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TRANSACTIONS
OF THE
NEW YORKSTATE MEDICAL ASSOCIATION.
COMMITTEE ON PUBLICATIONS.
ALFRED L. CARROLL, M. D., of New York County, CHAIRMAN.
JOHN W. S. GOULEY, M. D., of New York County.
S. B. W. McLEOD, M. D., of New York County.
JOHN SHRADY, M. D., of New York County.
JOHN G. TRUAX, M. D., of New York County.
PRINTED BY THE FLESS & RIDGE PRINTING COMPANY.,
FIFTH AVENUE, N. Y.
TRANSACTIONS
OF (Rokaº S. O'Lººkº,
THE NEW YORK STATE
MEDICAL ASSOCIATION,
FOR THE YEAR 1892.
VOLUME IX. : ; §
EDITED FOR THE ASSOCIATION
By OGDEN C. LUDLOW, M. D.,
OF NEW YORK COUNTY.
PUBLISHED BY THE ASSOCIATION,
64. MADISON AVENUE,
NEW YORK CITY.

* {
i
:
CoPYRIGHT, 1893,
By THE NEW YORK STATE MEDICAL ASSOCIATION.
C O N TE N T S.
PAGE
Officers and Council for 1891–92 .
Committee of Arrangements for 1891–92
Officers and Council for 1892–'93 .
Officers of the Branch Associations for 1893
List of Presidents and Vice-Presidents . . . . . . . . .
List of Fellows registered at the Ninth Annual Meeting . . .
List of Delegates and Invited Guests at the Ninth Annual Meeting
Address of Welcome and Report of the Committee of Arrangements.
By J. G. TRUAx, M. D., of New York County . . . . . .
President's Annual Address. By JUDSON B. ANDREWs, M. D., of Erie
County • e º e s e º e s - © e º 'º º º
Preumotomy for Relief of Tubercular Abscess and Gangrene of the
Lung ; Twice on the same Patient. Recovery. By JOHN BLAKE
WHITE, M. D., of New York County . . . . . . . . .
Traumatic Osteo-Arthritic Lesions which involve the Proximal Seg-
ment of the Ankle Joint; Their Pathological Anatomy and Treat-
ment. By THOMAS H. MANLEY, M. D., of New York County
Muscular Traction for Hip-Joint Disease. By THOMAS M. LUDLow
CHRYSTIE, M. D., of New York County . . . . . . . .
Some Recent Cases of Appendicitis. By NATHAN JACOBSON, M. D., of
Onondaga County . . . . . . . . . . . . . . .
Ectopic Pregnancy. By HENRY D. INGRAHAM, M. D., of Erie County
Antiseptic Waginal and Intra-Uterine Injections unnecessary, if not
injurious, in the daily Practice of Obstetrics. By DARWIN COL-
VIN, M. D., of Wayne County . . . . . . . . . . .
The Palliative Treatment of such Cases of Cancer of the Uterus and
its Adnexa as are not Amenable to Radical Operative Measures.
By J. E. JANVRIN, M. D., of New York County . . . . .
A Case of Puerperal Eclampsia at the Seventh Month, with a few
Thoughts from Practical Experience as to Treatment. By Douglas
AYRES, M. D., of Montgomery County . . . . . . . .
Tumors of the Orbit. A Detailed Account of Nineteen Cases illus-
trating the Paper on the same subject, presented to the New York
State Medical Association at its Meeting in 1891. By CHARLEs
STEDMAN BULL, M. D., of New York County . . . . .
Paraplegia. By CHARLEs W. BRow N, M. D., of Washington, D. C.
The Question of Maternal Impressions. By H. S. WILLIAMS, M. D.,
of New York County . e - - - -
i
|
18
30
39
60
64
77
86
92
98
. 105
130
. 135
Wi OONTENTS.
Clinical Contributions to the Subject of Brain Surgery. By Roswell
PARK, M. D., of Erie County . . . . . . . . . . . 146
A Plea for the Early Extirpation of Tumors. By JoHN W. S. GoulEY,
M. D., of New York County . . . . . . . . . . . 167
Remarks on a New Method of Intestinal Anastomosis. By BENJAMIN
M. RICKETTS, M. D., of Cincinnati, Ohio . . . . . . . . 187
A Report of some Cases of Compound Depressed Fracture of the Skull.
By GEORGE D. KAHLo, M. D., of Indiana . . . . . . . 189
The Achievements of American Surgery. By FREDERIC S. DENNIS,
M. D., of New York County . . . . . . . . . . . 201
Memoranda, Practical and Suggestive. By H. D. DIDAMA, M. D., of
Onondaga County . . . . . . 245
Acute Pleurisy. By FRANK S. PARSONs, M. D., of Northampton, Mass. 256
A Clinico-Pathological Study of Injuries of the Head, with Special
Reference to Lesions of the Brain Substance. By CIIARLES
PHELPs, M. D., of New York County . . . . . . . . . 274
The Aetiology of Gastric Ulcer. By CHARLEs G. STOCKTON, M. D.,
of Erie County . . . . . . . . . . . . . . . .
The Examination and Commitment of the Public Insane in New York
City. By MATTHEw D. FIELD, M. D., of New York County .. 365
Mitral Stenosis in Pregnancy. By ZERA. J. LUSH, M. D., of Wyoming
354
County . . . . . . . . . . . . . . . . . . 379
The Use of Electricity in Midwifery. By OGDEN C. LUDLow, M. D.,
of New York County . . . . . . . . . . . . . . 388
The Rôle of Microbes in Disease. By N. B. SIZER, M. D., of Kings
County . . . . . . . . . . . . . . . . . . 405
Abdominal Hysterectomy for Myoma. By FREDERICK A. BALDWIN,
M. D., of New York County . . . . . . . . . . . 421
Extraction of Steel from the Interior of the Eye with the Electro-
Magnet. By ALVIN A. HuBBELL, M. D., of Erie County . . 427
The Mental Symptoms of Fatigue. By EDWARD CowLES, M. D., of
Somerville, Mass. . . . . . . . . . . . . . . . 441
A Review of some Injuries of the Upper Extremity. By E. M. MooRE,
M. D., of Monroe County . . . . . 469
Fractures of the Patella treated by Continuous Extension ; Patients
not confined to bed. By Jose.P.H. D. BRYANT, M. D., of New York
County . . . . . . . . . . . . . . . . . . 512
Winter Cholera in Poughkeepsie. By JAMES G. PortEous, M. D., of
Dutchess County . . . . . . . . . . . . . . . 521
Suggestions Relating to Improvement of Quarantine. By STEPHEN
SMITII, M. D., of New York County . . . . . . . . . 531
The Limit of Responsibility in the Insane. By JoHN SIIRADY, M. D.,
of New York County . . . . . 540
Some Personal Observations and Reſlections upon Alcoholism, the
Eſfects of Alcoholic Abuse upon Posterity, and the Treatment of
Alcoholism. By H. ERNST ScLIMID, M. D., of Westchester
County . . . . . . . . . . . . . . 545
CONTENTS. Wii
Climatology in its Relation to Disease. By S. J. MURRAy, M. D., of
New York County . . . . . . . . . . . . . . . 559
Pelvic Version. By T. J. McGILLICUDDY, M. D., of New York County 567
Should we treat Fever ? By S. T. ARMSTRONG, M. D., of New York
County . . . . . . . . . . . . . . . . . . 576
Brief Comments on the Materia Medica, Pharmacy and Therapeutics of
the Year ending November 1, 1892. By E. H. SQUIBB, M. D., of
Kings County . . . . . . . . . . . . . . . . 588
Dermic and Hypodermic Therapeutics. By S. F. RogFRs, M. D., of
Rensselaer County . . . . . . . . . . . . . . . 676
Some Recent Experience in Renal Surgery. By E. D. FERGUSON,
M. D., of Rensselaer County . . 678
The Treatment of Neglected Cases of Rotary Lateral Curvature of
the Spine. By REGINALD H. SAYRE, M. D., of New York County 687
Memoir of Abram Du Bois, M. D. By SAMUEL S. PURPLE, M. D.,
of New York County . . . . . . . . . . . . 716
Memoir of M. Calvin West, M. D. By THOMAS M. FILANDREAU, M.D.,
of Oneida County . . . . . . . . . . . . . . . 721
Memoir of Myron N. Babcock, M. D. By T. B. REYNoLDs, M. D., of
Saratoga County . . . . . . . . . . . . . . . 723
Memoir of Lucien Damainville, M. D. By AUSTIN FLINT, M. D., of
New York County . . . . . . . . . . . . . . . 725
Memoir of Nathaniel Clark Husted, M. D. By RICHARD B. CouTANT,
M. D., of Westchester County . . . . . . . . . . . 727
Memoir of James Ferguson, M. D. By G. R. MARTINE, M. D., of
Warren County . . . . . . . . . . . . . . . . 735
Memoir of William Chace, M. D. By THOMAs D. STRONG, M. D., of
Chautauqua County . . . . . . . . . . . . 736
Reports of the District Branches:
First District Branch . . . . . . . . . . . . . . 737
Second District Branch . . . . . . . . . . . . . 738
Third District Branch . . . . . . . . . . . . . . 740
Fourth District Branch . . . . . . . . . . . . . 756
Fifth District Branch . . . . . . . . . . . . . . 758
Kings County Medical Association, Annual Report . . . . . . 764
New York County Medical Association, Annual Report . . . . 767
Proceedings, Ninth Annual Meeting . . . . . . . . . . 774
Annual Report of the Council . . . . . . . . . . . . 778
List of Fellows by District and County . . . . . . . . . . 783
Alphabetical List of Fellows . . . . . . . . . . . . . 806
Retired Fellows . . . . . . . . . . . . . . . . . 824
Non-Resident Fellows . . . . . . . . . . . . . . . 824
Honorary Fellows . . . . . . . . . . . . . . . . 824
Corresponding Fellows . . . . . . . . . . . . . . . 824
Deceased Fellows . . . . . . . . . . . . . . . . 826
Index . . . . . . . . . . . . . . . . . . . . . 831
OFFICERS AND COUNCIL FOR 1891–?92.
PRESIDENT.
JUDSON B. ANDREWS, M. D., Erie County, Fourth District.
WICE-PRESIDENTS.
FIRST DISTRICT, W. D. GARLOCK, M. D., Herkimer County.
SECOND DISTRICT, GEORGE E. McDONALD, M. D.,
Schenectady County.
THIRD DISTRICT, LEROY J. BROOKS, M. D., Chenango County.
FIFTH DISTRICT, HENRY WAN HOEVENBERG, M. D., Ulster County.
SECRETARY (and Acting Treasurer).
E. D. FERGUSON, M. D., Rensselaer County.
CHAIRMAN OF THE LIBRARY COMMITTEE.
J. W. S. GOULEY, M. D., New York County.
MEMBER OF THE COUNCIL AT LARGE.
WILLIAM McCOLLOM, M. D., Kings County.
ELECTED MEMBERS OF THE COUNCIL.
FIRST DISTRICT, E. T. RULISON, M. D., Montgomery County.
6 & g ºf JOHN P. SHARER, M. D., Herkimer County.
SECOND DISTRICT, THOMAS WILSON, M. D., Columbia County.
6 & & & J. B. HARVIE, M. D., Rensselaer County.
THIRD DISTRICT, H. O. JEWETT, M. D., Cortland County.
& 4 & & GEORGE DOUGLAS, M. D., Chenango County.
FourTH DISTRICT, S. T. CLARK, M. D., Niagara County.
& © & & THOMAS D. STRONG, M. D., Chautauqua County.
FIFTH DISTRICT, JOHN G. TRUAX, M. D., New York County.
& 6 6 & A. L. CARROLL, M. D., New York County.
COMMITTEE OF ARRANGEMENTS FOR 1891–292.
JUDSON B. ANDREWS, PRESIDENT.
E. D. FERGUSON, SECRETARY.
Ea:-officio Members of the Committee.
JOHN G. TRUAX, Chairman.
CHARLES E. DENISON, Secretary.
E. S. F. ARNOLD,
GLOWER C. ARNOLD,
F. A. BALDWIN,
ALFRED L. CARROLL,
ELLERY DENISON,
A. PALMER DUDLEY,
JOHN F. ERDMANN,
THOMAS W. P. FLINN,
JOHN W. S. GOULEY,
GEORGE T. HARRISON,
CHARLES A. LEALE,
N. W. LEIGHTON,
OGDEN C. LUDLOW,
JAMES C. MACKENZIE,
WILLIAM McCOLLOM,
S. B. WYLIE MCLEOD,
WALENTINE MOTT,
A. D. RUGGLES,
JOHN SHRADY,
STEPHEN SMITH,
E. H. SQUIBB.
OFFICERS AND COUNCIL FOR 1892–'93.
The Tenth Annual Meeting will be held at the Mott Memorial Library, in
New York City, on October 10, 11, 12 and 13, 1893.
PRESIDENT.
S. B. W. McLEOD, M. D., 247 W. 23d street, New York City.
WICE-PRESIDENTS.
FIRST DISTRICT, R. N. COOLEY, M. D.,
Hannibal Centre, Oswego County.
SECOND DISTRICT, J. C. HANNAN, M. D.,
Hoosick Falls, Rensselaer County.
THIRD DISTRICT, N. JACOBSON, M. D., Syracuse, Onondago County.
FourTH DISTRICT, Z. J. LUSK, M. D., Warsaw, Wyoming County.
SECRETARY AND TREASURER.
E. D. FERGUSON, M. D., Troy, Rensselaer County.
CHAIRMAN OF THE LIBRARY COMMITTEE.
J. W. S. GOULEY, M. D., 324 Madison Ave.,
New York, New York County
MEMBER OF THE COUNCIL AT LARGE.
JOHN SHRADY, M. D., 149 W. 126th street, New York City.
ELECTED MEMBERS OF THE COUNCIL.
FIRST DISTRICT, E. T. RULISON, M. D.,
Amsterdam, Montgomery County ; term expires 1893.
& & & & A. P. DODGE, M. D.,
Oneida Castle, Oneida County; term expires 1894.
SEcoRD DISTRICT, THOMAS WILSON, M. D.,
Claverack, Columbia County; term expires 1893.
& & & & J. B. HARVIE, M. D.,
Troy, Rensselaer County; term expires 1894.
THIRD DISTRICT, H. O. JEWETT, M. D.,
Cortland, Cortland County; term expires 1893.
& & & & M. CAVANA, M. D.,
Oneida, Madison County ; term expires 1894.
FourTH DISTRICT, THOMAS D. STRONG, M. D.,
Westfield, Chautauqua County; term expires 1893.
& 4 & & F. H. MOYER, M. D.,
Moscow, Livingston County; term expires 1894.
FIFTH DISTRICT, JOHN D. TRUAX, M. D.,
17 E. 127th St., New York, New York County; term expires 1898.
“ DISTRICT, A. L. CARROLL, M. D.,
80 W. 59th St., New York, New York County; term expires 1894.
OFFICERS OF THE BRANCH ASSOCIATIONS FOR
1892.
FIRST OR NORTHERN BRANCH.
The Ninth Annual Meeting will be held as appointed by the President and
Secretary.
OFFICERS.
PRESIDENT, R. N. COOLEY, M. D.,
Hannibal Centre, Oswego County.
SECRETARY, EZRA GRAVES, M. D.,
Amsterdam, Montgomery County.
EXECUTIVE COMMITTEE.
WILLIAM GILLIS, M. D., Fort Covington, Franklin County.
ISAAC DE ZOUCHE, M. D., Gloversville, Fulton County.
THOMAS McGANN, M. D., Wells; Hamilton County.
W. D. GARLOCH, M. D., Little Falls, Herkimer County.
J. MORTIMER CRAWE, M. D., Watertown, Jefferson County.
ALBERT A. JOSLIN, M. D., Martinsburg, Lewis County.
H. M. LEACH, M. D., Glen, Montgomery County.
G. ALDER BLUMER, M. D., Utica, Oneida County.
E. F. MARSH, M. D., Fulton, Oswego County.
GUY REUBEN COOK, M. D., Louisville, St. Lawrence County.
SECOND OR EASTERN BRANCH.
The Ninth Annual Meeting will be held at Saratoga Springs, Saratoga
County, on the fourth Thursday in June, 1893.
OFFICERs.
PRESIDENT, J. C. HANNAN, M. D.,
Hoosick Falls, Rensselaer County.
SECRETARY, JOSEPH E. BAYNES, M. D., Troy, Rensselaer County.
ExECUTIVE COMMITTEE.
W. B. SABIN, M. D., West Troy, Albany County.
E. M. LYON, M. D., Plattsburgh, Clinton County.
T. F. WOODWORTH, M. D., Kinderhook, Columbia County.
OFFICERS OF THIE, BRAWCH ASSOCIATIONS. 5
LYMAN BARTON, M. D., Willsborough, Essex County.
ROBERT SELDEN, M. D., Catskill, Greene County.
J. P. MARSH, M. D., Troy, Rensselaer County.
I. G. JOHNSON, M. D., Greenfield Centre, Saratoga County.
H. C. WAN ZANDT, M. D., Schenectady, Schenectady County.
WILLIAM HAGADORN, M. D., Gilboa, Schoharie County.
G. R. MARTINE, M. D., Glens Falls, Warren County.
A. J. LONG, M. D., Whitehall, Washington County.
THIRD OR CENTRAL BRANCH.
The Ninth Annual Meeting will be held at Elmira, Chemung County, on the
third Thursday in June, 1893.
OFFICERS.
PRESIDENT, N. JACOBSON, M. D., Syracuse, Onondaga County.
SECRETARY, C. L. SQUIRE, M. D., Elmira, Chemung County.
EXECUTIVE COMMITTEE.
H. C. ROGERS, M. D., Binghamton, Broome County.
W. R. LAIRD, M. D., Auburn, Cayuga County.
F. W. ROSS, M. D., Elmira, Chemung County.
H. C. LYMAN, M. D., Sherburne, Chenango County.
F. W. HIGGINS, M. D., Cortland, Cortland County.
W. B. MORROW, M. D., Walton, Delaware County.
M. CAVANA, M. D., Oneida, Madison County.
F. O. DONOHUE, M. D., Syracuse, Onondaga County.
JOSHUA. J. SWEET, Unadilla, Otsego County.
B. T. SMELZ.E.R., M. D., Havana, Schuyler County.
ELIAS LESTER, M. D., Seneca Falls, Seneca County.
W. L. AYER, M. D., Owego, Tioga County.
WILLIAM FITCH, M. D., Dryden, Tompkins County.
FOURTH OR WESTERN BRANCH.
The Ninth Annual Meeting will be held at Rochester, Monroe County, on the
Second Tuesday in May, 1893.
OFFICERS.
PRESIDENT, Z. J. LUSK, M. D., Warsaw, Wyoming County.
SECRETARY, WM. H. THORNTON, M. D.,
570 Niagara St., Buffalo, Erie County.
6
NEW YORK STATE MEDICAL ASSOCIATION.
EXECUTIVE COMMITTEE.
J. A. STEPHENSON, M. D., Scio, Alleghany County.
S. J. MUDGE, M. D., Olean, Cattaraugus County.
NELSON G. RICHMOND, M.D., Fredonia, Chautauqua County.
C. FREDERICK, M. D., Buffalo, Erie County.
W. TOWNSEND, M. D., Bergen, Genesee County.
H. MOYER, M. D., Moscow, Livingston County.
M. MOORE, M. D., Rochester, Monroe County.
W. Q. HUGGINS, M. D., Lockport, Niagara County.
F. D. WANDERHOOF, M. D., Phelps, Ontario County.
JOHN H. TAYLOR, M. D., Holley Orleans County.
JEREMIAH DUNN, M. D., Bath, Steuben County.
DARWIN COLVIN, M. D., Clyde, Wayne County.
A. G. ELLINWOOD, M. D., Attica, Wyoming County.
WILLIAM OLIVER, M. D., Penn Yan, Yates County.
C.
M.
F.
R.
FIFTH OF SOUTHERN BRANCH.
The Ninth Annual Meeting will be held in Brooklyn, Kings County, on the
fourth Tuesday in May, 1893.
OFFICERS.
PRESIDENT, S. B. W. McLEOD, M. D.,
247 W. 23d street, New York City.
SECRETARY, E. H. SQUIBB, M. D.,
P. O. Box 760, Brooklyn, Kings County.
ExECUTIVE COMMITTEE.
D. LE ROY, M. D., Pleasant Valley, Dutchess County.
. RUSHMORE, M. D., Brooklyn, Kings County.
H. MANLEY, M. D., New York, New York County.
C. CONNER, M. D., Middletown, Orange County.
W. MURDOCK, M. D., Cold Spring, Putnam County.
L
D
i
. D
. G. RAWE, M. D., Hicksville, Queens County.
. U. JOHNSTON, M. D., New Brighton, Richmond County.
ILLIAM GOWAN, M. D., Stony Point, Rockland County.
. D. WOODEND, M. D., Huntington, Suffolk County.
. H. DE KAY, M. D., Wurtsborough, Sullivan County.
. WAN HOEVENBERG, M. D., Kingston, Ulster County.
H. E. SCHMID, M. D., Tarrytown, Westchester County.
§
H
LIST OF PRESIDENTS AND WICE-PRESIDENTS
FROM THE FOUNDING OF THE ASSOCIATION.
1884.
PRESIDENT.
HENRY D. DIDAMA, M. D., Onondaga County, Third District.
WICE-PRESIDENTS.
FIRST DISTRICT, J. MORTIMER CRAWE, M. D., Jefferson County.
SECOND DISTRICT, TABOR B. REYNOLDS, M. D., Saratoga County.
FourTH DISTRICT, B. L. HOVEY, M. D., Monroe County.
FIFTH DISTRICT, *NATH'L C. HUSTED, M. D., Westchester County.
*-*-m-º.
1885.
PRESIDENT.
*JOHN P. GRAY, M. D., Oneida County, First District.
WICE-PRESIDENTS,
SECOND DISTRICT, WILLIAM H. ROBB, M. D., Montgomery County.
THIRD DISTRICT, JOHN G. ORTON, M. D., Broome County.
FourTH DISTRICT, JOSEPH C. GREENE, M. D., Erie County.
FIFTH DISTRICT, * JOSEPH C. HUTCHINSON, M. D., Kings County.
1886.
PRESIDENT.
E. M. MOORE, M. D., Monroe County, Fourth District.
WICE-PRESIDENTS.
FIRST DISTRICT, WILLIAM GILLIS, M. D., Franklin County.
SEcoRD DISTRICT, H. C. WAN ZANDT, M. D., Schenectady County.
THIRD DISTRICT, * FREDERICK HYDE, M. D., Cortland County.
FIFTH DISTRICT, J. G. PORTEOUS, M.D., Dutchess County.
1887.
PRESIDENT,
*ISAAC E. TAYLOR, M. D., New York County, Fifth District.
* Deceased.
8 MEW YORK STATE MEDIOAL ASSOCIATION.
WICID-PRESIDENTS.
FIRST DISTRICT, JOHN P. SHARER, M. D., Herkimer County.
SIRCOND DISTRICT, L. C. DODGE, M. D., Clinton County.
THIRD DISTRICT, * GEORGE W. AVERY, M. D., Chenango County
FourTH DISTRICT, DARWIN COLVIN, M. D., Wayne County.
1888.
PIRICSIDENT.
JOHN CRONYN, M. D., Erie County, Fourth District.
WICE-PRICSIDENTS.
FIRST DISTRIOT, BYRON DE WITT, M. D., Oswego County.
SIBoonD DISTRICT, ROBERT SELDEN, M. D., Greene County.
THIRD DISTRIOT, CHARLES W. BROWN, M. D., Chemung County.
FIFTH DISTRIOT, EDWIN BARNES, M. D., Dutchess County.
1889.
PRESIDIENT.
WILLIAM T. LUSK, M. D., New York County, Fifth District.
WICE-PRESIDENTS.
FIRST DISTRICT, S. H. FRENCH, M. D., Montgomery County.
SIRCOND DISTRIOT, R. C. McEWEN, M. D., Saratoga County.
THIRD DISTRICT, ELIAS LESTER, M. D., Seneca County.
FourTH DISTRIOT, THOMAS D. STRONG, M. D., Chautauqua County.
1890.
PRIESIDIENT.
JOHN G. ORTON, M. D., Broome County, Third District.
WICE-PRIESIDIENTS.
FIRST DISTRIOT, DOUGLAS AYRES, M. D., Montgomery County.
SEcond DISTRIOT, M. H. BURTON, M. D., Rensselaer County.
FourTH DISTRIOT, E. M. MOORE, J.R., M. D., Monroe County.
FIFTII DISTRIOT, WILLIAM MoCOLLOM (Wice WILLIAM B. EAGER,
(deceased), Kings County.
*
1891.
PRIESIDENT,
STEPHEN SMITH, M.D., New York County, Fifth District.
+
* Deceased,
PRESIDENTS AND WICE-PRESIDENTS. 9
WICE-PRESIDENTS.
FIRST DISTRICT, DOUGLAS AYRES, M. D., Montgomery County.
SEoonD DISTRICT, A. T. WAN WIRANKEN, M. D., Albany County.
THIRD DISTRICT, J. D. TRIPP, M. D., Cayuga County.
FourtTII DISTRICT, ROBERT J. MENZIE, M. D., Livingston County.
tºmºsº-ºº:
1892.
PRESIDENT.
JUDSON B. ANDREWS, M. D., Erie County.
WICE-PRESIDENTS.
FIRST DISTRICT, W. D. GARLOCK, M. D., Herkimer County.
SIEconD DISTRICT, GEORGE E. McDONALD, M. D., Schenectady County.
THIRD DISTRICT, LEROY J. BROOKS, M. D., Chenango County.
FIFTH DISTRICT, HENRY WAN HOEVENIBERG, M. D., Ulster County.
LIST OF FELLOWS REGISTERED AT THE NINTH
ANNUAL MEETING IN NEW YORK CITY,
Held November 15, 16, and 17, 1892.
FIRST DISTRIOT.
HERKIMER COUNTY.
Garlock, W. D., Little Falls.
MONTGOMERY COUNTY.
Ayres, Douglas, Fort Plain.
ONEIDA COUNTY.
Dodge, A. P., Oneida Castle.
OSWEGO COUNTY.
DeWitt, Byron, Oswego.
rºm-
SECOND DISTRICT.
CLINTON COUNTY.
Dodge, L. C., Rouses Point. Lyon, E. M., Plattsburgh.
Holcomb, Oscar A., Plattsburgh.
COLUMBIA. COUNTY.
Wilson, Thomas, Claverack.
GREENE COUNTY.
Selden, O. G., Catskill. Selden, Robert, Catskill.
IRENSSELAER COUNTY.
Bontecou, R. B., Troy. Harvie, J. B., Troy.
Burbeck, Charles H., Troy. Lyon, George E., Troy
Cahill, John T., Hoosick Falls. Phelan, M. F., Troy.
Ferguson, E. D., Troy. Rogers, S. F., Troy.
Hannan, J. C., Hoosick Falls.
WARREN COUNTY.
Martin, G. R., Glens Falls.
THIRD DISTRICT,
BROOME COUNTY.
Fitzgerald, John F., Binghamton.
FELLO WS AT THE WINTH "AWWUAJC MEETING. 11
CAYUGA COUNTY.
Tripp, J. D., Auburn.
CHEMUNG COUNTY.
Brown, Chas. W., Washington, D. C. Ross, Frank W., Elmira.
Drake, Emory G., Elmira.
CHENANGO COUNTY.
Brooks, Leroy J., Norwich. Douglas, George, Oxford.
CORTLAND COUNTY.
Higgins, F. W., Cortland. Jewett, H. O., Cortland.
DELAVARE COUNTY.
Morrow, W. B., Walton.
MADISON COUNTY.
Cavana, Martin, Oneida. Huntley, James F., Oneida.
ONONIDAGA COUNTY.
Brown, U. H., Syracuse. Jacobson, Nathan, Syracuse.
Didama, H. D., Syracuse.
OTSEGO COUNTY.
Leaning, J. K., Cooperstown.
SENECA COUNTY.
Seaman, Frank G., Seneca Falls.
TIOGA COUNTY.
Ayer, W. L., Owego. Cady, George M., Nichols.
FOURTH DISTRICT.
CATTAR AUGUS COUNTY.
Mudge, S. J., Olean.
CHAUTAUQUA COUNTY.
Strong, Thomas D., Westfield. Ames, Edward, Kalamazoo, Mich.
RRUE COUNTY.
Andrews, J. B., Buffalo. Park, Roswell, Buffalo.
Congdon, Charles E., Buffalo. Putnam, James W., Buffalo.
Cronyn, John, Buffalo. Stockton, Charles G., Buffalo.
Hubbell, Alvin A., Buffalo. Thornton, W. H., Buffalo.
Ingraham, Henry D., Buffalo. Tremaine, W. S., Buffalo.
GENESEE COUNTY.
Jackson, A. P., Oakfield.
LIVINGSTON COUNTY.
Moyer, F. H., Moscow,
12
ME W YORK STATE MEDICAL ASSOCIATION.
MONIROE COUNTY.
Goler, G. W., Rochester.
Hovey, B. L., Rochester.
WAYNE
Horton, D. B., Red Creek.
Moore, E. M., Rochester.
COUNTY.
WYOMING COUNTY.
Ellinwood, A. G., Attica.
Lusk, Z. J., Warsaw.
FIFTH DISTRICT.
DUTCHESS COUNTY.
Barnes, Edwin, Pleasant Plains.
LeRoy, Irving D., Pleasant Valley.
Porteous, J. G., Poughkeepsie.
Pultz, M. T., Stanfordville.
VanWyck, R. C., Hopewell Junction.
