opinion of its own. The people who would shrink
from the presumption of understanding a question of contingent remain-
ders, or of eminent domain, may have little respect for any rule of law
touching the responsibility of the insane. Have we not a right to ask
the judges to make themselves acquainted with the nature of insanity by
all the means within their reach, so that, instead of directing the jury by
a servile repetition of something that others have said before them, with
no other authority than the fact that it has been said, they shall present
only the established facts of science, and such considerations as are natu-
rally suggested by them : Let it be remembered that we are dealing
with a branch of medical jurisprudence, and, therefore, that the study
here recommended belongs as well to the lawyer as to the physician. I
do not suppose, indeed, that the soundest instructions would always be
followed by a proper verdict, for juries are too fond of manifesting their
independence by disregarding whatever may conflict with their own
foregone conclusions. But it would remove somewhat the distrust now
felt of judicial decisions, in which the advancement of knowledge is
entirely ignored, and would prepare the way for a better and more
satisfactory administration of justice.
A still better step, as above intimated, would be that already taken
by the courts of New Hampshire, whereby the question of responsibility
R E S P O N S I BILITY OF THE IN S.A. N. E. 1109
is treated as a matter of fact, not of law, to be determined, like other
matters of fact, by the jury. In the performance of this duty, juries
would be governed by the evidence, aided by the explanations of the ex-
perts. This would not necessarily insure a correct verdict; for the evi-
dence might be conflicting, the experts might disagree, and the jury might
be governed more by its prejudices than by the real merits of the case.
It is doubtful, however, if anything better could be obtained under our
mode of procedure, and this is not likely to be changed at present. Some
improvement might follow from putting into the jury-box men of higher
personal character, moral and intellectual, than such as are often found
there. This improvement could be more easily made, I am sorry to say,
than could one equally if not more efficient, whereby the experts should
prepare themselves more carefully for their duty, and should discharge
it, divested of every unworthy bias.
DISCUSSION ON DR. RAY's PAPER.
After the reading of the preceding paper, Dr. CLEMENT A. WALKER, of
Boston, said:—I wish to express my sense of obligation to Dr. Ray for the
clear and distinct manner in which he has presented this subject in his
valuable paper. Just now, such papers are much needed, for there seems to
be at present a reaction setting in against the insane, causing them to be
held responsible for acts committed while under the influence of insanity.
This reaction is particularly strong in Massachusetts, where the action of
the executive in commuting the death penalty to imprisonment, in the case
of a man convicted of murder, and who was by many regarded as insane, has
been received with astonishment, and has been condemned as an unjust act.
There are some in our specialty who may differ with the ideas of Dr. Ray in
regard to the limited responsibility of the insane, but his views in this
respect have my full endorsement.
The President, Dr. JoHN P. GRAY, of Utica, said:—I do not agree with Dr.
Ray in drawing such a distinct line between the intellectual and moral elements
of the mind, for this would divide the mind into parts, and would give, as a
logical result, moral and intellectual disorders, independent of each other. I
believe in the essential unity of mind, and I cannot assent to his view either
as being sound psychology, or as true in clinical observation. I observe, how-
ever, that, though Dr. Ray makes this theoretical separation, yet when he
comes to treat of actual insanity, and of responsibility, he reunites the moral
and intellectual faculties.
1110
THE SIMULATION OF INSANITY BY THE INSANE.
BY
C. II. IIUGHES, M.D.,
LATE SUPERINtENDENT AND PHYSICIAN of THE MIssou RI STATE LUNATIC ASYLUM.
THE literature of insanity feigned by the sane mind is extensive, and
dates back to the earliest period of recorded history. The feigning of
Ulysses in profane, and of David in sacred, story, are familiar to all, as is
likewise the history of Tucius Junius Brutus, who saved his life by suc-
cessfully assuming imbecility, and Shakspeare's two oft-quoted examples
in the characters of Edgar and Iſamlet—the latter, I think, blending some
actual mental disease with simulation; but upon the subject of the present
paper, the simulation of insanity by the insane, not much has been written,
though enough is known to make it a proper subject of inquiry.
Not less interesting to the student of morbid psychology than the well-
defined, well-recognized forms of insanity, are those obscure, anomalous
conditions of mind which occasionally appear, but in regard to which he
fails to obtain any light from the standard books. Though more nume-
rous, probably, than they are generally supposed to be, yet they are com-
paratively so rare, and so imperfectly understood, that, for the most part,
after exciting a little temporary curiosity, they pass from attention, and
are forgotten. And yet they must ever constitute a very important class
of mental disorders, for the reason that their existenee, however infre-
quent, must necessarily modify the conclusions that might be drawn
from the more common forms of mental disease. In fact, no physician
needs to be told that many important steps in the progress of his science
have been made by the careful and persistent observation of what, at
first, seemed to be anomalous and exceptional cases."
The meagre record of cases of simulation by the insane, to be found in
the literature of psychiatry, may be due partly to the fact that the ne-
cessity of Searching these cases out, has not been so imperative as the
detection of feigning by the actually sane, who so often simulate insanity
to defeat the ends of justice, and for other sinister purposes; partly to the
fact that proof of simulation, in the case of persons already adjudged to
be insane, possesses no real, practical value ; but mainly to the fact, which
I think observation has established and will continue to prove, that the
insane do not, in general, assume either different degrees or forms of
insanity from those with which they are actually afflicted.
We might here paraphrase a familiar quotation, and say in manić
veritas, for the lunatic is generally true to the promptings of, and mainly
dominated by, his acquired, morbid nature. To the practised eye, a tinge
of insanity colors nearly all that a general lunatic says or does, and it is
doubtful if, in the acute stage of profound and constant general mania,
the actually insane do ever simulate. The general insurrection and
rebellion of all the ideational and emotional centres which seem to
' Dr. I. Ray, Remarks introductory to case of Bernard Cangly : American Journal of
Insanity, July, 1865.
SIM U L A TI O N OF IN S A NITY BY T H E IN S A. N. E. 1111
characterize this form of mental alienation, the universal tumult into
which all the faculties of the mind are at this time thrown, would seem
to leave no room for the planning and contrivance essential to simulation,
though it be never so imperfectly done. The assuming of a character
different from the dominant and all absorbing morbid impulses of the
individual, would be contrary to all observation in acute, general mania,
and is to my mind impossible, notwithstanding the existence, in this
form of mental disease, of considerable method and shrewdness in plan-
ning and executing in the direction of morbid fancies and inclinations.
To attempt simulation would only seem possible, if possible at all in this
form of mania, after the violence and excitement had passed away and
the disturbed faculties had become comparatively calm, with the return
of some degree of rational appreciation of acts committed and of
penalties incurred, and to be avoided, and with an obliviousness, on the
part of the individual, of the fact of his insanity. Here the question
would present itself as to the actual existence of insanity at the time of
feigning, while its pre-existence might be readily conceded.
Feigning has the nature and quality of rationality, and is rarely, if
ever, practised without a motive. It proceeds primá facie from a rational
mind, just as motiveless acts proceed primá facie from a mind deranged;
yet we know that all acts without motives are not the offspring of in-
Sanity, as we know that acts prompted by rational motive do not proceed
from the sound mind only. We sometimes see, however, a kind of un-
conscious imitation, in some exceptional, morbid, mental states, of psy-
chopathic and neuropathic conditions seen in others, and occasionally
a kind of simulation lacking the conscious element in real insanity—a
mere freak of disease—which, however, is scarcely worthy to be called
true simulation. The insane appear at times, when they have an object
to accomplish, more crazy than, and different from, what they really are;
this is the sense in which we use the term simulation, and this condition
is akin to that of feigning by the sane.
Of course we do not expect to find feigning in advanced, general de-
mentia; but we may not search for it in vain in the intervals and remis-
sions of recurrent or periodical mania; after the mania transitoria;
possibly in certain stages and forms of what is called chronic, general
mania; in the hysterical and partial forms, the so-called monomanias; and
in the moral or affectional forms of insanity—the “namie sans délire” of
Pinel. Let me, however, repeat, to be plain, that in that profound, general
involvement of the mind in disordered action, which depends probably
upon more or less implication of the whole brain, and which we term
acute, general mania, feigning would seem an impossibility. The psy-
chical conditions essential on the One hand to simulation, and on the
other to the truthful acting out of acute, general, mental disease, seem
incompatible; the real victim of such a malady would not be same enough
to simulate, except during a so-called lucid interval, and comparative or
entire freedom from disease.
Simulation, while it presupposes a degree of sanity, does not require
that the patient should be wholly sound in mind, and might be attempted
by a convalescent patient, not thoroughly recovered, for the purpose of
remaining longer in the hospital or for some other reason. Supposed
feigning, in what appears to be a case of acute, general mania, should
lead us to suspect the correctness of our diagnosis, and to review the steps
by which we have reached the conclusion that the person is actually
insane. I am not prepared to say this much of other forms of mental
1112 H U G H E S,
disease, except dementia. We may admit the possibility of subsequent
feigning after the subsidence of a paroxysm of acute, general mania, and
still hold to its general improbability, simulation being, as has been said,
an attribute of sanity, just as is the existence of a reasonable motive,
though both do often actuate the mind deranged. We should fall into
a grave error, however, should we deny the possibility of other forms of
insanity than those which I have excepted, being accompanied with
either acts of feigning, or motives; an error which facts of daily obser-
vation among the insane fully prove.
The government of insane-asylum households, as every physician
knows, is conducted upon the idea that the insane, like the sane, though
in a degree more or less modified by disease, are actuated by ordinary
motives, and can be kept within certain rational limits of conduct and
expression by the conditional rewards and inducements to correct be-
havior there employed. The rude and indecorous often act with pro-
priety when such a course is made the condition upon which they are
permitted to take part in the amusements and religious exercises of the
asylum, or to have other rational indulgences allowed them. Proper let-
ters are written, and delusions suppressed by the writers thereof, in some
instances, after the patients have learned that very insane letters are
discountenanced by the superintendent, and returned to the writers for
improvement in regard to their rational tenor. The love of absent wife
or husband, father, son, or daughter, as the case may be, and the natural
desire to communicate with them, sometimes leads to compliance with
the superintendent's somewhat compulsory request, and to the expunging
of all evidences of insanity from their letters, by the patients themselves;
and at this point the re-establishment of the rational exercise of volition,
in restraining and refraining from the expression of morbid fancies,
sometimes commences, and the patient’s convalescence begins.
The fact, therefore, that the insane are more or less influenced by
rational restraints and motives, like the same, though in an impaired and
lessened degree, would seem to need no further illustration. All who
have much observed them, know that they are constantly induced to do
the above and other acts which may result in benefit to themselves.
They not unfrequently pretend to have abandoned cherished delusions,
and to have entirely recovered their reason, with the view of securing a
premature discharge from the asylum ; and even good judges of insanity
among medical superintendents have sometimes been deceived by the
plausible pretences of such patients, who, failing to convince the asylum
medical-officers, have sometimes succeeded in getting the hearing of
courts, and have been released on writs of habeas corpus, only to convince
every one, after a time, of their perfect fitness for perpetual restraint.
The co-existence of insanity with the power of devising the most plau-
sible explanations of erratic and insane conduct, is sometimes seen before
courts of justice, as in the case of Col. M., District Attorney in one of
the Southwestern States, under President Jackson, as detailed by Dr.
Ray." Mr. M. entertained the delusion that he was cousin to the Duke
of Wellington, and to Napoleon; he cut off his own nose, and, after the
rhinoplastic operation had been performed, cut out the cicatrix on his
forehead whence the nasal flap had been taken. “He was a passionate,
dangerous lunatic,” according to Dr. Bell, and yet so plausible in expla-
nation and extenuation of his conduct, and in defence of his personal
' Medical Jurisprudence of Insanity, 4th ed., p. 196.
SIM U L A TI O N OF INS A NITY BY THE IN S.A. N. E. 1113
and legal rights, that no asylum could hold, and no tribunal seriously
punish him. -
The celebrated suit of Wood v. Dr. Monroe, in England, for false im-
prisonment, as cited by Bucknill and other writers, also illustrates how
a really insane person may succeed in concealing his mental weakness
for a time from the most astute observers. The severest examination
failed to detect Wood's mental infirmity until he was asked what had
become of the Princess with whom he corresponded in cherry-juice,
which immediately caused him to reveal his insanity, and he lost his
case. Discovering the cause of his failure, he renewed the suit in Lon-
don, and then all the ingenuity of the bar, and the authority of the
court, could not elicit an exposure of his delusions, though he still enter-
tained them.
The simulation of insanity would seem no more difficult than the
assumption of sanity by the insane. If they can conceal, or explain
away so as to deceive the best judges, mental defects which they actually
possess, why may they not assume abnormal traits which they do not
possess : In the corridors of an insane asylum we sometimes see one
lunatic contemptuously or in sport caricaturing the whims and vaga-
ries of another, all the while fancying himself the sanest of men, while
he regards his brother lunatic as the simplest of simpletons, or the most
knavish of knaves. “Amidst our criminal population, too, are hundreds
who can hardly be said to be sane and responsible, but who, in the lower
ranks of life, commit a succession of crimes of no great magnitude, which
render them the almost perpetual inhabitants of jails. Some of them
are so violent, outrageous, and destructive—so silly in their motiveless
fury, and so childish in mind—that we may call them imbecile, or insane,
and have good grounds for our opinion.” These are the illy fed and
clothed, badly raised and housed, inhabitants of the densely populated
portions of our large cities, or the neglected children of drunken, epilep-
tic, or otherwise mentally maimed, parents, whose blood has been
poisoned with alcohol, opium, nicotine, and the noxious vapors usually
abounding where these cerebro-mental abortions come forth and grow up
into dwarfed and diseased maturity. At the maternal fount they drink
in disease, and are never afterwards entirely well—never perfectly sound
in mind, and never able to act out a natural life. When these human
abnormities grow up to manhood and womanhood, having led a life of
deceit, we might reasonably expect to find them simulating insanity, as
they sometimes do, when detected in, and incarcerated for, criminal acts,
being all the while unconscious that they are already really victims of
disease. This class should receive more careful examination, with a view to
the discovery of simulation among its members. That many cases are not
recorded, may be due to the fact that sufficient search for them has not
been made, simulation by the actually insane not having, until a com-
paratively recent period, been conceded by writers. I can recall the
names of no authorities more remote than Griesinger and Baillarger,
who have admitted the possible co-existence of simulation with real
insanity.
Armand Laurent,” as lately as 1866, gave several illustrative cases,
especially in connection with imbecility. A case was reported in the
American Journal of Insanity for 1863, but the most recent and unequiv-
| Blandford's Lectures, is 71, p. 390.
2 Etude Médico-Légale sur la Simulation. Parle docteur Armand Laurent. Parie, 1866.
1114 HU G H Es,
ocal recognition of the fact of simulation conjoined with actual disease,
by high authority, is to be found in the report of the case of Michael
Trimbur, in the number of the same journal for October, 1874.
It would be interesting to know what might have been the modifica-
tion of Dr. Parchappe's view of the mental condition of Lambert, whose
case is reproduced by Dr. Ray,' had the physician of the asylum at Rouen
had in view the possibility of blended simulation with some remaining
insanity. It will be remembered that Dr. Parchappe pronounced the case
one of simulation of unconsciousness, after the prisoner had come to him-
self, in order the better to escape responsibility for his acts, he having, in a
paroxysm, induced either by the virus or by the fear of hydrophobia, mur-
dered his mistress and another woman without provocation, and giving
as a justification for the homicidal act, in regard to the former of his vic-
tims, the insane reason that he desired to bestow her money in charity,
which, he said, she would never have done had she lived. On the day of
the murder, Lambert admitted killing his mistress, and repeatedly
exclaimed, “Jesus my God, my fortune is made,” and begged his captors
to release him because, he said, he “had eight more murders to commit.”