RINGS COUNTY.
Baker, Frank R., Brooklyn,
Baker, George W., Brooklyn.
Biggam, W. H., Brooklyn.
Creamer, Joseph, Brooklyn.
Feely, James F., Brooklyn.
Leighton, N. W., Brooklyn.
McCollom, William, Brooklyn.
Minard, E. J. C., Brooklyn.
North, N. L., Brooklyn.
Paine, Arthur R., Brooklyn.
Russell, William G., Brooklyn.
Sizer, Nelson B., Brooklyn.
Squibb, E. H., Brooklyn.
Squibb, E. R., Brooklyn.
Steinke, H. C. O., Brooklyn.
Sullivan, J. D., Brooklyn.
Wieber, George, Brooklyn.
Wycoff, R. M., Brooklyn.
NEW YORK COUNTY.
Armstrong, S. T., New York.
Arnold, E. S. F., New York.
Arnold, Glover C., New York.
Baldwin, F. A., New York.
Bryant, Joseph D., New York.
Bull, Charles Stedman, New York.
Carroll, A. L., New York.
Chrystie, T. M. L., New York.
Curry, Walker, New York.
Davis, J. Griffith, New York.
Delphey, Eden W., New York.
Denison, Charles E., New York.
Denison, Ellery, New York.
Dennis, Frederic S., New York.
De Quesada, Gregorio J., New York.
Dudley, A. Palmer, New York.
Eastman, Robert W., New York.
Eliot, Ellsworth, New York.
Erdmann, John F., New York.
Flinn, Thomas W. P., New York.
Flint, W. H., New York.
Furman, Guido, New York.
Gouley, J. W. S., New York.
Harrison, Geo. Tucker, New York.
Holmes, Martha C., New York.
Hubbard, Samuel T., New York.
Janvrin, J. E., New York.
Ring, Ferdinand, New York.
Leale, Charles, New York.
Ludlow, Ogden C., New York.
Lukens, Anna, New York.
Lynch, P. J., New York.
Mackenzie, James C., New York.
Manley, Thomas H., New York.
McLeod, Johnston, New York.
McLeod, S. B. W., New York.
FELLO WS AT THE WINTET ANNUAL MEETING. 13
McLochlin, J. A., New York. Shrady, John, New York.
Milliken, S. E., New York. Shrady, John E., New York.
Mott, Valentine, New York. Silver, Henry M., New York.
Murphy, John, New York. Smith, J. Lewis, New York.
Murray, S.J., New York. Smith, Stephen, New York.
O’Brien, M. C., New York. Thompson, Van Beverhout, New
Ochs, B. F., New York. York.
Phelps, Charles, New York. Truax, J. G., New York.
Porter, P. Brynberg, New York. Wallach, J. G., New York.
Purple, Samuel S., New York. Weeks, John E., New York.
Rau, Leonard S., New York. Weston, Albert T., New York.
Ricketts, B. M., Cincinnati, Ohio. White, J. Blake, New York.
Ruggles, A. D., New York. White, William T., New York.
Sayre, Reginald H., New York. Wiggin, F. H., New York.
Shea, Dennis L., New York. Williams, H. Smith, New York.
ORANGE COUNTY.
Conner, M. C. Middletown. Wanderweer, J. R., Monroe.
ROCKLAND COUNTY.
Govan, William, Stony Point.
sullivan county.
Crocker, Edwin, Narrowsburg. Piper, C. W., Wurtsborough.
ULSTER COUNTY.
Wan Hoevenberg, H., Kingston.
WESTCHESTER COUNTY.
Acker, T. J., Croton-on-Hudson. Schmid, H. Ernst, White Plains.
NON_RESIDENT FELLOWS.
Murdoch, James Bissett, Pittsburg, Pa.
SUMMARY BY DISTRICTs OF FELLOWS IN ATTENDANCE.
First District, . e g © tº & * º 4
Second District, . e {} ſº e º e & 16
Third District, . te & . . e g * 19
Fourth District, . e e • s • o e g 21
Fifth District, & re e & e º e * 96
Non-Resident, . t tº e & ſº * s 1
Total, . & º tº gº g fo & gº 157
DELEGATES FROM OTHER MEDICAL ORGAN
ISATIONS AND INVITED
ATTENDANCE.
CONNECTICUT.
CHARLES D. ALTON, M. D., HARTFoRD,
INDIANA.
GEORGE D. KAHLO, M. D., INDIANAPOLIS,
MAINE.
B. B. FOSTER, M. D., Port LAND,
MARYLAND.
W. H. McCORMICK, M. D., CUMBERLAND,
MASSACHUSETTS,
EDWARD COWLES, M. D., SOMERVILLE,
FRANK S. PARSONS, M. D., NorthAMPTON,
MINNESOTA.
J. W. SCOTT, M. D., ST. CHARLEs,
RHODE ISLAND.
CHARLES O'LEARY, PROVIDENCE,
GUESTS IN
Delegate.
Invited Guest.
Delegate.
Invited Guest.
Invited Guest.
Invited Guest.
Invited Guest.
Delegate.
ADDRESS OF WELCOME AND REPORT OF THE
COMMITTEE OF APRANGEMENTS.
By J. G. TRUAx, M. D., of New York County, Chairman of the
Committee.
GENTLEMEN-Again it becomes my duty, as chairman
of the Committee of Arrangements, to welcome you to
this city, and to this, the ninth annual meeting of the
New York State Medical Association.
That it is a pleasure to us to see you coming, year after
year, to these meetings, needs not verbal expression that
it may be understood.
The efforts of your Committee of Arrangements to pro-
vide something which will in a measure compensate you
for loss of time, and the trouble necessarily connected
with a journey to this city, is proof sufficient that your
presence is appreciated.
In this connection I will take the liberty of informing
you, that it is not as easy a task as it might at first ap-
pear to be, to secure the matter within our own ranks for
a three-days’ session.
To some of you, more than one appeal is required be-
fore gaining your consent to take part in these exercises,
I know that this seeming unwillingness to write papers
for our annual meetings does not arise from want of in-
terest in our Association or its work, but rather from
fear that what might be offered would not equal in merit
that which further efforts on the part of your Committee
of Arrangements could secure. However becoming this
modesty may be, one can readily realise that it does not
lessen the labor of those whose duty it is to secure the
material for a meeting. The existence of such a con-
dition of affairs might be accounted for on the ground,
that for no kind of work is the physician overpaid, or
paid too quickly; and in this, the hardest field of labor,
16 NEW YORK STATE MEDICAL ASSOCIATION.
his reward comes late, if ever. Not for a moment would
I have you think that the chairman of your Committee
of Arrangements has ever become discouraged. So much
willingness on the part of many Fellows to perform any
labor imposed upon them by your chairman, has pre-
vented any such feeling from taking possession of him.
Our Association is growing all the time, yet a little more
effort on the part of each Fellow, to secure new members,
would add greatly to our numbers, as well as to the in-
fluence we exert upon the profession at large, and upon
the public. Your chairman is particularly anxious that
the growth of the Association may be very rapid during
the year to come. He is perfectly satisfied, judging from
the success of his own efforts in this direction in the
past, that enough new desirable men can be secured
during the next year, to bring Our membership to num-
ber a thousand. Will you encourage us by doing what
you can in this direction ?
There are to be two addresses—one by the president,
Judson B. Andrews, M. D., of Erie County ; and the
other by Frederic L. Dennis, M. D., of New York
County. The discussions, which have been a feature of
so much importance in the programmes of the past, have
been omitted this year.
Altogether, there are forty-six subjects to be con-
sidered by forty-four speakers. These contributions
come from the five districts of the State, and from sister
States, in the following proportions:
The First District, 2
Second ‘‘ 2
Third ( 6 3
FOUlrth. “ 8
Fifth % ( e 27
State of Massachusetts, 2
& C Indiana, 1
( & Ohio, 1
District of Columbia, 1
ADDRESS OF WELCOME. 17
In the five districts, Fellows of the Association from
eleven counties contribute essays in the following pro-
portions:
First District, Montgomery County, 2
Second ‘‘ Rensselaer 6 ( 2
Third ‘‘ Cortland ( & 1
“ “ Onondaga ( & 2
Fourth ‘‘ Erie Ç G 6
{ % & 4 Wayne { % 1.
{ % ( & Monroe { % 1
Fifth { % New York & 6 23
( & { % King|S & C 2
& 4 { % Dutchess & 6 1
{ % { % Westchester { % 1
If no time be lost, and the discussions are confined to
the ten minutes allowed to each person, your committee
is of the opinion that two evening Sessions, in addition
to the regular morning and afternoon sessions, will be
sufficient. The morning sessions will be opened at nine
o'clock, the afternoon sessions at One, and the evening
Sessions ath alf-past seven. One paper has been re-
ceived since the distribution of the official programme;
it is by B. Merrill Ricketts, M. D., of Cincinnati, Ohio.
PRESIDENT'S ANNUAL ADDRESS.
*=====e
THE ALIENIST AND THE GENERAL PRACTI—
TIONER. .
BY JUDSON B. ANDREws, M. D., of Erie County.
Movember 15, 1892.
The student of to-day appreciates as never before the
Constant widening of the field of medical knowledge, and
realises the impossibility of becoming equally proficient
in all the varied departments which have been developed
during recent years. He is also forced by the logic of
events to acknowledge that much of the real progress
in medicine is due to the zeal and patient research of the
skilled specialist. The division of labor implied by the
term, the outcome of our advancing civilisation, is com-.
mon to all the arts and sciences, and is true evolution in
medicine. It has wrought such changes that the general
Dractitioner, who formerly decried the specialist, now
joins hands with him in the effort to benefit humanity.
Experience has made them friends, and the family physi-
cian Willingly summons him to his aid without distrust,
Or the fear that he may lose the confidence of his patient.
To properly sustain his position the specialist must be
thoroughly trained, first, as a physician, and secondly, in
the branch in which he assumes to be skilled; otherwise
his knowledge is superficial and inexact, and his view is
narrowed down to his personal horizon, as he sees only
through his own myopic glasses. Breadth of vision
comes only from breadth of knowledge. Specialism
Suffers more from pretenders, who without sufficient
education in the general science of medicine, and with
but a Smattering of special training, assume to possess
peculiar skill, than from the opposition or distrust of
TEIE PRESIDENT'S ANNUAL ADDRESS, 19
the general physician. Like all other frauds they are in
time discovered and relegated to their true position in the
profession. The opportunities for acquirement are too
many, and the demands of the public are too great, to
allow ignorance to flourish, or to excuse its existence,
least of all in the man who makes pretense of Special
medical skill.
As all specialties are but an outgrowth from the
general field of medicine, no one can successfully divorce
them, or even bring them into conflict. This inter-
dependence places an obligation upon the general practi.
tioner to acquire a degree of knowledge of the various
departments of medicine. While, for instance, he may
not be able to perform the most delicate, or the major
operations in surgery, he must at least have such a
familiar acquaintance with the subject, as will enable
him to seek the aid of the surgeon when the need of his
patient demands it. It is only during the past few
years, however, that it has been possible for him to attain
such knowledge; but now the longer curriculum and
the increased number of instructors in our medical
schools, place it in the power of the student to gain an
acquaintance with the various departments, as he has
the advantage of both didactic and clinical illustration
in the recognised special courses.
There are, however, some specialties which, till within
a recent period, have been separated and kept to a large
degree distinct from the general practice of medicine,
and among them is that of the alienist. The reason for
this state of things is to be found in the peculiar nature
of the disease, which made it impossible to care for the
insane at their homes, and rendered it necessary to
Commit them to institutions erected for their care and
treatment. As the physician was thus compelled to
intrust his patient to those in charge of asylums, he lost
interest in the conduct of the case, and also the incen-
tive to fit himself for taking charge of this class of
patients. It was enough for him to recognise the
20 NEW YORK STATE MEDICAL ASSOCIATION.
existence of mental disturbance, and then to adopt
measures to relieve himself of the responsibility in-
Volved in the treatment. When sent to an asylum, the
patient passed completely from the control of the
family physician, who, either because of distance, or
lack of opportunity, rarely or never visited his patient,
or kept himself informed of his progress. Another fact
which in part accounts for the separation of the alienist
from the general practitioner, is that no instruction was
given in the medical schools upon the subject of insanity.
It was not recognised as a physical disease, but was
believed to be induced by some occult power, little
understood, and still less investigated. The metaphysi-
cal idea of insanity, the remnant of the old view that it
was the result of divine displeasure for sins committed,
had a perverting influence, not only in the lay mind,
but even in the medical profession. Those of us who
graduated from medical schools prior to twenty years
ago, and I might make the number of years even less,
received little, if any instruction on the subject of
insanity, and many of us never heard the disease men-
tioned by our instructors, or found it treated of in any
intelligent way in the text-books on practice. It was
inevitable that those who were in charge of asylums
should be a class by themselves, and looked upon as
possessing a certain knowledge and skill which was
denied the rest of the profession, and that under all
these conditions, the study of the mind, as it was popu-
larly called, should be a sealed book to the general
practitioner. Another reason why the subject of insanity
did not claim general attention in the profession, was
the fact that the laws of commitment to asylums, either
did not demand certificates of lunacy to be made out, or
if they did require them, they only registered the
opinion of the physician, and not the reasons on which
that opinion was based. This rendered unnecessary any
study of the disease, and was simply giving a bonus to
ignorance. Nearly all experience and knowledge which
THE PRESIDENT'S ANW UAE, ADDRESS. 21
was of any real value, was centred in the few superin-
tendents of asylums which existed in the State, and
these were numbered, almost if not quite, by the fingers
of one hand. There were a few exceptions to this rule,
for the profession has always counted among its num-
bers some men who, like our venerable friends, Pro-
fessors Moore and Cronyn, were equipped in this, as in
other specialties.
According to the report of the Illinois State Board of
Health for 1891, there are, in the United States and
Canada, one hundred and forty-eight medical Schools
and colleges, and in fifty-three of them, lectures are
given on the subject of insanity, and in seventy-five of
them, in diseases of the nervous system. This is cer-
tainly an indication of progress in medicine during the
past twenty years. This progress is not confined to this
continent, and is even more marked among other nation-
alities. In Great Britain, the medical council has added
to the general course the study of insanity, and has made
examinations and clinical instruction an obligatory part
of the five years' course of medical education. The vari-
ous institutions for the care of the insane which are
located in proximity to medical schools, are Opening
their doors for clinical instruction, and the positions of
teachers are being largely filled by the superintendents of
asylums.
In this country, attendance upon lectures on insanity
has been made compulsory in but few of the schools.
Others will no doubt soon be added to the number, and
all should demand at least a passing knowledge of the
Subject from each of their graduates. The instruction
should be of a practical character. Lectures given by
those who have but a theoretical acquaintance with the
Subject, derived from reading and study, without ex-
perience in the treatment of the insane, can, in the nature
of things, be of little practical utility to the student.
Years ago the importance of instruction in insanity at-
tracted the attention of some of the ablest men in the
22 NEW YORK STATE MEDICAL ASSOCIATION.
specialty. To Dr. Gray, of Utica, one of the early
presidents of this association, the profession owes a debt
of gratitude for his persistent and self-sacrificing labors
in behalf of instruction in this branch. His lectures,
among the first delivered in this city, were marvels of
that clearness and precision which come only from inti-
mate knowledge of the subject, and from personal care
of the insane.
The value of this knowledge to the general practitioner
can hardly be overestimated. He is called upon to make
the diagnosis, and to express his opinion as to the needs
of his patient who is suffering from mental disturbance.
Without instruction he is helpless, and proves but a
broken reed to the family, when he should be the firm
support. Many cases of insanity are kept at home dur-
ing the early period of the disease, when the chances of
recovery, under proper care and treatment, are hopeful,
from ignorance of the real condition. Too often, cases
of melancholia are allowed to drift on to death by Sui-
cide, from the lack of appreciation of the danger which
threatens. It is painful to hear of a patient sent from
home to a distant point, under the delusive hope that
change of climate or of surroundings will effect a cure,
when from his depression and self-absorption, the indi-
vidual is unable to appreciate his condition, or cannot
be roused from the all-pervading mental gloom which
enshrouds him, and when he demands kind, intelligent
nursing, and the closest attention to his condition in
order to effect the re-establishment of his normal, mental
and bodily health.
With obligatory instruction in mental diseases, made
a part of the curriculum of study, there would be a more
correct appreciation of mental states, and an earlier diag-
nosis of the existence of disease ; a more intelligent
treatment would be adopted, and as a consequence, the
statistics of recovery would be more favorable. There
would also be fewer medico-legal cases, and a marked
diminution of will contests. Patients far advanced in
THE PRESIDENT'S ANNUAL ADDRESS. 23
dementia, or suffering from general paralysis of the in-
sane, would not be received into hospitals and the friends
given a favorable prognosis, and we would hear much
less from physicians and from the friends of patients
about the diagnosis of “brain softening” in simple, and
often curable cases of insanity.
The law now makes it the duty of the physician to
fill out certificates of lunacy, and in them to record the
reasons for his belief in the insanity of the patient.
They should, and with a proper knowledge of the Sub-
ject on the part of the physician, would contain such
valid reasons on which the belief in lunacy was predicated,
as would carry conviction, and even satisfy a jury of their
sufficiency. The simple statement—I quote from a cer-
tificate—that “he presents the usual symptoms of chronic
dementia,” would not shield a practitioner from a suit
for false imprisonment upon insufficient grounds for his
commitment to an asylum, unless there actually existed
more cogent reasons for such a step ; and if they do exist,
why should not they be distinctly stated in the certi-
ficate % Fortunately the facts of the case generally sus-
tain the physician more strongly even than his statement
in the certificate. The fundamental fact which the cer-
tificate should express is too often ignored, viz.: the
change in the individual, in his mode of feeling, think-
ing, or acting, based upon the physical changes induced
by disease ; or, stating it in correct order, first the phys-
ical changes, and then the departure in mental states.
Certificates thus formulated will stand the required test,
and will meet the demands of the State authorities who
Supervise the papers of commitment.
I do not wish or intend to arraign the physician, but
simply to point out the direction in which improvement
can be made, and which will naturally follow the better
facilities for instruction enjoyed by the younger men in
the profession.
Although the family physician so generally recognises
the presence of insanity when it occurs in his patients,
24 NETW YORK STATE MEDICAL ASSOCIATION.
and also the necessity of treatment, I can but think he
Sometimes neglects to enforce preventive measures in
cases where his influence might avert the threatened
danger. It is during early life and the period of develop-
ment that the greatest care should be exercised, and
the physician should interpose his authority for the
good of his patient. The duty of the physician, as well
as the parent, during these periods, is well stated by Dr.
Clouston in his recent work on “The Neuroses of
Development.” He teaches, as all alienists and neurol-
ogists do, the doctrine of nutrition to its fullest extent.
His advice is summed up in this sentence: “Fatness,
Self-control, orderliness, are the three most important
qualities to aim at. Build up the bone, and fat, and
muscle, especially the fat, by any means known to us,
during the period of growth and development.” There
is nothing so conducive to nerve equilibrium as a
fully nourished body, for it gives repose and freedom
from irritability. Stated in a general way, it is the
poorly nourished and the ill-developed who suffer from
the neuroses which are so often the precursors of insanity.
Give to children fresh air; withhold from them
nitrogenous and stimulating foods during the period of
development of the reproductive function; repress the
imaginative faculties, and develop the lower centres in
all of the mentally active and precocious; let the
education and growth of the body take precedence,
and that of the mind will naturally and healthfully
follow. Finally, promote order, method, and system.
They are most important elements of mental health, as
well as of success, and are especially lacking in the
weakly neurotic."
Another direction in which the family physician can
exercise control in the way of prevention, is in opposing
ill-advised and ill-assorted marriages among the neuro-
tic, the epileptic, and insane. The extent to which the
uneducated indulge in these unions, and their indiffer-
1 Clouston.
TEIE PRESIDENT'S ANNUAL ADDRESS. 25
ence to the danger thus incurred, are sufficient to arrest
the thoughtful attention of those familiar with the facts.
Within a few days there was admitted to the hospital
under our charge, a patient who had been epileptic for
years, and yet had married only three weeks before his
admission. The result was a series of epileptic attacks,
accompained by maniacal violence and homicidal ten-
dencies. His friends urged the step in the belief that
marriage would cure the fits.
It is not an uncommon occurrence for the friends and
relatives of a man whose sexual powers have been
weakened by secret habits, to seek an alliance with some
unsuspecting woman, in the hope of effecting a cure ;
and, on the other hand, it is not rare for the friends of a
hysterical, enfeebled woman, whose reproductive func-
tions have been blighted by some of the various disorders
common to the sex, or who has suffered from insanity,
to scheme to arrange a marriage, which will relieve them
from the burden of caring for her. What must be the
baneful results of such marriages to the individuals, to
their posterity, if they have any, and to the community
which is generally called upon to support, not only the
progeny, but often the parents Then there is the large
class of defectives, the higher grade imbeciles, who are
allowed to form marriages without let or hindrance. I do
not doubt that every practitioner of years, who may
read these remarks, can recall instances of one or of all
of these very cases. We cannot lay the blame at the
door of the medical man, but it may lead us to inquire
of ourselves whether we have done our whole duty in
educating the people and informing them of the danger
incurred, or in arousing a public sentiment against the
COnSummation of such wicked frauds.
It is in these two directions of caring for the young
during the developmental period, and in preventing
union between the defective classes, that much can be
accomplished in the way of preventing mental disorders.
Add to this the care of the general health in other cases
26 NEW YORK STATE MEDICAL ASSOCIATION,
not included in the above, and the medical man has
exhausted his resources in the way of prevention.
It is often easy, after the actual occurrence of an attack
of insanity, to look back over the history of the case,
and note the causative influences which have led up to
the final catastrophe, and Sometimes to see how this
might have been avoided if entire control of the patient
could have been exercised. This is, however, impossible
in most cases. The physician is overpowered by the
environment of the individual. The absolute necessity
for hard, grinding toil, even to the breaking down of
health, in the effort to support a family, and the fret and
worry of life, are stronger than all the advice and en-
treaty of the physician, who perhaps foresees the end
from the beginning. Relief is only obtained when, from
the open outbreak of the mental disorder, the strong
hand of the law steps in and consigns the unfortunate
individual to the hospital provided by the kindly charity
of the public. Such an array of facts leads the alienist
to sympathise most heartily with the general practitioner
in his difficulties in the treatment of insanity, and
cements more firmly the bond of union between them.
It is to the greater confidence of the general profes-
sion in the asylums of the State, that their growth and
success is in a great measure due. The last census
report attributes the increase of patients under care in
asylums, to a greater willingness to place these unfortu-
nates in such places, as a consequence of increased con-
fidence in the conduct of hospitals for the insane. The
basis of this confidence is found in the improvements in
these institutions, due to the promotion of the hospital
idea in the treatment of the insane, to the greater indi-
vidualisation rendered possible by the increase of medical
Officers, to the change made in appointments after Civil
Service examinations of both officers and attendants, to
the wonderful improvement in the service brought about
by the introduction of training schools into hospitals for
the insane, and to the supervision of a legally constituted
THE PRESIDENT'S ANNUAL ADDRESS. 27
Lunacy Commission. These are the steps of progress
which have placed the hospitals of our State in the front
rank of like charitable institutions of the world, and in
all of these measures the State of New York took the
initiative. If to these we add the restriction of mechan-
ical restraint, the employment of patients, the improve-
ments in construction resulting from the introduction
of hospital and infirmary wards, and of nurses’ homes,
the greater attention to moral treatment by a resort to
varied means of entertainment, and by the use of
physical culture, and lastly, and most important, the
general employment of night nursing, we present a con-
densed retrospect of the improvement in our hospitals
for the insane, which rightly enlists the confidence of
the profession and of the community. This confidence
is shown not only in the large number of patients com-
mitted under certificates by general practitioners, but
by the interest manifested by them in the conduct of the
various hospitals of the State. The very progress made
by these hospitals has been rendered possible only by
the support of the profession. The former barriers
having been thus broken down, the alienist is brought
into closer relations with his professional brethren.
As indicating the tendency of the times, I quote a cir-
cular recently issued to the Managers of State Hospitals
by the State Commission in Lunacy.
ALBANY, Nov. 10, 1892.
THE CLINICAL TEACHING OF INSANITY IN PUBLIC
HOSBITALS FOR THE INSANE.
To the Managers of State Hospitals:
The Association of Medical Superintendents of American Institutions
for the Insane, at its annual meeting, held at Toronto, Canada, in 1871,
adopted the following resolutions:
Resolved, That, in view of the frequency of mental disorders among
all classes and descriptions of people, and in recognition of the fact that
the first care of nearly all these cases necessarily devolves upon physicians
engaged in general practice, and this at a period when sound views of the
disease and judicious modes of treatment are specially important, it is the
unanimous opinion of this Association, that in every school conferring
medical degrees, there should be delivered, by competent professors, a com-
28 NEW YORK STATE MEDICAL ASSOCIATION.
plete course of lectures on insanity and on medical jurisprudence, as con-
nected with disorders of the mind.
Resolved, That these lectures should be delivered before all the students
attending these schools, and that no one should be allowed to graduate
without as thorough an examination on these subjects as on the other
branches taught in the schools.
Resolved, That in connection with these lectures, whenever practicable,
there should be clinical instruction, so arranged that, while giving the
student practical illustrations of the different forms of insanity and the
effects of treatment, it should in no way be detrimental to the patients.
Since the adoption of these resolutions public sentiment has become
more pronounced in favor of carrying out their purpose and spirit.
The fact that insanity is a far more frequent and serious disease than
many others, the nature and symptoms of which medical students are re-
quired to possess a practical knowledge before being permitted to gradu-
ate, renders it of the highest importance to the general public that a wider
diffusion of correct knowledge of the disease and of its proper manage-
ment, particularly in its early and most curable stage, should obtain
among the medical profession. This is especially important, in view of the
fact that, in a large majority of cases, the presence of the disease, in the
first instance, must necessarily be determined by the general practitioner—
usually the family physician.
Citizens of the State, of all classes, could not fail of being benefited by
the diffusion of a practical knowledge of the subject among the general
medical profession. The recognised want of such knowledge is largely
due to the fact that, with few exceptions, it is only within a comparatively
recent period that this important branch of medical science has been sys-
tematically taught in medical schools. Furthermore, it is well known that
but few of the schools wherein such teaching is now had are able to pro-
cure the necessary material for clinical instruction in psychiatry outside of
hospitals for the insane; and inasmuch as it is only from public institu-
tions that such material can be drawn, it would seem that no greater ob-
jection could properly be raised to the giving of such instruction, under
proper restrictions, in hospitals and asylums for the insane, than to the
clinical teaching of other branches of medicine in general hospitals, a prac-
tice which now extensively prevails throughout the civilised world.
There being large numbers of patients in the public hospitals for the
insane who would offer no objection to the giving of clinical instruction to
students of medicine in their presence, the commission would earnestly
recommend that the Board of Managers of the several State hospitals
afford to medical colleges situated in their vicinity, as well as to the prac-
ticing physicians who may desire to avail themselves of the privilege,
such facilities for the clinical study of mental diseases, as in the judgment
of the medical superintendent may be wise and proper.
By the Commission.
T. E. McGARR, Secretary.
THE PRESIDENT'S ANW UAL ADDRESS. 29
This recommendation of the Commission has its in-
spiration in their desire to give to the student of medi-
cine an opportunity to enter this field of study, which,
until a comparatively recent time, has been so much
neglected by a large part of the medical world. It gives
authoritative sanction to clinical instruction in the State
hospitals, which, if properly utilised, will advance edu-
cation in our medical schools, and place it within the
power of every physician to equip himself more thor-
oughly for the duties and responsibilities of professional
life.
In closing, we would enforce the plea for making the
study of psychological medicine obligatory upon all
students, and would urge upon our schools the necessity
of adding the theoretical and clinical study of insanity
to their curriculum. It is done in Great Britain ; why
should it not be done in America .
PNEUMOTOMY FOR RELIEF OF TUBEROULAR
ABSCESS AND GANGRENE OF THE LUNG;
TWICE ON THE SAME PATIENT.
RECOVERY.
By John BLAKE WHITE, M. D., of New York County.
Movember 15, 1892.
Up to nearly twenty years ago the annals of Surgery
were silent respecting operative procedures upon the
lungs. Dr. Rickman J. Godlee, a well-known authority
on this subject, considers the surgical treatment of
pulmonary cavities to be still in its infancy, and believes
that it is destined to be more frequently employed, and
with better results. While it is quite true that the
great father of medicine, two thousand years ago, re-
ferred to abscesses located within and without the lung,
and even defined the point of selection for operating and
draining them, to Estlander belongs the credit of Origi-
nating and establishing in our day the surgical treat-
ment of diseases of the lungs.
It is in this class of cases especially that a prompt and
correct diagnosis is an essential condition to cure. As
Soon as the character of the case has been determined,
operative procedures should at once be instituted, for,
although Ordinary abscess of the lung may terminate in
recovery, no case of gangrene of the lung has been known
to recover without surgical interference. I purposely
exclude from consideration in this paper all empyemas,
confining my remarks strictly to pulmonary abscesses.
Morton, of Philadelphia, in 1837, in his work on con-
Sumption, related a very interesting case of tuberculous
abscess of the lung, communicating by a fistulous canal
PWEUMOTOMY. 31
with an abscess on the back. With our present knowl-
edge, this case would probably not have terminated
fatally. The patient, previous to his admission to the
hospital, had a slight cough, accompanied by severe
pain between the shoulders, especially on the right side,
and by haemoptysis. After a time a swelling appeared
on the right side of the chest between the base of the
scapula and the spine. Two months later there was
hectic, with profuse and purulent expectoration and oc-
casional haemoptysis. The tumor was elastic, and evi-
dently contained air. After internal medication had been
used ineffectually for six weeks, the tumor ruptured
spontaneously, and discharged a large quantity of
foetid pus, of the same character as that expectorated.