On the following day he denied having killed his mistress, but said “if
I did, I do not remember it.” Four days after the murder he recognized
the hatchet with which he had done the deed, but denied all knowledge
of the murder. I do not offer this as certainly a case of simulation con-
joined with insanity. It may or may not have been such, and, as my
purpose is rather to elicit discussion than to advance positive opinions,
I have deemed an allusion to it not out of place. Dr. Ray, in summing
up this case, concludes that it was one of feigned insanity, while Dr.
Parchappe, as we have seen, thought that it was an example of simula-
tion after recovery. May not the simulation have begun before recovery
had been completed, after a realization, upon the part of Tambert, that
he had committed heinous crimes from the penalty of which there
appeared to him no escape, except in assuming unconsciousness of his
acts :
Cases like that of the criminal in the prison at St. Ange, as related by
Prof. Monteggia and translated by Marc and Ray, and like that of Samuel
S. Rich,” which occurred in this country, come to mind, in this connec-
tion, as having shown perhaps phases of simulation, which might have
been revealed had the possibility of simulation co-existing with insanity
been entertained by the profession in those times. There was no history
of epilepsy in the case related by Prof. Monteggia, and though no such
rigid search could have then been made for epileptiform complication as
would be made now, there is not the slightest suggestion of anything of
this character in the history of the case as it has come down to us.
It may not be transcending the limits of scientific propriety, to sug-
gest simulation in connection with real insanity as a possible explanation
of some of the features of the famous case of Joseph Waltz,” still fresh in
the minds of all. There was undoubtedly simulation, and it was most
bunglingly done ; Waltz pretended to be suffering from dementia, which
was certainly not the case. His “don’t know” answers, made so often
to interrogatories concerning facts which he clearly knew (such as the
names of his mother and father, and his own age), and the post-mortem
examination, clearly prove this point.
| Op. cit., p. 415. * American Journal of Insanity, April, 1860.
* Ibid., July, 1874,
SIM U L A TI O N OF INS A NITY BY THE IN S A. N. E. 1115
Just here the thought occurs, that when equally honest and expe-
rienced experts view a case, which they have had equal opportunities
of observing, on the one hand as one of insanity, and on the other as
wholly one of feigning, it may be reasonable to look for co-existent simu-
lation and real disease, to explain the discrepancy of opinion. The case
of Waltz also suggests another possibility, viz., that in some cases, the
eagerness of counsel to make out a case of insanity from too meagre data,
aided unintentionally by the suggestive questionings of the physicians
who visit the prisoner at the counsel’s request, may sometimes lead a
prisoner, not in the beginning so disposed, to attempt feigning ; and that
if the same may thus obtain an idea that simulation can be successfully
practised, we need not be surprised to see the same thing undertaken by
Some real, though not pronounced, lunatics.
In a letter from Dr. Buckmill, referring to the case of Jesse Pomeroy,
whom Dr. B. had visited with Dr. Edward Clarke in the jail at Boston, in
April, 1875, the writer says “some physicians had suggested concealed
epilepsy . . . . as the cause of this boy's blood-thirsty propensities, and
had questioned him as to the existence of an aura. Whether this boy
had got the idea into his head or not, I know not, but he told Dr. Clarke
and myself that he often had the feeling that a light feather was drawn
across his forehead from one temple to the other. Now, as Dr. Clarke
remarked to me at the time, this is not the accurate description of an aura,
which follows the course of nerves.”
“Generally, after the acute stage has passed off, a maniac has no
difficulty in remembering his friends and acquaintances, the places he
has been accustomed to frequent, names, dates, and events, and the
occurrences of his life. The ordinary relations of things are, with some
exceptions, as easily and clearly perceived as ever, and his discrimina-
tion of character seems to be marked by his usual shrewdness.” IIis
replies to questions may or may not indicate delusions or other extrava-
gances of thought, while his whole demeanor and conversation may
show that he has some appreciation of his previous mental condition,
and a fair conception of his present surroundings. Under these circum-
stances, it is not difficult to suppose that a really insane person, finding
himself arrested, and in the hands of the law, on the charge of murder
or other crime, which he knows that he has been seen to commit, and
from the penalty of which there seems to him no escape except through
the plea of insanity, might conclude to simulate such a form of insanity
as in his opinion would secure his exculpation. Such a person might
not believe in the existence of his own real mental disease, and might
fear that those who were to try him would be equally incredulous; the
insane are not generally conscious of the extent and degree of their
mental derangement. Admitting, then, the existence of a sufficient
degree of rationality, in an insane person, to prompt to an effort at self-
preservation through the act of feigning, would he probably assume a
more exaggerated form of mental disorder, just as same men usually do
with the view of making a favorable impression, and with the cus-
tomary result of over-acting and detection ? We cannot reason out an
answer to this question, and practical illustrations are too few to enable
us to generalize on the subject.
An insane person, having once been an inmate of an asylum, would
there have opportunity to become familiar with the Ordinary character-
' Ray, op. cit., p. 390.
1116 H U G H E S.
istics of insanity, and would not, I think, be so likely to assume the
tragic and exaggerated forms of madness, as one more ignorant. His
capacity to successfully reproduce what he had observed in the asylum,
would depend upon the degree of mental soundness existing in him at
the time at which he had been an inmate, and remaining with him at
the time of attempted feigning. Insanity is a crippled, rather than a
destroyed, or obliterated, mentality.
From the nature of insanity, we see that feigning is possible oftener
than it is shown by experience to occur in connection with the usual
forms of the disease. Insanity is an impairment of one or more of the
mental faculties, by reason of disease involving the brain; and as it may
exist in every degree, observing the same pathological laws as any other
disease, it is evident that acts which in themselves are rational in cha-
racter, may be done by the insane. A sick man is seldom so sick, unless
it be in the last and hopeless stage of his malady, that he can do none of
the acts which he could perform when well. Among the acts, therefore,
which the insane must be deemed capable of performing, we must include
simulation. It is not uncommon for the healthy human mind to dis-
semble, especially in civilized life; and this natural trait does not always
wholly forsake the mind diseased, though it must be confessed that the
insane wear less of a mask than the mentally sound, and thus we come
again to the general truth as applied to the insane, in manić veritas.
Some exceptions to this rule have come to my notice, and further obser-
vation may discover more; but not enough to invalidate the rule as
applied to insanity in general: Eacceptio probat regulum. A mental phe-
nomenon worthy of note here, but not germane to the subject, is the
unconscious or semi-conscious imitation, rather than simulation, of in-
sanity, which is displayed on certain occasions by those who largely in-
herit the insane neurosis. It consists in a sort of sympathetic taking-on
of an evanescent form of insanity by other members of a family, under
great excitement, as when one of their number has become profoundly
afflicted with some marked form of mental disorder. A father or mother,
for instance, brings to the asylum a son or daughter, when, from the ex-
aggerated and unnatural conduct of the parent, aside from the natural
manifestation of grief to be looked for on such an occasion, but which is
sometimes wanting, the superintendent finds it difficult to determine
which for the time acts the most insanely, parent or child. The conduct
of the parent appears anything but rational, yet a return to home, di-
vested, in a measure, of anxiety and the weariness of watching, with a
season of rest and sleep, and better appetite and digestion, suffice to re-
store the disturbed balance of the mental faculties, and the parent, by
reason of regular life and habits, escapes the affliction of positive insanity,
though possessing and transmitting a neuropathic diathesis but one re-
move from it.
Insanity, as Prichard observes, sometimes co-exists with an apparently
unimpaired state of the intellectual faculties; though “the ideational
portion of the faculties,” as Blandford remarks, “is so intimately joined to
the emotional, that the two must be sound together, or unsound together.”
Admitting the existence of so slight an intellectual aberration, in cer-
tain kinds of insanity, that the intellectual lesion is more theoretical
than apparent, it is easy in such cases to concede the possibility of simu-
lation on the part of the patient, to extenuate erratic and immoral con-
duct, the result of disease. The subjects of moral insanity sometimes
simulate inebriety, as well as insanity, to palliate and excuse what ap-
SIM U L ATION OF INS A NITY BY THE IN S.A. N. E. 1117
pears to them and to others, not expert in detecting mental aberration,
inexcusable conduct. The case of Col. M., already alluded to, was one
of this kind; many of his freaks were excused and explained away,
when they could not be denied, upon the plea that he had drunk a little
too much on that particular occasion.
It is not easy to perfectly imitate diseases involving the mind in dis-
order, notwithstanding that Zacchias has said that feigning is easy, and
detection difficult. The unconscious “method that is in madness, the
constant and consistent reference to the predominant idea, which the
practical observer detects amidst the greatest irregularity of conduct
and language,” requires all the mental faculties in their fullest vigor,
and unimpaired by disease, for successful personation, and is then rarely
successfully feigned before the eye of the physician who is experienced
in detecting the true features of morbid mentality. While, therefore,
we may concede the possibility of occasional successful feigning by the
mind in full possession of all of its faculties, we should not expect the
crippled mind of an insane person to deceive us, and the fact of simula-
tion being detected should not preclude the possibility of co-existing
insanity in any particular case.
Dr. Ray, in his report of the case of Trimbur,” says: “The criminal
classes, to which most of these simulators belong, know as well as every-
body else that the plea of insanity is one of the dodges whereby people
now escape the punishment of their crimes, and they may not forget to
act accordingly when they become insane themselves.” This was the
case with Trimbur, who, “being unconscious of his own real insanity,
but with mind enough to understand his situation and to remember
what he had heard about insanity in connection with crime, concluded
to make a show of being crazy.”
The following case, communicated to the writer by Dr. Joseph Work-
man, for many years the distinguished medical superintendent of the
Toronto (Canada) Lunatic Asylum, seems equally illustrative of blended
simulation and real disease, and, as it has never been published, I give it
here in Dr. Workman's words:–
Some ten or twelve years ago, I met [says Dr. Workman] with a case of
genuine simulation in a man who had murdered his wife. He had previously
been a patient under my care, for about a year, when he undoubtedly was insane.
Just as I was on the point of discharging him as recovered, he eloped. I did
not use much exertion to recapture him. He went home to his farm, and got on
well until his insanity returned, taking the form of jealousy of his wife, which,
I need not say, was utterly causeless. One day, in the sugaring season, in the
bush, he killed her with a billet of firewood. He was apprehended—did not in
fact try to escape—admitted his crime, and was tried at the next assizes. I
was summoned as an expert witness, and had a long interview with him in the
jail before the trial. I knew him at first glance, and asked him if he did not
remember me? He said that he did not ; that he did not think that he had
ever seen me. “Why, John,” I said, “you must remember me well; you lived
in the same house with me for over a year, and talked with me hundreds of
times. You remember being in the asylum ?” No! He had no such recollection,
but people had told him that he had been there. “Well, you have not forgotten
your old friend Mr. E., the steward 7” He did not know him at all, and so on
throughout all our colloquy. I had the most thorough conviction of this man’s
stupid mendacity and bootless simulation, and at the same time of his insanity
at the time of committing the murder, and I stated both to the jury. He was
| Ray, Op. cit., p. 388. * American Journal of Insanity, October, 1874.
1118 - - H U G H E S,
acquitted on the ground of insanity, and was committed to the asylum for
criminals, at Kingston, where he is still detained.
Two or three years after his trial, as I was passing through the asylum in
company with the medical superintendent, a patient stepped up and held out
his hand, addressing me very courteously, and inquiring after all my family.
I did not recognize him until the medical superintendent told me that he was
my old friend J. C. “Oh John,” said I, “how is it that you know me so well
to-day, but did not know me at all in Guelph jail?” His reply was, “I did
not want to know you that time.” This man had certainly a very powerful
motive for simulation of mental frailty, but he played his part too unskilfully
to impose on my credulity. Jealousy was not the cause, but the form of his
insanity, and when he had forever got rid of the subject of his delusions, a
sober after-thought assumed the government. He was, as I believed, still in-
sane, yet possessing that degree of stupid cunning which not a few sane people
evince. He knew that he would be hanged unless acquitted on the ground of
insanity, for in Canada murderers generally have but little chance of escaping
the death-penalty. Had he been thoroughly sane, he would have known that
sufficient proof of his past insanity, both in the asylum and afterwards, could
have been produced, and he would have abstained from his clumsy simulation,
or he would have acted his part more cleverly. I could not say that he com-
mitted the common error of simulation—overdoing his work. He did not rave,
babble, or declaim, or indulge in foolish antics and grimaces.
In criminal cases, when an individual, in whom there exists undoubted
evidence of mental disease, actually pretends to have a form or symp-
toms of mental disorder not in harmony with the kind of insanity which
actually afflicts him, or not in the natural course of his disease, the pre-
sumption is reasonable that there also exists in him a sufficient degree
of rational volition and appreciation of surroundings to modify the de-
gree of his responsibility to law. The perplexing question then arises as
to whether the individual’s state of mind at the time of feigning be the
same that it was at the time of violating the law; the presumption is in
favor of a clearer mind at the time of the simulation than at the height
of the insanity, and this appears to have been the case with Dr. Work-
man's patient. The mind disturbed by disease, varies in the intensity
and degree of its disordered manifestations at different times, even as
the healthy mind is known to vary on different occasions in the display
of its natural peculiarities and powers.
Other questions are here presented, of a medico-legal character, relative
to criminal responsibility and testamentary capacity in certain cases,
which, in the present state of our knowledge of psychology, cannot be
satisfactorily answered in general terms. Eminent alienists all admit,
in the abstract, the existence of different and variable degrees of rational
capacity and responsibility in mental disorder. There are, as Locke
says, “degrees of madness as there are of folly,” but to determine pre-
cisely what amount of impaired mind-power exists in particular cases,
may often puzzle the most learned and experienced psychological experts.
The law has attempted to cut the Gordian knot, to untie which has so
long baffled the most thorough students of the mind diseased, by deciding
that the capacity to distinguish right from wrong, should settle the
question of responsibility to law in criminal cases; but practically we
know that an individual may clearly know right from wrong, and yet,
under the overpowering influence of cerebral disease, be irresistibly im-
pelled to do the wrong. The importunities of the insane to be restrained,
when suggestions of violence, prompted by morbid states of the brain,
arise in the mind, and when the patient’s own recollection of his past
SIM U L A TI O N OF INS A NITY BY THE IN S.A. N. E. 1119
experience teaches him that resistance to his insane impulses beyond a
certain limit is impossible, are familiar to all accustomed to come much
in contact with the insane in asylums. The physiological fact of uncon-
scious cerebration is applicable to the mental operations in disease, as
well as in health, and to many acts of the insane, especially of the epi-
leptic class, but certainly not to all. The legal test therefore fails, and
indeed it has been much qualified of late in the rulings of the courts.
We must concede, however, that this test can be justly extended much
further than at first blush would appear to be proper, for unconscious
cerebration in a paroxysm of insane fury would save many a lunatic who,
a short time before or after, would fully comprehend the nature and
quality of his acts.
The facts admitted in this digression would tend to prove the possi-
bility of simulation by the insane, even if it were not established by expe-
rience; knowing, as many insane persons do, that they have unconscious
states in which their irresponsibility is conceded by all, it would not be
strange for an insane man to pretend to have been in such a state, when
he really had not, to escape censure or punishment for some act which
he knows that he ought not to have done, and the impulse to do which
he knows that he could have resisted. I do not now allude to those acts
of the insane which, from their history, we might expect them to com-
mit, such for instance as suicide in the suicidal form of madness, homicide
in the homicidal, burning in the pyromaniacal, stealing in the kleptoma-
niacal, etc.