The opening was then enlarged, and a pint of pus
evacuated ; but the relief was only temporary, and the
patient died four days later, no doubt from septicaemia.
Dr. Samuels," has reported a case seen by him in the
London Chest hospital. There were the physical signs
of fluid in the chest, considerable fever, night-sweats,
and abundant foetid expectoration.
Upon inserting an aspirating needle between the fifth
and sixth ribs, two ounces of foetid pus were withdrawn.
This was followed by considerable tumefaction at the
site of puncture, and on incising this, about three ounces
of pus escaped. The cavity was washed out and drained.
Subsequently the seventh rib was resected, and a cavity
in the lung the size of an orange was discovered. The
patient died suddenly on the fourteenth day, immedi-
ately after an epileptiform seizure, in which there was
paralysis of the right arm.
Dr. A. W. Meigs” has reported the case of a boy, eight
years old, who had been ill for three years previous to
Coming under his care. The trouble began with an acute
abscess of the lung. Examination of the right lung
revealed dullness in the region of the third rib, with
*Medical Press and Circular, 1887.
*Archives of Pediatrics, 1887.
32 NEW YORK STATE MEDICAL ASSOCIATION.
“cracked-pot” sound extending down to the liver. The
respiratory sounds were harsh ; there was prolonged ex-
piration at the base of the lung posteriorly; and here
the respiration was feeble and harsh, and percussion
showed dullness over this area. Large quantities of
pus were expectorated after violent paroxysms of
coughing. Dr. Meigs believed from the symptoms and
distinctly clubbed fingers, that there was a cavity in the
chest containing pus. An incision was made, free drain-
age was established, and the patient recovered.
The following case of gangrene of the lung cured by a
surgical operation has been reported by Drs. Paul and
Perier : *
A man, fifty-eight years of age, was attacked by a
severe bronchitis, and soon developed all the symptoms
of gangrene and of Septicaemia. Cavernous sounds were
most intense over the second intercostal space, so Dr.
Perier made an incision here, seized the lung with a pair
of very fine forceps, and kept it in contact with the pari-
etal pleura while an incision was made into the lung,
and the wound enlarged with forceps. On introducing
the finger, a round opening was felt. After thoroughly
cleansing this cavity, two drainage tubes were inserted
side by side, and the wound closed. Air circulated
freely through these tubes at each inspiration and
expiration. The fits of coughing ceased at once, the odor
disappeared from the sputa, and the fever subsided. Two
weeks after the operation, the drainage tubes were re-
placed by a piece of Salol gauze, and at the end of seven
weeks the wound had healed, and the patient was com-
pletely restored to health.
Dr. Runeberg,” of Sweden, has described a successful
case of pneumotomy for pulmonary abscess following
pneumonia, and has collected eleven similar cases. Dis-
carding three of these on account of uncertainty as to
the diagnosis, there remain eight cases, three of which
1 Bulletin de l'Académie de Médecine.
* London Medical Record.
PWEUMOTOMY. 33
resulted fatally, though death was not attributable to
the operation. He believes pneumotomy indicated when
the diagnosis is clear and the abscess accessible, but
deprecates the use of antiseptic irrigations, as he con-
siders thorough drainage sufficient.
Among other authorities may be mentioned Dr. Arthur
Neve," who reported a case of abscess in the upper and
anterior part of the right lung, which was operated upon
successfully. Drs. Bearman and Pengreuber” have re-
ported a case of pneumotomy for the relief of an abscess
located in the middle portion of the right lung. M.
Pasteur” has recorded a very interesting case of gangrene
of the lung occurring in a boy seven years of age. The
amount of repair which took place under unfavorable
circumstances was most encouraging, and seemed to
indicate that an earlier operation might have saved the
patient’s life. Thiriar * has operated successfully upon
a case for the relief of an empyema, communicating with
an abscess cavity in the right lung.
I now ask your attention to the following case, which
occurred in my own experience: On April 8, 1889, Miss
A—, thirteen years of age, having a tubercular family
history, was attacked with croupous pneumonia of the
right lung. During this illness she was under the care
of Dr. T. A. Pease, of Norwood, N. Y., and was also
Seen in consultation by Dr. J. Reynolds, of Potsdam.
The pneumonia ran a favorable course, and, as Dr. Pease
reported, reached a crisis on the morning of the ninth
day, when resolution began, and from that time on the
patient improved rapidly, so that the temperature, pulse,
and respiration became normal within three weeks. At
this time there was no cough or expectoration except
that resulting from a chronic catarrh of the air passages,
to which she had been subject since she was three years
* London Lancet.
* New Orleans Medical Journal.
* London Lancet, Oct. 20, 1889.
* La Semaine Medicale.
34 NEW YORK STATE MEDICAL ASSOCIATION.
of age. At the end of the second week of convalescence,
the temperature rose to 102° F., the respiration became
more labored, the cough spasmodic, the expectoration
difficult and scanty, and there was very pronounced
pain and tenderness about the affected side. Dullness
on percussion now extended from the angle of the
scapula until it involved the entire lower half of the
lung, both anteriorly and posteriorly. The case was
now believed to be one of interstitial pneumonia with
fibroid degeneration and infiltration. This condition,
with temporary improvement and relapses, and with
marked disturbance of the digestive functions, continued
until the case passed out of the hands of Dr. Pease.
The care of the case next devolved upon Dr. Reyn-
olds, of Potsdam, who continued in attendance until
January 1, 1890, when the patient was taken to the
Adirondacks for several weeks, whence she was brought
to New York. Soon after her arrival in New York, I
was summoned to see her, and upon examination, found
her suffering from an acute broncho-pleuro-pneumonia
engrafted upon an old unresolved pneumonia, which had
degenerated into a fibrosis of the right lower lobe, and
a part of the middle lobe. She was under my care about
two weeks. After she had recovered sufficiently from
the attack, she was carried to Thomasville, Ga., where
she remained under the care of Dr. Cortelyou until the
end of the following spring, when she returned to Nor-
wood. Soon after reaching home, she was again placed
under the care of Dr. Pease, from whom I received the
following account of her condition:
“Miss A– coughs less than before her trip South,
and her respiration is improved, though marked dullness
is present over the central portion of the right lung, with
loud, moist rāles on auscultation. Last evening she was
brought into my office, retching, vomiting, coughing and
expectorating an intolerably foetid greenish matter. She
continued to expectorate large quantities of this offensive
Sputa, and was frequently harassed by violent par-
PWEUMOTOMY. 35
Oxysms of coughing, accompanied by most painful irri-
tation of the larynx, and frequent emesis.”
All internal remedies judiciously and skillfully em-
ployed by Dr. Pease having proved unavailing, and the
case increasing in gravity, a consultation was determined
upon, and I was called to Norwood. On my arrival,
July 26, 1890, I proceeded, in company with Dr. Pease,
to examine the patient, and we speedily came to the
conclusion that a large area of the right lung had become
gangrenous, and that there was an abscess communicat-
ing with a bronchus. An exploratory puncture con-
firmed this diagnosis. The patient presented a pinched
and extremely cachectic appearance; indeed, her condi-
tion seemed in every respect so critical that we thought
no time should be lost, and determined to operate at an
early hour on the following day.
Assisted by Drs. Pease and Larkin, of Norwood, the
patient being under the influence of chloroform, I pro-
ceeded to make an incision in the sixth intercostal space,
about one inch anterior to the axillary line. The dif-
ferent layers of tissue, including the pleura, were in
turn divided, and a careful examination made of the
Seat of the lesion. When the finger was pushed through
the intercostal space, it came in contact with the smooth
Outer surface of condensed lung. A fluctuating spot
Was discovered, through which the point of the knife
Was directed. This liberated about two ounces of very
foetid pus, having the same odor as that which had been
expectorated. The wound was next irrigated with an
antiseptic solution, a drainage tube inserted, and anti-
Septic dressings applied.
The patient slowly rallied after the operation, with the
aid of hypodermic injections of brandy and digitalis.
There was an immediate relief of all distressing symp-
toms, and after a few days of depression, she began to
improve, and continued to gain strength until the dis-
charge ceased. The cavity continued to drain, until, at
the expiration of two months, the discharge was so re-
duced that it was judged expedient to remove the tube.
36 WEW YORK STATE MEDICAL ASSOCIATION.
However, a month after the removal of the tube, urgent
symptoms again set in ; there was a distressing, paroxyS-
mal cough, with fever, and such an offensive greenish
expectoration that it often excited nausea and vomiting.
Dr. Pease discovered an area of dullness in the posterior
aspect of the lower right lobe, and again summoned me
to visit the patient, which I did on the 22d of September,
1890. Upon examination, I found quite a favorable con-
dition about the seat of the previous operation, but dis-
covered a region of decided dullness in the posterior
part of the lower lobe, extending upwards under the
angle of the scapula. With the assistance of Dr. J.
Reynolds, of Potsdam, and Drs. Pease and Larkin, of
Norwood, I re-opened the thorax, one inch posterior to
the axillary line. There was present the same condi-
tion of the lung as at the first Operation. On Opening
the cavity, several ounces of very foetid pus escaped,
along with fragments of necrotic tissue and a portion of
gangrenous lung containing the remains of a well-defined
ruptured bronchus. A good-sized soft rubber tube was
inserted, and after thoroughly washing the wound with
an antiseptic lotion, appropriate dressings were applied.
For three weeks there was a free discharge of foetid pus,
but the patient was immediately relieved of cough, ex-
pectoration, and septicaemic symptoms. Air circulated
freely through the drainage tube, on both inspiration
and expiration, and often, during the process of irrigat-
ing the cavity, the antiseptic solution would be coughed
up. The tube was not removed for eight months.
Two years have elapsed since the last operation, and
the patient now has better health than she enjoyed in
early childhood. The menstrual function, which had
been arrested during her illness, was re-established in the
November following the last operation, and was accom-
panied by a marked disturbance of the whole system.
The clubbed finger nails which so disfigured her hands
have disappeared. She is able to take a full amount of
exercise, and is at present in perfect health.
PWEUMOTOMY. 37
In this case, regular irrigations with a mild solution
of peroxide of hydrogen proved decidedly beneficial.
Nevertheless, there is every reason for the exercise of
great caution in the irrigation of pulmonary cavities.
The danger of too frequent and indiscriminate irrigations
of pus cavities in the lungs, is strikingly shown in a case
reported by W. Pasteur,” of London, in which the pa-
tient was signally relieved by the operation, but sank
rapidly on the tenth day. Bowditch, of Boston, con-
demns too diligent washing out of pus cavities, pul-
monary and pleural—an opinion which meets with my
support ; and he further ventures the statement that the
proportion of cases in which irrigations might be re-
quired, is possibly one in four hundred. I am, however,
of the opinion that in gangrenous cavities, such as the
one under consideration, irrigation is safer than in cavi-
ties discharging laudable pus. I have seen, in consulta-
tion, an instance of metastasis to the shoulder joint,
which promptly followed irrigation of a pleural pus
sac. So serious was the involvement of the joint, that
an operation was required for its relief. The patient,
however, ultimately made a good recovery, without any
impairment of the use of the joint.
In the performance of all operations on the lungs, the
strictest and most diligent observance of antisepsis
should be unfailingly carried out. Cases of gangrene of
the lung are never too far advanced for surgical inter-
ference, even though presenting evidences of profound
Septic contamination. Spillman and Haushalter con-
sider it necessary to excite adhesion of the pleura before
Operating, but I do not consider this an essential pro-
Cedure, and though it may be a more favorable condition
under which to operate, delay for pleural adhesions to
OCCur, might prove, in some instances, decidedly unsafe.
Resection of the rib is seldom required in the very
young, except to facilitate the discovery of an abscess in
Obscure cases.
* British Medical Journal, Oct. 20, 1888.
38 NEW YORK STATE MEDICAL ASSOOIATION.
The corrugated white rubber tubing similar to that
herewith exhibited, and used in the case just reported,
proved far more useful for the purpose of drainage than
the ordinary soft rubber tubing usually employed. My
attention was first called to the value of this kind of
tubing for drainage tubes, by Dr. Egbert H. Grandin. I
have found it much less liable to compression, and the
resulting occlusion of its calibre by the intervention of
granulation tissue, and I feel quite Satisfied that it main-
tains better, as well as longer drainage, in addition to
its being as well tolerated by the patient.
DISCUSSION.
DR. J. G. TRUAx, of New York county, said he wished to thank the
author for his paper, and also to add his own experience on this subject.
Within the last five years he had operated twice for abscess of the lung.
In one case, that of a child about eight years of age, he simply performed
aspiration of the lung, and the child made a good recovery. The second
case was a male adult, from whom he removed a portion of a rib, opened
the abscess, introduced a tube, and kept up irrigations for about two
years, during all of which time there was more or less discharge from the
abscess cavity. He had not been able to obtain the man's subsequent
history, but he had been informed that the patient was now dead. Twice
the tube was removed, and the external wound allowed to heal over ; but
both times he was compelled to re-open the wound on account of the pent-
up discharges. His cases had never been published, and he could not
recall all the details, but they fully confirmed the statements made in the
paper.
DR. E. D. FERGUBON, of Rensselaer county, wished to Bay in connec-
tion with the specimen of rubber drainage tubing which had been ex-
hibited by the author, that a drainage tube should possess two essential
qualities, viz., one, the ability to maintain its tubular character, and the
other, sufficient elasticity to prevent doing harm to the walls of the cavity
in which it rest8. In the walls of a pulmonary cavity, for instance, it is
Quite possible, if the tube be allowed to remain for a considerable time,
for a process of ulceration to be cstablished by the portion of the tube
lying within the cavity; and this might occur even with tubes having the
firmness of those just exhibited. IIc was satisfied that in draining such
an Organ a8 the lung or the kidney, considerable judgment is required to
determine the proper structure and resiliency of the tube to be employed.
In his own practice, he had 80ttled this point by employing a double tube;
the Outer one, which passes through the parietes, or through a sinus,
where the pressure is considerable, being more resilicnt to lateral com-
pression than is the inner tube, which is much Hoſter, but still sufficiently
firm to keep its form and Secure proper drainage.
TRAUMATIC OSTEO_ARTHRITIC LESIONS WHICH
INVOLVE THE PROXIMAL SEGMENT OF
THE ANKLE_JOINT : THEIR PATH_
OLOGICAL ANATOMY AND
TREATMENT.
By THOMAS II. MANLEY, M. D., of New York County.
November 15, 1892.
Physical violence is frequently a cause of more or less
serious injury to the anatomical structures which com-
pose the ankle-joint. There are few who have reached
or passed middle-life, who have not at some time so
wrenched this articulation, that they have experienced
more or less temporary inconvenience.
The ankle-joint, though subjected to the greatest
strains, manifests in a singular degree the power of
resisting inflammation, and is seldom permanently an-
chylosed as a consequence of vulnerating force. Al-
though classified by anatomists as a ginglymus, never-
theless, well-marked, though limited motion, is permitted
in the direction of abduction, adduction, and rotation.
The head of the astragalus is the fulcrum for the lever-
age of the distal end of the tibia. This joint is supported
and powerfully acted on by four sets of tendons, which
Cross it anteriorly, posteriorly, and laterally—the two
former in locomotion, and the latter chiefly in steadying
the leg on the foot. The ligamentous envelope which
Sheathes the tendons and binds the malleoli to the
astragalus, is of great density and strength, and, like
the tendino-ligamentous insertion of the quadriceps into
the patella, is so firmly incorporated with the external
Surfaces of the bones that, when subjected to sudden and
Severe strain, the bone gives way before the ligaments
divide. The ankle-joint is so formed that, without its
40 JNETW YORK STATE MEDICAL ASSOCIATION.
extensive tendinous and ligamentous braces, luxation
would be a common event. In its normal state, this is
scarcely ever possible without fracture of the epiphyseal
ends of the tibia or fibula, or both. In lesions, attrib-
utable to indirect violence, where the force is expended
on the tibio-tarsal articulation, the tarsus, astragalus,
and calcaneum are always passive agents, while the sole
active factors are the leg, or the articular ends of its two
long shafts.
Although the epiphyses of the tibia and fibula appear
before the third year, their complete union with the
diaphyses is not effected until the twenty-fifth year.
According to Cloquet,' this process of development is
sometimes delayed until the fortieth year, and the pro-
cess of Ossification may remain imperfect through life.
The tibia and fibula are bound firmly together at the
ankle-joint by a strong ligamentous band, which makes
their separation difficult. The fibular shaft, inferiorly,
except within an inch of its distal apophysis, is every-
where covered by muscular tissue, and is bound to the
tibia above the ligament by the interosseous membrane.
The long, broad, flange-like process of the fibula, which
constitutes its inferior articular end, extends much far-
ther down the lateral wall of the astragalus than its
fellow. Its articulation with the head of the astragalus,
though continuous with that of the tibia, is wholly lat-
eral, while the major portion of the articular surface of
the tibia is horizontal. The function of the fibula, then,
is limited to steadying, and not supporting, the leg on
the foot. The head and shaft of the fibula are of more.
compact structure than cancellous tissue, and hence are
less resilient, and more brittle than the tibia. The inner
surface of the latter bone, from its superior to its inferior
articulation, is wholly uncovered by muscular tissue,
and as this bone is subjected in locomotion to constant
concussion, it is rich in cancellous tissue, and is elastic.
* Anatomie des Os du pied, p. 167, Cloquet.
1 Anatomie des Articulations, p. 203, ed. ii.
LESIONS OF THE ANKLE, JOINT. 41
Having thus far examined very briefly the structures
which enter into the proximal segment of the ankle-joint,
and the parts with which they are in immediate contact,
it will be more easy to appreciate those abnormal condi-
tions which occur here as a result of accident. These
may be divided into lesions of the soft parts, and lesions
of an osteo-arthritic character, in which fracture and dis-
location are combined. Free action at the ankle-joint
may be destroyed, and a permanent crippling remain
after a severe sprain at this articulation, which in no
way primarily affects the bones. Many of these sprains
give as much pain as a fracture, or require a longer time
to recover.
In order to estimate the extent of injury, as well as to
forecast the probable results, we must consider the
pathology of a severe sprain ; and, at the outset, it may
be well to remember that the appearance of the soft
parts which enclose the joint, or are continuous with it,
often bears no relation to the gravity of the injury.
When the sprain is severe, it may be quite impossible to
put any weight whatever on the foot, and in the milder
forms, there is always a free extravasation of blood into
the capsule of the joint, often associated with a lacera-
tion of, and leakage from the thin-walled veins in the
cellular membrane. Haemorrhage into a joint is quickly
absorbed and gives rise to little inconvenience, the over-
tension of the tendons and contusion of the parts yield-
ing promptly to the bath, bandage, and rest. In a severe
Sprain of the ankle, important structures have been
Severely injured, and limitation of joint-action is sure to
follow, if active and appropriate measures are not em-
ployed early. In many instances, the ligaments have
been ruptured, the nerves over-stretched or lacerated,
the capsule of the joint over-strained, so that the peri-
Osteum or the cancellous structure of the bones may
undergo inflammation. When the injury has not been
Very great, and the patient has a sound physique, full
functional restoration is generally secured.
42 NEW YORK STATE MEDICAL ASSOCIATION.
Certain sprains of the ankle attended with over-strain
of the tendons, and followed by inflammation of the
synovial lining of the thecal envelopes of the tendons, by
synovitis, neuritis, periostitis, and arthritis, may end
in anchylosis or muscular atrophy, with a weak, pain-
ful articulation. In one such case which I saw, although
there was moderate motion in the joint, there was a most
acute hyperaesthesia along the cutaneous filaments of
the internal division of the plantar and internal saphen-
ous nerves, exhibited on the slightest motion, and loco-
motion, without the aid of crutches, was for a long time
quite impossible. In all the other muscular or Osseous
cases which I have examined, there was anchylosis
present. In some of them, the sural muscles were re-
tracted, requiring the use of a raised heel in walking.
It goes without saying that, should a joint be kept im-
mobilised sufficiently long, muscular wasting must in-
variably follow, with degenerative changes in all the
structures of the leg, ankle, and foot.
CONTUSIONS OF THE ANEKLE.
Contusions of the ankle are always the result of direct
violence, such as kicks, blows, or crushing injuries.
The lower third of the leg is almost devoid of muscular
tissue, as it is here that the greater part of the muscles
taper into tendons. In females, the bones in this region
are well covered with a thick layer of adipose tissue,
but in the healthy, active male, little fat is lodged here,
and the bones and sinews are very superficial. This is
pre-eminently the region of the body in which the conse-
Quences of degenerative vascular changes may be most
frequently seen and studied. It may be said that fully
25 per cent. Of all adults present disturbances of nutri-
tion in the lower region of the leg, the skin and subcu-
taneous cellular tissue undergoing atrophic changes,
and the walls of the superficial and deep veins becoming
dilated. The periosteum suffers from the effects of this
impaired circulation, and the osseous tissues of the tibial
LESIONS OF THE ANKLE-JOINT, 43
diaphysis are nourished by the deep arterial vessels in
the Haversian canals rather than by those On the peri-
phery. As a result of these pathological changes, the
bone becomes fragile, and is never again capable of per-
fect repair.
It is clearly apparent, then, that age and the previous
condition of the parts at the seat of injury, must always
very largely determine the ultimate results in every case
of severe contusion in the vicinity of the tarsal ends of
the tibia and fibula. The degree of momentary com-
pression to which the skin may be subjected, without
destroying its vitality, or causing a fracture of the un-
derlying bone, is astonishing. Many cases of this de-
scription have come under my observation, but it was
not until it had been proven in courts of justice, and I
had examined several well-attested cases, that I could
convince myself that it was possible for the wheel of a
railway street-car to roll over the leg without inevitably
destroying the tissues at the seat of injury. Certainly,
the rate of speed and the weight of the car have much to
do in determining the character and extent of the injury.
LESIONS OF THE SOFT PARTS OVERLYING THE TIBIO-
TARSAL ARTICULATION, ASSOCIATED WITH
DISLOCATION, FRACTURE, OR BOTH.
The force necessary to Sunder the tendino-ligamentous
junction at the ankle sufficiently to separate the head
of the astragalus from the articular ends of the tibia and
fibula, and open the joint, almost invariably causes such
complete disorganisation of the blood-vessels and nerve-
trunks as to render amputation imperative. Such an
injury always results from direct force expending its
energy on a large area. In this class of cases, the shock
to the system is always well marked, and even though
Complete reduction is possible, a painful, palsied, or an-
chylosed joint remains. A complete compound disloca-
tion of the head of the astragalus out of the tibio-fibular
44 NEW YORK STATE MEDICAL ASSOCIATION.
mortise I have never seen, nor can I find Such a case OIL
record except in injuries causing destruction of the
joint.
A partial dislocation at the ankle-joint in any direction
is very rarely witnessed, without fracture of the diaphy-
sis of the fibula and a diastasis of the apophysis of the
tibia; in other words, the actual condition commonly
encountered is a fracture-dislocation, the morbid anat-
omy of which is limited to a physical disorganisation of
the bones, with a displacement of their articular sur-
faces, attended with haemorrhage, laceration of the soft
parts, and a condition favorable to the advent of inflam-
matory changes.
This brings us to a consideration of what is at present
commonly designated Pott’s, or Dupuytren’s fracture of
the fibula. As this lesion derives its greatest interest
and importance from the distortion or dislocation, which
leads often to ultimate limitation of motion, this feature
deserves special attention.
POTT'S FRACTURE–DUPUYTREN’S FRACTURE–FRACTURE
AND DISLOCATION OF TIIIE TIBIA AND FIBUL.A.
This lesion, which is limited to the ankle-joint in the
typical form, must always be regarded as a very grave
injury; for, notwithstanding what may be said to the
contrary by contemporaneous writers, our most improved
methods of modern surgical treatment have rendered us
little, if any, aid in obviating the diminished strength,
joint-action and deformity, which, in the hands of the
most experienced, may occasionally follow. In many
respects this injury resembles a Colles’ fracture, a con-
dition which, in spite of the almost endless varieties of
apparatus devised for its treatment, has thus far defied
surgical art, and, in a certain number of cases, has left
the patient with a crippled or deformed hand.
Both are fracture-dislocations, occurring, with very
rare exceptions, in adult life, and in consequence of in-
I, ESIONS OF THE ANKLE-JOINT, 45
direct violence. Like Colles' fracture, the typical injury
in Pott's fracture is not so much confined to the bone
elements as to the soft parts—the synovial membrane,
vessels, nerves, and tendons. The typical tibio-tarsal
dislocation, with a diastasis or fracture, like the fracture-
dislocation of the radius and ulna, is happily not com-
mon. In a statistical table of all the fractures treated in
the Harlem Hospital in-door service, which has been
very kindly prepared for me by Dr. George D. Kahlo,
the present house-surgeon, it will be seen that in 1,045
fractures of all kinds, there are but forty-four set down
as Pott's fractures. About two-thirds of these came
under my care, and I may say that there was not a single
one which remained with us during the entire course of
treatment, which did not yield to simple measures, and
quit the service with fairly useful joints, and little, if
any, appreciable deformity. We have been fortunate ;
the arthritic lesions were not of a serious character, or
our results would have been different.
Many of these tabulated cases occurring in my service
were not examined by me, as the splints had been ad-
justed before I saw them ; and hence it is probable that
Several of them were diagnosticated by the internes as
Pott's fracture, which were wanting in all the essentials
Of that fracture. In no other way can I account for the
discrepancy between our figures and Malgaigne's tables.
He collected 160 cases, and found that they constituted
but 3 per cent. of all the fractures which entered his
Service. He saw no case under fifteen years, and but
two over seventy years. In Dupuytren’s 207 collected
cases, 2 per cent. of all fractures, but 10 per cent. oc-
curred in females. Seven-tenths occurred on the right
side, and nearly two-thirds were met with in the winter
Season. This author maintained that fracture of the
fibula was always consecutive to that of the internal
malleolus.
Malgaigne' fixed the heel of a cadaver in a vise, and
* Malgaigne: “Elementes de Chirurgie,” Frac. and les Disloc., p. 307.
46 WEW YORK STATE MEDICAL ASSOCIATIOW.
made forcible abduction, when he found that the internal
malleolus fractured before the fibula. He then reversed
the experiment, using the foot as a lever, and making
forcible abduction, but with the same result. On the
contrary, Maissoneuve,” repeating this experiment, found
that on making abduction, the internal lateral ligament
was sometimes completely ruptured, without fracturing
either malleolus; though, when this occurred, the force
spent itself on the tibio-fibular ligament, and diastasis at
the tibio-fibular articulation followed, permitting of a
twisting, rotary motion, and fracture of the fibula. Some
distance from the joint.
Stimson’s” experiments on the cadaver seem to bear
out Maissoneuve's observations, for he says: “It will be
Seen that by fixing the leg and forcing the toes outward,
while the ankle is held at right angles, the first to yield
is the exterior tibio-fibular ligament; then the anterior
fibres of the internal lateral ligament, and almost coin-
cidently the fibula breaks by the twisting of its lower
end,” etc. This author claims that the same sequence
occurs clinically.
The results of the experiments of these distinguished
authors are hard to reconcile, except on the ground that
the subjects experimented on were of different ages, and
the quality of force employed was variable. In any
event, deductions from such experimental work on the
dead body possess at best but a relative value, and can
under no circumstances be regarded as definite and con-
clusive.
Such are the theories, from an experimental stand-
point, as to the causation of Pott's fracture ; but, as we
are dealing with lesions in the living subject, it may be
well to stop for a moment and review the influences
which bring about during life the so-called fracture of
Pott. We must not lose sight of those innate influences
in the bones themselves. This fracture is scarcely ever
1 Maissoneuve : “Fracture du Perone,” etc., p. 172.
* “Pott's Fracture at the Ankle,” Mass. Med. Soc., June, 1892.
I, ESIOWS OF THE AWAOLE, JOINT, 47
seen until the processes of Ossification are complete. The
premature ossification of the bone, or a preponderance
of compact non-vascular tissue, may favor a morbid brit-
tleness, so that a wrench or twist may produce what is
known by the French as fracture par arrachment, in-
stead of simply a severe sprain.
Y AIRIETIES OF FRACTURE-DISLoCATION AT THE
ANEKLE-JOINT.
It has been seen that it is only when the extent of dis-
location is considerable, the displacement and laceration
of nerve, tendon, and ligament is extensive, and when a
double fracture occurs, that a serious condition is present.
But there are many intermediate phases, and it is as
absurd as it is erroneous to assume that every case of
tibio-fibular distasis, or apophyseal separation of the
tibial flange, with or without fracture of the fibula, is a
grave injury, demanding special and protracted care.
In those cases in which the extent of separation of the
fragments of the broken internal malleolus, and the
degree of deformity is not great, reposition and retention
are not difficult. When the head of the astragalus has
sprung back into its socket, thereby maintaining perfect
extension, the interosseous membrane aids in fixing the
fibula, so that no matter how oblique the fibular fract-
ure may be, its coaptation and solid union are readily
effected.
In a severer form of Pott's fracture, intra-articular
haemorrhage, cellulitis, and synovial inflammation are
complications which may greatly retard recovery, or
terminate in an inflammatory infiltrate of Osseous or
other cellular deposits, external to the articulation.