There is one fact which might in some instances deter insane persons
from feigning, even when the disposition and capacity existed, and that
is the knowledge which they possess of the estimation in which they are
held, as irresponsible. Who, accustomed to live with the insane and thus
made familiar with their true character, does not know how keenly con-
scious they are of the existence of this erroneous estimate of their real
condition as regards responsibility, removed, as they are in the asylum,
from those sources of irritation which have caused, or which tend to
keep fresh opened, their mental wounds? A patient once told me that
he would have his liberty, or kill me. I said, “Then you would be
hanged.” He answered, “They could not do that, I am insane.” “Dut,”
said I, “you would not be insane on that subject. You know it would
be wrong, and your insanity is not homicidal.” He said, and said truly,
“No jury would ever hang a lunatic for anything that he might do in an
insane asylum.” Not being able thus to intimidate him, I approached
him ever afterwards with caution, and always dodged, when practicable,
the discussion of the question of his personal liberty. This patient used
the word lunatic sneeringly, for, though admitting that he was not al-
ways right in his mind, he did not consider himself seriously insane,
though, at times, he was really very much so, his paroxysms of excite-
ment lasting many days at a time. It is easy to conceive of circum-
stances under which such a patient might simulate, as well as rely upon,
his reputation for insanity.
The fact of unconscious cerebration, before alluded to, as we see it
manifested in cases of hysteria, mingled with conscious and partly
volitional, mental activity, explains the simulation of real insanity
which sometimes co-exists with this singular morbid state. In hysterical
insanity, there seems to be a morbid desire to act out actually control-
lable vagaries, as well as those really insane promptings which are beyond
the control of the will. The insane of hysterical tendencies often act in
1120 H U G H ES,
a seemingly controllable, but very insane, manner, apparently through a
morbid craving for extraordinary sympathy and attention. Occasionally,
however, their actions are apparently wholly motiveless, as with other
and aggravated forms of insanity.
Though simulation is rarely practised without motive, it is possible
for the motive to be sometimes a very foolish one, and, while it may
be unaccompanied by delusion, yet scarcely explainable upon the hypo-
thesis of perfect sanity. Such a case would lead to great perplexity in
the mind of the physician.
The egotistic feeling so often uppermost in the mind diseased, caus-
ing the insane to seek in so many ways to attract attention, or excite
wonder and commiseration, is only an exaggeration of a not uncommon,
natural trait of rational minds. It may be doubted whether the case re-
ported by Dr. Bell, an abstract of which may be found in Dr. Ray’s' excel-
lent work on the jurisprudence of insanity, was without real disease as
well as blended simulation. Dr. Ray, in introducing the case, regards it
as “somewhat curious, considering the youth of the subject, the apparent
want of motive, and the severity of the symptoms.”
The lad, thirteen years old, had fallen on his head two years previous to
admission, and ever since that period had exhibited some anomalous symptoms
of disease, which had been referred by his physicians to derangement of the
digestive organs. For the last few months, the symptoms had been more
severe and decided. He had refused food for long periods, had had spasms,
had lain with his eyes fixed and his legs drawn up, would hold his breath and
strike. On admission to the asylum, he presented the appearance of a sickly,
emaciated boy, under puberty, unable to stand, exhausted by suffering, breath-
ing quickly, and passing his evacuations in bed. Every few minutes he had a
frightful spasm, commencing with a convulsive shaking of the head, pawing of
the hands, and turning up of the eyes. Soon his hands would vibrate against
his sides and chest, his countenance would be dreadfully distorted, and then
would commence a horrid scream that might be heard over the whole premises.
In this condition, with occasional remissions, and the addition, at one time, of
diarrhoea, he remained for about a month. . . . Being watched through a
hole in a blanket hung before his window, he was observed to jump up and
stride about his room as actively as any body, but at the slightest noise
resumed his old position, screaming and groaning.
Dr. Bell broke in upon him before he could regain his bed, chided him
for his deceit, and bade him walk into the hall. “The spell is broken,”
'says the record, “the feeble knees are made strong, the convulsed and
distorted visage is calm and smooth, and the young deceiver goes forth
clothed and in his right mind.” Dr. Chipley, commenting on this case.”
says, “We can scarcely conceive that one would assume a character so
painful to sustain, without some deliberate purpose, or an end to be accom-
plished ;” and yet no motive such as might be supposed to actuate the
rational mind, is at all apparent in this case. The fact of the boy’s hav-
ing refrained from his usual manifestations on the unexpected appearance
of Dr. Bell, whom he doubtless held in no small degree of awe as the all-
powerful head of the establishment, while it proves a power of control
over the actions under great external influences, and is strongly presump-
tive of feigning, does not, to my mind, conclusively establish the fact of
entire sanity. There is nothing absolutely incompatible with insanity
in sudden cessation of its symptomatic manifestations. If this youth
| Op. cit., p. 405. * American Journal of Insanity, July, 1865.
SIM U LATION OF INS ANITY BY THE IN S.A. N. E. 1121
was willing to make such continued, great, and painful sacrifices of com-
fort and character for the ridiculous and unreasonable purpose of exciting
wonder and commiseration, such a motive, coupled with the youth’s
history and all the attendant circumstances, is well calculated to excite
Our suspicions as to his entire mental soundness. There were at the
time, doubtless, others in the hospital more insane than this boy, and
perhaps others, regarded as undoubtedly insane, who were fully as rational
as he. A good deal of sanity may still exist among those who are too
insane to mingle with the rational world.
Visitors, passing through the corridors of a hospital for the insane,
often remark this fact, and the asylum-officers are often asked why cer-
tain patients are restrained of their liberty, because of their presenting
to the casual observer so little appearance of insanity. So proper are the
manners and conversation of patients, at times, that an unfounded dis-
trust of public hospitals for the insane has sometimes been engendered in
the public mind from this source—the insane themselves behaving so
well in the presence of visitors, and at other times, under the present
wise and scientific system of classification, medical and moral manage-
ment, and restraint—the latter, in this country as in England, hardly
exceeding non-restraint.
It would unduly lengthen this paper to detail the many instances which
might be gathered of insane persons, on certain great occasions which
made profound impressions upon their minds, having behaved with unac-
customed propriety, and having suspended for the time-being all manifes-
tations of insanity, or to mention instances of great and unexpected events
having been the beginning of recovery. Every one accustomed to the care
of large bodies of the insane, knows that grand and unusual occurrences,
which would startle and profoundly impress the rational mind, sometimes
favorably impress the insane, notwithstanding that, in the main, they
are either regarded with indifference, or cause aggravation of existing
excitement. Some instances in point might be mentioned in connection
with the burning of asylums. No such event has ever happened in my
own experience, but the burning of a large stable and barn on the asylum
premises at Fulton, early one evening, in full view of a good portion of
the patients, gave opportunity to witness, in some degree, the different
conduct of different lunatics under such circumstances. A very few of
the patients were more excited than usual ; the majority were indifferent;
and some gave us valuable aid in our efforts to suppress the flames and
save the stock.
The coercive methods of treatment, recommended and practised by
Celsus, demonstrated the power of self-restraint in some cases, under
the influence of overmastering fear; and in our own day, threats and
punishments, though for obvious reasons neither practised nor advised
as curative agencies, are not without some influence in subduing some
refractory and noisy patients into submissive silence, as may be learned
by visiting some of the almshouses and jails to which many of these
unfortunates are yet consigned in the United States. It may be con-
ceded that to be influenced by fear to such an extent as to suspend all
display of insanity, is, in some cases, good evidence of feigning ; but it
must not be so regarded in all. Fodéré has been criticized, by a writer
rom whom I have already quoted,' for having relied upon the test of
ear in the case of a female, who acted her part, if she were only acting,
* Dr. Chipley, American Journal of Insanity, July, 1865.

71
1122 HU G H ES,
so perfectly that the doctor was on the point of certifying the case. He
returned to her door, however, and said with a stern voice, “To-morrow
I will visit her again, and if she continue to howl, if she be not dressed,
and her chamber not put in order, you must apply a red-hot iron between
her shoulders.” He found things in order the next morning, and on
this proof alone, with strong evidence to the contrary, immediately de-
cided that it was a case of simulation. “Put was this decision justified,”
asks the writer, “by the simple fact that the patient changed her con-
duct under the terror inspired by severe threats º' And he answers the
question by referring to the self-control exercised by patients under the
influence of fear, or the hope of reward. The poteney of authority in
suddenly suppressing through fear all appearances of mental derange-
ment in those who are really insane, is, of course, exceptional ; I can
hardly conceive of such instrumentalities being successful in aggravated
cases of general cerebro-mental disease, yet their occasional influence in
controlling the less general forms of insanity, especially where simula-
tion co-exists, is not to be doubted.
In hospitals for the insane, the power of one having authority is some-
times shown in the restraint which some patients put upon morbid and
quasi-morbid displays, in the presence of the chief physician, and the
arrest of paroxysms of hysteria by commands and threats, before the
disease has reached the point of recognized insanity, is nothing new to
the profession at large. This characteristic of partial control under
ordinary circumstances, reaching the point of entire control under
extraordinary circumstances, in cases of hysterical insanity, is too
familiar to the profession to need further notice; it extends also, as I
have endeavored to show, to other cases.
The power of self-restraint implies the power of simulation. Hys-
terical patients are undoubtedly more prone than others to “put an
antic disposition on,” as IIamlet has it, and are more disposed to act
insanely than to exercise aright what power they really possess of at
least restraining within more rational bounds the ridiculous displays
which they often make.
The following case presents, I think, some interesting features:—
Teuben S., aet. 25, married, of limited education and of intellect below the
average, with a history of domestic infelicity, masturbation, and three weeks’
insanity before admission, entered the Missouri State Lunatic Asylum on
April 6, 1867, and was discharged, recovered, on November 15 of the same
year. He had been an attaché of a sort of travelling circus, and theatrical
and minstrel troupe, before the development of his insanity. After becoming
insane, he had been seized with a sudden desire to preach, and, securing an
audience in one of the country towns of Missouri, he conducted the services
in such an obscene, blasphemous, and Outrageous manner, that he was driven
from the pulpit. His insanity becoming apparent to the neighborhood soon
after, he was sent to the asylum.
At the asylum he endeavored to preach in the same way, but being put into
an empty, quiet room, with a single window looking out on the lawn, and no
audience, he soon grew tired of addressing vacancy, and changed his perform-
ances to tearing up his bedding and clothing, and soiling the walls and floor
of his room. His occupation in the corridor changed to negro minstrelsy of
the most ridiculously insane character, mingled with some really good hits at
men and things which he had learned. He was fond of applause, and much
i I doubt this statement as to his natural intellect. His history was not given by near
relatives or by those who had known him long.
SIM U L A TI O N OF INS A NITY BY THE IN S.A. N. E. 1123
encouraged when he excited laughter. The manner and intensity of his per-
formances could be very much varied by our signification of approval or dis-
approval. He would seriously hurt himself, if permitted, in his attempted
feats of ground and lofty tumbling. I never had the slightest doubt of his
insanity, and have not to this day.
This patient’s propensity for acting, after he had come to eat and sleep well,
gradually wore off, but, during his convalescence, the least encouragement
from officers or attendants would start him to performing. To keep him
quiet, it was necessary that no notice should be taken of his antics, and the
attendants were instructed accordingly. After his discharge from the asylum,
he went to a distant part of the State, but soon returned to Fulton, and en-
gaged in the business of a barber. He did not change his name, but denied
ever having been in the asylum, though all the attendants knew him as our
former patient, and often met him. He conducted his business properly
enough, as far as I know, but the attendants who visited him, none of whom
he would ever recognize, still thought him insane. It soon got noised about
that he had been an inmate of the asylum, and he and his brother, who was
also his partner, left for other parts.
There was no reason for believing this man to be wholly feigning. There were
no charges of any kind against him, and no friends were interested in having
him shielded from any punishment; moreover, he made several clever attempts
to escape, at one time remaining away for a whole day before being recaptured.
It is true that his performances were mainly given when he could get an audi-
ence, and were prompted by love of applause and notice; but he slept very
little, when not narcotized, and occupied himself at all hours of the night in
tearing his blankets, littering his room with straw, and doing every conceivable
mischief, in addition to soiling his room and person. Before we had concluded
to employ the necessary restraint, he was always doing something ludicrous
or destructive, and the poor fellow’s antics and appearance excited more
laughter than any other patient on the male side of the house. When he
came to the asylum he was extremely emaciated, indifferent to food, and,
indeed, to everything except notice and applause. Egotism was constantly
uppermost with him. His pulse was quick, and he was never known to be
quiet while awake. As he convalesced he grew quiet and thoughtful, his pulse
became slower, and he slept better, and improved in appetite and flesh.
This case was certainly a remarkable one: Could any conceivable
motive have been found, we should have suspected simple feigning. The
patient was evidently not aware that he was acting the part of a lunatic
to an audience of insane persons, and in this respect the case differs from
others, the simulator, same or insane, generally appreciating, in some
degree, the nature and extent of his acting and surroundings. Still the
case serves to show the power which the insane possess of acting some-
what for a purpose, much after the manner of other people.
Though a mania for display is not uncommon with the insane, its ap-
preciable modification by the applause or disapproval of those about the
patient, would be taken, in most instances, for pure feigning without the
co-existence of cerebral disease. Everything in this case but the one
fact of the patient's acting most insanely when most observed, contra-
dicted the notion of feigning. His physical condition, his antecedent
history, the nature of his acts, and, after recovery, his changed demeanor,
all pointed to the existence of real insanity.
I turn now briefly to a class of cases regarded by many as more devilish
than lunatic, viz., the morally insane ; who know how they are con-
sidered, and why they are in the asylum, and who take advantage of
their reputed insanity to do many things from which they might perhaps
refrain if they chose, but to which disease really prompts them. They
1124 HU G H ES,
sometimes pretend to a degree of intellectual impairment not natural to
them in their diseased condition.
These patients know where they are and why they are there, and to a
certain extent are able to behave themselves with propriety when motives
are powerful enough to induce them to do so, particularly under the
absolute authority which they know that they have over them at the
asylum—exercised, it is true, in the mildest and least irritating way, but
usually with firmness and certainty. At home, with those whom they have
been accustomed to manage, they are uncontrollable, and behave them-
selves like very devils, so that they get no sympathy. The world outside
does not understand them, and cannot get along with them, and indeed
those in charge of asylums wish that these patients could be cared for
elsewhere.
With distorted views of men and things about them, just short of
delusion; dissatisfied and suspicious, often without the shadow of a
cause ; sometimes devoid of affection and gratitude; sleeping and eating
poorly ; never in a state of mental composure, but always quarrelling
with the cook, the laundress, the attendants, or some fellow-patient ;
with bowels often habitually constipated, circulation disturbed, and
general appearance of ill health, if these patients are insane—and I think
that they are—they can also simulate to an aggravating degree, when
it serves their purpose, abnormal mental states not actually existing in
them. -
The possibility of self-control under exceptionally powerful external
influences coming to the aid of the will of persons reputed to be insane,
does not preclude all possibility of the existence of real insanity. A
more or less modified power of self-control exists in the incubative stage
of most forms of insanity, even under ordinary circumstances, and per-
sists oftentimes until the case has passed into the form of final and hope-
less dementia. After recovery, our patients sometimes tell us how they
resisted morbid promptings to extravagant words and conduct, before
these found unwilling and resistless expression. Suicides and homicides
by the insane are seldom without premonitory preparations, threaten-
ings, and warnings, and much of the freedom of intercourse, coupled
with safety, of asylum-life is due to this fact. Even in cases of well-
advanced insanity, morbid impulses of various kinds are sometimes long
and repeatedly resisted before their final consummation.
The power to restrain and suppress insane promptings, so frequently
exhibited by the insane, implies the power to simulate the features of
insanity. In all asylums for the insane, there are chronic cases in which
the original delusion, though still persisting, ceases to dominate the pa-
tient as in the beginning—cases in which the aggravated demonstrations
and exclamations of the patient are disproportionate to his delusion.
The insane man’s oft-repeated actions and expressions become a sort of
second nature, as habit becomes with the same. There is a kind of
automatic simulation here; these patients act out a state of feeling
which is not real to them. If once tormented with a painful delusion,
they cease to suffer as acutely as in the beginning, if they suffer at all,
and their attention is more easily diverted from self.
Our asylums afford many examples in which the patients, yielding
more or less to their delusions, also more or less modify or suspend the
expression of them. This fact is illustrated and recognized in the moral
treatment of the insane. Even Sane persons are not free from dis-
simulation, and while insanity in the main reverses the natural charac-
SIM U L ATION OF INS A NITY BY THE IN S.A. N. E. 1125
ter, it sometimes throws off the natural disguise put upon the conduct
and conversation in health ; thus we may find the natural disposition
to dissemble, in not very profound forms of mental disease, displaying
itself less guardedly than in health. Hysteria is an apt illustration of
this fact, both before and after it becomes actual insanity.
The insane, like the same, though on the whole more truthful than the
latter, are not always and altogether what they seem in acting out their
real psychic impulses. They are sometimes more crazy than they appear,
and sometimes appear more insane than they really are. We have gene-
rally to scrutinize an insane character closely to fully comprehend it.
Esquirol's estimate of the value of constant observation, in order to
become familiar with the subject, expressed very nearly the truth: We
must live with them to fully know them. Simulation of insanity may
exist in connection with actual psychical defect, the result of disease of
the brain, just as disease of the stomach, lungs, or other organ, may be
accompanied with a greater or less degree of healthy function. Only
death obliterates and destroys all function, while disease, short of death,
modifies and perverts organic activity.
Physical disease, involving the so-called physical organs in contradis-
tinction to the organ of the mind, is not always or usually entire physi-
cal destruction ; and so disease involving the mind and its organ, is not
always or usually entire mental overthrow or obliteration; rather is the
latter the exception, than the rule. Do we not, therefore, err, if we seek
to find in every case of apparent mental aberration all simulation, or all
insanity ? Is there anything in the nature of insanity, as we recognize
its different forms, incompatible with simulation? I think not, except
it be in profound and advanced general mania and dementia; and from
this cursory survey of a field which grows wider as we view it, I con-
clude that it is not only not impossible for the insane to simulate in-
sanity, for a purpose, in any but its graver forms of profound general
mental involvement, but that they do sometimes actually simulate acts
and forms of insanity for which there exists no pathological warrant
that can be discovered in the real disease by which they are affected.
DISCUSSION ON DR. HUGHES’s PAPER.
After the reading of the preceding paper, Dr. Is AAC RAY, of Philadelphia,
said:—Until the present century, insanity was seldom put forth as an excuse
for crime. Its frequent occurrence in our day has made it a duty of phy-
sicians to make themselves acquainted with its phenomena far more accu-
rately than was before required. It often becomes their duty to say, in a
matter of life or death, whether a certain person is same or apparently insane,
and, if the latter, whether the apparent insanity is real or simulated. Most
of the insane know as well as other people that insanity is an excuse for
crime, and there is no reason why they may not strive to use it as such,
when occasion calls, by feigning some manifestations of the disease over and
above those belonging to their own particular form of the malady. To do
this requires no more shrewdness and self-command than it does to conceal
their delusions, as they sometimes do. The fact that they are already
insane does not preclude the need of simulation, for the well-known reason
that the insane generally do not recognize their own infirmity. To them, the
need of the excuse seems just as strong and just as apparent as it would to
others. -
Dr. Hughes's mention of Dr. Bell's case calls to mind a form of mental dis-
1126 H U G H Es, SIMULATION OF INS ANITY BY THE IN SANE.
order, not unfrequently met with in general practice, in which the real and the
simulated are curiously mingled together. It occurs mostly in women, begin-
ning usually in a morbid fondness for sympathy, and for the attentions be-
stowed on the sick and suffering, and originating either in some hysterical
condition, or in a decidedly insane temperament. There is nothing which
persons thus disposed will not endeavor or endure, and the aches and ails
which they affect, from a simple cough to fits and dislocations, no man can
number. We are all familiar with them, no doubt. I knew of one who, not
content with keeping a couple of watchers up all night for months together,
would, when at all displeased, dislocate her jaw; and another who would,
under similar circumstances, dislocate her hip. In such cases there is, un-
doubtedly, much mental disease, and also much downright simulation. And
it is not always easy to determine what is to be attributed to the one, and
what to the other, while a mistake may lead to great wrong and suffering. I
call to mind the case of a young girl of some culture and refinement who kept
her bed more than a year, unable to move without assistance, and regarded by
friends and physicians as extremely ill. At last some one, walking in the
garden, observed her, through a window in her room, rise from the bed and
jump about as lively as a cricket. Of course there was an end to this sort of
performance, but there soon appeared a good deal of mental disorder, which
finally made her so troublesome that she was placed in our hospital. There,
for weeks together, she behaved with the utmost propriety, evincing neither
in conduct nor in conversation the slightest sign of insanity. This condition
would alternate with periods when she lay in bed, unconscious apparently of
everything around her, her face highly flushed, and her pulse fast and full.
She took food Only through the tube, and passed her evacuations in bed.
From us she passed into the charge of an Indian doctor, by whom, it was said,
she was cured. Some light is thrown on the psychological history of this case
by the fact that a brother and sister were spiritualists, and that her mother
presented many indications of the insane temperament. Now, had this young
woman committed a criminal act, I fear that the plea of insanity would have
availed her little in view of this instance of detected simulation.
ON THE BEST MODE OF PROVIDING FOR THE SUBJECTS OF
OHRONIC INSANITY. .
BY
CHARLES H. NICHOLS, M.D.,
suPERINTENDENT OF THE GOVERNMENT HOSPITAL FOR THE INSANE, W Ash INGTON, D. C.
MAN lives by reason; the brute by instinct. The greater size and
complexity, and the higher organization, of the organs of reason, render
them more susceptible to derangement than those of instinct; while the
complex necessities, motives, and struggles, which belong to a life of
reason, evolve the numerous exciting causes of such derangement just in
proportion as the reasoning being develops his pre-eminent intellectual
powers, and puts his feeble instinct into abeyance. When reason or
motive is perverted by cerebral disorder or defect, man is both a depen-
dent and an aggressive being. The utter incapacity to provide for him-
self which causes him to be regarded as an infant, in the eye of the law,
is more apparent because of its most frequent occurrence at a time of life
when he is most independent in his normal powers, and when both his
absolute and artificial wants are most numerous and pressing. Intensity
of purpose and action is often in direct ratio to perversion of judgment
or motive, and the insane man is not only disqualified for providing for
his numerous wants, but has the inclination and power, if left to himself,
to be exceedingly dangerous to life and property.
Insanity is a term used to express the mental symptoms of a physical
disease or defect which generally admits of partial relief, and which
often admits of entire cure. If cured, the subject of the disease regains
all his inestimable, human prerogatives—the ability to mingle in society,
and freedom to will and to do of his own good pleasure. If relieved, as
far as each case admits of relief by the diligent and skilful use of the
appliances of modern science and benevolence, a life of sickness and pri-
vation is rendered comfortable and often measurably happy. Such a
helpless, dangerous, privative, and yet remediable when not curable, in-
firmity, appeals not only to the deepest sympathies, but to the self.
interest of the whole race among which it prevails. Insanity is every-
where regarded as the chief ill to which flesh is heir ; and it is the sen-
timent of enlightened Christendom, however imperfectly and variously
that sentiment may be expressed, that the insane of all classes should
have all their needs provided for, because they cannot provide for them
themselves; should have the medical and moral treatment that will
alleviate, if not cure, their grievous disease; and should, as a rule, be
restrained of their liberty, because it is unsafe for them to be at large.
If not cured, the pathological conditions of the brain which give rise
to mental derangement, rapidly pass into a chronic condition, whose
average duration is about equal to one-half of the mean length of human
life. The result of efforts to establish by observation and pathological
research the relations between the duration of mental disease and its
curability, is the practice of classifying cases of not more than one year's
duration as recent and presumptively curable, and those of more than
1128 NIC HOLS,
one year's standing as chronic and probably incurable. Experience
shows that this generalization is useful in estimating the tendencies in
respect to recovery, or duration of illness, of large masses of the insane,
and the provisions required for their proper maintenance and treatment;
but when it is considered that, under the circumstances most favorable
to recovery, about fifty per cent. of all the cases of insanity that occur
in a community pass this arbitrary boundary-line which has been set to
divide recent from chronic mental disease, while the rapidly diminishing
probabilities of recovery are not found to be extinct in individual cases
until the expiration of the third or fourth year after the invasion of the
malady, it will be seen that such a generalization can be only an approxi-
mation to the truth, with many exceptions. As the recent insanity of a
community imparts an increment of not far from fifty per cent. of all
the cases that annually occur, to those of technically chronic mental dis-
order, while an uncertain period of several years expires before individual
cases become hopeless, the two classes are, for a considerable period at
léast, inseparably linked with each other, and either a philosophical or
a practical consideration of “the best mode of providing for the subjects
of chronic insanity,” should obviously form a harmonious part of a com-
prehensive scheme of providing for the treatment of insanity of every
duration and form.
In the year 1866, the Association of Medical Superintendents of
American Institutions for the Insane," a body of the highest acknowl-
edged authority in America in relation to the wants and claims of the
insane, after an exhaustive discussion of the exact subject of this paper,
adopted the following five propositions, the first four unanimously, and
the last one by a considerable majority of the members present at the
meeting of that year:—
I. The large States should be divided into geographical districts of such
size that a hospital, situated at or near the centre of each district, may be
practically accessible to all the people living within its boundaries, and avail-
able for their benefit in case of mental disorder.
II. All State, county, and city hospitals for the insane should receive all
persons, belonging to the vicinage designed to be accommodated by each hos-
pital, who are affected with insanity proper, whatever may be the form or
nature of the bodily disease accompanying the mental disorder.
III. All hospitals for the insane should be constructed, organized, and
managed, substantially in accordance with the propositions adopted by the
Association in 1851 and 1853, and still in force.”
| Including those of the United States of America and of the Provinces of the Dominion
of Canada.
2 Propositions offered by Dr. Kirkbride, and adopted at the meeting of the Association
of Superintendents held in Philadelphia, May 21, 1851 :—
(1) Every hospital for the insane should be in the country, not within less than two miles
of a large town, and easily accessible at all seasons.
(2) No hospital for the insane, however limited its capacity, should have less than fifty
acres of land devoted to gardens and pleasure grounds for its patients. At least one hun-
dred acres should be possessed by every State hospital, or other institution for 200 patients,
to which number these propositions apply unless otherwise mentioned.
(3) Means should be provided to raise ten thousand gallons of water, daily, to reservoirs
that will supply the highest parts of the building.
(4) No hospital for the insane should be built without the plan having been first sub-
mitted to some physician or physicians who have had charge of a similar establishment, or
who are practically acquainted with all the details of their arrangements, and having re-
ceived his or their full approbation.
(5) The highest number that can with propriety be treated in one building is 250, while
200 is a preſerable maximum.
PROVISION FOR SUBJECTS OF CHRONIC INSA NITY. 1129
IV. The facilities of classification or ward separation possessed by each in-
stitution, should equal the requirements of the different conditions of the
(6) All such buildings should be constructed of stone or brick, should have slate or
metallic roofs, and, as far as possible, should be made secure from accidents by fire.
(7) Every hospital having provision for 200 or more patients, should have in it at least
eight distinct wards for each sex, making sixteen classes in the entire establishment.
(8) Each ward should have in it a parlor, a corridor, single lodging rooms for patients,
an associated dormitory communicating with a chamber for two attendants, a clothes-room,
a bath-room, a water-closet, a dining-room, a dumb-waiter, and a speaking-tube leading to
the kitchen or other central part of the building.
(9) No apartments should be provided for the confinement of patients, or as their lodging-
rooms, that are not entirely above ground.
(10) No class of rooms should ever be constructed without some kind of window in each,
communicating directly with the external atmosphere.
(11) No chamber for the use of a single patient should ever be less than eight by ten
feet, nor should the ceiling of any story occupied by patients be less than twelve feet in
height.
(12) The floors of patients' apartments should always be of wood.
(13) The stairways should always be of iron, stone, or other indestructible material,
ample in size and number, and easy of ascent, to afford convenient egress in case of acci-
dent from fire.
(14) A large hospital should consist of a main central building, with wings.
(15) The main central building should contain the offices, receiving rooms for company,
and apartments, entirely private, for the superintending physician and his family, in case
that officer reside in the hospital building.
(16) The wings should be so arranged that if rooms be placed on both sides of a corridor,
the corridor should be furnished at both ends with movable, glazed sashes, for the free
admission of both light and air.
(17) The lighting should be by gas, on account of its convenience, cleanliness, Safety,
and economy.
(18) The apartments for washing clothing, etc., should be detached from the hospital
building. &
(19) "the drainage should be under ground, and all the inlets to the sewers should be
properly secured, to prevent offensive emanations.
(20) All hospitals should be warmed by passing an abundance of pure, fresh air, from
the external atmosphere, over pipes or plates containing steam under low pressure, or hot
water, the temperature of which at the boiler does not exceed 212 degrees Fahr., and which
are placed in the basement or cellar of the building to be heated.
(21) A complete system of forced ventilation, in connection with the heating, is indis-
pensable to give purity to the air of a hospital for the insane, and no expense that is re-
quired to effect this object thoroughly, can be deemed either misplaced or injudicious.
(22) The boilers for generating steam for warming the building, should be in a detached
structure, connected with which may be the engine for pumping water and for driving the
washing apparatus and other machinery.
(23) All water-closets should, as far as possible, be made of indestructible materials, be
simple in their arrangement, and have a strong downward ventilation connected with them.
(24) The floors of bath-rooms, water-closets, and basement-stories, should, as far as possi-
ble, be made of materials that will not absorb moisture.
(25) The wards for the most excited class should be constructed with rooms on but one
side of a corridor not less than ten feet wide, and the external windows should be large,
and should afford pleasant views.
(26) Wherever practicable, the pleasure grounds of a hospital for the insane should be
surrounded by a substantial wall, so placed as not to be unpleasantly visible from the
building.
The following propositions, also offered by Dr. Kirkbride, were adopted at a meeting of
the superintendents held in Baltimore, May 10, 1853:—
(1) The general controlling power of a Hospital for the Insane should be vested in a
board of trustees or managers: if of a State institution, selected in such manner as will be
likely most effectually to protect it from all influences connected with political measures or
olitical changes; if of a private corporation, by those properly authorized to vote.
(2) The board of trustees should not exceed twelve in number, and should be composed
of individuals possessing the public confidence; distinguished for liberality, intelligence,
and active benevolence; above all political influence; and able and willing faithfully to
attend to the duties of their station. Their tenure of office should be so arranged, where
1130 NICHOLS,
several classes received by such institution, whether these different conditions
be mental or physical in their character.
V. The enlargement of a city, county, or State institution for the insane,
which, in the extent and character of the district in which it is situated, is
conveniently accessible to all the people of such district, may be properly
carried, as required, to the extent of accommodating 600 patients, embracing
the usual proportions of curable and incurable insane in a particular com-
munity.
No one of these propositions has since been either repealed or modi-
fied, and the experience of the ten years which have elapsed since they
changes are deemed desirable, that the terms of not more than one-third of the whole
number shall expire in any one year.