This may cause undue pressure on the neural cords on
their way to the foot, or on the blood-vessels. But, the
imOst serious and unmanageable of all phases of fracture-
dislocation at the ankle is when, along with a double
fracture, the internal lateral ligament is completely torn
48 WEW YORK STATE MEDICAL ASSOCIATION.
in two on the same line as the fracture of the tibial apo-
physis. By this rupture, the equilibrium of the joint is
lost; the foot fixed, with the weight of the body concen-
trated on the horizontal articular surface of the tibia,
which has now lost its moorings, turns on its own axis,
and, in this twisting motion, sunders the tibio-fibular
union; and the same spiral motion, ascending, splits the
shaft of the fibula in its most brittle and exposed part.
The head of the astragalus having left its mortise, may
Occupy various relations with the articular surface of the
tibia. Now, the spasmodic contraction of the powerful
and unopposed muscles of the leg, acting on the foot,
tears the capsule widely open, and causes contusion and
laceration of the vascular and neural elements lying in
close relation to the joint. Inflammation inevitably fol-
lows, and it is quite inconceivable that after such an
injury anything like perfect functional restoration is
possible.
This latter, type, then, and this only, is what Percival
Pott so fully and clearly described, and it is the only
fracture at the ankle which should bear his name.
DIAGINOSIS.
When there is a difference of opinion as to the precise
morbid changes which constitute a certain specific lesion,
it is clear that a definite diagnosis is difficult. This is
particularly the case with apophyseal fractures. It is
most unfortunate that this injury should have been
designated Pott's fracture, for the theory of causation as
described by the English surgeon, and the principles of
treatment formulated by him, were disputed by Dupuy-
tren, and have, in large part, been recently ignored by
Stimson. This wide divergence of opinion on cardinal
features implies that these surgeons did not observe
quite the same lesion. It would greatly aid in diagnosis .
if this so-called Pott's fracture were simply designated
“fracture-dislocation ” at the ankle-joint. In another
LESIOWS OF THE AWKLE-JOINT, 49
type of fracture-dislocation, the internal or the external
lateral ligament has given way, thus permitting a rolling
of the head of the astragalus, inward or outward, with
an inversion or eversion of the part.
When there is complete separation and mobility, these
fractures may be readily detected at the first examina-
tion. If there be no displacement, unless the muscles
are well relaxed and considerable force is employed,
crepitus will be absent, and it will often be difficult to
determine the presence of a fracture. Under these cir-
cumstances, the employment of an anaesthetic and
of violent manipulations must be condemned.
One should always hesitate before making a diagnosis
of Pott's fracture; for the profession, as a whole, has
an exaggerated notion of the seriousness of this lesion;
and, as has been pointed out, it is only in those cases
attended with marked, irreducible dislocation, and ex-
tensive damage to the arthritic structures, that this
designation is at all applicable.
TREATMENT OF SPRAINS, CONTUSIONS, AND FRAC-
TURE-DISLOCATIONS AT THE ANKLE-JOINT.
The treatment of sprains and contusions may be studied
together, for the same line of treatment applies to both,
when there is no laceration of the skin. Our treatment
should vary with the pathological condition present. If
called immediately after the injury, our efforts should
be directed to relieving pain and preventing the develop-
ment of inflammation. The limb should be placed in an
elevated position, and well supported; the use of the
bandage will depend on the manner in which it is toler-
ated. In most cases, if applied before the Supervention
of inflammation, it is of infinite value in relieving the ar-
terial throb, overcoming muscular spasm, and steadying
the joint. When there is very much pain, with or with-
Out tumefaction, and a sanguineous effusion into the
capsule or soft parts, the free application of leeches is a
powerful prophylactic against subsequent inflammation.
4
50 NEW YORK STATE MEDICAL ASSOCIATIOW.
Bathing, either cold or warm, rubefacients, or counter-
irritants, will be required in many cases, and will serve
a useful purpose. -
One of the most important questions of late years, in
the surgical treatment of severe joint contusions and
sprains, is that of immobilising the limb–giving it rest,
as it is said. Immobilising a sprained ankle-joint by
plaster-Of-Paris, is a practice which cannot be too strong-
ly condemned. It is true that the injured part needs
temporary rest; but it is physiological, not mechanical
rest which is required. Physiological rest must not be
confounded with immobilisation. The joint may be am-
ply supported by the simplest splint which will permit
of ready removal, moderate motion, massage, the appli-
cation of medicaments to the bandage, and other
measures; but, with the knee flexed, the Sural muscles
relaxed, a well-padded bandage applied, and the limb
properly supported, splint is very often unnecessary.
Since, then, any sort of permanent fixation is so liable
to be followed by anchylosis, we must be on the alert for
this unfortunate sequela ; for ordinarily we are responsi-
ble for its occurrence.
It is surprising with what rapidity degenerative
changes occur in contiguous parts, after joint injury,
when all joint motion is completely arrested. There is
in the child an immediate cessation of growth, and in
the adult, the nutritive processes are so profoundly
affected, that atrophic and degenerative changes pursue
Such a swift and destructive course, that after the lapse
of but a few weeks, all hope of restoration of normal
joint-action is forever destroyed. Passive motion, then,
should be contemporaneous with other measures. When
this gives rise to such unbearable pain that it cannot be
practiced, we may be assured that the brunt of the in-
jury has been borne rather by the bone than by the soft
parts, and that pathological changes are advancing in the
bone elements, which we can only modify or arrest by
bold and prompt antiphlogistic procedures.
LESIONS OF THE ANKLE-JOINT. 51
It is obvious, then, that we must treat severe ankle-
joint concussions, or twists, with promptness, energy,
and patience, avoiding above all things protracted im-
mobilisation; and, in children, in whom arrest of growth
in the affected limb, means a crippling for life, no device
should be employed which might seriously interfere with
the nutritive processes. Should anchylosis, however,
follow our treatment, or be present when we are called
to attend the case, let us be assured that it is a stiffening
of the joint arising entirely from molecular organic
changes, before we decide that it is beyond relief, and
are content with the let-alone policy. I have seen quite
a number who have been entirely cured of their lame-
ness, more than a year after their injuries, by thoroughly
breaking up the adhesions in and about the joint. Of
course, it is needless to say, that before One undertakes
to break up an anchylosis, one must very carefully
examine the bones, and test the muscles, or One will, in
unfit cases, surely fracture the shafts, as I did myself in
two patients, very early in my experience. In both
cases, the bones were less fragile, than the adhesions, as
a result of pathological changes.
The management of Pott's fracture, is very variously
described in our different treatises on fractures. Dupuy-
tren and Hamilton bound the foot and leg to an internal
splint, with the foot markedly adducted, the several
muscles being relaxed by the bending of the knee. Pott
himself said little about splints, but attached great im-
portance to posture. Speaking about this, he said:
“The limb should be laid on its outside, with the knee
moderately bent ; by this the muscles forming the calf,
and those tendons which pass behind the fibula and
under the os calcis, are all put in a state of non-resistance,
When all trouble and difficulties will vanish immediately.
The foot being easily placed right, the joint reduced,
and by maintaining the same disposition of the limb,
everything in general will succeed very happily, as I
have often experienced.” -
52 NEW YORK STATE MEDICAL ASSOCIATION.
The more modern plan of fixing the fragments and the
joint, is by splints applied about the articulation, the
limb being extended, and resting on its dorsal aspect.
Such is the plan recently recommended by Prof. Stim-
Son. But let us not forget that we are something more
than moving automatons, and that we should treat this
injury on sound surgical principles, regardless of the
individual preferences of different surgeons. Let us ap-
preciate the fact, that we have a fracture, opening into
a joint, with more or less displacement of the articular
Surface. We cannot provide a new set of ligaments;
and, hence, this dislocation may be entirely irreducible,
Or, if reducible, it cannot be retained without producing
dangerous pressure or anchylosis. When the tibial sur-
face is posterior to and below the head of the astragalus,
extensive laceration or overstretching of the ligaments is
inevitable. Decided, lateral luxation entails rupture of
the ligament, with perhaps, a tearing off of a portion of
its OSSeous surface of attachment. It is apparent, then,
that as this element of dislocation predominates in
aggravated cases, its efficient reduction and retention
should particularly concern us. For the efficient accom-
plishment of this purpose postural treatment occupies
the front rank. Muscular relaxation, topical applica-
tions, and the bandage with appropriate supports, will,
as Pott has well said, suffice in most cases. It must not
be overlooked, however, that when considerable joint
disorganisation has been followed by active inflamma-
tion, defective joint action with deformity can, in no way,
be wholly obviated.
Whatever line of mechanical treatment may be insti-
tuted, it is well to know that this has its limitations,
and, if misdirected or too protracted, may conduce to a
pathological condition which may render the joint and
foot of less use than if nothing whatever had been done.
The trophic changes, and loss of function which invari-
ably follow, traumatic or pathological, joint lesions and
fractures, are clearly and concisely described in a classi-
I, ESIOWS OF THE A WHOLE-JOIWT. 53
cal production recently presented before the American
Orthopaedic Association by Prof. Roswell Park.” From
a study of the experimental and clinical observations of
French, German, English and American surgeons, this
author concludes that an injury to the shaft of a bone,
or to any of the joint structures, which causes protracted
inaction or long-continued immobilisation, invariably
induces an arrest of growth, degeneration of bone sub-
stance, muscular wasting, and impairment, or entire loss
of function in the affected limb. Therefore, in fracture-
dislocations at the tibio-tarsal articulation, as in a Colles'
fracture, or a fracture opening into the elbow-joint, the
greatest caution should always be observed in severe
cases, to remove every sort of fixation apparatus at the
earliest possible date, with a view to commencing passive
exercise, and thereby preventing organic changes in the
structural elements of the bone and muscles, which might
lead to muscular or arthritic anchylosis.
For the purpose of maintaining the normal nutrition
of the joint, and obviating, as far as possible, Subsequent
weakness and limitation of motion, massage, friction, and
uniform, but interrupted pressure, are important. The
precise time at which manipulations of the ankle should
be commenced, will depend, in a certain measure, on local
Conditions. If there has been an extensive rupture of
ligament and tendon, any disturbance of adjustment-
pressure will be immediately followed by a subluxation,
SO that immobilisation must be continuously maintained
for a considerable period, even at the expense, perhaps,
of an anchylosed joint. But this condition is excep-
tional. In those cases in which the chief lesion is osse-
Ous, the propriety of disturbing the fragments by early
handling of the foot, may be questioned, as such inter-
ference would seem to retard union. My experience,
however, in the treatment of fractures in general, has
been, that the changing of dressings, and moderate
kneading of the muscles, with slight motion of the frag-
* “A Study of Atrophy,” Gaillard's Medical Journal, Oct., 1892.
54 NEW YORK STATE MEDICAL ASSOCIATION.
ments, seem rather to stimulate the reparative process.
Fortunately, in these ankle-lesions, in which after the
most judicious treatment, the range of motion is re-
stricted or is entirely lost, the limb often remains firm,
and a thousand-fold more useful than any artificial Sub-
Stitute. In those extreme cases, in which, through tibio-
fibular diastasis and rupture of ligaments, there has been
an irreducible axial rotation of the head of the tibia on
the articulating surface, with pronounced posterior or
lateral displacement, a weakened, crippled joint remains,
necessitating for comfortable locomotion the adjustment
of some prothetic appliance, which will give ample sup-
port.
I never undertake to liberate a joint under an anaes-
thetic. The two accidents cited, happened while my
patients were under ether; while in every instance in
which I have been able, without an anaesthetic, to open
the surfaces, by a sudden but cautious motion, the result
has been good and permanent. In my judgment, it is
much better, in genuine, Osseous anchylosis, to divide
the tendons, and, if necessary, open the joint, than to
apply great force.
FRACTURES OF THE FIBULA AND POTT'S FRACTURE.
& rc , ºr || || Tº g 3 his
DLAGNOSIS. # à § | # * 5 § 3 | # 59 | ##
> QD c H C gº o ſº C & § {:
E | Q #, P 5, 5 | E-3
Fibulae :
Simple . . . . . . . . 22 2 14 10 tº tº & © 13 11
Compound. . . . . 2 e e 2 tº tº tº tº . . || 2 . .
Comminuted. . . 1 1 1
Pott’s :
Simple . . . . . . . . 36 11 35 12 tº $. tº º 32 15
Compound. . . . . 2 2 2
Total. . . . . . . . 63 13 5 22 tº tº we tº 50 26
Actual number of deaths from fractures, including traumatic am-
putations, etc., 117, showing a mortality of 9.4 per cent. of the cases
treated.
Ratio of cases cured is 70 per cent., which is exclusive of those trans-
ferred as improved and unimproved, immediately or shortly following the
time of receiving the injury.
I, ESIONS OF THE ANKLE, JOINT × 55
RíSUME.
POTT'S FRACTUIRE.
Number occurring in the male. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Number occurring in the female. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11–49
Of the right leg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Of the left leg... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Leg undesignated. . . . . . . . . . . . . . . . . . . . . . . . . .* * * * * * * * * * * * * * * * * * * * 18–49
Age
Yr9. No Yr9. JWo. Yr9. Mo Yrs. No
12 1 29 4 38 1 47 1
21 2 30 1 39 2 48
22 1. 31 1 40 3 51 1
24 2 32 1 41 1 52 1
25 2 34 2 42 1 53 1
26 3 35 3 43 1 57 1
27 1 36 1 45 2 65 1
28 1. 37 3 46 1 68 1
Summary of Ages.
Yrs. JNo. Yrs. Wo. Y7's. No.
Under 20. . . . . . 1 30–40. . . . . . 15. . . . . 50–60. . . . 4
20–30. . . . . . 16 40–50, ..... 11..... Over 60. ... 2
- Classification by Months.
Jan. . . . . 6 April. . . . . 2 July. . . . . 3 Oct. . . . . 4
Feb. . . . . 5 May. . . . . . 4 Aug. . . . . 3 Nov... .. 5
March... 5 June...... 2 Sept. . . . . 4 Dec.. ... 6
Summary as to Seasons.
Spring, 11. Summer, 8. Autumn, 13. Winter 17.
Percentage.
Percentage of Pott's fracture to total number of fractures treated
(exclusive of those of the metatarsus, phalanges, etc.), 4.009 per cent.
FRACTURES OF THE FIBUL.A.
Number occurring in the male. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Number occurring in the female. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2—27
Of the right leg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Of the left leg. ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - e º ºr e ºs e º 'º e º e
Leg undesignated. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8–27
Age
Yrs. JWo. Yºs. Mo. Yrs. Mo. Y78. No:
9 1 23 1 31 1 41 1
14 1 25 1 32 2 45 2
20 1 28 2 33 1 49 1
21 1 29 2 34 2 51 1
22 1 30 1 35 1 56 1
38 1 64 1.
Summary of Ages.
Yº's JVo Yr9. No Yr9. No
Under 20....... 2 30–40. . . . . . . . 9 50–60. . . . . . . 2
20–30. . . . . . . 9 40–50. . . . . . . . 4 Over 60. . . . . . . 1.
Classification by Months,
Jan. . . . . 5 April. . . . . 3 July..... 7 Oct. . ... 1
Feb .... 1 May. . . . . . 3 Aug. . . . . 1 Nov. . . . . 2
March... 1 June. . . . . . 0 Sept. . . . . 2 Dec. . . . . 1
Summary as to Seasons.
Spring, 7. Summer, 8. Autumn, 5. Winter, 7.
3.
REPORT OF FRACTURES TREATED AT THE HARLEM HOSPITAL
(Evelusive of Phalanges, Metacarpus and Metatarsus, Carpus a
nd Tarsus), from
DIAGNOSIS.
January 1, 1887, to September 1, 1892.
Skull; Simple .
Compound . ©
Compound depressed . e e
Compound, depressed and multiple
Com., compl., commi., depr.
Simple multiple e e
Simple depressed .
Of base . º
Nasal bones: Simple
Compound te s
Zygomatic process: Simple
Superior maxilla : Simple.
Compound . e *
Compound Complicated
Inferior maxilla : Simple.
Compound &
Malar e ſº 0. tº
Vertebrae ſº * &
Ribs : Simple
Compound
Multiple
Complicated .
Pelvis : Ilium .
Pubes . º tº
Sternum : Complicated
Clavicle: Simple . g
Compound complicated.
.g is 2.3 ## * 2.É. #:
Male. || 3 || 3 |E ###| : § 3|É : COMPLICATIONS AND REMARKS.
ºr | Q o,IT as C. ©
19| ..| 12| 1 || 3| 3| 15 ..] [comp. compl., 1; operation, 2.
33 5, 29| 2 | 6 ||6| 27 . . Of base, 3; radius, 1 ; clavicle.
42 3 27 2. 14 15, 29 . . Operation in 39 cases.
1| 1 iſ . . 1| 1 || 1 ... Of base, 1 case ; operations, 2.
1. . . . . . . 1| 1] . . . . . Gunshot wound.
1] . . . . . . . . . 1 1. . . . . . & g
..] 3 2 . . 1| 1 || 2 | . .
38|| 10|| 5 || 1 || 34; 42|| 5 || 1
4] . . . 4. . . . . . . . . . 4. . .
6|| 1 || 7 | . . . . . . . 7] . .
1] . . . 1 . . . . . . . . . 1 . . dº ſº e © &
11| 1| 11 ...| 1 || 1 || 10 1|Death from other injuries.
2 . . . 2 . . . . . . . . . 2 . . [fracture of skull.
1] . . . . . . . 1| 1| . . . . . Also comp., compl., comminuted.
24. 2 22 1| 3| 3 22 1|Other injuries complicating, 3.
15 . . 1; 1| 1 || 1 1; ..|Other injuries complicating, 1.
21| 3 2 1 13| 19| 3| 2 tº e e wº &
82 9 52| 31|| 5 || 3 50 38|Other injuries complicating, 3.
6|| 1 || 6 ...| 1 || 1 || 6 ...|Other injuries complicating, 1.
4| 1| 5 | . . . . . . . . 5! . . & © g e º
15| . . 3| . . | 12| 12| 3| . .
15| . . . 13| 1 || 1 || 1 || 13| 1
4] ...| 1 | . . 3| 3| 1 | . .
1] . . . . . . . . . 1] 1 . . . . . gº * & © &
65 7| 60 10] 2 2. 59 11|Other injuries complicating, 2.
1] . . . . . . . . . 1 1 . . . . . tº * & º


Scapula: Body
25 4. 23 3| 2: 2 23 4|Other injuries complicating, 2.
Coracoid process 1| . . 1] . . . . ..] 1 . . * & ſº º *
Acromion process. 6| . . 6] . . . . . 5| 1 tº e * e ©
Humerus: Simple 50 13 52 6 5) 5 51] '7|Other injuries complicating, 5.
Compound . e g 15 4 14 ..] 5 6' 13 ... Other injuries complicating, 2.
Internal complications . * 1| 1 | 11| . . . . . . . . . 11] . & e g & º
Comp, compl. and commi’d. . . . 11| 11 . . . . . . . . . 11] . . & & wº te *
Radius: Simple 82] 21| 91| 7 12 11| 85| 7|Other injuries complicating, 11.
Compound 9| 1| 7| 2 1 1| 7| 2 |Other injuries complicating, 1.
Greenstick 1, 1] 2 . . . . . . . . . 2 . . c * º te gº
Ulna ; Simple 27| 5 30 1 1, 1] 30 1|Other injuries complicating, 1.
Compound . wº e t 5| 1 || 5 ... 1 1 4 1|Also fracture of skull, 1.
Olecranon process: Simple . 5|| 1 || 5 ...| 1 || 1 || 5 ...|Fracture of skull, 1.
Compound g º 2| 1 || 2 ...| 1 || 1 || 2 ...|Died from senility and other injuries.
Radius and ulna: Simple. 16| 5 19 . . 2, 2, 19 ...|Other injuries complicating, 2.
Compound . º e ſº 7| 6 6 . . 3| 3| 6 . . Other injuries complicating, 2.
Comp., compl. and commi’d. 1| 3| 3| 1 | . . . . . 3| 1 tº tº & e g
Femur. Simple e 49 19 46 12 10| 9 47| 12|Other injuries complicating, 8.
Compound 10 ..] 5 .. 5 5| 5 ..|Other injuries complicating, 2.
Multiple * 2 . . . 1] . 1| 1 || 1 ..|Other injuries complicating, 1.
Trochanter major . 2] . . . 2 . . . . . . . . . 2 .. tº sº e ę tº
Intra-capsular 9| 8 || 6 11 . . . 6] 11 © e ge & wº
Patellae: Simple 12| 3| 12 2. 1 1| 13 1|Other injuries complicating, 1.
Compound 3] . . . 3. . . . . . . . . . 3] . . e § & © e
Tibia ; Simple . 57| 8 43| 20 2. 2 40 23|Other injuries complicating, 2.
Compound 36] 2 24 12. 2. 2 25 11|Other injuries complicating, 2.
Fibula: Simple 43| 11| 43| 11| . . . . . 34| 20 tº & t g &
Comminuted 4| . . ; 3. 1] . . . . . | 3| 1 & * > * > e &
Compound . 13 2 11 . . 4. 4. 11 ...|Other injuries complicating, 4.
Pott's : Simple 42|| 5 || 35| 12 . . . . . 32 15 & iº e
Compound º e 2 . . . 2 . . . . . . . . . 2 . . g º e tº e
Tibia and Fibula : Simple 48| 12 29, 28 3| 3| 29| 28|Other injuries complicating, 3.
Compound © & 48 6. 29, 13 12 12| 29| 13|Other injuries complicating, 7.
Total 1045, 197; 871. 193| 178] 190| 838. 214

58 NEW YORK STATE MEDICAL ASSOCIATION.
DISCUSSION.
DR. E. M. MooRE, of Monroe county, said he had made some experi-
ments upon the cadaver, and had undertaken to create dislocations of the
ankle-joint, watching carefully the steps by which these fractures were
produced, and the character of the dislocation ; and he had found, as stated
in the paper, that the external malleolus is apt to be the first to give way.
If one conducted the experiments slowly, one could see the bone pulled
apart because of the superior strength of the ligaments. In these experi-
ments, made many years ago on the cadaver, in the course of study on
Colles’ fracture, he found that the ligaments attached to the styloid process.
were stronger than the styloid process itself, so that this process would be
completely pulled off. Ruptures of the ligament did occur occasionally
without fracture of the bone, but the rule is, that the bone yields first. He
had always used Dupuytren’s simple splint on the inside, with the limb
slightly twisted around, provided it did not disturb the separation of the
internal malleolus. He had always carefully watched for fracture of the
internal malleolus, and had frequently found it, but not always. In case
of fracture of the internal malleolus, along with fracture of the fibula, if
the internal malleolus be not pressed out by twisting the astragalus a little
too far, which Dupuytren’s splint is apt to do, the result is perfect.
Everyone must be aware that there is a tendency on the part of the frac-
tured end to turn outward toward the tibia; this is easily obviated by
bringing the line of fracture so that the inferior end will be drawn out to
its full extent. According to his observation, when there is fracture of
bones held together by an interosseous ligament, there is always a tendency
on the part of the fractured ends to bend in to the opposite bone. This is
So in the forearm, and in the tibia may even go so far as to spread the
ankle-joint, and produce deformity. His rule was, to bring the lower
fragment out, and allow it always to slightly overlap the upper fragment.
If you turn it too much, there will be a displacement of the internal
malleolus, but the padding applied to the internal malleolus, against which
you draw, is very apt to keep it in place. In carefully imitating Dupuy-
tren, we are not likely to go very far astray. If, however, the fracture at
the internal malleolus were very movable, he used a pasteboard splint on
each side, with pads on the side of the splint, in order to keep them in
place. The author emphasised very properly the great difficulty experi-
enced when there is splitting of the tibia, allowing a very material dis-
placement of the astragalus, and also necessitating a relaxation of the
tendo Achillis, and the tendency there is, as a matter of course, for the
foot to be pulled forward. If anchylosis occurs in that position, the entire
usefulness of the foot is destroyed. His own practice has been to combine
the two ideas, viz.: he desired to carry out Dupuytren’s idea, and also to
Secure relaxation of the tendo Achillis, and make some traction. Accord-
ingly, he used the double inclined plane, fastening the foot to the foot-
board, and turning it a little upon itself, to produce Dupuytren's twist,
thereby relaxing the muscles. By making traction on the foot, and draw-
I) ISO/USSION. 59.
ing it down, the strain is taken off from the movable fragment, and We can
then put a pad on the inside to push the fragments together. In this Way,
we accomplish everything desirable in the treatment of Colles' fracture.
He had not met with the difficulty, and with the bad results, which the
text-books speak of in connection with this fracture, and he had never had
a case of anchylosis following the treatment just outlined. There is
always a certain amount of stiffness wherever there is inflammation, but
this all passes off after use. Briefly, then, the treatment consists in putting
the foot right, holding it there, drawing sufficiently upon it to Counteract
the action of the muscles, and securing perfect adjustment by means of
pads, and if necessary, by the use of ether, motion, and massage. He did
not agree at all with Dr. Manley in respect to Colles’ fracture. If any one
does not have good results in Colles’ fracture, it is because he is not up to
the times—but more of this in his paper to-morrow.
DR. MANLEY, in closing the discussion, said that he felt very thankful
to Dr. Moore for his criticism of his paper, and he fully agreed with the
line of procedure which Dr. Moore had considered the ideal one. He
would add, that this treatment was applicable to any other fracture of the
leg, accompanied by much displacement, as the fundamental feature of
this method was relaxation. In the typical Colles' fracture, not only in
his own experience, but in that of the very best surgeons, so far as he
knew, the results were not satisfactory. Even the distinguished author on
fractures, Dr. Frank H. Hamilton, did not escape deformity after receiv-
ing a Colles’ fracture.
MUSCULAR TRACTION FOR, HIP-JOINT
DISEASE.
By THOMAS M. LUDLow CHRYSTIE, M. D., of New York County.
(Read by title November 15, 1892.)
Clinical study of the effect of traction in the treatment
Of hip-joint disease will demonstrate two facts:
1st. That the force of traction is exerted entirely upon
the muscles of the thigh, and not upon the articular
structure of the hip-joint; and
2d. That when firm and efficient counter-traction, Or
counter-resistance to traction, is furnished, there is no
need of any lateral or abducting force.
By traction is meant the pulling of the limb in a direc-
tion from the hip-joint, and in a line with the position
held by the thigh in reference to the median line of the
body. Any lateral or abducting force used in connection
therewith, diminishes the force of the traction proper,
and interferes with the object in view. This object is,
briefly stated, the stretching of the muscles until they
have lost their tone, and are, in fact, so temporarily
paralysed that they are unable to take on the spasmodic
contractions which are the peculiar feature, and chief
cause of hip-joint disease. Furthermore, when this con-
dition is attained, there can exist the rest and quiet
which permit the subsidence of the inflammation in and
about the hip-joint.
Traction has now been in use, and growing in favor
for over a quarter of a century, but there has been, and
is a widespread notion that its effect is exerted, either to
pull or hold apart the Opposing articular surfaces, or to
keep them from coming together with any degree of
pressure. Aside from the fact that such a theory cannot
be verified by clinical observation, it leads to a very in-
MUSOULAR TRACTION FOR HIP-JOINT DISEASE. 61
efficient use of traction. With such view, the grasping
of the limb anywhere on the digital side of the hip is
deemed sufficient, with the result that the grasp is rare-
ly placed above the lower third of the thigh ; indeed
often only the foot or leg is grasped, and the muscular
part, the upper two-thirds of the thigh, is entirely neg-
lected, though this is the very part which most needs
attention.
Whether it be true that the inflammation of the hip-
joint acts as a reflex stimulus to muscular spasm, or the
muscular spasm, as the cause of the hip-joint disease, is
due to some neurosis, it is certain that this spasmodic
muscular action is the chief symptom to be treated. The
theory that phimosis is a potent cause of hip-joint dis-
ease, by exciting these muscular spasms, shows the
prominence the latter occupy in the aetiology of this
disease. It may even be stated, that the present system
of preventing the weight of the body from coming upon
the affected limb, is a plan to relieve the limb from mus-
cular action, rather than to preserve the hip-joint from
concussion.*
It has been held that the muscular spasm is of the
nature of swimmer’s cramp, where relief is obtained by
tightly constricting, as well as pulling the affected mus-
cular tissues. I have found this, to a great extent, true.
For the purpose of grasping the muscles of the thigh,
I apply the adhesive straps on the inner side of the
thigh, as high as the crotch, and On its Outer side to the
trochanter; the retaining roller bandage is carried high
enough to cover the adhesive straps, and often includes
the pelvis to prevent slipping. The rest of the limb is
grasped low down—to within an inch of the ankle. The
constriction of the muscular upper part of the thigh is
as efficient in securing comfort to the patient, as is the
traction, and the object of both is to secure control of
the muscles of the thigh. The apparatus used to exert
* Rationale of Permanent Dressings. Prof. A. B. Crosby, Med. Record,
N. Y., Sept., 1873.
62 WEW YORK STATE MEDICAL ASSOCIATION.
the traction force may be the weight and pulley, or
some of the numerous means of employing the ratchet-
bar, all of which must be familiar objects to the surgeon.
As the sole purpose of this article is to draw attention to
the importance of considering traction as muscular, and
not articular, the consideration of apparatus is omitted,
except the statement that the splint, reaching underneath
the foot, in order to take adhesive straps from both sides
of the limb for its entire length, may, for that reason,
be considered the most efficient.
Counter-traction is of course arranged on the proximal
side of the hip-joint ; but the construction of the pelvis
places it on a level with the digital side, thus obscur-
ing its mechanical relations to the traction. For this
reason, they have not been so clearly studied as they
should be. Very often a good form of traction is of no
service because of inefficient counter-traction. The ef-
fect of traction is then deceptive, and ingenious devices
are resorted to in order to increase its efficacy ; but all
to no purpose so long as the defect in the counter-trac-
tion is unremedied. With apparatus, the counter-trac-
tion is ordinarily obtained by padded straps passing
either side of the perinaeum. These straps are generally
round, in order to pass between the thigh, and the
scrotum or vulva, but on account of their shape, they
often press upon the sciatic until it is unendurable.