(3) The board of trustees should appoint the physician, and, on his nomination, and not
otherwise, the assistant physician, steward, and matron. It should, as a board or by com-
mittee, visit and examine every part of the institution, at frequent, stated intervals, not
less than semi-monthly, and at such other times as it may deem expedient, and should
exercise so careful a supervision over the expenditures and general operations of the hos-
pital, as to give to the community a proper degree of confidence in the correctness of its
management.
(4) The physician should be the superintendent and chief executive officer of the estab-
lishment. Besides being a well-educated physician, he should possess the mental, physical,
and social qualities to fit him for the post. He should serve during good behavior, and
should reside on, or very near, the premises, and his compensation should be so liberal as
to enable him to devote his whole time and energies to the welfare of the hospital. He
should nominate to the board suitable persons to act as assistant physician, steward, and
matron; he should have the entire control of the medical, moral, and dietetic treatment of the
patients, and the unrestricted power of appointment and discharge of all persons engaged
in their care; and should exercise a general Supervision and direction of every department
of the institution. -
(5) The assistant physician or physicians, where more than one are required, should be
graduates of medicine, of such character and qualifications as to be able to represent and
to perform the ordinary duties of the physician during his absence.
(6) The steward, under the direction of the superintending physician and by his order,
should make all purchases for the institution ; keep the accounts; make engagements with,
pay, and discharge those employed about the establishment; have a supervision of the
farm, garden, and grounds; and perform such other duties as may be assigned him.
(7) The matron, under the direction of the superintendent, should have a general super-
vision of the domestic arrangements of the house, and, under the same direction, do what
she can to promote the comfort and restoration of the patients.
(8) In institutions containing more than 200 patients, a second assistant physician and
an apothecary should be employed, to the latter of whom, other duties, in the male wards,
may be conveniently assigned.
(9) If a chaplain be deemed desirable as a permanent officer, he should be selected by
the superintendent, and, like all others engaged in the care of the patients, should be
entirely under his direction.
(10). In every hospital for the insane, there should be one supervisor for each sex, exer-
cising a general oversight of all the attendants and patients, and forming a medium of
communication between them and the officers.
(11) In no institution should the number of persons in immediate attendance on the
patients be in a lower ratio than one attendant for every ten patients; and a much larger
proportion of attendants will commonly be desirable.
(i2). The fullest authority should be given to the superintendent to take every precau-
tion that can guard against fire or accident within an institution, and to secure this an effi-
cient might-watch should always be provided.
(13) The situation and circumstances of different institutions may require a considerable
number of persons to be employed in various other positions; but in every hospital, at least
all those that have been referred to, are deemed not only desirable but absolutely necessary,
to give all the advantages that may be hoped for from a liberal and enlightened treatment
of the insane.
(14) All persons employed in the care of the insane should be active, vigilant, cheerful,
and in good health. They should be of a kind and benevolent disposition, should be edu-
cated, and in all respects trustworthy, and their compensation should be sufficiently liberal
to secure the services of individuals of this description.
PROVISION FOR SUBJECTS OF C H R O NIC INS ANITY. 1131
were adopted, has fully established their soundness and practicability
(except, possibly, in respect to the last, which fixes an arbitrary maximum
number of patients that may be accommodated in one institution), not
less than ten States and one Province, if not more, having proceeded to
provide for their insane upon the principles which they enunciate, and to
embody them in their statutes. As I have intimated, the best provision
for the subjects of chronic insanity should be embraced in a comprehen-
sive plan of providing for the insane of all classes. The above proposi-
tions were intended to embrace such a plan, and, as I was their author, it
will suit my convenience in the treatment of this question to attempt to
reproduce the considerations that led to the views which they express:
and perhaps this mode of presenting the matter will be more satisfactory
to the Section, and more useful to the public, than any other. I propose
to consider the propositions Seriatim, and to lay particular stress upon the
bearing of each upon the care of the subjects of chronic insanity.
The first proposition declares that “the large States should be divided
into geographical districts of such size that a hospital situated at or near
the centre of each district, may be practically accessible to all the people
living within its boundaries, and available for their benefit in case of
mental disorder.” The obvious purpose of this is to affirm that institu-
tions for the insane must be within the reach of the people whom they
are intended to accommodate, in order that their insane may be sent to
them ; and it was framed in view of the fact that many hundreds of per-
sons suffering from acute insanity had not received the hospital treatment
that had been provided for them, and had consequently run into the
hopeless stages of the disease, because of the long, fatiguing, and expen-
sive journeys necessary to reach either the nearest hospitals, or those to
which they were entitled to go. It is obvious that the principles of this
proposition lie at the very foundation of an adequate provision for the
insane, whether the form of their disease be recent or chronic. In an
article on “The Use of Insane Hospitals,” in the number of the Journal
of Insanity for January, 1866, by Dr. Edward Jarvis, will be found a table
which shows that, in the course of a series of years, twenty-two institu-
tions in the United States and the Dominion of Canada received annually
an average of one patient to 3974 of the population of the districts in
which they were situated, and that the ratio of patients to population
constantly and rapidly diminished in every case as the distances from the
institutions increased, until an average of only one patient in 18,978 of
the population of the fourth tier or belt of counties from the hospital cen-
tres, was sent to them. It is not reasonable to suppose that institutions
for the insane breed insanity in the populations immediately surrounding
them, nor that insanity is of more frequent occurrence in their near
neighborhood than in more remote districts, and hence the only reason-
able conclusion is that the remote districts were, solely on account of
their remoteness, to a great extent deprived of the use of hospitals. This
less use of hospitals by distant districts, is doubtless in some part due to
the less acquaintance with their management and benefits than is acquired
by people situated nearer to them, but in greater part to the disinclina-
tion of public authorities, and the inability of friends, to incur the ex-
penses of transporting patients long distances with the necessary escorts,
and to the apprehended danger to the lives of delicate persons from the
exposures and fatigues of a protracted journey.
It follows, as Dr. Jarvis says, that hospitals are somewhat local in their
operation, and that, in order that their benefits may be enjoyed in case
1132 NICHOLS,
of need, they must be, in the language of the proposition, practically
accessible to all the people residing within the boundaries of the district
which each is intended to accommodate. A necessity so vital to the
welfare of the people, becomes the bounden duty of the State. No rule
limiting hospital districts to an exact and uniform area can be laid down.
Indeed, it would not be possible to divide the States and Provinces in such
a way that a central institution should not be more or less difficult of
access from one or more remote corners of the district which it was
intended to accommodate, but intelligent legislators will in most cases be
able to approximately meet the requirements of the proposition, if they
are imbued with a sense of its vital importance to the needs of an afflicted
class of their constituents. In districting States and Provinces having
large areas of unsettled, or partially settled, territory, reference should be
had to the probable direction and extent of the growth of their popula-
tions, lest a sufficient number of institutions for the whole area of the
State or Province should be so placed in the original centres of population
as not to accommodate the subsequent settlements. Indisputable facts
show that the remote inhabitants of a district must be able to reach its
hospital by a journey that can be made during the waking hours of a
single day, or they will not avail themselves of its benefits. Such a
generalization will aid in the practical solution of this problem, for it will
readily be seen that insane persons can be conveyed to a hospital by rail-
road from a distance of seventy-five or a hundred miles with more con-
venience and less expense than they can be conveyed half that distance
by ordinary carriage-roads, and that the number and directions of the
railroads and the character of the carriage-roads of a proposed district,
should have much influence in determining its size and shape, and the
situation of its hospital. The practicability of the early treatment of
acute insanity will increase the number of recoveries, and proportionately
diminish the number of cases of chronic insanity to be provided for.
This brief discussion of this first and fundamental element of all ade-
quate public provision for the insane, is, therefore, pertinent to the par-
ticular question under consideration.
I now come to the second proposition of the series. It is that all
State, county, and city hospitals for the insane, should receive all persons
that belong to the vicinage designed to be accommodated by each hospi-
tal, who are affected with insanity proper, whatever be the form or nature
of the bodily disease accompanying the mental disorder. Except in
some of the New England States, the ordinary poor of the United States
are generally maintained in county alms-houses, and, in harmony with
that practice, and mainly from mistaken motives of economy, most county
authorities are disposed to provide for their insane poor as well as for
their other dependent classes. The populous and wealthy counties, whose
insane are numbered by hundreds, and are sufficient to fill one or more
institutions of suitable size, may properly establish and maintain hospi-
tals of their own, and thus save the cost of transportation, and secure the
benefits of local employment and trade, and of easy access. It may with
reason be maintained that as State legislators and officials are from their
position, if not from their personal character, likely to entertain broader
and more liberal views of their duty to the sick and unfortunate, and to
be less under the influence of petty local strifes and parsimonies, than the
officials of the subordinate municipalities, the States and Provinces should
take direct charge of this class of their dependents, so peculiar in its
wants and in its liability to suffer from neglect or abuse. There are
PRO VISION FOR SUBJECTS OF C H R O NIC INS ANITY. 1133
several county and city institutions the material appointments and man-
agement of which are equal to those of the average State and Provincial
asylums, and it is due to truth and professional character to declare, in
this public manner, that the unsatisfactory condition of others is attribu-
table to defective means and organization, and not to the very respect-
able medical gentlemen who now have, or have had, charge of them.
Without exception, these gentlemen appear to have discharged their
duties with humanity and ability, and with very remarkable industry
and perseverance in view of the difficulties and discouragements that have
attended their work. City institutions for the insane are subject to the
same objections as those of the county, and to the additional objection
that a city will seldom, if ever, be able to afford within its limits the area
of ground necessary for salubrity, privacy, and cultivation; and rather
than that a city should go outside of its territory to establish and main-
tain an institution for its own exclusive benefit, it would be more feasi-
ble for the common authority over the city and neighboring municipali-
ties to take charge of this sacred function of government, and administer
it for their equal benefit.
To effectively prevent the peculiar abuses that are liable to creep into
institutions for the insane governed by local authorities, State and Pro-
vincial statutes, with heavy penalties for their violation, should require
them to be constructed, organized, and conducted, substantially as the
State and Provincial hospitals or asylums are usually appointed and
maintained ; and should especially require them to receive, whenever
the friends may desire it, the insane of the favored classes in respect to
property, either as pay patients, or as free patients, supported, like all
others, from the common fund of the municipality. One of these courses
is pursued by all the State institutions, and there is no one feature of
their organization that is as effective as this in preventing their manage-
ment from falling below a liberal, curative standard. The poor will
generally be well taken care of when they receive such treatment as the
middle classes in respect to fortune are willing to pay for, or are satis-
fied with without payment, except indirectly as taxpayers. The rich
will generally be sent to the corporate or private institutions, all the in-
mates of which are independent, and can more conveniently receive in
them such indulgences as their habits and tastes require, and their means
allow, than they can in large institutions, most or all of the inmates of
which are a public charge. The second proposition, in theory at least,
solves the question before the Section. The reception and care by every
public hospital for the insane of all persons belonging to the vicinage—
that is, within the hospital district—who are affected with insanity pro-
per, includes, of course, the reception of those whose insanity is chronic,
and this is believed to be the best of all the provisions for their care
which have been, or are, or possibly can be made, or which have been
suggested or advocated.
The movement of the insane, under this scheme, will be simply as fol-
lows: The recently insane are promptly placed in district hospitals, and
there receive the treatment most conducive to their comfort and re-
covery. About one-half of them recover, and return to their homes and
employments, or die, in the course of the year that follows their admis-
sion; the other half remain where they are without additional expense
for transportation, and continue to receive care and treatment adapted to
the condition of each case. Those who still give promise of improve-
ment, are treated with that end in view, and occasionally reward perse-
1134 NICHOLS,
vering efforts in their behalf by entire recovery of reason; those who
continue to be actively maniacal, or melancholic, or who exhibit suicidal,
homicidal, or other specially dangerous propensities, and the paroxysmal
cases, whether simple or epileptic, receive the care that secures to each
:ase the highest degree of comfort and safety of which it is susceptible,
and that is as necessary now as in the acute stage of the disease. A few,
perhaps ten per cent., of the annual additions to the chronic members
of the hospital family, pass early into the mechanical, but not always
unhappy, life of passive dements, whose bodily habits are regulated,
and whose comforts are ministered to, by the order and appliances
of the institution, while they engage, with more or less interest in
its character and results, in such labor as they are capable of, in the
wards, kitchens, laundry, and stables, and in the gardens and fields,
when the sun is not too hot for their weak brains, nor the air too cold
for their feeble circulations. The subjects of chronic insanity render
considerable assistance in the wards occupied in part by the recent cases,
and somewhat reduce the number of attendants that need to be em-
ployed; while the labor of the insane is mostly performed by the chronic
patients, the recovery of those who have been recently affected is Occa-
sionally much promoted by industrial exercise, and they will here and
there fall into a party of regular workers with more facility than they
will work either by themselves, or in company with others whose cases
are entirely of their own class. The habitual employment of a large
number of patients is calculated to suggest and justify a variety of occu-
pations, among which the recently affected may find those adapted to
their respective capacities. The insane may be much benefited by labor,
and may also be greatly injured by it: compulsory labor would cause
the rapid and cruel sacrifice of many of the insane, both of the acute
and chronic classes. The condition of the brain and the probable effects
of labor upon it, should be carefully considered before each patient is
put to work, and the effects of his work as carefully watched. The
medical judgment that prescribes and regulates the labor of the insane,
should be as able and critical as that which prescribes the drugs that are
administered to them ; and a medical staff accustomed to consider the
conditions under which a large number of subjects of both recent and
chronic insanity may labor without detriment, if not with advantage,
will become more acute and just in its discriminations, and less liable
to fall into injurious errors, than a staff of less experience in this par-
ticular. The extreme vicissitudes of the American climate, with its
fierce summer-heats and depressing winter-colds, seem to admit of less
labor by the insane in the open air than the more equable climate of
Europe. If the disease be more active here than there, as many repre-
sent, our insane cannot advantageously work as much, either in-doors or
out, as theirs, and yet, if such a sense of the importance of labor as a
sanitary measure in treating the insane, especially of the working classes,
prevailed here as appears to prevail abroad, the systematic employment of
our patients would probably become a constant feature in the adminis-
tration of our hospitals, with an improvement in the health, content-
ment, quietude, cheerfulness, and happiness of their inmates.
The scheme of providing for the insane of all classes in institutions
situated at or near the centres of limited districts, renders it practicable
for the kindred of the chronic patients to visit them occasionally, and,
in addition to the immediate happiness which such visits confer, opens
the way to the return of a portion of the subjects of passive, settled de-
PROVISION FOR SUBJECTS OF C H R O NIC INS ANITY. 1135
mentia to the care and support of their families. The practice of fur-
loughing patients, which obtains among the English asylums, has been
resorted to, to a limited extent, in this country and the Provinces. If
it should here become an approved measure, either of treatment or of
relief of over-crowded institutions, it will be practicable and frequently
resorted to only under the district system. A patient’s return on furlough
to his home, one or two hundred miles from the hospital, must in prac-
tice prove equivalent to a final discharge, both from the custody and from
the oversight of the institution. The subjects of chronic insanity, to
whom the habits of the hospital have become a second nature, are effi-
cient aids in maintaining its discipline. Most of the recent patients,
admitted one by one, unconsciously imitate the companions with whom
they are thrown, and readily fall into the order of the hospital, without
friction, and 'without special instruction or exercise of authority which
many would excitedly, if not violently, repel.
In America, the insane of every degree of culture and refinement, and
of ignorance and rudeness, as well as of every nationality, are received
into all our institutions. The character of the institution into which a
patient is sent, is mainly determined by his means, or those of his near
friends who may aid him in his extremity. Each class has its conditions
of happiness: The first for every class, is society after its kind ; after
that, the cultivated demand articles of taste and delicacy, which are an
inconvenience to the ignorant; the ignorant demand the substantial con-
ditions of physical comfort and health, which, by themselves, are bare,
deficient, and depressing to the refined. After insanity has been under
treatment for a year, those cases that are complicated with paralysis and
other indubitable evidences of organic cerebral disease, may be classed
with the cases of four or more years’ duration, while cases which exhibit
no evidences of organic disease may still be classed among the hopeful,
and should be treated as such ; but beyond the rule, which should be
inflexibly adhered to, that the violent and turbulent should be entirely
separated from the quiet and Orderly, all rules of classification in Ame-
rican institutions are, and should be, regarded as generalizations which
afford much aid in a proper distribution of the inmates of each establish-
ment, but from which there must be constant departures in every effort
to secure the highest comfort and the utmost alleviation of which indi-
vidual cases are susceptible. As a general rule, epileptics should be
placed in one or more wards by themselves, but it would be an unneces-
sary cruelty to subject a person of refined sensibilities, whose paroxysms
are light and infrequent, to the constant observation of the painful scenes
of an epileptic ward ; such a patient may often be an agreeable and use-
ful associate of the convalescents. On the other hand, culture is some-
times brutalized by dissipation and disease, and, though not physically
violent, the possessor of early social and educational advantages is some-
times a most unfit associate for real gentlemen and ladies. It must be
obvious, and this is the lesson of experience, that such a critical classifi-
cation can be carried into more satisfactory details in the treatment of
the collected insane of a community, than in the exclusive treatment of
either class, or of a single division.
In estimating the necessary conditions of the best provision for the
subjects of chronic insanity, it should be borne in mind that this is pre-
cisely the same disease in its nature and phenomena as recent insanity :
they differ only in duration, in the proportion of cases of passive
dementia, and in the prospect of restoration. It follows that the active
1136 NICHOLS,
forms of chronic, mental disease require precisely the same treatment as
the recent. The protection of society and of the individual, and the
mitigation of the pains and privations of disease, are as much demanded
in the case of the chronic maniac, whether his mania be constant, recur-
rent, periodical, or epileptic, as in that of the recent; and it stands to
reason that a medical staff, constantly accustomed to treat recent insanity
with the expectation of curing it, is likely to be better prepared, both by
knowledge and habit, to treat chronic disease for its alleviation, than
one whose professional efforts in the exclusive treatment of chronic dis-
ease are very rarely rewarded by a full restoration.
The theoretical grounds of the rule that all public institutions should
receive the subjects of both recent and chronic insanity, are sustained by
the crucial test of experience. Nearly every institution for the insane in
Christendom is to-day occupied by cases of every variety, duration, and
manifestation; from the last admitted, in which the outbreak occurred
but a short time ago, to the most hopeless case of fatuity. The exceptions
are a very few—not, I think, as many as half a dozen altogether—which
are occupied exclusively by chronic and presumptively incurable inmates;
I know of none which receives only recent cases and discharges them as
soon as they become chronic. The presence of recent and chronic cases in
all institutions is, of course, due in part to the retention of cases which were
admitted when recent, and which have passed to the chronic state; but
it is by no means wholly due to a circumstance so natural and purpose-
less. Not only was the subject of the care and treatment of the victims
of chronic insanity fully discussed, both in Great Britain and on the
continent of Europe, long before the question became an urgent one in
this country, but, after trying various experiments in separating, to a
greater or less degree and in various ways, the acute from the chronie
cases, the Europeans have all, I understand, come back to what in Eng-
land is called the public-asylum, and here the State-asylum, or hospital,
system. In fact, if the public institutions for the insane in the United
States and the Provinces of the Dominion were to be distinguished by
the character of their inmates in the respect under consideration, they
should be styled asylums for the subjects of chronic or incurable insanity,
and if the recent and chronic cases were to be separated, the most numer-
ous class (the chronic) would naturally take the present institutions,
which are much too large for the recent, and the pertinent and pressing
question of the day would then be the best provision for the recent or acutely
insane. Estimates kindly furnished me by 27 superintendents of the
United States, show that, on an average, 12% per cent. of the cases of
insanity in 22 States are of less than one year's duration, and the
remainder chronic. Five of their superintendents estimate the average
ratio of recent to chronic cases of insanity in the Provinces of Canada
to be 7.1% per cent. As only five of the States make full provision for all
their insane, in institutions having a resident medical head, it may be
that the ratio of recent to chronic cases, under treatment in them, is a
little greater than in the whole insane population of those States; but I
am more inclined to think that the estimates of recent cases are too high,
and will not be borne out by the results of treatment. The proposition
is not only sustained by the practice of the institutions of both the old
and new worlds, but by the authority of the ablest and most experienced
men in the specialty; among readers of the English language the names
of Dr. Buckmill and Dr. Robertson, of England, and Dr. Earle, of this
country, are best known in this connection.
P R O W, ISI O N F O R S U B.J E CTS OF C H R O NIC IN S A NIT Y. 1137
Perhaps a full consideration of the plan of providing for the subjects
of chronic insanity, now as fully set forth as the time allowed me will
permit, should embrace answers to the objections that have been, or may
be, made to it. It has been said that the retention of chronic cases in
the hospitals in which they have been placed, brings no direct relief to
the wretched lunatics in the county alms-house receptacles. It does not,
except by arresting all additions to their number, which would certainly
be a great and happy achievement; but the objection is answered by a
simple declaration of the obvious truth, that it is less expensive and in
every way more feasible to provide for the alms-house insane in district in-
stitutions than in any other proper way. It will cost less for the necessary
enlargement of buildings and their appointments, and for transportation.
If a sufficient number of district institutions already exist, they can be
enlarged both so as to retain all the patients whom they do not cure,
until they die, if their condition require it, and to receive the alms-house
patients at less expense than would be incurred by providing for them
either independent central, or district, asylums of a proper kind ; and if
there are not enough district institutions to make them practically acces-
sible to all acute cases, they certainly should, for reasons that have been
given, be provided as rapidly as possible with accommodations for all the
chronic cases of the vicinage.
It has been said that the States (I do not recollect that it has been said
of the Canadian Provinces) will not incur the outlay necessary to pro-
vide institutions with such appointments and management as are deemed
necessary for recent cases; but this declaration is shown to be unfounded
by the activity and liberality which are displayed at this moment by the
greater number of the leading States, in establishing excellent district
institutions for all their insane, of both the acute and chronic classes.
Five States have provided for every case within their borders not pre-
ferably provided for by friends, and others will soon have discharged the
same duty. An editorial table in a recent number of the American
Journal of Insanity shows that the total present and prospective capa-
city of the institutions for the insane in the United States is for 35,325
inmates, at a cost, according to a table prepared by Dr. Conrad, of the
Maryland IIospital, of at least $35,000,000, with an annual expenditure,
at this time, for maintenance, of $5,000,000. This has mainly been
accomplished in the last half of that century of our national existence
which has just terminated, scarcely as many as the Odd 325 of the num-
ber now under treatment having been provided for fifty years ago. I ain
sorry to be compelled to acknowledge that there is not yet sufficient hos-
pital provision for the insane in the United States, and that in a few
instances that which exists is seriously defective in material appointment
and organization; but I cheerfully submit the work of the first century
of the Republic in the personal care and legal protection of the insane,
to the judgment of our impartial psychological brethren abroad, with
much confidence that it will be deemed to be indicative of a high degree
... of enlightenment and liberality on the part of the American people who
have sustained it with their means; of true science and humanity on
the part of American psychologists; and of genuine Christian benevo-
lence on the part of the noble men and the philanthropic woman,' who
have executed it with the best efforts of their heads and hearts.
As the third, fourth, and fifth propositions relate to the means and
| Miss D. L. Dix.
1138 NIC HO LS,
modes which render the approved and prevailing plan of providing for
the subjects of chronic insanity practicable and successful, I shall briefly
consider them together. The propositions of 1851 and 1853, referred to
in the series of 1866, and quoted in the foot-note to page 1128, express
in considerable detail the essential conditions, both material and admin-
istrative, of the successful treatment of the insane, and, being of acknowl-
edged authority, have prevented many costly errors of ignorance in
establishing the institutions of the country, and have efficiently promoted
the general uniformity and excellence of their management. With the
experience of the quarter of a century during which those propositions,
40 in number, have been in force, they are, with slight modifications,
considered as judicious and binding as when they were put forth, except
that a change of circumstances has rendered it necessary to depart from
two or three of the rules which use arbitrary numbers in expressing
their requirements. The increased numbers of the insane to be provided
for, and the larger ratio of the chronic to the curable inmates of our in-
stitutions at the present time, as compared with that of twenty-five years
ago, have rendered it necessary and admissible to treat a much larger
number of patients in one institution than was then considered proper.
Like many institutions of government, education, and business, those for
providing for the insane have grown upon our hands until they have
become much larger than was anticipated when those propositions were
framed and adopted. Other things being equal, the evidence of experi-
ence and authority shows that hospitals having 500 patients are managed
as advantageously to their inmates, and quite as economically, as those
having half that number; and there is nothing in experience, nor, to my
mind, in theory to show that hospitals containing a still larger number
of inmates, “ embracing,” in the language of the fifth proposition of the
series of 1866, “the usual proportions of curable and incurable insane
in a particular community” are not equally well managed. Of course it
is necessary, and, I believe, conducive to the welfare of patients and the
advancement of the specialty, that the ratio of staff-physicians should
not only be proportionate to the number and character of the patients,
but that the physicians should be charged with more authority and
responsibility than they usually possessed twenty-five or more years ago.
That they should be men of ability, liberal education, and sound princi-
ples, no one will deny. It does not appear to me that the number of
assistant physicians required in large institutions for the insane can be
determined by a rule of universal applicability, but I think that a pro-
portion of one to one hundred cases of active disease, whether acute or
chronic, and one to two hundred chronic cases that are ordinarily quiet
and orderly, will, on the one hand, afford no opportunity for the rust
and vices of idleness, and will, on the other, be sufficient for the per-
formance of every useful professional office in the medical and moral
treatment of the patients, with time for the relaxation necessary to the
maintenance of cheerful health, and for professional and general im-
provement. .**
The prevalent overcrowding of institutions for the insane, is highly pre-
judicial to the welfare of their inmates. Not only should this be avoided by
the provision of ample room for the number of cases under treatment, but
the facilities of classification or ward separation possessed by institutions
which receive all the insane of a community, should considerably exceed
those ordinarily provided, in order that, in addition to the usual classi-
fication, based mainly on conduct and the activity of disease, there should
PROVISION FOR SUBJECTS OF CHRONIC INS ANITY. 1139
be sub-classes of epileptics, of dipsomaniacs, of regularly working patients,
and of patients who are too demented, or who, though able, are too indo-
lent, to work—each of these classes requiring some special provision and
treatment.
In enlarging district institutions, in addition to extending the original
structure as far as it will admit, I think that one or more detached build-
ings or wards may be desirable in effecting all useful purposes of subdi-
vision. I certainly see no objection to them for the use of the quiet
classes of agricultural patients, if not placed too far from the main struc-
ture, if the topography of the grounds favor the erection of such wards,
and if it be thought otherwise desirable; but I should always consider
it an indispensable condition of good management, that the assistant
physician having immediate charge of the inmates of a block or group
of blocks, should have such a residence that he could not only conveni-
ently see his patients often, but that he could be readily consulted at all
hours of the day and night. In some cases, the fitness of accommodations
might be most economically and conveniently secured by the erection of
new and improved buildings on the same grounds with old and imperfect
ones, and the devotion of the former to the recent cases and their suitable
associates among the chronic, and of the latter to the most hopeless
cases or to those belonging to the collateral classification which I have
recommended. -
When a district institution contains as many as 600 patients of both
sexes, and the number is likely to considerably increase, a second com-
plete set of hospital buildings should be provided in the same neighbor-
hood, and, if practicable, on continuous grounds, and the sexes separated
by retaining one in the old buildings and placing the other in the new.
The buildings for each sex should be separately inclosed, and not much
less than half a mile distant from each other, unless a hill or wood should
present a natural barrier to the view and hearing of one from the other.
The two sets of buildings being in the same neighborhood, patients of
both sexes can at the same time be accompanied to and from them by
the same friends or officers, and the same relatives can visit patients of
both sexes by one journey, which will not unfrequently be both a conve-
nience and a saving of expense. The employment of each sex will con-
veniently and economically supplement that of the other. The men will
raise vegetables, milk, etc., for both establishments, and the women may
do the washing, mending, etc., for the men as well as for themselves.
The separate care of each sex will render admissible many relaxations of
the restraints to personal liberty that prudence requires when both sexes
occupy connecting wings of the same continuous structure. After the
separation, the superintendent may remain in charge of both establish-
ments, with an adjunct in immediate charge of each, or there may be an
independent superintendent of each, under the same board of manage-
ment, as circumstances may render most expedient. e
All public buildings, particularly those belonging to a government of
the power and dignity of a State or Province, should present just claims
to architectural fitness and taste. Edifices occupied by the insane should
be at least neat and cheerful in their appearance; and their construction
of durable materials in the most enduring manner will prove most econo-
mical in the end. Cost should be held subordinate to every essential sani-
tary provision, as drainage, ventilation, the supply of light, heat, and
water, and abundant room and means of classification; and just in propor-
tion as such provisions are subordinated to necessary cost in the construc-
1140 NIC HOLS,
tion and fitting up of buildings for the insane, do these become custodial
receptacles which deny to their inmates the benefits of hospital treatment.
There is, however, some incongruity in providing highly ornamental and
costly structures mainly for the treatment of the insane poor, most of whom
have little or no aesthetic eahacity to appreciate and be benefited by the
outlay ; and it may be feared that the taste and ambition of legislatures
that at one period authorizes the high embellishment of hospital struc-
tures at considerable cost, will at another be accused of extravagance, and
that, in the strifes of political parties, such expenditures will be made the
pretext, if not the reason, for withholding appropriations for the most
necessary purposes. Happily, the first cost of the essential provisions for
the most humane and beneficial treatment of the insane of the dependent
classes, has now been determined by a wide and varied experience, and is
found to be much less than has been sometimes expended for the purpose,
and not to exceed the means of any State. What the States and Provinces
have already accomplished in this direction, and most of it in the short
period of less than fifty years, while they have been at the same time
not only providing their capitols, court-houses, penitentiaries, and other
buildings that directly appertain to the necessary functions of govern-
ment, and also making considerable outlays for institutions for the blind,
for the deaf and dumb, and for feeble-minded youth, affords as positive
a guaranty as anything that lies in the future can, that at no distant day
all of them will adequately care for all their insane poor, as well as no
little excuse for what appears to impatient benevolence and sometimes
unpractical science, to be inexcusable tardiness in the discharge of their
imperative duty.
DISCUSSION ON DR. NICHOLS’s PAPER.