This can be remedied without diminishing the counter-
traction, by flattening it behind, and having it terminate in
two straps, in order to distribute the pressure over a
greater surface. They are best made out of strong web-
bing, covered with a roll of woolen goods sewed at each
end to the webbing, this covered with a layer or two of
flax (not cotton) lint, and the whole covered with Surah
or China silk. These straps must be watched, and
promptly renewed before they are worn out. The skin
receiving the counter-traction, must be carefully wiped
clean daily with alcohol, or alcohol and tannin.
The counter-traction is defeated by a yielding of any
MUSOULAR TRACTION FOR HIP-JOINT DISEASE. 63
part of the apparatus. By attention to such points, I
have found very much less force needed to overpower
muscular spasm, than where the resistance is uncertain
and unsteady. When using the weight and pulley, rais-
ing the foot of the bed to procure counter-traction, is
useless during the attacks of strong muscular spasm
which at times occur. The pelvis must be secured to the
head of the bed, and the affected limb raised so as to
swing clear of the bed. During the spasmodic attacks,
a box may be so placed that the patient can brace the
foot of the well limb against it while the weight is in-
creased to an adequate degree. I have in this manner
occasionally used fifty pounds with great effect. The
pulley should be not less than five inches in diameter.
Every case differs as to its needs, and its management
involves an infinite variety of details, but all with a view
to securing firmness and precision in both traction, and
its accompanying force, counter-traction.
SOME RECENT CASES OF APPENDICITIS.
|By NATHAN JACOBSON, M. D., of Onondaga County.
November 15, 1892.
In presenting a few cases of appendicitis, which it has
been my fortune to see recently, it is not my purpose to
consider in detail this most important pathological con-
dition ; nor can I hope to place before this Association
any facts which may be new. My object is rather to add
my observations to existing data, for out of the accumu-
lated experience of all, must be developed the true
pathology and treatment of appendicular disease.
With the presentation of the result of his investiga-
tions into the pathology of the appendix, to the Associa-
tion of American Physicians, in 1886, Fitz established a
new era in our knowledge of these conditions. Since
Morton, in the spring of 1887, deliberately cut down
upon, and successfully removed an ulcerated appendix,
and the equally successful undertaking of Sands at the
close of the same year, the surgical treatment of the
diseased appendix has been completely changed.
The subdivision of appendicitis into many forms, only
serves to obscure a proper conception of the condition,
and renders more difficult a decision as to the proper
treatment. In a large number of cases, inflammation of
the Vermiform process is of a catarrhal type, terminating
without suppuration. It is not easy to determine, with
mathematical accuracy, what percentage of cases belong
to this class, but it has been stated to be as high as eighty,
or even ninety-five per cent. This large group comprises
those to be treated by medicinal measures.
The very fact that such a large number of cases is quite
certain to recover in the hands of the physician, makes
it all the more necessary that he should be on his guard
RECENT CASES OF APPENDICITIS. 65
not to include amongst them a single case which might
ultimately demand surgical treatment. To determine
which cases are to be treated medicinally, and which
surgically, will often tax the ingenuity and skill of the
physician. I shall deal in this paper only with such
cases as require surgical measures. To this class belong,
first of all, cases in which the inflammation reaches the
suppurative stage. As types of the Suppurating form,
not involving the peritonaeal cavity, I desire to refer
briefly to two cases.
CASE I. On the 29th of January of the current year, I was requested
by Dr. Breese, of Syracuse, to see with him a man, forty-one years of age,
a machinist, who gave a negative family history. Twenty-five years pre-
viously, he had had typhoid fever, and five years later, small-pox. He
stated that he had had numerous “bilious attacks,” which were always
preceded by pain in the right iliac fossa, severe enough to make walking
difficult. This pain would increase in intensity until it prostrated him ;
then nausea, and fermentation of food in the stomach would occur, and he .
would be ultimately relieved by free emesis, and evacuation of the bowels.
He recalled having had, twenty years previously, a tumor form in the right
iliac region, which ultimately disappeared. On January 1, 1892, the pain
returned, but he kept about until the 16th of the month, each day finding
walking much more difficult, and the pain more severe. A tumor, steadily
increasing in size, appeared in the right iliac fossa during the two weeks
preceding my visit to him. There was constant fever, anorexia, and
nausea, but no vomiting ; the bowels moved once daily. I found tume-
faction reaching well down to Poupart's ligament, upwards as high as the
level of the umbilicus, and internally for a distance of three inches.
Rectal examination revealed the presence of a tumor. His hygienic sur-
roundings were very poor, and the prospect of care at home no better.
He was therefore sent to St. Joseph's Hospital on the following day. Upon
his arrival, we found that during the preceding night there had been a
spontaneous rupture of the abscess into the rectum, and all evidence of
tumor had disappeared. Pus was discharged for five days, after which his
local and general condition constantly improved, and he left the hospital
on the 18th of February, thoroughly well.
The statement is usually made, that recurrent forms
of appendicitis rarely lead to suppuration. This is
evidently not the universal rule; for I take it, we are
Obliged to regard his so-called “bilious attacks” as
manifestations of appendicular inflammation. It has
been recently said that rectal examination is very valu-
5
66 MEW YORK STATE MEDICAL ASSOCIATION.
able, in determining at an early period the presence of
disease of the appendix. For myself, I have only encount-
ered it very late. Lange, and others, have operated
upon this variety of abscess, which the Germans prefer
to call “paratyphlitis,” by incision through the rectum,
with, as a rule, a successful issue.
CASE II. H. C. H., thirty-eight years of age, was seen in consultation
with Dr. J. L. Heffron, July 14, 1892. During the past winter, he had
been Seriously ill with typhoid fever, from which he seemed to have made
a very satisfactory recovery. At various times during the past few years,
he had had attacks of severe pain in the right side of the abdomen,
associated with nausea and constipation. Nine days prior to my visit, he
had been seized with a severe pain in the bowels, well down in the right
inguinal region. The bowels were moved daily, by administering one
drachm of Rochelle Salts each morning, and tympanites was controlled by
intestinal antiseptics. Hot applications not only failed to relieve the pain,
but were irksome to him. The temperature had not been elevated,
although at my visit it reached 102° F. The pulse had usually been about
80. His pain was not at all severe, and he did not really feel very sick.
After the fifth day, a tumor could be mapped out, reaching along the brim
of the pelvis, from the anterior superior spinous process, downwards
three or four inches. It was very firm, did not fluctuate, and was not at
all tender. Neither the condition of the patient, nor of the tumor, seemed
to demand active interference. I did not see him again until November
22d. There had been a daily rise of temperature. The thigh was drawn
upwards, and rotated inwards; the tumor had grown rapidly in size, was
very tense—in fact too tense to permit the recognition of fluctuation.
Immediate operation was advised, and under ether, the abscess was freely
opened by an incision running one inclabove, and parallel to Poupart's
ligament from its outer third up to the anterior superior spinous process.
In carrying the incision deeply, the peritonaeum was incised for the dis-
tance of an inch, the omentum protruding. This was speedily closed with
catgut suture. It was estimated that nearly a pint of pus was discharged.
The wound was thoroughly irrigated and packed with iodoform gauze.
Daily irrigation with a sublimate solution, and packing with iodoform
gauze was kept up. The closure of the wound has been very slow, and in
fact at this late day there still remains an unhealed sinus, about one and
a half inches deep, and one-quarter of an inch broad. The general health
of the patient has steadily improved, but mentally he is greatly depressed
because of his tedious convalescence.
This case is another example of suppuration occurring
in a chronic relapsing appendicitis. The vermiform pro-
cess probably had melted away in the course of the
RECENT CASES OF APPENDICITIS. 67
suppurating inflammation. The abscess cavity, with its
thickened walls, evidently stood in the way of prompt
repair, and subjected the patient to the annoyance of very
tardy recovery, and the possibility of a permanent sinus.
CASE III. As very strikingly opposed to the slowly forming pus
collections which are hemmed in by adhesions, and from which the peri-
tonaeum is thus protected, I desire to report the history of a patient, seen
with Drs. Elsner and Didama, October 3, 1891. He was unmarried; twenty-
three years of age; a candle-maker. He was very vigorous, and had not
required medical attendance since childhood. On the morning of October
2d, he had gone to his work as usual, but at ten o'clock called upon Dr.
Elsner, complaining of pain in the bowels. Upon examination, the abdo-
men was found to be distended, rigid, painful on pressure, particularly so
at the “McBurney point,”—two inches from the anterior superior spinous
process, on a line drawn to the umbilicus. It was learned later, that on
the preceding day he had been obliged to return home from his work be.
cause of abdominal pain, but finding relief from medicines administered
at home, he resumed work. When first seen by Dr. Elsner, the temper-
ature was normal, but the diagnosis of appendicitis was made. Within
twenty-four hours the condition was greatly aggravated. There was con-
stipation, increasing pain, some vomiting, general peritonitis, temper-
ature 102.5°, pulse 96. In the afternoon, when seen by me, in company
with the physicians mentioned, it was decided to do a laparotomy. The
patient was properly prepared with the usual antiseptic precautions.
An incision along the outer border of the right rectus abdominis muscle
was then made. There was but little bleeding. Upon incising the peri-
tonaeum, thick yellow pus appeared. The wound was enlarged, and the
caecum exposed. Upon its surface were thick, adherent flakes of pus;
the omentum was not gangrenous, the peritonaeum was thickened, and
there was some pus in the iliac fossa. The appendix was reached without
difficulty, and was found lying to the outer side of the caecum, and
adherent to the surrounding tissues, but it was easily separated. It was
thickly infiltrated, darkly discolored, and upon its free extremity pre-
sented a gangrenous ulceration. There was no perforation, and it did not
Contain any concretion. It was one and three-quarter inches long. After
ligation, it was cut off, its cut surface cauterised with concentrated car-
bolic acid, the diseased surfaces touched with a strong sublimate solution,
a drainage tube inserted, with a packing of iodoform gauze around it, and
the wound partially closed. After the operation the pulse was 130. At 10
P. M. the patient was resting quietly, but the pulse had gone up to 150, the
respirations to 32, and the temperature to 102.8°. The patient had not
urinated voluntarily during the entire day. The following morning the
nurse reported that the patient had passed a quiet night. At 10 A. M. the
temperature was 102.8°, pulse 130, respirations 30. At 3 P. M. a marked
change suddenly came over him; the temperature shot up to 105.5°, and
68 NEW YORK STATE MEDICAL ASSOCIATION,
the pulse to 160; his respirations became shallow, and there was mutter-
ing delirium with great depression. When seen by me at 6 P. M., he was
unconscious, and the pulse flickering ; an hour later, he was dead.
This very rapid development of ulcerative appendici-
tis, awakening, almost from the start, a septic peritonitis,
without any previous manifestations of disease of the
vermiform appendix, is very unusual. That a person
should have continued his work after a peritonaeal in-
flammation had developed, and not presented himself to
a physician for treatment, hardly seems possible.
The period at which an operation is performed is not
to be designated as “early,” because only a few hours,
or even days have elapsed since the treatment was begun ;
this period cannot be measured by any length of time.
An “early” operation is one done while the disease in-
volves only the appendix. If peritonitis is present, it
matters little whether it has required one hour, or one
week for its development. The complication is equally
serious in either event, and the operation, no matter how
soon performed after the appearance of septic periton-
itis, is no longer to be regarded as an early operation.
Dr. Jacobi has made a very happy suggestion, namely,
that an operation, to be successful, must be not only
early, but timely. Very few cases have recovered, in
which septic peritonitis has co-existed. Recently, how-
ever, Abbé has secured the successful termination of
some of his cases, by making a second incision upon the
left side of the abdomen, and in this way establishing
thorough irrigation.
CASE IV. I was called by Dr. E. A. Didama to Cortland, N. Y., Feb-
ruary 10, 1892, to see a young man twenty-seven years of age. He had
never been seriously sick, but for several months, upon exertion, had
complained of a “pain under the ribs" on the right side. There never
had been an acute attack of pain or fever. He had felt as well as usual
until the morning of the 8th, when he was seized with such severe pain in
the epigastrium as to oblige him to leave his work. There were slight
elevation of temperature, great pain, and constipation. An anodyne was
administered. On the following day the pain was intensified, and it was
necessary to administer morphine hypodermically. On this day vomiting
RECENT' OASES OF APPENDIOITIS. 69
set in ; on the 10th the symptoms were all aggravated, and the pain local-
ised in the right side, and he was unable to retain either food or medicine
administered by the mouth. Under the influence of a mercurial cathartic,
the bowels moved loosely several times. One movement in the afternoon,
which contained solid faecal matter, relieved the patient considerably. At
1 P. M. the temperature was 102.5°, and the pulse 102. When seen by
me at 3 o'clock the temperature was 101° F., pulse 110, respirations
rapid and shallow ; both limbs were extended, and the patient moved
about in bed with great pain. The entire iliac region was exceedingly
sensitive to the touch, and the abdomen slightly distended. Along the
outer border of the iliac fossa dullness existed for a space one inch in
breadth ; no tumor could be felt. The most tender point was one and one-
half inches from the anterior superior spinous process, on a line to the
umbilicus. The patient felt somewhat improved, but the persistence of
the local signs led me to advise laparotomy. Assisted by Drs. Didama
and Higgins, of Cortland, after a hasty preparation of the patient, I made
an incision four inches in length, along the right linea semilunaris. Upon
incising the peritonaeum, a stream of thin pus appeared. The appendix
did not readily come into sight, but was discovered by my finger, external
to, and behind the caecum, extending upwards, and adherent throughout
its entire length. It was greatly thickened and infiltrated, purple at its
terminal extremity, and gangrenous near its attachment to the caecum, for
a distance of one and one-half inches. With some difficulty it was de-
tached, and dissected well down to the caecum. The parts were sponged
out with an antiseptic solution, the intestines protected with sponges; the
appendix drawn up, ligated with silk at its base, and after tying its
mesentery, removed. The cut end was cauterised with carbolic acid, the
cavity was thoroughly mopped with sublimate solution, 1 to 1000, a drain-
age tube introduced, surrounded with a packing of iodoform gauze, and
the wound partially closed at its upper extremity. The patient rallied
promptly from the operation, and two hours later the temperature was
98.5°, pulse 78. He slept fairly well during the night. A change of
dressings was made early next morning. He still remained free from
fever, and though suffering at the time of dressing, was otherwise free
from pain. The appendix was found to be six inches in length, distended
With a quantity of thin pus, and contained no less than one dozen firm
Concretions of faecal character. Word was received on the 13th of the
patient's continued improvement, and the statement made that apparently
nothing could interfere with his recovery. Shortly before 10 o'clock on
the evening of the 15th, I received a message calling me immediately to
Cortland. On this evening the patient had suddenly developed a rise of
temperature, and great pain in the iliac fossa. The bowels had moved
daily, and there had been substantially no discharge from the wound.
Anaesthetising the patient, I made an examination of the wound, and
found it rather adherent at its surface. Beneath the superficial adhesions
there was a small quantity of pus, and on displacing the head of the colon
a stream of liquid faeces appeared. Cleansing the wound as well as pos-
70 NEW YORK STATE MEDICAL ASSOCIATION.
sible, an examination showed a perforation into the caecum, close to the
appendicular attachment. Its edges were promptly denuded and inverted,
and the wound closed with a Lembert suture.
The patient rallied nicely from this operation, but gradually sank under
the development of septic peritonitis, and died on the 20th of February.
The very promising course of this case in the early
days following the operation, had led us all to look for-
ward, with apparently good reason, to a happy termina-
tion; but despite the irrigation of the wound with
antiseptic solutions, and the subsequent careful packing
with iodoform gauze by Dr. Didama, the septic inflam-
mation led to perforation of the caecum.
CASE W. September 24, 1892, I was called by Dr. C. S. Roberts to see
J. M., twenty-one years of age, a butcher, who was supposed to have a
strangulated hernia. The patient was said to have a right indirectinguinal
hernia, which he had been able to reduce whenever it protruded, by lying
down and keeping quiet for a short time. On the evening of the 22d, he
lifted a heavy quarter of beef, and was speedily seized with pain in the
abdomen. During the night, the pains became very severe, and were
restricted to the region of the umbilicus. On the morning of the 23d, he
was given two large doses of “salts.” His bowels had moved on the pre-
vious day, but did not respond to the salines. The pains increased in
severity, and Dr. Roberts, being called, administered an opiate, without
relief. A soft, elastic tumor existed in the upper portion of the right side
of the scrotum. Taxis was applied, and also heat, but ineffectually. The
patient was put upon his back, with thighs elevated, and resting upon a
chair. In this position I found him at 4 P. M., on the 24th of September.
Examination of the tumor revealed an elastic swelling the size of a small
hen's egg. Above and below it, the spermatic cord could be felt. The
abdomen was not distended, but was exceedingly rigid ; the tongue had a
broad, brown central streak; the pulse was 80, and the temperature 100.5°.
The entire abdomen was tender to pressure, but the pain was par-
ticularly on the right side, and tenderness to the digital pressure was most
marked at the “McBurney point.” The opinion was expressed, that
whatever the Swelling in the scrotum might be, it had nothing to do with
the abdominal trouble, which was believed to be a beginning general
peritonitis, dependent upon appendicitis. Laparotomy was advised, and,
assisted by Drs. Roberts and H. D. Didama, was undertaken in the usual
way. The incision was made along the outer border of the rectus abdom-
inis muscle. After controlling the haemorrhage, which was slight, the
peritonaeum was opened, but no pus was found. The appendix was con-
cealed in a mass of adhesions. From these it was carefully separated, and
was found to be about one and one-half inches in length, thickened, almost
purple in Color, its surface in a condition of gangrenous inflammation.
RECENT CASES OF APPENDIOITIS. 71
Near its base it was constricted and bent upon itself. It was ligated at its
base, cut off, and its cut end cauterised with carbolic acid. Every part
was carefully washed, and, as there had been no pus present, the wound
was closed by suture. It was now thought advisable to investigate the
character of the scrotal swelling. An incision over it soon exposed an
encysted hydrocele of the cord. This was split open, stitched to the sur-
rounding skin, and packed with iodoform gauze.
In the evening, the urine, which had been retained for twenty-four
hours, was drawn with a catheter. He passed a very restless night, but
suffered more from the cystic, than the abdominal operation. On the
following day, the temperature reached 101.5°, but his tongue was less
dry, and the abdomen less tender. There was no vomiting; the bowels
remained constipated. By the 28th of September, all evidence of peri-
tonaeal inflammation had disappeared, and from this time, the patient made
an uninterrupted recovery.
In this case, the timely removal of an appendix, begin-
ning to be gangrenous, arrested peritonaealinflammation,
and resulted in a very happy recovery, where I believe a
delay of twenty-four hours would have placed the
patient beyond operative relief.
CASE WI. C. W., forty years of age ; married; seen September 9, 1891.
He had usually enjoyed good health, but early in May last, while at Bald-
winsville, he was seized with pain in the right side of the abdomen, accom-
panied by nausea, fever, and constipation; and he was confined to his bed
one week. During the latter part of July, a similar attack confined
him to his room for a few days. Two days ago, the third recurrence
manifested itself. During the months which had intervened, there had
been more or less constantly present, a tender spot on the right side of his
abdomen, which frequently interfered with locomotion. An examination
showed a very slight tumor. Tenderness to finger pressure was marked at
the “McBurney point.” There was persistent nausea, but no vomiting.
During the following week the patient was kept abed, although the acute
manifestations disappeared about the 14th of the month. All that remained
Was a slight dullness along the outer border of the iliac fossa, and a
little induration just above the level of the anterior superior spinous pro-
Cess. The patient, who had become greatly depressed because of the three
recurrences of inflammation of the vermiform appendix, in the course of
four months, very readily consented to the suggestion, that because of the
persistence of the disturbance, the appendix ought to be removed. On
September 20, 1891, he was removed to St. Joseph's Hospital, Syracuse,
and on the following day, assisted by some of the gentlemen of the hospi-
tal staff, after the usual preparations, I made an incision into the abdom-
inal cavity, as heretofore described, and after a little difficulty, discovered
the appendix adherent on all sides to the outer and posterior portion of
the caecum. It was one and three-quarter inches in length, densely infil-
72 NEW YORK STATE MEDICAL ASSOOIATION.
trated, and constricted at its base. Protecting the peritonacal cavity with
Sponges, the vermiform process was removed with a knife, and its base
cauterised with the Paquelin cautery. The abdominal wound was closed.
There was nothing to mar the patient's recovery, which proceeded in every
way satisfactorily. In the fourteen months which have elapsed since the
operation, the patient has not had the slightest suggestion of a return of
his former symptoms, and has improved so much in his general condition,
that, to use his own words, “he feels quite like a new being.”
The cases presented form an excellent text for the dis-
cussion of the surgical treatment of appendicitis, inas-
much as they present the various surgical aspects of the
disease. But as I have already occupied so much time,
I prefer to briefly summarise the propositions I have to
offer, and put them in the form of a series of conclusions,
based not only upon my own cases, but upon the accu-
mulated experience now at the disposal of the profes-
SIOIl.
OONOLUSIONS.
1. As the appendix, and not the caecum is the primary
seat of disease, these forms of inflammation should be
known as appendicitis. The terms typhlitis, perity-
phlitis, and paratyphlitis, are not only confusing, but
incorrect.
2. It is most important to determine whether the inflam-
mation is non-Suppurative or Suppurative. If Suppura-
tive, it is equally vital, for proper treatment, to establish
whether the diseased appendix and the purulent collec-
tions are to be hemmed in by protective adhesions, or to
remain in direct communication with the general perito-
naeal cavity.
3. With symptoms of moderate severity, and no ten-
dency of the inflammation to increase in extent or intens-
ity, but rather to decrease after thirty-six hours, it is
Safe to treat the case medicinally.
4. The exhibition of salines or other cathartics in the
early stage of an appendicitis, is not only inadvisable,
but apt to interfere with the development of protective
adhesions, and may even be responsible for perforations.
IRECENT CASES OF APPENDIOITIS. 73
Exploration with the needle to determine the presence
of pus, is useless, and may be dangerous.
5. The violence of the symptoms, and their continu-
ance, and progression, indicate the presence of existing
suppuration, and render operative interference justifia-
ble. The earliest manifestations of a developing general
peritonitis make immediate operation absolutely impera-
tive.
6. Each case is to be considered in the light of the in-
dividual symptoms it presents. The absence of fever is
not to lull the medical attendant into a belief of security.
The proper moment for operative intervention in a given
case cannot be established by the period of time elaps-
ing since its development. Timely operation implies its
performance before the appearance of septic peritonitis,
or other serious complications.
7. Where the inflammatory process is of moderate
severity, and evidence of tumor formation is present,
operation can be delayed until the fifth, or even as late
as the twelfth day. The incision then to be made, is to
begin parallel with Poupart's ligament, an inch above its
centre, and curve upwards along the outer border of the
iliac fossa, and is thus to be made entirely extra-perito-
naeal.
8. Acute cases, manifesting signs of perforation or
gangrene, with no evidence of protective adhesions, de-
mand immediate operation, the incision to be carried
along the outer border of the rectus abdominis muscle,
and directly into the free peritonaeal cavity.
9. Advanced cases of suppuration, in which the ab-
Scess is post-caecal, can be opened by rectal incision.
10. Patients, in whom attacks of appendicitis persist-
ently recur, especially when localised tenderness con-
tinues, should submit to the removal of the appendix
during an intermission.
74. NEW YORK STATE MEDICAL ASSOCIATION.
DISCUSSION.
DR. FRANK W. Ross, of Chemung county, said that the paper just pre-
sented put the subject in the fairest way he had ever heard. He had paid
some little attention to these cases during the past year, and he could
recall one case of recurring appendicitis, where there were eight relapses
within one year. The appendix was finally removed, and the patient
made a good recovery. In another case, upon which he operated four
months ago, the original attack was apparently one of general peritomitis.
The trouble returned in one month, and during the next six weeks the
patient remained in bed, but the tumor did not disappear from the iliac
region. Several attempts were made to find pus, but none was found un-
til about a week or ten days ago; then, on making the incision described
by the author, an entirely extraperitoneal accumulation of pus was found,
and evacuated. A large drainage tube was inserted, together with gauze
packing. There has been no elevation of temperature, and the patient is
now doing extremely well. Last week he had a case in which an abscess
pointed posteriorly. He had thought it was possibly an abscess of the liver,
but at the autopsy it was found to be a case of appendicitis, the appendix
being bent backward and situated behind the caecum, and difficult to find.
A large number of cases of appendicitis recover without surgical interfer-
ence, and many physicians oppose operation on the ground that ninety per
cent. recover without such a procedure ; but they allow the ten per cent.
to die. The subject had been so clearly presented in the paper that there
should be no mistake in regard to what cases are, and what are not suit-
able for operation.
DR EDEN. W. DELPHEY, of New York county, said that five years ago
he had seen a case of recurrent appendicitis, in which there had been from
twelve to fifteen attacks. The patient was a married man, twenty-two
years of age. When first seen by the speaker, he had been suddenly seized
at two o'clock on that afternoon with such a severe pain in the right iliac
fossa, that he was taken home in a carriage. He was suffering greatly,
and there was nausea, but no vomiting. On examination, his abdomen
was found to be distended and tympanitic ; there was dullness in the right
iliac fossa, and marked tenderness over “McBurney’s point.” He was
given hypodermically, fifteen minims of Magendie's solution, and chloro-
form by inhalation during the paroxysms. During this time the propriety
of operation was suggested, but the family physician replied, that one of
his previous attacks had been more severe than this one. It was learned
subsequently that he had given the patient teaspoonful doses of the deodor-
ised tincture of opium, and had kept up the chloroform inhalations for
awhile, and had then administered salines. The next morning he was
much better, and thirty-six hours from the onset of the attack he was able
to return to his work, and was apparently well. This is one of those cases
in which the patient was exceedingly ill, yet recovered without operation.
So serious did the attack seem to be, that the speaker said from his pre-
vious experience with such cases, he expected a fatal termination.
DISCUSSION. 75
DR. E. M. MooRE, of Monroe county, said that the paper was one of
the clearest it had been his good fortune to hear, notwithstanding that
papers on this theme had come up frequently during the past two years,
before every medical society whose meetings he had attended. The mat-
ter is clearing up slowly, but it is not yet entirely clear. The fact still
remains, as already stated, that ninety per cent. recover without operation.
He had seen these cases over and over again in years past, and had ex-
pected them to get well, and had seen them do so. This very year he had
treated a case in which the symptoms were decidedly severe. There was
great pain on the slightest touch, over what is called “McBurney’s point,”
and for a considerable area around it. The temperature was 102°, and he
had everything in readiness for an operation, but it was thought best to
wait a little, as it was evening. The next morning he still hesitated, nor
could he make up his mind on the following day, as the patient was no
worse ; and then it was noticed that there was a slight change for the bet-
ter. Slowly but surely the patient went on to complete recovery. One of
the chief reasons for postponing operation in this case, was that he could
not discover any dullness whatever on percussion. Although willing to
admit that this is misleading on account of gas in the colon, causing more
or less resonance, he had found it a valuable guide. Notwithstanding the
light which had been thrown upon the subject to-day, he would still be at
a loss to know when to operate, unless percussion showed flatness. No al-
lusion had been made in the paper to the fact that these cases sometimes
point in the loin. He had met with three undoubted cases of this kind.
In One, which he saw for the first time at a late stage, stinking pus was
found, which had given no evidence anteriorly of its existence. In another
Case, which was opened in the loin and drained, the patient made a good
recovery. In still another, the incision was made far to one side, near the
antero-Superior spinous process of the ilium. He always made it a rule,
therefore, to examine for tenderness upon the back, as well as on the front,
The opening of these abscesses was not much more difficult than of other
purulent accumulations.
DR. JACOBSON, in closing the discussion, said that we were always con-
fronted with the very difficult question of deciding which cases are
Operative, and which are not operative. He had stated in his paper that
from eighty to ninety-five per cent. were treated successfully by medicinal
means, but it was none the less our duty in that other class, which demands
Surgical treatment, to operate. The great practical point is, at what time
is it our duty to operate 2 The presence of fever will not decide this ques-
tion, for he had seen cases in which there was no rise of temperature. In
One Case, Which he saw for the first time a few hours before death, the tem-
perature had not been above 999 throughout the whole previous week of
illness, yet all the local manifestations of suppurative peritonitis were
present, with the general disturbance incident to septic infection. Regard.
ing these abscesses forming in the loin, he said that when operation was
Performed at a late stage, pus might be found at various points; he had
76 NEW YORK STATE MEDICAL ASSOCIATION.
Seen it in the perivesical space, and in the caecum connecting with the ap-
pendix. Those abscesses which pointed in the loin, he looked upon as
retroperitonaeal, rather than purulent collections associated with appen-
dicitis. He had recently seen such a case, in which the attending physician
made a diagnosis of appendicitis, but the family refused their consent to
an operation. The case seemed to him to be one of retroperitonaeal ab-
scess. The patient passed into other hands, and at the autopsy, it was
found that caries of the spine was responsible for the abscess, and that
there was no appendicitis. Where there is no tumor, but violent fulmi-
nating signs of a beginning peritomitis, one should operate without waiting
for the presence of a tumor; but if there is no peritonaeal complication,
one can afford to wait. The pulse will be found a more trustworthy guide
than the temperature to the true condition present. The thermometer is
altogether too frail a staff to lean upon in this class of cases. He could
not understand how some advise postponing operation if the appendix be
gangrenous and no protective adhesions formed, for the gangrenous appen-
dix, like any other gangrenous part, should be removed, the only precau-
tion being, to do this at a time when it is not likely to be followed by any
Septic complication. The speaker said he would like to know the experi-
ence of others in regard to the frequency of typhoid fever as a possible
primary cause of inflammation in the appendix.