After the reading of the preceding paper, Dr. Is AAC RAY, of Philadelphia,
said:—The increase of insanity among us has led to much inquiry as to the
best means of caring for its subjects, who are mostly of the indigent class, with
the greatest degree of economy compatible with a proper regard to their com-
fort and cure. One of the conclusions arrived at by many intelligent men,
some of them superintendents of our hospitals for the insane, is that the larger
our hospitals, the more cheaply they may be built and maintained. This con-
clusion I have always regarded as unsound, and the more the experiment has
been tried, the more it has confirmed me in this opinion. True, an institution
for 200 patients would, undoubtedly, cost less, proportionately, than one for 40
or 50 patients, other things being equal. But the rule is not absolute. There
comes a point where the economical result is reversed, so that the larger the
hospital, the more expensive it will prove. Indeed, it would be hard to show
how increase in size can be followed by decrease in expense. A well organized
hospital-staff should consist of a Superintendent, two assistant physicians, a
steward, matron, and a force of attendants equal to one to every five or ten
patients. A farmer, and more or fewer assistants, will be needed for outside
work. Not less than this is required in a hospital of 300 patients. Conse-
quently, a hospital for 600 must require double the number of assistant-phy-
sicians, and double the number of attendants, and of indoor and outdoor ser-
wants. The matron and steward will each require a helper. Where or how the
cost of maintenance is diminished, is not very obvious. True, the cost of one
superintendent is supposed to be saved, but, unquestionably, the larger the estab-
lishment the larger would be the salary of the superintendent, and as more
care and responsibility would be thrown on the assistants, their compensation
would naturally be increased. So that little, if anything, could be saved in
PROVISION FOR SUBJECTS OF CHR os IC INSANITY. 1141
that direction. Besides, I believe, it is generally understood among those who
have had some experience in the financial history of institutions requiring the
expenditure of more or less money, that the practice of economy is much
affected by the amount of money disbursed. The smaller it is, the more fru-
gally it is spent. In the daily handling of large sums, there comes, as a
result of such familiarity, a sort of contempt for small sums not likely to pro-
duce the strictest economy. This is human nature, and implies no lack of
honesty or Sagacity. ' Though not very familiar with the reports of our hos-
pitals, of late years, yet I have the impression that our largest hospitals show
no decided advantage over the smaller, in the cost of maintenance. Any little
difference in their favor may be, very likely, the result of other causes. Ac-
cording to the report of the Willard Hospital, for the year 1874, the average
cost was $3.17 per week, if I recollect rightly, which is little less than it is in
Some of our smaller State hospitals. And yet it is supposed that in the former
the patients are all of the kind that can be properly maintained at the least
expense. And this figure is likely to be increased in future years, by the
repairs and renewals, always a formidable item in the expenditures, and none
the less, certainly, where the buildings are cheaply constructed, and all the
appointments of a makeshift kind. -
Nor do I see how the expense of construction can be diminished by the plan
much favored just now, of having the hospital consist of several buildings,
separate and independent, scattered over the premises, instead of a single
structure receiving all the patients under its roof. The idea that anything is
gained by this mode of construction is such an obvious fallacy that one hardly
knows how to meet it. It certainly has always been supposed that, in build-
ing, the less you have of wall and roof, the less will be the first cost ; and if
that be so, it is self-evident that 20 or 30 patients can be more cheaply pro-
vided for in a hall, in the usual way, than in a building designed only for them.
Nor does it need any special proof to show that the expense of warming and
ventilating several detached buildings must be far greater than would be needed
for a single one of equal capacity. The fact is obvious at sight. In short,
the clamor against “palatial” structures, to use the popular phrase, is little
better than claptrap, thoughtlessly used by people supremely ignorant of the
cost of building at the present day, as well as of the peculiar requirements of
a hospital for the insane. As the result of my own observation and experi-
ence, I am convinced that four hospitals for 300 patients each, can be both
built and maintained at a less cost than one for 1200 patients, equal provision
being made in both cases for the kind of care to which the insane, even in the
lowest grades of the disease, are entitled.
I doubt, however, whether it is possible to have, in these mammoth estab-
lishments, certain qualities of administration indispensable to their highest
purposes. The animating spirit, the close and thorough supervision, inspiring,
guiding, correcting every movement, and essential to our highest idea of hos-
pital management, will be but feebly manifested under such conditions. The
patient is but an atom in the great mass around him, losing the attributes of
humanity, Sane and insane, in the technical character of patient.
Contending as I now do, and as I always have done, against the establish-
ment of large hospitals, I cannot give an unqualified approval to Dr. Nichols's
paper. With this exception, however, I heartily concur in all his conclusions.
Dr. THOMAS S. KIRKBRIDE, of Philadelphia, said:—I am sure that we must
all appreciate the value and importance of the excellent paper which we have
just heard read. There is little in it with which I do not agree entirely. On
one point, however, I must confess that my views differ from those expressed
by my excellent friend, and that is, in regard to the best size for hospitals for
the insane. We all know that this is a point on which there has, of late years
at least, been a difference of opinion in the Association of Medical Super-
intendents. As it now stands, indeed, it is the only one of our many pro-
positions that has not received an unanimous, or very nearly unanimous,
1142 NICH O LS,
approval by the members. I still believe that the original proposition was
right. I believe that the size then recommended is really better than any
other, but I am also fully aware of all the arguments that can be brought to
justify much larger hospitals, especially those of expediency and even possi-
bility. It is fully shown by reliable statistics, as I believe, that the people of
the State will derive more benefit from several small hospitals in different
parts of the State, than from one large one at a central point; and I think that
it will also be found that the former can be provided with quite as small an
expenditure of money, and can be carried on at no greater cost per patient.
Dr. Nichols has recommended the plan, which has now been fully tested. and
which, even by the first decision of the Association, allows as many as 500
patients being collected in one vicinity ; and this is by having separate hospi-
tals for the sexes. This plan I feel that I have a right to say is no longer an
experiment. A trial of sixteen years under my own observation has shown
that, in every respect, it is a most valuable arrangement, having many advan-
tages and no disadvantages. It has also received unqualified approbation from
many other distinguished psychologists in addition to Dr. Nichols. I am
aware that it has been said that, while I argue in favor of hospitals for 250
patients, practically, I have been providing one to accommodate twice that
number. This, however, is a mistake. The Pennsylvania Hospital for the
Insane, at Philadelphia, is really made up of two entirely distinct hospitals,
one for each sex, and it has been so, as already said, for more than sixteen
years. Both hospitals have the same board of managers, and, for reasons not
necessary to detail here, have always had the same physician-in-chief and
superintendent. It is anticipated, however, that ultimately each will have its
own separate superintendent, and that the only connection between them will
be the board of managers.
Now, what we have done, is exactly what I would propose for any hospital.
First build your hospital for 250 patients. This will commonly be occupied
by both sexes. When this is filled, or nearly so, build another for a similar
number of patients. Separate the sexes; have distinct organizations—all on
the same tract of land, but with entirely separate pleasure-grounds. There
may be the same water-works, gas-works, bakery, machine-shop, and other
common arrangements, that will add to the economy of the institution. This
provides for 500 patients in one locality, and yet conforms to the original
proposition of the Association. I do not propose entering into any extended
discussion of the reasons why I believe that these smaller hospitals have a d-
vantages, but there is one that I cannot avoid referring to, and that is the per-
sonal intercourse which a superintendent is able to give to his patients, when
their number is not so great as to prevent his paying daily, or very nearly daily,
visits to each. I believe this to be one of the most important of all his duties,
and one which generally, if he is rightly constituted for his position, no one can
do for him. It is true that an assistant may be superior to his chief in this
respect, but this is not to be anticipated, and if it is so, the assistant ought to
have charge of a hospital himself. Two hundred and fifty patients, or about
that number, are as many as any superintendent can visit daily, with tolerable
satisfaction to himself and to them.
Now, I do not wish to be misunderstood in this matter. I still think, as the
Association at first thought, that this size of 250 is the very best, but I do not
mean to say that no other is admissible. I am well aware how much easier it
is to get an appropriation for the extension of a hospital, than for the building
of a new one. What I mean to say is this:—Build your hospitals, in different
parts of a State, of a capacity for 250 patients, and in sufficient numbers to
accommodate all your insane, if you can do so. If you cannot do this, and
yet can build single hospitals for 500, 700, or even 1000 patients at one point,
by all means do so. The hospitals you must have at all hazards. If you
cannot get what I regard as the best arrangement, come as near to it as you
can, let the size be what it may.
P R O VISION FOR SU B.J E CTS OF C H R O NIC INS ANITY. 1143
The President, Dr. JoHN P. GRAY, of Utica, said :—I should object to put-
ting buildings half a mile apart, if for no other reason, because such an
arrangement would render it difficult, if not impossible, for the superintendent
to consult constantly with his subordinate officers. I was chairman of the
commission which located the Willard Asylum. We found the point on the
lake the most desirable place for the main hospital building; the building now
called the “branch,” and more than half a mile away, was then erected; it was
the old State Agricultural College, and was subsequently remodelled to receive
patients. But there is a resident physician in the “branch,” as there are in
other separate buildings, since constructed, and these physicians, for all prac-
tical purposes, exercise the power and control of resident superintendents, for
the communication between these (listant structures and the main hospital-
building is by telegraph. Although that is an institution for the subjects of
chronic insanity, there are five medical men, a superintendent and four assist-
ants, for a thousand patients—and they are needed. Though as a commissioner
I voted to place the main building on the lake, I did not like the feature of
having buildings half a mile or more apart. In this instance it seemed a neces-
sity, though undesirable. -
As to the other question, as to the number to be accommodated in a single
institution, or under one superintendent, there is great difference of opinion.
Some think it just as practicable to have 2000 as 1000, or less. I think that
600, the maximum of the proposition of the Association of Superintendents,
passed a few years ago, is as many as should be under one superintendent,
even if the buildings be separated, and each have a resident physician. In Eng-
land, some of the best public institutions are larger than those in this country,
and, according to Dr. Buckmill, in his recent letters on American Asylums,
published in the Lancet, are not as well supplied with medical officers. That
at Wakefield, the West-Riding Asylum, standing at the head, has 1800 patients.
In reply to the criticisms of Dr. Kirkbride on the qualifications of assistant
physicians, I think it important to have assistants who have had hospital
experience. I should object to taking young men just out of a medical col-
lege, and without medical experience, and putting them in such responsible
places. Dr. Kirkbride's remarks as to qualifications would apply with double
force in an asylum where the buildings were separated.
I N D E X.
Abdomen, penetrating wounds of 631
Acid, salicylic, 506
ADAMs, morbus coxarius, 599
subcutaneous division of thigh-bone, 624, 629
Address on American medical literature, 223
hygiene and preventive medicine, 21
—— medical biography, 91
chemistry and toxicology, 49
jurisprudence, 167
staff of U. S. army, 286
medicine and medical progress in the United States, 1
– mental hygiene, 205
——— obstetrics, 138
—-— progress of medical education, 265
— Surgery, 73
—— of welcome, Xxxiii
AGNEw, C. R., Diseases of conjunctiva, 902 et seq.
—, D. H., morbus coxarius, 600
Alcohol as food and medicine, 452
ALLEN, mechanism of joints, 510, 514, 515
Altitudes, high, influence of, on phthisis, 387
Anaemia, pernicious progressive, 432
Anaesthetic, nitrous oxide as an, 642
Analgesic effects of rapid breathing, 642
Anatomy, pathological, investigations in, 462
Anchylosis of hip-joint, 624
Aneurism, treatment of 545
Aneurismal disease of orbit, 912
Antiseptic surgery, 518, 535
ARNOLD, influence of modern life on nervous diseases, 375
Artificial drum-membrane, 974
AsHHURST, treatment of aneurism, 572, 574
Aspiration, 862
Astringents in diseases of conjunctiva, 893
ATLEE, J. L., fibroid tumors of uterus, 823
—, W. L., fibroid tumors of uterus, 808, 826
Aural disease, early treatment in, 947
-msmºmºsºme from bathing, etc., 1008
— vertigo, 1000
AYREs, croup and diphtheria, 365
*-* *
BALDw1N, influence of high altitudes on phthisis, 421
—, quarantine, 1069
BARKER, labor in narrow pelves, 793
BARNEs, convulsions in children, 799
—— fibroid tumors of uterus, 823, 826
– introductory remarks, 761
— labor in narrow pelves, 793, 794
non-puerperal hemorrhages of womb, 775
– ovariotomy by enucleation, 806
BARTHOLOW, croup and diphtheria. 364
amºm- influence of Inodern life on nervous diseases, 366, 377
typho-malarial fever, 338
Bathing, a cause of aural disease, 1008
Bibliography of medical jurisprudence, 192
1 146 IN DE X.
Biography, medical, address on, 91
Biology, Section on, 467
Bladder, stone in, 609 -
in Finland, 662
BLAKE, tests for hearing of school-children, etc., 992, 999
Blood, microscopy of 467
Bow DITCH, address on hygiene, etc., 21
influence of modern life on nervous diseases, 375
Brain, microscopic study of 1083
3reathing, rapid, analgesic effects of, 642
}}RODIE, morbus coxarius, 601
BUCK, early treatment in diseases of ear, 947
Buenos Ayres, vital statistics of 1029
BULKLEY, eczema and psoriasis, 691
treatment of syphilis, 738 et seq.
—— unity or duality of venereal sores, 716
variation in type, etc., of skin diseases, 682 et se/.
3UMISTEAD, virus of venereal sores, its unity or duality, 708, 715, 716
BURNETT, artificial drum-membrane, 987
aural vertigo and variable hearing, 1000
hearing of school children, 999
tests for hearing, 958
BURNS, non-puerperal hemorrhages of womb, 775
BYFor D, labor in narrow pelves, 793
– non-puerperal hemorrhages of womb, 762, 776
– puerperal fever, 856
Calculous diseases, 609
CAMPBELL, J. A., non-puerperal hemorrhages of womb, 774
—, H. F., morbus coxarius, 598
CANNIFF, antiseptic surgery, 530, 531
CA RPENTER, antiseptic surgery, 533
— morbus coxarius, 601
CARTER, diseases of conjunctiva, 904
— progressive myopia, 941
Caustics in diseases of conjunctiva, 893
Centennial medical commission, vii
CHAILLE, address on medical jurisprudence, 167.
—— microscopy of blood, 487
Chemistry, medical, address on, 49
Children, convulsions in, 796
partially deaf, instruction of 992
school, tests for hearing of 992
Cholera, quarantine for, 1059
Commission, centennial, vii
Congenital pulsating exophthalmos, 921
Congress, minutes of the, xxxvii
– officers of the, xi
Conjunctiva, caustics and astringents in diseases of 893
Conus, 923
Convulsions from high temperature in children, 796
Corneal diseases, 942
Coxalgia. See Morbus coxarius. ,
Crime, responsibility of the insane for, 1097
Croup, pseudo-membranous, 341
CUPPLEs, morbus coxarius, 599
Cysts, ovarian, 859
DALTON, excretory function of liver, 501
—— mechanism of joints, 514
—– prevention of fungous growths, 508, 509
DAvis, address on progress of medical education, 265
– alcohol as food and medicine, 461
—— influence of modern life on nervous diseases, 375
– typho-malarial fever, 339
Deaf children, instruction of 992
and dumb, education of 1004
IN DE X.
1147
DENISON, influence of high altitudes on phthisis, 387
!)enmark, venereal disease in, 745
Dermatology, Section on, 665
1) IDAMA, microscopy of blood, 486, 487
I)iphtheria and pseudo-membranous croup, 341
Disease-germs, 1011
Diving, a cause of aural disease, 1008
I)rum-membrane, artificial, 974
DRYSDALE. treatment of syphilis, 741
Duality of syphilis, 708
DUFFY, influence of high altitudes on phthisis, 420
DUGAs, penetrating wounds of abdomen, 631
DUHRING, leprosy, 721
—— treatment of syphilis, 740
variation in type, etc., of skin diseases, 682 et seſſ.
DULLEs, simple ulcer of stomach, 424
Dumb, education of deaf and, 1004
DUN LAP, fibroid tumors of uterus, 824
Ear, disease of, from bathing, etc., 1008
early treatment in, 947
— Section on, 947
— — middle, inflammation of 988
Eczema and psoriasis, 691 *
Education of deaf and dumb, 1004
medical, address on, 265
of partially deaf children, 992
Electrolysis for ovarian cysts, 859
ENDERs, leprosy in Sandwich Islands, 717
ENGELSTED, variation in type, etc., of skin diseases, 683, 68 i
venereal disease in Denmark, 745
Enucleation, ovariotomy by, 801
Epilepsy, etiology of 378
EstLANDER, stone in bladder, in Finland, 662
temperature of Osteosarcoma, 658
——— typho-malarial fever, 340
Etiology of epilepsy, 378
Eustachian tube, inflammation of 988
EvP, address on surgery, 73
Excision of lower jaw, 605
Excretory function of liver, 489
Exophthalmia, pulsating, 912, 921
Eye, Section on diseases of, 893
Femur, subcutaneous division of 624
Fever, puerperal, 829
typho-malarial, 305
— yellow, quarantine in, 1059
Fibroid tumors of uterus, 808
Finland, stone in bladder in, 662
FITCH, paracentesis, aspiration and transfusion, 862
FLINT, address on medicine and medical progress, 1
-, Jr., excretory function of liver, 489, 502
Fungous growths in solutions for hypodermic use, 506
Geographical distribution of calculous disorders, 609
Germs, disease, 1011
Gestation, uterine hemorrhage in, 870
GIBBONs, croup and diphtheria, 363
——- influence of high altitudes on phthisis, 422
modern life on nervous diseases, 374
—— simple ulcer of Stomach, 431
GooDELL, mechanism of labor in narrow pelves, 777, 793, 795
non-puerperal hemorrhages of womb, 772
puerperal fever, 855
GoRDON, non-puerperal hemorrhages of womb, 774
(30ULEY, excision of lower jaw for phosphorus necrosis, 605
1148 IN DE X.
GRANT, antiseptic surgery, 533
morbus coxarius, 600
Gravid uterus, retroversion of 890
GRAY, address on mental hygiene, 205
microscopy of brain, 1096
provision for subjects of chronic insanity, 1143
responsibility of the insane, 1109
GREEN, J., diseases of conjunctiva, 903
—, progressive myopia, 940
, T., influence of modern life on nervous diseases, 373, 377
GROSS, address of welcome, xxxiii
closing remarks, xlix
morbus coxarius, 597, 600, 602
HAMILTON, C. C., croup and diphtheria, 365
———, F. H., antiseptic surgery, 532
HARE, croup and diphtheria, 363
– influence of high altitudes on phthisis, 423
simple ulcer of stomach, 430
HARLAN, congenital pulsating exophthalmos, 921
— diseases of conjunctiva, 903
HARTSHORNE, quarantine, 1070, 1071
Hearing, tests for, 958, 992
– variable, 1000
HEITZMANN, treatment of seborrhoea, 723
syphilis, 739, 740
unity or duality of venereal sores, 716
Hemorrhage, uterine, in gestation, 870
non-puerperal, 762
Herniotomy, opening the sac in, 634
HEwson, antiseptic surgery, 530
— nitrous oxide as an anaesthetic, and analgesic effect of rapid breathing, 642
High temperature, convulsions from, 796
HINGSTON, morbus coxarius, 598, 603, 604
Hip-disease. See Morbus coxarius.
Hip-joint, anchylosis of 624
Histology, investigations in, 503
HopDER, non-puerperal hemorrhage of womb, 773
Hodge, fibroid tumors of uterus, 825
HoDGEN, antiseptic surgery, 518, 531
Hol\IES, convulsions from high temperature in children, 796, 800
HowARD, croup and diphtheria, 364
— influence of modern life on nervous diseases, 375
— pernicious progressive anaemia, 432
HUBBARD, puerperal fever, 857
HUGHES, simulation of insanity by the insane, 1110
HUNT, alcohol as food and medicine, 452
quarantine, 1071
relations of pharmacist to medical profession, 1075
HUTCHINson, centennial medical commission, vii
HUTCHIson, excision of lower jaw, 608
HYDE, antiseptic surgery, 534
excision of lower jaw, 608
opening sac in herniotomy, 634
Hygiene, address on. 21 -
— mental, address on, 205
Hypodermic injection, fungous growths in solutions for, 506
Inflammation of Eustachian tube and middle ear, 988
Insane, responsibility of 1097
simulation of insanity by, 1110
Insanity, chronic, mode of providing for subjects of 1127
Instruction of deaf and dumb, 1004
partially deaf children, 992
Instruments, obstetrical, 827
Inversion of uterus, chronic, 873
IN DE X. . 1149
Jaw, lower, excision of, 605
JoHNSON, influence of high altitudes on phthisis, 422
JoHNSTON, microscopy of blood, 467, 486 et seq.
Joints, mechanism of, 510
Jon Es, artificial drum-membrane, 987
modes of treating inflammation of Eustachian tube and middle ear, 988
JoyNEs, microscopy of blood, 488
Jurisprudence, medical, address on, 167
bibliography of, 192
KEMPSTER, microscopic study of brain, 1083
KERR, quarantine, 1071 -
KEYEs, treatment of syphilis, 726, 739, 740
— unity or duality of venereal sores, 715, 716
KIMBALL, fibroid tumors of uterus, 824
— ovariotomy by enucleation, 806
KINLOCH, antiseptic surgery, 533
KTRKBRIDE, provision for subjects of chronic insanity, 1141
KNAPP, tumors of optic nerve, 905
Labor, mechanism of 777
LAZAREWITCH, obstetrical instruments, 827
LEBERT, simple ulcer of stomach, 424
Leprosy in Sandwich Islands, 717
LISTER, antiseptic surgery, 535, 541 et seq.
excision of lower jaw, 608
— introductory remarks, 517
— morbus coxarius, 594, 601 et seq.
treatment of aneurism, 573
Literature, medical, address on, 223
Liver, excretory function of, 489
LORING, progressive myopia and conus, 923, 940, 941
LUSK, labor in narrow pelves, 793
—— puerperal fever, 829, 858
McGUIRE, morbus coxarius, 601
MADDIN, croup and diphtheria, 364
– influence of modern life on nervous diseases, 374
MAsoN, simple ulcer of stomach, 431
MASTIN, calculous disorders, 609
Maxilla, inferior, excision of, 605
MEARs, puerperal fever, 857
Mechanism of joints, 510
labor, 777
Medical biography, address on, 91
chemistry, address on, 49
— education, address on, 265
— jurisprudence, address on, 167
bibliography of 192
literature, address on, 223
profession, relations of pharmacist to, 1075
staff of U. S. army, address on, 286
Medicine and medical progress, address on, 1
– preventive, address on, 21
– Section on, 305
Membrana tympani, artificial, 774
Mental diseases, Section on, 1083
hygiene, address on, 205
Microscopic study of brain, 1083
Microscopy of blood, 467
Middle ear, inflammation of 988
MINER, ovariotomy by enucleation, 801, 807
Minutes of the Congress, xxxvii
Modern life, influence of, on nervous diseases, 366
MooRE, morbus coxarius, 598
subcutaneous division of femur, 630
1150 INDEx.
Morbus coxarius, 575
Myopia, progressive, 923
Narrow pelves, mechanism of labor in, 777
Necrosis, phosphorus, 605
NEFTEL, etiology of epilepsy, 378
—— influence of modern life on nervous diseases, 374
Nerve, optic, tumors of, 905
Nervous diseases, influence of modern life on, 366
NICHOLs, mode of providing for subjects of chronic insanity, 1127
Nitrous-oxide gas as an anaesthetic, 642
Non-puerperal hemorrhage of womb, 762
Obstetrical instruments, 827
Obstetrics, address on, 138
— Section on, 761
Officers of the Congress, xi
——— Sections, xiii
O'HARA, simple ulcer of stomach, 431
OLD RIGHT, croup and diphtheria, 364
. – treatment of syphilis, 739
Opening the sac in herniotomy, 634
Ophthalmology, Section on, 893
Optic nerve, tumors of, 905
Orbital aneurismal disease, 912
Osteosarcoma, temperature of, 658
Osteotomy, subcutaneous, 624
OTIs, treatment of aneurism, 572
Otology, Section on, 947
Ovarian cysts, electrolysis for, 859
Ovariotomy by enucleation, 801
Paracentesis, aspiration, and transfusion, 862
PARVIN, address on obstetrics, 138
— non-puerperal hemorrhage of the womb, 775
—— ovariotomy by enucleation, 807
Pathological anatomy, investigations in, 462
PEASLEE, fibroid tumors of uterus, 824
— ovariotomy by enucleation, 806
Pelves, narrow, mechanism of labor in, 777
Penetrating wounds of abdomen, 631
PEPPER, croup and diphtheria, 362
– typho-malarial fever, 339, 340
Pernicious progressive anaemia, 432
Peru, Verrugas, a disease peculiar to, 685
Pharmacist, relations of, to medical profession, 1075
Pharmacopoeia, universal, 1072
Phosphorus necrosis, 605
Phthisis, influence of high altitudes on, 387
PoolEY, antiseptic Surgery, 530
– diseases of conjunctiva, 904
– morbus coxarius, 601
– treatment of aneurism, 57.1
PoRTER, unity or duality of venereal sores, 715
Post, morbus coxarius, 597, 603
subcutaneous division of femur, 629
treatment of aneurism, 572
Pseudo-membranous croup, 341
Psoriasis and eczema, 691
Puerperal fever, 829
Pulsating exophthalmia, 912. 921
Puncture of gravid uterus, 890
**
Quarantine, 1059
Rapid breathing, analgesic effects of, 642
RAwson, vital statistics of Buenos Ayres, 1029
INDEx. - 1151
RAY, microscopy of brain, 1096
provision for subjects of chronic insanity, 1140
— responsibility of the insane, 1097
simulation of insanity by the insane, 1125
Refraction, defects of, and myopia, 923
Refractive lesions and corneal diseases, 942
Responsibility of the insane, 1097
Retroversion of gravid uterus, 890
RICHARDson, J. G., excretory function of liver, 502
fungous growths in solutions for hypodermic use, 506, 508, 509
microscopy of blood, 486 et seq.
— T. G., morbus coxarius, 599
subcutaneous division of femur, 630
RIDGE, alcohol as food and medicine, 461
RISLEY, diseases of conjunctiva, 903
progressive myopia, 941
Roch ESTER, convulsions in children, 799
non-puerperal hemorrhage of womb, 774
— retroversion of gravid uterus, 890
RosBBRUGH, non-puerperal hemorrhage of womb, 773
RUDNEW, investigations in histology, 503 -
pathological anatomy, 462 - - - -
— prevention of fungous growths in solutions for hypodermic use, 509
Sac, opening the, in herniotomy, 634
Salicylic acid, 506
Sandwich Islands, leprosy in, 717
Sanitary science, Section on, 1011
SATTERTHWAITE, antiseptic surgery, 542, 543
—— disease germs, 1011
SAYRE, morbus coxarius, 575, 600 et seq.
subcutaneous division of femur, 629
School-children, tests for hearing of, 992
Schools for deaf and dumb, 1004 *
Scott, influence of modern life on nervous diseases, 375
— simple ulcer of stomach, 430
– typho-malarial fever, 339
Seborrhoea, 723
Section on biology, 467
—— dermatology, 665
——— medicine, 305
——— mental diseases, 1083
—— obstetrics, 761
——— ophthalmology, 893
—— otology, 947
—— Sanitary Science, 1011
——— Surgery, 517
— syphilis, 665
Sections, officers of the, xiii
SEMELEDER, electrolysis for ovarian cysts, 859
SERVAIs, subcutaneous division of femur, 629
SHEPARD, non-puerperal hemorrhage of womb, 774
SHERMAN, non-puerperal hemorrhage of womb, 774
Simple ulcer of stomach, 424
SIMPson, labor in narrow pelves, 794
— non-puerperal hemorrhage of womb, 773
– ovariotomy by enucleation, 807
— puerperal fever, 857
Simulation of insanity by the insane, 1110
Skin-diseases, variations in type and prevalence of 665
SMITH, J. L., diphtheria and pseudo-membranous croup. 341
, J. W., simple ulcer of stomach, 431
SPEIR, treatment of aneurism, 573
SPENCER, artificial drum-membranes, 974. 987
SQUIBB, universal pharmacopoeia, 1072
Staphyloma, posterior, 923
Statistics, vital, of Buenos Ayres, 1029
1152 iN DEx.
STEVENs, corneal diseases and refractive lesions, 942
STILLE, simple ulcer of stomach, 430
Stomach, simple ulcer of 424
Stone in bladder, 609
in Finland, 662
STRAwBRIDGE, diseases of conjunctiva, 903.
STUART, influence of high altitudes on phthisis, 422
Subcutaneous division of thigh-bone, 624
Sub-periosteal excision of lower jaw, 605
Surgery, address on, 73
– antiseptic, 518, 535
— Section on, 517
Swimming, a cause of aural disease, 1008
Syphilis in Denmark, 745
– treatment of 726, 741
– unity or duality of 708
Syphilography, Section on, 665
TAYLOR, treatment of syphilis, 739, 740
-— unity or duality of venereal sores, 715, 716
Temperature, high, convulsions from, 796
— of Osteosarcoma, 658
Tests for hearing, 958, 992
Thigh-bone, subcutaneous division of, 624
THOMson, diseases of conjunctiva, 904
— progressive myopia, 940, 941
ToDD, non-puerperal hemorrhage of womb, 775
ToNER, address on medical biography, 91
Toxicology, address on, 49
Transfusion, 862
TRENHOLME, non-puerperal hemorrhage of womb, 774
— puerperal fever, 857
– uterine hemorrhage in gestation, 870
TUFNELL, treatment of aneurism, 571, 574
Tumors of optic nerve, 905
—— uterus, fibroid, 808
TURNBULL, bathing, swimming, and diving, as causes of aural disease, 1008
—— education of deaf and dumb, 1004
Typho-malarial fever, 305
Tyson, microscopy of blood, 487
Ulcer, simple, of stomach, 424
Unity or duality of venereal sores, 708
Universal pharmacopoeia, 1072
Uterus, chronic inversion of 873
fibroid tumors of, 808
— gravid, retroversion of 890
— hemorrhage from, in gestation, 870
non-puerperal, 762
VAN BUREN, aneurism, 545
– antiseptic surgery, 541
VANDERPOEL, quarantine, 1070, 1071
VAN HARLINGEN, variation in type, etc., of skin diseases, 684
Variable hearing, 1000
Venereal disease in Denmark, 745
— sores, virus of, its unity or duality, 708
Verrugas, 685
Vertigo, aural, 100
Vital statistics of Buenos Ayres, 1029
Vosburgh, non-puerperal hemorrhage of womb, 775
WALKER, responsibility of the insane, 1109
WARD, verrugas, 685.
WEIR, antiseptic surgery, 534
Welcome, address of, xxxiii
I N I) E X . 1153
W. H. G., J. C., leprosy, 722
variation in type and prevalence of skin-diseases, 665, 683, 684
, J. P., chronic inversion of uterus, 873
ovariotomy by enucleation, 806, 807
————— puerperal fever, 857
WILDER, mechanism of joints, 514
WILLIAMs, E., diseases of conjunctiva, 903, 904
orbital aneurismal disease and pulsating exophthalmia, 912
——— progressive myopia, 941 -
———, H. W., caustics and astringents in diseases of conjunctiva, 893, 902, 903
progressive myopia, 941
Womb. See Uterus,
WooDwARD, address on medical staff of U. S. army, 286
*-**** croup and diphtheria, 363
*-*= typho-malarial fever, 305, 338, 340
Woodworth, quarantine, 1059
WoRMLEY. address on medical chemistry, etc., 49
Wounds of abdomen, 631.
*-*-* ====
*-*= amam-mºm-m
YAN DELL, address on American medical literature, 223
Yellow fever, quarantine in, 1059
YEOMANs, puerperal fever, 855
simple ulcer of stomach, 430
ZA VARIKINI, investigations in histology, 503
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