ECTOPIC PREGINANCY.
By HENRY D. INGRAHAM, M. D., of Erie County.
November 15, 1892.
Last December the writer was called in consultation
to a neighboring city to see Miss L , nineteen years
of age. He learned that for the past two years she had
been a book-keeper in a large mercantile house ; her
previous health had been good ; menstruation began at
the age of sixteen, and had been normal except that on
two or three occasions she had gone a week or two past
her time. About four weeks before I saw her, she should
have menstruated, but she got her feet and skirts wet,
and the flow did not appear. Her mother then gave her
some tansy tea. The flow soon came on, and it had con-
tinued, except for a day or two at a time, ever since.
Six weeks before I saw her, while at breakfast one morn-
ing, she was suddenly seized with excruciating pain in
the left inguinal region. She was faint, but did not lose
consciousness, and there was nausea and slight vomit-
ing, with chilliness, weakness, and dizziness. Her mother
assisted her to a couch, where she lay during the fore-
noon. In about an hour the pain was less severe, and
the other symptoms gradually subsided, so that in the
afternoon she felt so much better that she walked half a
mile, and rode five miles in the street-cars, to see the
family physician. He gave her some medicine, and the
Second day after her visit, she was so much improved
that she went to her work, one and one-half miles dis-
tant, riding in the street-cars most of the way. She con-
tinued to work until the fifth day, when she fainted at
the store, and was taken home in a carriage. She re-
mained at home three days, and again went to work. Four
days later she again fainted, and was again taken home.
78 MEW YORK STATE MEDICAL ASSOOIATION.
After that she did not go to work, but lay upon a couch
the greater part of the time during the day. The ab-
dominal pain gradually increased, and marked tender-
ness developed. Her appetite failed, and nausea and
vomiting occurred. At this time a very competent phy-
sician was called. He ordered her to bed, gave morphine
per rectum, and put hot applications to the abdomen,
yet she continued to grow worse. Upon examination, he
discovered a swelling in the left inguinal region, the na-
ture of which was not clear to him, so he called in a gen-
eral surgeon, who, I am told, thought the mass was con-
nected in some way with the bowels, and was the cause
of her constipation, which was so severe as to constitute
almost obstruction of the bowels. He advised the re-
moval of the patient to the hospital for an operation,
but to this her parents would not consent.
The patient continuing to grow worse, the writer was
called, and first saw her about ten o’clock in the morn-
ing. She was very anaemic, with a small, rapid, feeble
pulse of 140 ; temperature 104°. There was excru-
ciating pain in the abdomen, which was very tender,
distended, and tympanitic. She had that peculiar, anx-
ious expression, which is usually seen in the later stages
of general peritonitis; there was frequent vomiting, and
the bowels were constipated. She had slept but little
for several nights previously. Owing to the extremely
tender condition of the abdomen, it was difficult to ex-
amine the patient satisfactorily, yet in the left inguinal
region a large mass could be detected. Upon my sug-
gestion, a thorough examination was made under chloro-
form. The tumor was about the size of the foetal head,
and semi-fluctuating. Waginal examination revealed the
absence of the hymen, and a patulous OS ; from the uterus,
which was crowded somewhat to the right, and measured
three and one-fourth inches in depth, there was a slight,
bloody, shreddy discharge. After completing the exam-
ination, I remarked to the attending physician, that if
the patient were a married woman, I would think it was
EOTOPIO PREGINANCY, 79
a case of ectopic pregnancy, and that, at any rate, the
proper treatment was an operation, but that it was very
doubtful if the patient recovered, owing to the general
peritonitis. My prognosis, but not my diagnosis, was
made known to the family. They objected to the opera-
tion unless they could be assured that the patient would
recover. The following day a well-known gynaecologist
was called in, and he advised an operation, but feared
the result would be fatal. Without any urging or
assurance of recovery from me, the parents concluded
to have the Operation. Accordingly, the next morning,
it was performed under ether, and with the most thor-
ough antiseptic precautions. When the abdominal cav-
ity was opened, the large mass in the left inguinal region
was found enveloped by a very thin membrane, which
broke down as soon as the attempt was made to lift it
out. The mass of clotted blood and tissue was quickly
removed, and the left tube ligated, and removed.
The right tube and ovary were apparently healthy. The
intestines, which were much distended with gas, were
one mass of adhesions. It was necessary to draw off the
gas from them in several places with the aspirator, in
order to keep them within the abdominal cavity. The
abdomen was carefully cleansed by Sponging, and the
wound closed and dressed in the usual manner. The
patient rallied from the operation, but died two days
later from the peritonitis. The operation apparently
had no effect in prolonging life, or in hastening the fatal
termination. The tube was ruptured at the junction
of the middle with the outer third. Although the debris
was carefully examined, the foetus was not found, but
the placenta was recognised under the microscope, thus
definitely settling the diagnosis.
CASE II. Last January, my colleague Prof. Mynter was called to see
Mrs. D—, who being very ill, and not having the best surroundings at
home, was taken to the Buffalo Hospital of the Sisters of Charity. Her
history, as given in the hospital record, is as follows: She is an Ameri-
Can, twenty-five years of age. Her previous health was good. She has
80 NEW YORK STATE MEDICAL ASSOCIATION.
been married five years, and has one child, four years old ; no miscarriages.
Menstruation began at the age of fourteen, and has always been normal.
The last menstrual period occurred in the latter part of September, at which
time the flow was normal. In October, she missed her period, and soon
thought she was pregnant, as she began to have all the symptoms which
she had observed in the earlier months of her previous pregnancy. A few
days after the time she should have menstruated in November, and two
months from the time when she did menstruate, she was seized, without
any apparent cause, with a sudden and severe pain in the left inguinal
region; so severe, that she fell to the floor in a faint. She was assisted into
bed, and had remained there ever since, now six weeks. She began to
flow, and so sent for the family physician, who told her she was having a
miscarriage, For three or four days the flow was slight, then it stopped
for two or three days, but began again more freely, and the discharge was
shreddy and stringy. She was then told that the foetus had been expelled.
Since then, there had been a very slight, and nearly continuous flow.
When first seen, there was very marked abdominal distention and ten-
derness, with severe pain, especially in the left side. She had chills, fever,
night-sweats, vomiting, diarrhoea alternating with constipation, and fre-
quent micturition. IIer pulse was 130, temperature 103.5° and respira-
tions 30. She had becn treated first for threatened miscarriage, and then
for miscarriage; the uterus had been curetted, and vaginal douches given ;
and for the past four weeks she had been treated for peritonitis, with
opiates, tincture of iodine, and hot fomentations to the abdomen, but
without benefit.
Examination revealed a symmetrical, but much distended and tender
abdomen. The uterus was crowded forward so that the finger had to be
passed up back of the pubis to feel the cervix ; the body could not be
discerned. The vagina, posterior to the uterus, was very much distended,
and there was apparently a fluid accumulation behind it. It was thought
best to make an opening through the vault of the vagina, hoping to remove
the cause of the trouble in this way. The patient was given an anaesthetic,
and, with an aspirating needle, a thin, dark liquid was withdrawn. A small
opening was then made with a knife, and after enlarging this with a
uterine dilator, about three quarts of a thin, dark, stinking fluid gushed out.
This fluid contained many solid particles, varying in size from a pea to a
marble. The fluid was apparently mostly decomposed blood. You may
have some idea of the foctid character of the discharge, when I say that
the operation was performed in the presence of the senior class of Niagara
University, and that nearly all the students left the room because of the
stench. The cavity was washed out with a 1 to 4,000 bichloride solution,
and two T-shaped rubber drainage tubes inserted. The abdominal disten-
tion immediately disappeared, as did also the pain and vomiting; the fever
was greatly diminished ; and the patient slept well the following night
with very little opium. From that time on her recovery was steady and
continuous. Three days later, one drainage tube was removed, and two
days after this, the other tube. For a few days the cavity was packed
FOTOPIO PREGNANOY. 81
with iodoform gauze, but it filled up very rapidly. There was but little
discharge after the first day. The patient left the hospital perfectly well
in a little over two weeks.
I learned subsequently from the husband, that he had had gonorrhoea
just before marriage, that for a long time he was troubled with gleet, and
that two years ago he was operated upon for stricture; since then he had
had no discharge. I have seen the patient several times since she left the
hospital; she menstruates regularly, and is in perfect health.
CASE III. Mrs. S--, twenty-five years of age, had enjoyed good health
previously. She had been married four years, and had one child, three
years old ; no miscarriages. Menstruation began at the age of seventeen,
and has always been normal. Her last menstruation was on December
18th. On February 25th, Dr. Tobie was hurriedly summoned to see the
patient, whom he found in collapse. She had been suddenly seized
with intense pain in the left side, had fainted, and fallen to the floor.
Warmth was applied to the body, and stimulants and morphine adminis-
tered. For three days she had retention of urine, necessitating the use
of the catheter. For about a month past, she has had, at different times,
sharp pains in the left iliac fossa, but upon keeping quiet for a few
minutes, they would stop.
I was called by Dr. Tobie on March 3d to see the case with him. She
was pale ; pulse 85, temperature normal, pain and tenderness in the left
inguinal region. Waginal examination revealed the uterus crowded to the
right, os patulous, a bloody, shreddy discharge from it, and a boggy mass
to the left. From the history of the case and the examination of the
patient, I agreed with the attending physician that it was a case of ectopic
pregnancy with rupture into the left broad ligament, and probable death
of the ovum. She was given one-sixth of a grain of morphine, when re-
quired, and kept in bed. She gradually improved, but was confined to
the bed nearly six weeks, and was not able to be around the house much
for two months. Since then she has attended to her household duties,
She menstruated normally on April 5th, and has been regular ever since.
On November 1st, there was a small induration at the left, and posterior to
the uterus, about the size of the first joint of the index finger; but there
was no pain or tenderness. The patient says that for the past three or
four months she has felt as well as ever. It might be said here, that there
Was no secretion of milk in any of these cases when seen by me.
These cases are reported, not because they present any
very unusual symptoms, at least in their earlier stages,
but for the purpose of putting them on record, and to
aid in calling the attention of the general practitioner to
the earlier symptoms of ectopic pregnancy. It is the
significance of the earlier symptoms that should be
heeded before it is too late to benefit the patient. There
6
82 WETV YORK STATE MEDICAL ASSOCIATION.
is no doubt that ectopic gestation occurs much more
frequently than is generally supposed, and unless the
patient dies from haemorrhage or shock immediately
following the rupture, nearly all can be saved if properly
treated. I have now seen nine cases in which rupture
had occurred, and all were operated upon except the first
one I ever saw, who I believe might have been saved by
an Operation, and the last one mentioned in this report,
who did not need an operation, but recovered. My first
case was seen before much was known in regard to this
condition, but a post-mortem examination revealed the
true state of affairs. The earlier symptoms of the first
case reported to-day, are typical of ectopic pregnancy,
except that usually the patient is not able to be up and
attending to her work, as this one was for the greater
part of the time for nearly two weeks after rupture oc-
curred. The fact that this patient was an unmarried
woman may possibly have thrown the attending physi-
cian off his guard, but symptoms should always be in-
terpreted as their significance demands, regardless of the
condition of life. Although the patient claimed she had
not missed her period until she had been ill about two
weeks, and stoutly denied everything that would throw
any light upon the subject, I believe she had missed the
previous one, and that she had an idea that the suppres-
sion of menstruation was in some way the cause of her
illness. If I am correct in my supposition, rupture must
have occurred at about the sixth week of pregnancy.
There is not much doubt that the patient would have re-
covered had the operation been performed sufficiently
early, before general peritonitis occurred.
Some may be inclined to doubt the diagnosis in the
second and third cases. In the second case, there was
a typical history of ectopic pregnancy with rupture
into the abdominal cavity, the blood becoming encysted
in Douglas's cul-de-sac. If a ruptured tubal pregnancy
was not the cause of the accumulation of blood, what
was ? Although her family physician and one or two
EOTOPIO PREGINANCY, 83
consultants thought she had a miscarriage, there was
nothing to indicate it except the slight discharge. All
the evidence certainly points to ectopic pregnancy, and
I am not aware of any other condition which could ac-
count for all her symptoms. In the third case, the his-
tory of ectopic pregnancy, with rupture of the tube into
the broad ligament, and death of the ovum, was appar-
ently very clear, and I think the result shows the cor-
rectness of the diagnosis. f
It will be observed that the first two cases mentioned
had each been under the care of two or more physicians
for several weeks, yet a correct diagnosis had not been
made. In the last case, Dr. Tobie, to his credit be it
said, made a correct diagnosis the first time he saw the
patient, but not wishing to assume the entire responsi-
bility, promptly called in counsel.
The points which I wish particularly to emphasise are
these : When a woman, whether married or single,
skips one or more menstrual periods, and is suddenly
seized with sharp, excruciating pain in the lower part of
the abdomen, usually more marked on One side, grows
faint, has nausea, or vomiting, is unable to sit up or
walk, or walks with difficulty, has great tenderness on
One side of the abdomen, and a shreddy, stringy, uterine
discharge; and when, upon vaginal examination, a boggy
mass is felt, generally at one side of and posterior to
the uterus, it is time for the attending physician to call
On a competent consultant, unless he feels perfectly
able to manage a ruptured ectopic pregnancy. Even if
all the above symptoms are not present, a consultation
should be promptly called, as delay has cost many lives.
When rupture occurs, abdominal section is the proper
treatment, unless the rupture be within the folds of the
broad ligament, when absorption usually takes place.
Even then, when in doubt, operation is demanded. I
believe the use of electricity in the treatment of this
Condition is worse than useless—it is trifling with hu-
man life.
84 NEW YORK STATE MEDICAL ASSOCIATION,
DISCUSSION.
DR. E. M. MooRE, of Monroe county, said that two months ago he had
Operated upon a case of ectopic gestation, two and a half months after the
cessation of menstruation. The patient was forty years old, had been
married twenty years, and had never been pregnant, so that she had not
the slightest suspicion of her condition. This is interesting in connection
with what Mr. Bland Sutton has said about ectopic gestation being liable
to occur in women who have long been sterile, and in fleshy women. She
was seen by a physician in the neighborhood on July 8th. He found her
suffering extreme pain, without any antecedent symptoms; there was
marked pallor, and a small and rapid pulse; in other words, just such a con-
dition as indicated a haemorrhage into the cavity of the peritonaeum. She
Soon revived, and seemed to be quite comfortable, and there were then no
evidences present of general peritonitis. On August 5th, and on the 12th
of that month, she had similar attacks. It was at this time that the speaker
was called in to see her. He operated, and found a ruptured extra-
uterine pregnancy. The author had spoken about packing the cavity of
the pelvis with iodoform gauze. He had found in this case that after
tying off the tube, the mass, which was about the size of a large orange,
was still adherent down in the iliac fossa. While separating the mass, the
pelvic cavity suddenly became filled with blood ; the pelvis was immedi-
ately stuffed full of iodoform gauze, and a drainage tube inserted. The
haemorrhage was thoroughly and promptly controlled in this way. After
the operation there was only a moderate rise of temperature and pulse.
and at the end of the sixth day, the gauze and drainage tube were re-
moved. About three weeks after, she developed an abscess, which was
incised. He reported this case to show the facility with which we can
stuff the pelvic cavity with iodoform gauze in such an emergency.
DR. J. E. JANVRIN, of New York county, said that he had contributed
during the past Seven years several articles on this subject, and he
believed he was one of the first, if not the first in this country, to suggest
the Operation of exploratary abdominal section in all cases in which the
general Symptoms point to ectopic gestation. In all of his work in this
direction since then, he had never had any occasion to alter his opinion.
He believed with the author, that with the usual symptoms of pregnancy,
which where often present, together with irregular menstruation and
shreddy discharge, and the physical signs of some growth in the abdominal
cavity, to one side or the other of the uterus, which is, as a rule, exquisitely
Sensitive, the only justifiable procedure is to open the abdominal cavity.
He had had the pleasure of expressing his opinion before this Association
two years ago.
The first two cases reported by the author were typical of an ordinary
ruptured ectopic pregnancy, the third, of one down in the folds of the
broad ligament, and the fourth, of one situated low down, and hemmed in
by plastic exudation so that it could be opened through the vagina. The
subject of ectopic pregnancy has been repeatedly discussed, and cases like
I) ISO/USSION. 85
those presented in the paper were simply accumulative evidence. When
the symptoms are such as to indicate to one of experience in this depart-
ment of medicine, the probable existence of ectopic gestation, the use of
any form of electricity is simply postponing a laparotomy. It is a condi-
tion which should be dealt with promptly and thoroughly. We are cer-
tainly justified in performing such an operation ten thousand times more
than in a simple case of salpingitis, and yet no one hesitates in the latter
class to operate. In the majority of cases, we shall find our diagnosis cor-
rect, and even if the diagnosis be incorrect, such an exploratory incision
will facilitate the subsequent management of the case.
DR. E. M. MooRE, of Monroe county, remarked upon the fact, that in
three of the cases reported in the paper, the pregnancy was on the left side,
and asked Dr. Janvrin if this were the rule.
DR. JANVRIN replied, that he had seen a number of cases occurring on
the right side, and had not noticed that it was more frequent on one side
than on the other.
ANTISEPTIC VAGINAL AND INTRA_UTERINE
INJECTIONS UNNECESSARY, IF NOT IN-
JURIOUS IN THE DAILY PRACTICE
OF OBSTETRICS.
By DARWIN COLVIN, M. D., of Wayne County.
(Read by title November 15, 1892.)
I am well aware that it requires some courage to stand
before this intelligent body of medical men, as an
opponent of the practice of using antiseptic vaginal and
intra-uterine injections in the every-day practice of
midwifery. However, the extreme views which were
so liberally paraded in the journals, but a short time
since, are now seldom reiterated for want of conversions.
The practice of frequent flushings of the vagina with
antiseptic solutions when only normal processes are
going On, during, and immediately after parturition,
has begun its march, and is rapidly moving on to join
that innumerable caravan of other ephemeral fashions
which have preceded it. What good reason can the
accoucheur give for introducing poisonous solutions
upon mucous tissues, which are in a healthy condition ?
Such conduct reminds me of a story of my boyhood:
A stern parent was asked how he governed his boy. He
replied, “I always punish him whenever I see him, for
I know he has just come out of, or is just going into,
mischief.” To make the application :-the accoucheur
will punish with or without proper justification. I shall
have nothing to say about antiseptic precautions in the
various surgical procedures of the present day; it is
only against the unnecessary, and oftentimes dangerous
interference with normal physiological processes, that I
desire to enter a protest.
ANTISEPTIC INJECTIONS IN LABOR. 87
I will not consume your time in quoting authorities
for or against my position, as they are all familiar to you,
but I shall base my conclusions upon the results of more
than two scores of years of constant obstetric practice,
together with the care of between sixty and seventy cases
since that branch of general practice has been largely
abandoned. It has appeared to me when reading the
various contributions of those who write so learnedly
On the necessity of extreme antiseptic measures in partu-
rition, that they fail to make use of a reasonable amount
of what all practitioners should possess—good common
SéIlS62.
Do they ask themselves these very important ques-
tions: Is the mortality of lying-in women any less by
such means ? Is the death rate any less than it was fifty
years ago º Assuredly they cannot reply in the affirma-
tive.
All advocates of that complete metamorphosis of the
surroundings of the accoucheur and his patient, which
are so ludicrously emphasised in their writings, cannot
but be ignorant of the results obtained in the practice of
midwifery half a century ago, when the percentage of
recoveries was just as great as at the present day. True,
there was a less number of cases of cervical fissures and
perinaeal lacerations fifty years ago than at the present
time ; but that can be readily explained by the more fre-
Quent and unskillful use of the forceps.
If, then, the mortality is no less where there is so much
useless interference, why, I ask, is so much required ?
All should require careful, thorough, and complete
cleanliness, but do we always have that important factor
to aid us in the patient's recovery & When I think of
the scenes and surroundings of my early obstetric ex-
perience, I am almost led to say that even cleanliness is
Scarcely necessary to secure to the parturient female a
quick recovery. Ihave spent hour after hour in shanties
and log houses, in which I would not now consider it safe
to keep my horses; places where, in the winter, the snow
88 NEW YORK STATE MEDICAL ASSOCIATION.
could be seen sifting through the crevices, and where,
notwithstanding the log fire, my fingers would be so be-
numbed with cold, that I could neither make a digital
examination, nor ligatet he funis, until my fingers had
been first immersed in hot water.
No persons were at hand, to care for the patient, save
Some temporarily invited neighbors, and no injections
were used, yet, the patient recovered. There could have
been no nomadic tribes of germs in that day, for in con-
nection with this unpropitious state of things, I have
Often found upon my next visit, an almost unbearable
Odor arising from the bed-clothing. Frequently, upon
making further investigations, I would find that the
external genitals had had no introduction to soap and
water, and that the exsiccated blood had been allowed to
remain upon the parts, for fear, if removed, that “she
WOuld catch cold.”
Added to this evidence of ignorance, was the belief,
Quite frequently expressed, and as often carried out,
that the placenta should be burned “to prevent a broken
breast.” Fortunately, the immense fireplace afforded
every facility for its cremation.
While writing this paper, my memory goes back to
a score or more of abortions, many of them occurring in
the unmarried, where, for the purpose of concealment,
no physician was at first called in, and where not even
ordinary cleanliness was used, for fear of exposure; yet
in none of them was an antiseptic injection used, and all,
in which the placenta had been expelled, recovered. For
many years I was familiar with this state of things—
and such a thing as a fatal termination after parturition
at term, scarcely entered my mind.
True, at long intervals, I would hear of a death from
puerperal, or what was then called child-bed fever; yet
I had been in practice more than ten years before I saw
a case, and that was in consultation. Since that time I
have only seen three, these also being seen in consulta-
tion. Two of these had been treated by the fashionable
ANTISEPTIC TWJECTIONS IN LA BOR. 89
antiseptic injections, but how thoroughly I do not now
remember ; yet all died, though they were treated by
very clever practitioners.
I have performed seventeen craniotomies in my own,
and the practice of others, and although no antiseptic
injections were used, and frequently even cleanliness was
not observed, all of the women recovered.
Throughout the early period of my professional work,
there was scarcely one who pretended to be a nurse, and
if perchance one was found, she was generally some im-
pecunious relative or neighboring girl, who was expected
to do the work of the house, care for the other children,
and possibly milk a cow or two, besides attending to the
patient and baby for the stereotyped nine days. At the
expiration of this time, the so-called nurse was disposed
of, and the mother again took the helm, and went on
rapidly to recovery.
Now, some may say that “necessity drove this woman
from her bed,” but this I deny, for necessity does not
guarantee the patient against disease.
Picture to yourselves a highly sensitive, intelligent
young primipara watching the elaborate arrangements
being made for conducting her labor according to the
most approved antiseptic methods. Would it be strange
for her to exclaim: ‘‘Doctor, has that God whom
I have been taught is a synonym of love, after requiring
of me obedience to his command to multiply and re-
plenish the earth, placed my life in such jeopardy, as to
require you at this time to thus fortify yourself as an
antagonist of death ? Why am I in greater danger than
was the mother who bore me !”
Every physician should be governed in his treatment
of cases by the results. If, in the management of a
large number, the results have been perfectly satisfac-
tory without antiseptic injections, how can he expect that
a meddlesome change will be of service Strange as it
may seem to some, my records show that without the
use of any antiseptic injections, I have delivered at term,
90 NEW YORK STATE MEDICAL ASSOCIATION.
more than twelve hundred babies, with but one maternal
death, and that one occurred after an easy labor, and
within fifteen minutes after the extrusion of the pla-
centa. I have never been able to explain her death.
Now, this extremely favorable showing was not due to
the fact that these patients were living in the country,
as one of our Fellows remarked when criticising my
former paper. Why, may I ask, should we resort to
agents, which, if they could do no harm—and who can
say they will not—certainly cannot aid us in improving
upon the past 7
In an article written by a distinguished gynaecologist
of this country, on the subject of antiseptic injections
during and after labor, he says: “In private practice,
in the homes of comfort, with the attendance of the best
practitioners, and the care of good nurses, many a young
mother yields her life to the dangers which still accom-
pany home confinement. We are told that the records
of a prominent insurance company, reveal a mortality of
17 per cent. in private practice, and that among the
better class” (italics mine). No greater slander, and I
might almost say, untruth, was ever written. I believe
statistics will justify me in saying, that the mortality in
country practice, and without antiseptics, is not one per
cent.
Another more radical advocate of antiseptics in mid-
wifery, who is quite inclined to question the intelligence,
and even the veracity of the country practitioner, says:
“I believe that by far the greatest number of general
practitioners yet conduct their deliveries in the same
way that they learned at college many years ago, and
which they have been accustomed to follow since they
began to practice.” After having criticised the intelli-
gence of those physicians who are not converts to strict
antisepsis in midwifery, and who claim a small percent-
age of deaths in their practice, he says: “Either their
memory fails them, or they have a convenient definition
of puerperal fever, in consequence of which puerperae
ANTISEPTIO INJECTIONS IN LABOR. 91
die of peritonitis, metritis, pneumonia, pleurisy, heart
disease, liver complaint, kidney trouble, meningitis, ty-
phoid fever, etc., but never of a disease, the mere men-
tion of which, septicaemia, would touch the propriety of
adopting the antiseptic treatment.”
Poor country doctors, and those of cities who do not
choose to follow any man’s dictation in the use of anti-
septic agents in obstetric practice, when will you cease
to be so ignorant as not to be able to diagnose puerperal
fever from pneumonia, or heart disease ? How forcibly
does this writer exemplify the familiar proverb–º Alit-
tle learning is a dangerous thing !”
To those who have been taught that the genital organs
of every parturient woman are surrounded by germs,
which are ever ready to pounce upon them when they
begin that normal physiological work which the Almighty
requires for the purpose of peopling the earth, let me
say: Do not be startled, but abandon your prejudices,
and the future will hear you exclaim—“the otherwise
competent physician requires only complete asepsis of
the female genital organs after delivery, to make him a
successful obstetrician.”
THE PALLIATIVE TREATMENT OF SUCH CASES
OF CANCER OF THE UTERUS AND ITS
ADNEXA, AS ARE NOT AMENA-
BLE TO RADIO AL OPER–
ATIVE MEASURES.
By J. E. JANVRIN, M. D., of New York County.
JWovember 15, 1892.
During the past few years much has been written
upon the radical treatment of cancer of the cervix uteri,
and of the cervix and body. The treatment particu-
larly appropriate to the first condition, is the high am-
putation, as practiced by Dr. Byrne, of Brooklyn, and
Dr. Baker, of Boston ; or, in its stead, vaginal hysterec-
tomy. The only appropriate treatment in my opinion
for the second class of cases, i. e. when the uterus alone,
or the cervix and body, is involved, is vaginal hysterec-
tomy. In a paper on “The Limitation for Vaginal Hys-
terectomy in Malignant Disease of the Uterus,” which I
had the pleasure of reading before the Fifth District
Dranch of this Association at its meeting in Brooklyn
last May, and which was published in the New York
Medical Record, July 9, 1892, I endeavored to make clear
what my own experience in this operation had taught
Iſle.
It seems to me that the conclusions there given as to
the limitations of vaginal hysterectomy, are perfectly
legitimate. The cases appropriate for this operation
are those in which the disease is confined to the cervix
or uterine body, to both combined, to either of the above,
complicated by extension of the disease from the cervix
to the vaginal mucous membrane, and to a few cases in
which the uterine adnexa is the seat of old inflammatory
CANOER OF THE UTER US. 93
exudates. Necessarily all other cases would come within
the scope of this paper ; for example, cases in which the
disease has diffused itself to the uterine adnexa, or to
the peritonaeum, those in which the vaginal wall has
become deeply involved, those in which the lymphatics
and connective tissue between the vagina and bladder,
and between the vagina and rectum are affected, and,
consequently, all cases in which the bladder has become
involved, and probably nearly all in which the rectum
has participated in the disease process.
It is possible, but practically extremely rare, that a
cancerous neoplasm may develop in the rectum at the
same time with, but entirely independent of another
malignant growth in the cervix or uterus. In such a con-
dition, the removal of the lower segment of the rectum
at the same time that the uterus is removed, would be
perfectly legitimate, and would not materially increase
the immediate gravity of the situation. Unfortunately,
however, when both the cervix and rectum are involved
in the disease, that portion affecting the latter is gen-
erally an extension from the cervix, and hence the infec-
tion of the lymphatics precludes any attempt at a radical
Operation.
In the palliative treatment of all cases in which neither
high amputation or vaginal hysterectomy is justifiable,
there are many minutiae connected with both the local
and internal treatment, which, if observed, tend to delay
the advance of the disease, and to relieve the mental and
physical sufferings of these poor unfortunates.
To accomplish this in the best possible manner, one
should have control of a properly appointed hospital or
home. It should be located in the suburbs of a city so
as to Secure perfect rest and good country air, and yet be
Convenient to the attending surgeons. The surround-
ings should be cheerful, and its appointments suited to
the practice of modern aseptic surgery. The New York
Skin and Cancer Hospital fulfills these requirements in
its “Country Branch” at Fordham Heights, where accom-
94 NEW YORK STATE MEDICAL ASSOCIATION.
modations are furnished for nearly one hundred incura-
ble cases. The treatment of these cases during the past
eight years has prolonged life, and comforted hundreds
who could not possibly have been cared for in any other
way. -
Now, what can be done for these cases When the
tissues have thoroughly broken down and the discharge
has become very offensive, and the general health
greatly impaired, the first indication is to remove as
thoroughly as possible all the necrotic tissue, by careful
and extensive curettage. The curettage should remove
all the necrotic tissue, and as much of the underlying
diseased mass as is possible. To accomplish this, the
sharp curette must be made to penetrate deeply into the
base of the infiltration. Where the disease is confined
to the cervix and surrounding tissue, it frequently hap-
pens that the curette penetrates the cul-de-sac into the
peritonaeal cavity. Care should be taken, when this is
likely to occur, to protect the intestines from injury, by
pushing an antiseptically prepared sponge, to which a
strong silk thread is attached, up into the cavity, to sup-
port the intestines. I have made use of this method on
many occasions. Later on, when the final dressings are
being applied, a light tampon of iodoform gauze, loosely
inserted, keeps the intestines up, and prevents septic ab-
sorption by the peritonaeum.
As soon as the curettage has been done, all haemor-
rhage should be perfectly controlled by such styptics as
will not interfere with the further steps of the operation.
A saturated Solution of tannin will usually accomplish
this ; sometimes the hot water douche is all that is
needed. In some cases, the aid of the cautery at a red
heat is necessary. If these means fail, it is best to tam-
pon the vagina and leave the further steps of the opera-
tion for a subsequent date. The haemorrhage or oozing
having been perfectly controlled, and the parts wiped
dry, pledgets of antiseptic absorbent cotton, squeezed out
in a fifty per cent. Solution of chloride of zinc, are applied
CANOER OF THE UTER US. 95
to the raw surfaces, care being taken to protect the intes-
times and peritonaeum, when the cul-de-Sac has been
opened, by proper iodoform packing, smeared on its
vaginal surface with vaseline. The same process can be
used if the posterior wall of the bladder has been laid
bare during the curetting. The vaginal walls below the
excavation are protected by pledgets of absorbent cotton
thoroughly covered by vaseline. This dressing remains
Žn situ for twenty-four hours. It is then removed, and
the cavity washed out with a bichloride solution, one to
five thousand ; then thoroughly dried, and freely dusted
with the iodoform powder. Usually at the end of a
week, the sloughs caused by the chloride of zinc begin
to come away, and we shortly have a clean surface to
deal with. In the majority of cases I have found dry
iodoform the best application as soon as the sloughs be-
gin to come away. Aristol also acts well. The chief
indication is to keep the parts as clean as possible by the
use of some dry, stimulating and disinfecting applica-
tion. The moist or wet applications, such as disinfecting
douches alone, should be used as little as is consistent
with cleanliness, for the water remaining in the cavity
of the vagina softens the tissues and hastens their disin-
tegration. In cases of epithelioma or carcinoma affecting
the interior, and the body of the uterus, the same line
of treatment is followed. The entire cavity is thoroughly
curetted, in many instances to such an extent as to leave
but one-third or even one-fourth of its original wall, and
as soon as the bleeding is controlled and the cavity wiped
out so that it is as dry as possible, the Paquelin cautery
at a red heat is introduced, and this, in turn, followed
by the fifty per cent. solution of the zinc chloride.
There is, of course, nothing new in the use of the chlo-
ride of zinc. For many years the late Dr. Marion Sims
relied almost entirely upon it in his local treatment of
this condition, but it makes all the difference in the
world as to the results obtained, whether we first prepare
the parts by a thorough curettage, and then stop abso-
96 NEW YORK STATE MEDICAL ASSOCIATION.
lutely the haemorrhage and oozing, and thus have a dry
Surface upon which to apply the chloride, or simply ap-
ply it while the oozing is still going on. In the one case,
we get the most thorough effect; in the other, the chlo-
ride solution is washed away by the oozing, and often
spreads down upon the healthy tissues below, thus doing
more harm than good.
After the slough caused by the chloride has come
away, and we have a clean surface to treat, the applica-
tion of iodoform powder, aristol, pledgets of absorbent
cotton Squeezed out in spirits of turpentine, or a one to
three thousand bichloride solution, will aid materially in
keeping the surface in a clean condition for quite a while.
Some five years since, I gave the “aveloz” a thorough
trial in many of these cases, and found it an excellent
application as far as producing a slightly stimulating
and caustic effect was concerned. It seemed also to have
a somewhat sedative effect, and thus alleviated pain; but
the great objection to its use is its expense, and for that
reason, more than any other, it has been impossible to
use it on an extended scale.
After trying almost every kind of local treatment, in-
cluding injections of pyoktanin into the cervix, in these
unfortunate cases, I have become convinced that more
can be accomplished locally by carrying out thoroughly
the line of treatment above set forth, than by any other.
It remains for us to discuss the point as to whether any
internal medication will be of benefit. Of course it is
perfectly evident that when the disease has advanced to
Such an extent as to absolutely preclude any radical op-
eration looking to a cure, the system has become so thor-
Oughly infected that internal treatment can be made use
Of simply as a palliative measure. For this purpose, ar-
senic given after meals in gradually increasing doses up
to the point of toleration; the solid extract of red clover,
in half or whole teaspoonful doses before meals, and a
moderate amount of opiates to control as much as pos-
Sible the pain which sooner or later is sure to become
OANOER OF THE UTER US. 97
severe, seem to me to fill the requirements in most cases,
as well or better than any other remedies. The clover
is an excellent stomach tonic, and undoubtedly its good
temporary effects are due to this. It is no specific, as is
popularly believed, though when given early in the dis-
ease, its beneficial action is more apparent than later on ;
and I have every reason to believe that when given early
and perseveringly, it aids, to a certain extent, in checking
for awhile the progress of the disease.
Arsenic has the same good effect in these cases that it
has in all diseases in which the red blood corpuscles are
being destroyed. Frequently when given at the same
time with some of the preparations of iron, notably the
iodide, it seems for months to supply to the blood a de-
gree of nutrition which other remedies fail to give. To
relieve pain, and thus help to prolong life and make it
endurable, in these incurable cases, is one of the greatest
boons which we can bestow. The severe pains are almost
always periodical, beginning at a certain hour or hours,
every day or night. The greatest good is accomplished
by anticipating, as far as possible, their regular occur-
rence. The hypodermic use of morphine, or morphine
and atropine, half an hour before the pains are due, will
always modify, and frequently even prevent these parox-
ySms. I have found this method of using morphine far
Superior to waiting till the paroxysms begin. I believe
the carrying out of these rules, together with the general
treatment here mentioned, has been productive of much
good in prolonging life, and mitigating suffering ; in this
good work a careful attention to details, and the exercise
of a great deal of patience on the part of my assistants
in the hospital, have rendered valuable assistance.
In conclusion, I would add, that in a paper entitled
“Waginal Hysterectomy for Malignant Disease of the
Uterus,” “I have endeavored to describe clearly the steps
of the operation, and have also indicated the kind of
Cases in which I have been performing that operation for
the past eight years.
* New York Jour. of Gynaecology and Obstetrics, Sept. 1892.
y
A CASE OF PUERPERAL ECLAMPSIA AT THE
SEVENTH MONTH, WITH A FEW THOUGHTS
FROM PRACTICAL EXPERIENCE AS TO
TREATMENT.
By Douglas AYREs, M. D., of Montgomery County.
November 15, 1892.
Puerperal eclampsia, threatening as it always does the
life of the mother, cannot fail to seriously disturb the
mind of any practitioner of medicine, however extensive
may have been his experience. The mother, if she be in
labor, suddenly complains of pain in the head, or per-
haps of some derangement of vision, epigastric pain,
dyspnoea, etc., and soon after has a convulsive seizure,
which if once seen, can never be mistaken. The staring
eyes, the wonderfully rapid contractions of the facial
muscles, the rolling eyeballs, and contractions of the
muscles of the neck, drawing the face to the extreme
right or left; the livid appearance of the face, the pro-
truded tongue, the saliva forced from the angles of the
mouth—these take away almost every Semblance of “the
human form divine.” This, together with the contrac-
tions of the muscles of the extremities, is a condition
which has doubtless been witnessed by every physician
within the hearing of my voice; and all who have, will
acknowledge that it is One of the most serious diseases
that we are called upon to treat ; one in which the prog-
nosis is always grave, one that requires early and most
vigorous treatment. We can congratulate ourselves, per-
haps, in this fact, that it is not of frequent occurrence,
as various statistics prove that it occurs but once in about
five hundred pregnancies.
I have selected for this report, a case which occurred
in my practice during the past year, on account of its
PUERPERAI, ECLAMPSIA. 99
occurrence at the seventh month of utero-gestation,
thereby offering serious complications.
It is not my purpose at this time to discuss the aetiol-
ogy of eclampsia any further than to say, that it may
be of uraemic, reflex, or apoplectic origin; that while
albumen in the urine may be a very constant attendant,
these cases may occur without any, or scarcely any, be-
ing present. Great excito-motor irritability may act
reflexly and produce them—e.g., irritation of the gravid
uterus; but cases that can be traced purely to these
causes, I judge from my reading and practical experi-
ence, to be very rare. Those of apoplectic origin are
undoubtedly the most fatal. I would say in this connec-
tion, that I believe that those investigators who think
that the greater proportion of these cases have their
origin in uraemia, are correct; that is, uraemia in a gen-
eral sense, including any or all of the products of the
urine, which may be retained, as the result of imperfect
action of the kidneys, together with marked increase of
arterial tension.
The husband of Mrs. F. H. called at my office July 5,
1891, to inform me that she was seven months advanced,
in a second pregnancy, and that there was some Oedema
of the lower limbs, and some puffiness of the face. I re-
quested a sample of her urine for the twenty-four hours,
and examined it with reference to the presence of albu-
men. I found a large quantity present. The quantity
of urine passed was estimated to be about one-third less
than the normal average, or about thirty-four ounces.
The usual treatment was advised—mental quietude, milk
diet, iron tonics, and mild laxatives. About 4 P. M. On
July 9th, four days after his first call, I was hastily
Summoned to attend her. Her mother gave me the fol-
lowing history: She had felt as well as usual that day,
until the afternoon, when she complained of some pain
in the head, and went into another room, to lie down up-
On a couch. Shortly after, the mother heard a sound, as
Of Something falling, and going hastily into the room, J }
*
tº
e = *
100 NEW YORK STATE MEDICAL ASSOCIATION.
she found her daughter lying upon the floor in an uncon-
scious condition. There were slight convulsive move-
ments. The patient recovered consciousness in a short
time, and was then placed on the couch, where she lay
quietly, asking some questions with regard to what had
happened, but in a somewhat dazed manner. When I
arrived, she seemed perfectly conscious of her surround-
ings, and answered intelligently the few questions put to
her. I remembered that I had attended her in confine-
ment eleven years before, and that immediately after the
birth of the child, she had had an eclamptic convulsion, for
the relief of which I bled her very freely, removing nearly
thirty ounces, which seemed only sufficient to reduce the
force and volume of the pulse. After this, she rallied ;
and very luckily there was no recurrence. When I first
saw her, this time, the face was puffy, and the lower ex-
tremities quite oedematous ; she was thirty-six years of
age, a person of full habit, weighing, perhaps, one hun-
dred and forty or fifty pounds.
There had been in the past few days, no noticeable
diminution in the quantity of urine. Cold applications
were Ordered to the head, a stimulating enema was
given, and, by mouth, a full dose of calomel and jalap.
She soon had a severe convulsion. Venesection was
immediately performed, and it was necessary to remove
nearly twenty-five ounces before she returned to con-
Sciousness. There were now marked uterine contrac-
tions, and a vaginal examination showed the os somewhat
softened and dilatable. After dilating slowly and care-
fully with the fingers, three-quarters of a drachm of the
fluid extract of ergot, and one-third of a grain of mor-
phia were administered, and shortly afterward the
forceps were applied. By gentle traction during each
pain, I succeeded in a short time in delivering a dead
child. The uterus was carefully kneaded, and within a
half or three-quarters of an hour, the placenta was ex-
pelled. There was but a moderate amount of haemor-
rhage, as the uterus seemed to contract fairly well. The
PUERPERAI, ECLAMPSIA. 101
patient was now breathing easily, and quite unconscious;
pulse regular, and of fair strength. As she could swal-
low, a few ounces of milk were slowly given. She re-
mained in this condition for about three hours, when
another convulsion occurred, which was, perhaps, not so
severe as the previous one. The urine was then drawn by
catheter, and was found to contain about the same quan-
tity of albumen as before. I was unable to obtain any chlo-
ral until about two hours later, at which time there were
evidences that another convulsion was about to occur. I
immediately injected per rectum fifty grains, properly
guarded with mucilage. She was quiet for nearly six
hours, when there were muscular movements, evidencing
a recurrence, so the same amount was again injected. It
was necessary to make two more of these injections, at
about the same intervals, before all evidences of recur-
rence ceased. My patient remained in a partially un-
conscious condition for nearly fifty hours, but she took
Some milk at regular intervals. From this time on, she
began to recover, her convalescence extending over a pe-
riod of sixteen or seventeen days, during which time she
was troubled with amblyopia to such an extent as not to
be able to recognize any object brought within the usual
focal distance. There was a good deal of muscular ten-
derness, and quite marked prostration. The after-treat-
ment was tonic and alterative, with the usual aseptic and
antiseptic precautions.
There are a few questions of moment, which the treat-
ment of this case suggests:
1st. How important a factor is venesection for the
relief of the condition ?
2d. What cases would be most likely to be benefited
by it . -
3d. What is the value of chloral as a therapeutic
measure compared with chloroform by inhalation, and
morphia by subcutaneous administration ?
I believe that the prompt action of chloral makes it an
agent of the utmost importance; that it relieves the brain
102 NEW YORK STATE MEDICAL ASSOCIATION.
by lessening the force of the circulation and consequent
arterial tension ; and that it thereby wards off a threat-
ened brain lesion, at the same time that it protects the
endangered heart. But it is of the utmost importance
that it be administered before an irreparable injury has
taken place. It favors the action of the kidneys, and
gives us time to make use of other remedial agents cal-
culated to relieve the general oppression ; and, as a
prominent writer has said, it favors absorption, and
renders the patient more susceptible to this influence.
In the second place, I believe that women of full habit
with suffused face, and full, slow pulse, showing much
arterial tension, will always be greatly benefited by
venesection, and my personal experience has been, that
where this important measure has been neglected, death
has been much more frequent. I call to mind in this
connection eight cases which I treated by bleeding; in
three, with the addition of chloral to the treatment.
There was only one death, a primipara, sixth months
pregnant, whom I did not see until a serious brain
lesion had taken place. Barqueseau says: “Venesection
diminishes the general mass of the blood, relieves the
nerve centres, which have a tendency to become congested,
and by making the spinal bulb anaemic, we deaden
reflex irritability, which keeps up the hyperaemia, and
by which the convulsive attack may be revived.”
It is now something over twenty years since chloral-
hydrate became a prominent remedy in the treatment of
eclampsia. My first experience in the use of it at that
time was by subcutaneous injection. I was called in
consultation in a very severe case where the patient had
a number of convulsive seizures after free venesection.
I had seen but a few days before, an article in some of
our journals, about the use of the remedy subcutaneously.
I suggested it, and we made trial of it, injecting it
freely in the lower extremities. It relieved our patient,
but it was some time before the ulcerations resulting
from these injections were healed. I have since adminis-
PUERPERAL FOLAMPSIA. 103
tered it per rectum, as it is much more quickly and easily
given in this way, and, as many times, it cannot be given
by the mouth. I certainly much prefer it to chloroform ;
for although chloroform arrests the convulsive seizures,
it is usually only for a short time, and the patient can-
not be kept under its influence, for a length of time,
without danger. It produces congestion of the nerve
centres, and so may increase cerebro-Spinal congestion,
and also the asphyxia, to which complication there is a
predisposition. Depaul admits that it does modify,
to a certain extent, the eclamptic attacks; but Says they
as well as the complications exist none the less. There
is no doubt but that we have in morphia and chloroform
valuable remedies, the effects of which have been closely
and practically investigated by the profession, and that
they have held their place in professional confidence;
still, it seems to me, that some of the arguments pre-
sented, especially that against its long-continued use,
are well founded. As to morphia subcutaneously, I can
fully indorse its use, in doses not to exceed one-quarter
of a grain, to be repeated if necessary within, Say, one
hour; but I should fear the heroic doses recommended
by some writers, of from one-half to one grain, boldly
repeating it upon evidences of a recurrence, notwith-
standing the tolerance of the drug in eclampsia. I
believe that we have in hydrate of chloral an agent of
wonderful therapeutic value for the relief of reflex irri-
tation, and that we have in judicious, prompt, and
bold venesection, and in chloral, two agents, which
will never be supplanted by any more perfect or potent
measures. After twenty-seven years of active practice,
I can recall many cases treated in this manner, and the
great majority have recovered, some by venesection
alone, others by the two combined; but the former has
been my sheet-anchor, and I firmly believe, that when
early and judiciously done, it has saved, and will con-
tinue to save many mothers from an untimely death.
T04 NEW YORK STATE MEDICAL ASSOOIATION.
DISCUSSION.
DR. EDEN. W. DELPHEY, of New York county, said that among the more
common causes of puerperal eclampsia were, high arterial tension, a
watery condition of the blood, and quickened reflex activity, and, accord-
ing to recent European experimenters, the “bacillus of puerperal eclamp-
sia.” These observers have been able, by injections of cultures of this
bacillus into animals, to produce true eclamptic seizures. The arterial
tension and the watery condition of the blood are best treated by venesec-
tion, and for the quickened reflex activity, the treatment should be first by
inhalation of chloroform, and afterwards by the administration of chloral
and the bromides. About sixteen months ago, he saw a very severe case
of puerperal eclampsia, in which the examination of the urine showed
this secretion to be very scanty, and to contain only one and a half to two
grains of urea to the fluid ounce.
TUMIOR'S OF THE ORBIT.
A DETAILED ACCOUNT OF NINETEEN CASES II, LUSTRATING:
THE PAPER ON THE SAME SUBJECT, PRESENTED TO THE
NEW YORK STATE MEDICAL ASSOCIATION AT ITS MEETING
IN 1891.
By CHARLEs STEDMAN BULL, M. D., of New York County.
(Read by title November 15, 1892.)
CASE I. A boy, four and a half years of age, was brought to me by
his parents, in the latter part of January, 1876, with the following
history : He was a large child for his age, of the average mental devel-
opment, and had always been in robust health. There was no unfavora-
ble family history elicited after careful questioning, and no evidence of
inherited syphilis in the child. For several months the parents had no-
ticed a slight swelling at the outer angle of the left orbit, accompanied by
slight redness of the eyeball, and some swelling at the outer angle of the
upper lid. These symptoms gradually increased, but there was no com-
plaint of pain, and no evidence of any disturbance of vision. When I saw
the child, there was a very perceptible orbital growth at the outer angle,
which seemed to involve the upper and outer parts of the orbit. The left
eye was pushed downwards and inwards, but not forwards, and its motil-
ity upwards and outwards was decidedly limited. The upper lid was
slightly swollen, and drooped a little, but could be freely opened and shut.
The growth was entirely non-sensitive. The media were perfectly clear,
the iris reacted promptly, and the ophthalmoscopic examination was neg-
ative. Vision was apparently normal. There was a slight mucous dis-
Charge from the conjunctiva. A careful rhinoscopic examination revealed
nothing abnormal. No history of any injury could be obtained. The
boy was watched carefully, and by the middle of February the symptoms
had all increased. The eye was displaced downwards more decidedly, and
motility upwards was entirely lost. For two days the child had com-
plained of some pain. The pre-auricular gland on the left side had become
swollen and somewhat painful. Ophthalmoscopic examination was nega-
tive. By the first of March all the symptoms were much increased in
Severity. A slight ulceration of the cornea appeared just above the centre.
The motility of the eye was limited in all directions. The left pre-auricu-
lar gland was very much enlarged, but there was no other glandular infil-
tration. The orbital margin was swollen, and the swelling extended upon
the forehead and backwards into the temporal fossa. There was little or
no protrusion of the eye forwards, and the lids could still be opened.
106 NEW YORK STATE MEDICAL ASSOCIATION.
A diagnosis was made of pure orbital tumor, probably starting in the
periosteum, and owing to the somewhat rapid increase of the symptoms
and the high fever of the last two days, it was decided to operate and at-
tempt to save the eye. -
On March 3d the left external canthus was split, the incision being car-
ried outwards upon the temple for somewhat more than an inch. The
left temporal artery was divided, and at once ligated. The upper lid
was then carefully dissected upwards and turned over upon the fore-
head. After the bleeding had been checked, the orbital periosteum
was found very much thickened on the outer and upper walls of the Orbit.
The infiltration also involved the orbital tissue as far back as the finger
could extend, but did not seem to involve the capsule of the eyeball. The
latter was pushed carefully towards the nasal side, and held there. An in-
cision was then made through the periosteum along the Superior orbital
margin, and the periosteum was then carefully stripped up from the bone
on the upper and outer walls of the orbit, as far back as the knife and for-
ceps could reach. This was removed in strips, and with it also the orbital
tissue and the lachrymal gland. The periosteum was also removed from
the frontal bone and temporal fossa as far as it seemed to be infiltrated, and
the pre-auricular gland was carefully dissected out and removed. The
orbital cavity was then washed out with a mild solution of zinc chloride,
and the upper lid was brought down in place, and the lines of incision
carefully coapted and sutured. Atropine was instilled, and the eye closed
with the ordinary dressings then in use. For the first three days there was
considerable reaction, the lids being much swollen, and the wound dis-
charging considerable pus, so that one or two stitches had to be removed.
The cornea became generally hazy, but did not slough, and eventually
cleared up remarkably.
On March 15th a purulent discharge came on from the left ear without
any preceding pain, but was followed by severe pain, extending down the
left side of the neck, and accompanied by high fever and a pulse of 140.
An examination showed a perforation of the membrana tympani just be-
hind the handle of the malleus. The discharge from the auditory canal
ceased in four days, but the perforation did not close for nearly three
weeks. From this time there were no adverse symptoms, and the patient.
was discharged at the end of the sixth week. A microscopical examina-
tion of the growth proved it to be a spindle-cell sarcoma, which had origi-
nated in the periosteum. The little patient was seen regularly once a
month, but there was no return of the growth until the spring of 1880.
Its progress was then very rapid, for in less than two months it filled up
the entire orbit, causing marked exophthalmos, and destruction of the eye-
ball by sloughing of the cornea. The entire contents of the orbit, includ-
ing the eyeball and the entire periosteal lining, were then removed, as far
back as the apex of the orbit, by a second operation. The orbit was care-
fully washed out with a solution of mercuric bichloride (1–1000), and the
lids were closed and dressed in the usual manner. The patient did very
well, there being little or no reaction, and he was discharged at the end of
TU MORS OF THE ORBIT. 107
a week. He was seen at rather irregular intervals, although his parents
had been warned that the growth would probably return. In May, 1885,
he presented himself with a swelling of the lower lid and cheek on the left
side, which had appeared two weeks before. This proved to be a dense in-
filtration of the tissues of the lid and cheek, springing undoubtedly from
the diseased periosteum at the edge of the orbit. There was no return of
the growth in the orbit, and the appearance of the external infiltration did
not suggest its having spread from any complication in the maxillary sinus.
The parents declined to permit any further operative interference, but
allowed me to keep the boy under observation. The orbit gradually filled
up with the growth, while the external infiltration steadily advanced into
the temporal fossa, over towards the nose, and upwards upon the fore-
head; and the patient finally died from exhaustion, without any head symp-
toms, a little more than ten years after the first appearance of the tumor.
CASE II. Mrs. A. H., twenty-nine years of age, came to me on June
12, 1876, with the following history : Twelve years before, a small growth
appeared at the external angle of the left orbit, just beneath the superior
orbital margin. It was the size of a large pea, and for a number of years
occasioned no discomfort, and showed no tendency to increase in size.
After about six years of quiescence it began slowly to grow, and continued
to do so until it reached the size of a walnut, and caused a protrusion of
the upper lid and external canthus, and a slight displacement of the eye
inwards. It then ceased growing, and remained quiet until about four
months before I saw her, when it suddenly began to increase in size, and
became very painful. On examination, I found the following condition of
the parts: The upper lid was pushed forwards, and drooped considerably
Over the eye, but could be elevated, and the skin was of a marked dusky
red color. The eyeball was pushed downwards and inwards, and protruded
nearly half an inch beyond the plane of the fellow eye, and its motility was
limited in all directions. The conjunctiva was injected and the palpebral
Veins were engorged and prominent. The media were clear, and the
retinal veins were extremely engorged and tortuous. The patient com-
plained of a constant pain over the anterior surface of the superior maxilla
and at the infra-orbital foramen, and during the last four months, the vis-
ion of the left eye had materially failed. She could count fingers at twenty
feet, but was not able to read. The other eye was normal. The tumor
could be seen and felt through the lid, and by careful palpation the growth
could be felt along the floor and outer wall of the orbit. Rhinoscopic ex-
amination revealed a displacement of the septum nasi towards the right
Side, and a nearly complete obliteration of the left nasal meatus by what
appeared to be a moderately hard mass coming from the middle meatus.
Nothing could be felt with the finger posteriorly. The patient stated that
for some months she had not been able to breathe through the nose. With
this history, and the digital examination, it seemed probable that the
tumor had begun in the maxillary antrum or nasal meatus, and had involved
the orbit secondarily. Assuming this to be a correct diagnosis, the patient
Was told that the only means of relief was an operation, but that owing to
108 NEW YORK STATE MEDICAL ASSOCIATION.
the deep-seated nature of the growth, and its probable origin, its removal
would probably not be complete, and it would be likely to return. She
was also told that in all probability the left eye could not be saved, but
that an attempt would be made to preserve it. The vision by this time
had sunk to counting fingers at two feet, and the optic disc was beginning
to assume a dirty-white color. She consented to an operation, which was
done on the following day. The external canthus was split, and the upper
lid turned up over the forehead, and held there. A further examination
with the finger and large probe, showed that the entire orbit was filled
with the growth, and that any attempt to save the eye would
prove a failure. Enucleation was immediately done, and then the entire
contents of the orbit were carefully removed. The tumor could then be
seen projecting through a large opening in the orbital plate of the ethmoid,
and also through the sphenoidal fissure. It evidently filled the ethmoidal
cells, extending to them from the superior and middle nasal meatus, and
was of much greater extent than had been at first recognised. The orbital
plate of the ethmoid was then removed, and all the growth that could be
reached was dissected out. The floor of the orbit had not been perforated,
and the possibility of the autrum not being involved was recognised. The
lachrymal bone was next removed, and a free opening made into the nasal
meatus. This was found filled with the growth, which was removed by
forceps and fingers as far down as possible. It was necessary to break down
and remove the entire inner wall of the orbit, and even then the growth
could not be reached without great difficulty. The nasal meatus were
cleaned entirely of the growth by working from below through the nostril,
as well as from above, and then the orbit, ethmoid cavity, and nasal meatus
were thoroughly washed out with a solution of carbolic acid. A careful
examination of the opening from the maxillary autrum into the nasal
meatus was made, but no protrusion of the growth, or enlargement of the
opening discovered. The orbit was then tamponed, the upper lid replaced,
and the canthus sutured, and the ordinary bandage applied. The patient
did very well, having but little local reaction, and but slight rise in tem-
perature. She was discharged on the eighth day, with directions to report
once a week until further orders. There was no return of the growth for
eight months, when a small nodule was noticed in the left temporal fossa.
The left nostril still remained free, and the orbit was healthy and normal
in appearance. The patient was urged to allow the removal of this exter-
nal nodule, but declined to have it done. It grew slowly to the size of a
walnut, and then remained quiescent for several months. It then Sud-
denly began to increase, and at the same time a nodule was felt at the apex
of the orbit, and another on the inner side, in the cavity of the ethmoid
bone. All these nodules grew rapidly, and the one in the temporal fossa
soon extended from the lower margin of the zygoma upwards and forwards
upon the forehead, and backwards to the auricle. The lower portion was
moderately hard, but the portion which extended upon the forehead was
soft, fluctuating, and very sensitive to the touch. All further operative
interference was declined, as it would undoubtedly have hastened the
TU MORS OF THE ORBIT. 109
patient's death, which occurred after great suffering, four months later,
and about thirteen years after the first appearance of the growth. Before
the patient's death, the orbit and nasal meatus had become entirely filled
with the growth, which had also extended back into the pharynx.
The tumor removed from the orbit and neighboring cavities was Sarcoma-
tous in nature, of the small-cell variety, but in places was distinctly
myxo-sarcomatous. After the patient's death I was permitted to examine
the orbit, and found that the neighboring cavities, including the maxillary
sinus, were entirely filled by the growth, though the floor and roof of the
orbit were still intact.
CASE III. A young gentleman, twenty-two years of age, consulted me
in December, 1879. The left eye had been defective in vision since child-
hood, and occasionally squinted. For the past two weeks there had been
a constant dull pain in the orbit, with ptosis and Some protrusion of the
left eye. Examination showed limitation of motility in all directions,
chemosis of the ocular conjunctiva on the temporal side, Some ptosis and
slight exophthalmos; media clear, fundus normal, and W- #3. On the
floor of the orbit, reaching from the infra-orbital notch to the external
canthus, was a hard, resisting growth, which pressed the lower lid for-
ward, and which could be traced for some distance backwards into the or-
bit. It was very sensitive to pressure. The patient declined all operative
treatment. By February 16th the exophthalmos was very marked, and the
patient complained of severe occipital headache, and at times staggered
when he walked. The lower lid was everted, and the orbital growth was
very prominent at the external angle. There was dense infiltration of the
palpebral and ocular conjunctiva, the eye was immovable, the cornea was
hazy, and vision was reduced to perception of light. The patient also
complained of constant pain in the region of distribution of the infra-
orbital nerve. He consented to an operation, and two days later the eye
was enucleated, and the tumor removed with comparative ease. The latter
was attached very firmly to the sheath of the optic nerve, and only loosely
to the orbital tissue, but the latter was densely infiltrated especially along
the floor of the orbit, and on this account the entire contents of the orbit
were removed down to the periosteum, which latter seemed perfectly
healthy. The infiltration of the orbital tissue, and the pain over the infra-
Orbital nerve, led me to make another careful rhinoscopic examination, but
nothing abnormal was found. The tumor, on being examined, proved to
be a spindle-cell sarcoma, and the orbital tissue was infiltrated with small
round cells.
By the middle of April, or two months after the first operation, there
were well marked signs of a recurrence of the tumor in the periosteum on
the floor of the orbit. A second operation was immediately done, the peri-
Osteum, which was very much thickened, being stripped up on all sides
from the orbital margin to the apex. It was very vascular and the haemor-
rhage was profuse. The orbit was then washed out with a strong solution
of carbolic acid, and a careful examination with the finger was made of
the floor, inner wall, sphenoidal fissure and optic foramen, but no trace of
110 NEW YORK STATE MEDICAL ASSOCIATION.
abnormal growth could be discovered. The haemorrhage still continued,
and it became necessary to plug the orbital cavity. Violent reaction fol-
lowed in the skin of the lids, cheek and temple, and the tampon was re-
moved on the next morning. The skin of the left side of the face became
decidedly erysipelatous. The reaction slowly subsided, but left both lids
retracted and adherent to the external angle of the orbit, and the lower lid
adherent to the inferior orbital margin for its outer third. The cavity of
the orbit was much contracted, but the floor was found intact.
Two months later, on June 25, 1880, a firm nodule, as large as a filbert,
appeared over the left molar prominence. It was firmly adherent to the
periosteum, but the skin was freely movable over it. In a month this
nodule had increased threefold in size, and was elastic and sensitive to the
touch. Another nodule, much smaller, was discovered along the lower
margin of the orbit. On July 30th these two external nodules were thor-
oughly removed, the bone was carefully scraped, and then cauterised with
the actual cautery.
By the first week in September, an external tumor over the molar bone
had returned, and had reached the size of a small pear, but it was very
irregular and nodulated. The skin was drawn tightly over it and was but
slightly movable. This external growth was found to be continuous with
an orbital growth, which involved the floor, inner and outer walls of the
orbit, while the external growth extended down upon the superior max-
illa, and over into the temporal fossa. The patient urged a fourth opera-
tion, which was done in the following way : An incision was made along
the lower lid-margin as in the Arlt-Jaesche operation for entropium, and
was extended an inch and a half from the external canthus towards the
ear. A second incision was made from the inner end of the first incision
down along the nasal furrow to the ala of the nose. This skin flap was
carefully dissected up and reflected from the growth. The haemorrhage
was profuse, and it was necessary to ligate several vessels. The extra-
orbital portion of the growth was then thoroughly removed, and there was
then revealed a ragged opening through the anterior wall of the superior
maxilla into the antrum, through which the growth protruded. The tumor
was then removed from the orbit, and here a large ragged hole was discov-
ered through the floor of the orbit leading into the antrum, The tumor
filled the antrum, nasal meatus, ethmoid cavity and sphenoidal fissure, and
as much of it as could be reached was removed, the antrum and nasal
meatus being thoroughly emptied. The parts and cavities were then thor-
oughly washed out with a solution of mercuric bichloride (1–1000), and
the wound closed. No great reaction followed, though the temperature
went up to 103°, and there was not much suppuration. The external
wound healed, but in less than six weeks the growth again appeared in the
orbit and externally over the molar bone. The case had long been regarded
as hopeless, but the patient lingered in great suffering till the latter part of
January, 1881, and died from exhaustion, about fourteen weeks after the
apparent commencement of the disease.
TUMOR'S OF THE ORBIT. 111
CASE IV. In the latter part of September, 1880, a woman, forty-two
years of age, from whom I had previously removed a small growth, appar-
ently epitheliomatous in character, from the inner angle of the left lower
lid, three years before, presented herself with the following history: There
had been no trouble with the eye or lids for nearly two years. The eye
then began to be limited in motion outwards, and to slightly protrude. These
symptoms slowly increased, the upper lid became swollen, and a constant
dull ache in the orbit began. Finally the sight of the left eye began to
fail, and this frightened her and brought her to me. An examination
showed the right eye to be normal in every respect. In the left eye the
vision was #} unimproved ; the media were clear; there was a grayish dis-
coloration of the temporal half of the disc, and a narrowing in the calibre
of the arteries. The perimeter showed a contraction of the nasal half of
the field. The left upper lid was decidedly Oedematous and somewhat
reddened. The eyeball was pushed inward, and protruded very percepti-
bly in advance of the plane of the other eye. There was a decided infil-
tration of the tissues on the temple and on the cheek just below the inferior
orbital margin. The patient was told that she probably had a tumor of
the orbit, and that it must be removed, but that an attempt would be made
to save the eye, and she consented to the operation. As the exophthalmos
was directly forward, and the limitation of motility was outwards, the
conjunctiva was divided at the outer canthus, and the wound then en-
larged upwards and downwards. Almost immediately a growth was felt,
extending along the outer wall of the orbit and filling the entire apex.
The external rectus muscle was then divided at its insertion, and the eye-
ball turned far inwards. The dissection of the tumor was then continued,
but it was found so intimately connected with the sheaths of the muscles
and of the optic nerve, as well as with the periosteum, that I cut through
the nerve and the muscles near the apex of the orbit, as a necessary pre-
liminary to the removal of the tumor from its orbital attachments. The
growth extended on the inner side of the eye as well as on the outer side,
and after considerable trouble was removed, leaving the eye in place.
About three-quarters of an inch of the optic nerve were removed with
the tumor. The floor of the orbit appeared healthy and there was no
demonstrable connection between the growth in the orbit and the infiltra-
tion in the cheek and temple. There was no reaction, and the patient was
discharged at the end of ten days. The eyeball became slowly atrophic and
the cornea cloudy. This case was watched very carefully, being seen
every week or two, as the history of the case pointed to a recurrence of
the tumor. The infiltration of the cheek and temple slowly subsided,
and at the end of three months there was nothing abnormal in the patient's
appearance except the atrophied eyeball. Nearly ten months after the opera-
ation, however, there appeared a well-marked nodule on the external surface
of the Superior maxilla on the left side, just below the orbital margin, and
external to the infra-orbital foramen, and the diffuse infiltration reappeared
on the temple. The eyeball, which had previously receded into the orbit,
began again to protrude. Another careful examination was made of the
112 NEW YORK STATE MEDICAL ASSOCIATION.
naso-pharynx, but nothing abnormal was discovered. As the microscopical
examination of the first tumor had shown it to be a small-cell sarcoma, I
advised an immediate operation, including the removal of the atrophied
eye, but the patient refused her consent until November, 1881, nearly four
months after the reappearance of the growth. She was then suffering
severe pain at times in the orbit and temple. The eye again protruded
beyond the orbital margin, and the growth on the cheek had become as large
as a horse-chestnut, and was very sensitive. The skin was movable over
this growth, which was firmly adherent to the bone. The eyeball and en-
tire contents of the orbit were first removed. After the haemorrhage had
been checked, a careful examination showed a defect in the orbital plate of
the ethmoid rather far back, and another in the floor of the orbit. A probe
passed through these openings into the ethmoid cells and maxillary an-
trum discovered a gelatinous mass of considerable consistency in both.
This was sufficient evidence that both these cavities were filled with the
morbid growth. The large nodule was then removed from the su-
perior maxilla, and the external surface of the bone carefully examined,
but no opening into the antrum was found. No further attempt
was made to remove the growth from the cavity of the ethmoid or the
antrum, both on account of the severity of the operation and the hopeless-
ness of any successful removal of the diseased bones. The patient made a
good recovery, and there was no return of the external tumor on the sur-
face of the superior maxilla. The disease, however, soon extended from
the neighboring cavities into the orbit, and also invaded the nasal meatus,
and made rapid progress. The patient suffered considerable pain, and the
nasal cavity soon became so completely blocked that she breathed almost
entirely through the mouth. In three months the growth filled the orbit
and protruded between the lids, and could be seen at the entrance of
the left nostril. About four months after the last operation, she began to
complain of intense frontal headache, which at times rendered her delirious,
and in one of these severe paroxysms she had a violent convulsion. This
was general in character, and ended in coma, from which she never rallied.
An autopsy could not be obtained.
CASE W. On January 12, 1881, a gentleman, thirty-eight years of age,
presented himself at my office with the following history: The first symp-
tom which he had noticed had been a protrusion of the right eye, which
began five years before, and five months later the left eye also began to
protrude. During these five years there had been a steady increase in the
exophthalmos and in the limitation in motility of both eyes in all directions.
There had been some pain of late, which was located at the root of the nose
and just above both eyes. For a long time, but just how long he did
not know, there had been difficulty in breathing through the left nostril,
and for more than a year, respiration was entirely abolished through both
nostrils, and he had become an absolute mouth-breather. He had several
polypi removed from the right nostril at different times, with a temporary
improvement in breathing. An examination showed a marked protrusion
forwards and outwards of both eyes, so that the lids could with difficulty
TU MORS OF THE ORBIT. 113
be closed over them, and the axes were widely divergent. At one period
of the disease there had been crossed diplopia, which subsequently disap-
peared. The eyes were almost immovable, and the ocular conjunctiva was
deeply injected. The irides responded to light, the media were clear, and
the ophthalmoscopic examination showed nothing but engorged and pul-
sating veins. R. E. W = +}o : L. E. W = perception of light. The sight
had begun to fail one year ago in both eyes, and had slowly grown Worse.
There was pain on pressure backwards of the eyeballs. The posterior
nares on both sides were blocked by a growth extending across the anterior
pharyngeal space. The left nostril was occluded. The right nostril was
blocked by a polypus, which apparently grew from the left wall of the
meatus, entirely filled it, and pushed the inferior turbinated bone and
septum nasi over to the left side. It was soft, and bled easily. The
growth behind, which filled the posterior nares, and extended into the
pharynx, was hard and resistant, and apparently was attached to the body
of the sphenoid. Nothing was discernible on the floor or inner wall of the
right orbit, but in the left orbit the floor was pushed upwards, and the
orbital plate of the ethmoid pushed outwards, and I thought I could detect
a tumor in the orbit. The external surface of both cheeks and temples was
Smooth and normal in appearance.
The desperate character of the case was at once recognised, and the
patient was told that a complete removal of the growth was hopeless, but
that the growth could be removed from the nostrils, and his respiration
made more comfortable. To this operation he consented, and the nostrils
were cleared both anteriorly and posteriorly. A large, gelatinous polypoid
mass, attached to the outer wall high up, was removed from the right nos-
tril. By means of a guarded bistoury, blunt scissors and polypus forceps,
the entire mass was removed from the posterior nares, including with it a
large portion of the inferior turbinated bones. The haemorrhage at first
Was profuse, but was soon checked, and a careful examination of the parts
made. The whole middle and superior nasal meatus were filled with the
growth, which could also be felt protruding from the opening into the left
maxillary antrum. After the first week, I did not see this patient again
until five months had elapsed, when he came once more for the relief of
his respiration. His condition was then deplorable. The left eye was
sightless, the cornea cloudy and ulcerated, and the lids could not be closed.
The growth had appeared as a large protuberance at the left inner canthus,
projecting through the lids, and had also appeared at the inferior margin
of the orbit and filled up the temporal fossa. He had perception of light
still in the right eye, in which the optic disc was found in a condition of
gray atrophy. Both nostrils had again filled up with a solid, somewhat
resistant mass. I repeated the same operation, removing as much of the
growth as could be reached, and again rendering the nostrils free. The
maSS Was not polypoid, but on both occasions proved on microscopical
examination to be myxo-sarcomatous in character.
In two months the nasal meatus had filled up again, while the growth in
the right orbit had increased very rapidly. He suffered greatly from pain
8
114 JNETW YORK STATE MEDICAL ASSOOIATION.
deep in the orbits, and from frontal headache, but lived for nearly four
months longer without any additional head symptoms, and finally died
from exhaustion. In this case, although all the deep bones of the face and
base of the skull had become involved, the tendency of the growth had
been outwards. In spite of persistent urging, an autopsy was positively
refused. Before death the tumor had perforated the conjunctiva at the
inner angle of the left eye, and extended over the side of the nose and
down upon the cheek.
CASE. VI. Early in August, 1881, a woman, forty-five years of age,
consulted me and gave the following history : About two months before,
a Small, dark nodule had appeared at the supero-temporal margin of the
left cornea, Seated mainly in the conjunctiva. It was slightly movable,
and slowly increased to the size of a small lima bean. When I saw her,
the growth had encroached somewhat upon the cornea, and was painless
to the touch. On August 18th, I removed the tumor, which was found to
be adherent to the Sclera, and extended somwhat along the infero-temporal
margin of the cornea. It was friable, and bled easily. It was thoroughly
removed, and the surface of the sclera was then scraped and cauterised,
and the edges of the conjunctiva were brought together loosely over the
wound. I did not see the patient again until November 4th, when the
growth had returned. The tumor occupied the upper, outer, and lower
Quadrants of the ocular conjunctiva and sclera, and covered the temporal
third of the cornea. It was irregularly lobulated and somewhat flattened,
dark in color, quite vascular and non-Sensitive. It extended above the
eyeball into the orbit as far as the equatorial region, the eyeball was dis-
placed slightly towards the nose, and its motility upwards and inwards
was limited. The field of vision was narrowed on the temporal side, but
central vision was still #} + and the fundus was normal. The patient
was told that the eye must be enucleated at once, and on November 21st,
the entire contents of the orbit, including tumor, eyeball and ocular con-
junctiva were removed. The optic nerve was divided far back and looked
perfectly healthy, and the periosteum of the orbit also appeared normal.
The case did well, and there was nothing abnormal noticed until the
following June, 1882, when a small dark nodule was found on the outer
wall of the Orbit about half-way back. The patient declined another
operation, and I did not see her till the last of October, when the
growth filled the Orbit and protruded between the lids. It seemed as yet
to be confined to the orbit, for the naso-pharynx was clear and there was
no evidence of any trouble in the maxillary antrum. The patient now
consented to an Operation, and on November 2, 1882, the entire contents
of the orbit were again removed with ease, though the haemorrhage was
profuse. The periosteum was then cut through all round the orbital
margin, and was then stripped up on all sides as far as the apex of the
orbit, and removed. After the haemorrhage had ceased, the bone was
thoroughly Scraped, and then the orbit was washed out with a sublimate
solution (1–1000). These was little or no suppuration, and the raw surface
soon healed. I saw this patient at intervals until the autumn of 1886, a
TU MORS OF THE ORBIT. 115
period of four years, and there was no return of the tumor in that interval.
She then disappeared from observation, and I have heard nothing of her
since.
All the specimens removed at different times and examined, proved to
be true melano-sarcoma. The eyeball proved a very interesting specimen.
The tumor was almost entirely superficial and extrinsic. None of the
tissues of the eye were invaded by the growth, except the Sclera, and even
here only the superficial layers were infiltrated by the Sarcoma cells. The
region of the lymphatic channels round the opening of the vasa vorticosa
was entirely free from any infiltration, as were also the sheath of the optic
nerve and the nerve itself.
CASE VII. A gentleman, H. A., twenty-two years of age, was first
seen June 12, 1882, and gave the following history : He had always been
perfectly well, and had never noticed anything abnormal about his eyes
until five months ago, when the right eye began to protrude. Since then,
the exophthalmos had slowly but steadily increased, but there had never
been any pain. The vision of the right eye remained good until ten days
ago, when it suddenly became impaired. Examination showed that vision
was reduced to perception of light ; the protrusion of the eye was forwards
and slightly outwards, and motility outwards and inwards was decidedly
impaired. The iris reacted, the media were clear, and the fundus showed
a well-marked condition of papillitis with haemorrhages. At the inner
side of the orbit, a tumor could be felt, apparently springing from the
inner wall of the orbit, and sensitive on pressure. The left eye was normal
in every respect. The patient was told the probable nature of the trouble,
and consented to an operation, which was done on June 14th. The external
canthus was incised outwards for an inch, and the upper lid turned up on
the eyebrow. The ocular conjunctiva was divided in the horizontal merid-
ian, from the internal canthus to the corneal margin. The tendon of the
internal rectus muscle was next divided, and the eye turned strongly to the
temple. The tumor could then be plainly seen on the inner wall of the
Orbit, its anterior aspect being flattened. By means of a blunt hook, and
blunt pointed scissors, it was readily dissected from its periosteal adhesions
and removed entire with but trifling haemorrhage. It proved to be a long,
flattened growth, the size of a large lima bean, and was apparently entirely
enclosed in a capsule. A careful examination of the orbit discovered no
trace of any further growth, and the muscles and optic nerve seemed to be
intact, though the latter was somewhat flattened. The cavity was then
carefully washed out with a sublimate solution (1–2000). The tendon of
the internal rectus was stitched in place to the sclera, the conjunctiva
brought together, and closed over the opening with sutures, and the slight
Wound in the canthus closed in the same way. The eye was then bandaged
in the usual manner. Not a drop of suppuration occurred, and the patient
Was discharged at the end of a week. The tumor was hardened and
Sections were carefully made in all directions. It proved to be entirely en-
closed in a fibrous capsule, and was divided into several parts by fibrous
trabeculae, which seemed to be prolongations inwards of the fibrous
116 NEW YORK STATE MEDICAL ASSOCIATION.
capsule. The spaces between the trabeculae were filled with large and
Small round cells, with nucleus and granular contents. Regarded as a
whole, the growth would be classed as a sarcoma, or possibly a fibro-Sar-
Coma, as there were a few fusiform cells between the fibres of the
trabeculae. The superior oblique muscle was not injured. The patient’s
vision slowly improved, so that at the end of a month he could count fingers
at three feet from the eye ; but beyond this it did not improve, and event-
ually the optic disc took on the appearance of gray atrophy. The patient
was last seen in the autumn of 1884, a period of more than two years
after the operation, during which there had been no return of the growth,
and from the encapsulated condition of the tumor, it is probably safe to
conclude that it has not reappeared. .
CASE VIII. Fanny S., seventeen years of age, was first seen on Sep-
tember 24, 1884. Two years before, she had suffered from an attack of men-
ingitis, during which the vision of both eyes became affected, and has since
grown slowly but steadily worse. She has been deaf in both ears for
eight years, the cause being catarrhal inflammation of the middle ear, ex-
tending from the naso-pharynx. The right eye began to protrude about
one year ago, and the exophthalmos has slowly increased, but without any
pain. When I saw her, the right eye protruded forwards and outwards,
and was limited in motion in all directions. The iris was moderately
dilated and immovable. The fundus showed a gray atrophic disc ; vision
was sº. There was marked engorgement of the sub-conjunctival and
episcloral veins. The cornca was slightly cloudy from old keratitis. In
the left eye the cornea was still more cloudy, and the iris was dilated above
the normal, and very sluggish. The optic disc was discolored on the tem-
poral side, and the retinal veins looked engorged. Vision was ſº. There
was no exophthalmos, and no limitation of motility. An examination
of the naso-pharynx showed nothing abnormal beyond a general hyper-
trophy of the mucous membrane. There was no trace of any growth.
When the right eye was pressed backwards, a resisting mass was
felt at the bottom of the orbit. A diagnosis of orbital tumor on the
right side was somewhat hypothetical, and the patient was told she must
await developments. The exophthalmos slowly increased, and vision
slowly grew worse, but nothing absolutely certain was discovered until
eight months had elapsed, when a growth was felt for the first time on the
nasal side of the orbit. The patient was then told that an operation was
necessary, and that the eye must be enucleated, and to this she consented.
The eyeball was first removed in the ordinary way, great diſticulty being
met with in cutting the optic nerve ; and on examining the eye after
removal, the whole nerve was found to be enveloped in a dense fibrous
mass, showing that the tumor had been cut through. The entire contents
of the orbit, including the conjunctiva, were then removed, considerable
dissection being necessary around the optic foramen. The periosteum
was apparently healthy except at the apex of the orbit, where it was much
roughened from the adhesions to the growth. The latter measured about
three-quarters of an incli in length, and was roughly moulded to the shape
TUMOR'S OF THE ORBIT. 117
of the orbit. The optic nerve passed nearly through its centre, and was de-
cidedly flattened. The orbit was then washed out antiseptically, and
bandaged in the usual way. There was no defect in the orbital walls, and
no apparent prolongations of the tumor into any of the neighboring
cavities. A careful examination of the growth after hardening, showed
that it involved mainly the sheath of the optic nerve, the nerve itself being
but slightly encroached upon. It could not be decided positively whether
the tumor had originated in the sheath or in the periosteum of the orbit.
It extended forward upon the sclerotic for a short distance, this membrane
being intimately involved in the pathological process. Sections through
the tumor, both longitudinally and transversely, showed it to be composed
almost entirely of connective tissue bundles, the fibres being pressed
closely together. In some places between the fibres were a few fusiform
cells. The nearer the optic nerve was approached, the denser became the
fibres. The cells in the perineural lymphatic space were increased in
number and size. The optic nerve behind the eye, and within the tumor,
was flattened, and showed signs of interstitial neuritis. The optic disc
and the immediately surrounding zone of the retina showed the traces of
neuro-retinitis, but the rest of the eyeball, with the exception of the cornea,
was normal. The patient rapidly recovered, and has been carefully
watched since, but no return of the tumor has been observed. An inter-
esting feature in the case is the possible, I might almost say, the probable
connection between the preceding meningitis as a cause, and the develop-
ment of the orbital tumor, as the effect. We know that complications on
the side of the eye are by no means infrequent during or after the menin-
geal disease. The ocular complication is sometimes a purulent choroiditis,
but more often it is a neuro-retinitis, with or without papillitis. It is by
no means an improbable supposition that in the case just described, the
intra-cranial inflammation extended along the membranes of the brain, in-
volved the dural sheath of the optic nerve, and set up a hypertrophic
vaginitis, which subseqently took on the form of a tumor of the optic
nerve, or, more properly, of the nerve sheatlı, compressing the optic nerve,
and producing the exophthalmos.
CASE IX. On October 6th 1884, a young child, Jennie S., two and a
half years old, was brought to me by the mother, who gave the following
history : About a year before, after an attack of bronchitis, the mother
noticed a small swelling at the inner angle of the left orbit, beneath the
upper lid, which caused the lid to protrude. This was much less marked
When the child was lying down than when she was in an erect position.
It had grown somewhat during the year. There had been no other symp-
tom. When I saw the child, there was a small circumscribed orbital
growth at the upper and inner angle of the left orbit, beneath the upper
lid, and outside the periosteum. When the child sat or stood, the protru-
Sion occupied the region of the inner canthus, above the lachrymal sac, but
When she lay down it receded almost entirely from view. It felt elastic,
and I concluded it was an example of a retention-cyst of the orbit. The
tumor was punctured through the cul-de-sac beneath the lid, and a quan-
118 MEW YORK STATE MEDICAL ASSOCIATION.
tity of clear, straw-colored fluid escaped, and the cyst at once collapsed.
I told the mother that the little tumor might return, but that the child was
So young, it might be better to wait and see whether any more serious op-
eration would be necessary. For nearly three months there was no return
of the cyst; then it began to fill up again, and soon regained its former
dimensions. The mother also noticed that when the head was bent for-
ward, the swelling became much more prominent than ever before. I
then determined to attempt the removal of the entire cyst, still regarding
it as a retention-cyst developed in the orbital tissue. The upper lid was
strongly everted, and the eyeball turned to the outer canthus, and held
there by a strong suture passed through the conjunctiva on the nasal side
of the cornea, crossing the cornea, and passing through the skin of the
external canthus. The cul-de-sac was then opened at the inner canthus,
and the cyst at once presented. It extended well up under the arch of the
orbit, and far back into the orbit, but seemed to hug the inner wall. Its
attachments to the orbital tissue were very slight, and easily broken, but
on the side of the bone they were more firm, and in endeavoring to separate
the cyst wall from one of these adhesions, the sac ruptured, and a large
quantity of cloudy, yellowish fluid escaped. The cyst collapsed, and my
finger passed into a large cavity. An examination showed that the orbital
plate of the ethmoid bone and most of the lachrymal bone were absent, and
that the ethnoid cells formed one large cavity, which communicated with
the superior nasal meatus. This was proved by the fluid used in washing
out the orbit and cavity in the bone passing down and out through the nostril.
A drainage tube was then inserted. The little patient did very well. There
was almost no suppuration, and the drainage tube was removed on the
third day, and the child discharged on the eighth day. There has been no
return of the disease, but there was rather a marked sinking in of the
tissues at the inner canthus, and beneath the inner end of the orbit, so that
there is a marked difference in the appearance of the two eyes. If there
had been a carious process in the bone, which led to the disappearance of
the inner wall of the orbit, there would almost certainly have been some
general, as well as local, symptoms in the child during the process. For
this reason I am more inclined to regard the case as one of congenital ab-
sence, or arrest of development of the inner wall of the orbit, and the cys-
toid development in the cavity of the ethmoid and orbit, as the result of a
chronic catarrhal irritation of the nasal passages, perhaps connected with
the bronchitis from which the child had suffered,
CASE X. Early in November, 1884, I was called in consultation to see a
gentleman, fifty-two years of age, and learned the following history of his
case : For many years he had been a sufferer from lupus of the face, which
had first appeared as a small nodule on the left ala of the nose. It slowly
extended in several different directions, healing as it extended, until the
cicatrix and the Sore covered a space as large as a silver half-dollar. It
then remained quiescent for nearly two years, but subsequently extended
upon the left side of the nose and orifice of the left nostril. During the
past year its growth had been rather more rapid. When I saw him, the
TUMC) RS OF THE ORBIT. 119.
growth had entirely occluded the left nostril, filled the posterior nares, and
extended over the cheek and molar prominence, and slightly into the Orbit.
from the outside, pushing the eye upwards, outwards and forwards. It
had also extended into the zygomatic fossa. The eyeball was still freely
movable, and the axes of the two eyes could be made parallel, when the
diplopia, which ordinarily existed, disappeared. Vision was normal, the
media were clear, and the fundus was healthy.
My opinion had been desired as to the advisability and feasibility of an
operation, and I advised against any attempt to remove the external por-
tion of the growth, on account of the great extent of diseased tissue, and
the impossibility of procuring a flap of sound skin of sufficient size to close
the wound. There also seemed a probability that the growth had extended
from the nasal meatus to the maxillary antrum, and any attempt to remove
this part of the growth would have necessitated the removal of the anterior
bony wall of the antrum. The growth in the naso-pharynx might be
removed, and this would render the patient much more comfortable and his
respiration easy, and this I advised should be done.
On November 13th the patient was etherised, and with some difficulty
the left nostril and naso-pharynx were cleared of the growth, part being
removed through the nostril and part through the pharynx. The septum
nasi was found driven far over to the right side, and the growth had ex-
tended up into the nasal cavity on the left side, beyond the reach of opera-
tive interference. The immediate result was a great improvement in the
patient's comfort, which remained for nearly six months, before his respi-
ration became again obstructed. I declined any further interference on
account of the hopelessness of the case. The progress of the disease was
slow but steady. The whole left side of the face became gradually in-
volved, the disease extending down to the angle of the jaw, over on the
temple, and up on the forehead and bridge of the nose. The orbit filled
up apparently from the orbital margin, and the eye was pushed forwards
and inwards towards the nose; the eyelids became involved, the cornea
ulcerated, and then perforated, and a large staphyloma developed and pro-
truded between the swollen and half-closed lids. The patient lived for
two years and a half after the operation, suffered greatly, and finally died
from exhaustion. Throughout the entire course of the disease the progress
had been from without inwards, and the resulting disfigurement was un-
pleasant in the extreme. No autopsy was permitted, and thus no oppor-
tunity was offered of determining whether there had been any change in
the microscopical character of the growth. Before I first saw the patient,
portions of tissue had been removed from the external growth on the nose,
and had proved to be lupus. The portion removed from the interior of
the nose had the mixed appearance of lupus and sarcoma.
CASE XI. A little boy, R. P., three years of age, was brought to me in
November, 1884, with the following history: About two weeks before,
the mother had noticed a staring appearance of the right eye, which
increased to a positive protrusion of the eyeball. When I saw the child,
the lids were somewhat reddened, and the exophthalmos was directly
120 NEW YORK STATE MEDICAL ASSOCIATION.
forwards. Pressure on the eye backwards gave an elastic sensation, and
caused some pain. Inquiry developed the fact that the child had had some
symptoms of congenital syphilis at birth, and that the father was undoubt-
edly syphilitic. The case was watched for several weeks, but nothing
abnormal was observed except a slow increase in the exophthalmos. The
eyeball was apparently normal in every respect. I suspected the presence
of either a cyst or an abscess, and advised an exploratory puncture. This
was done, and a small trocar was passed into the Orbital tissue on the
nasal side of the eye, but with no result. No trace of any growth could be
felt in the orbit, and nothing was found in the nasal meatus or naso-
pharynx. The exploratory puncture, however, seemed to set up a more
active process in the orbit, for the exophthalmos rapidly grew worse, and
the child began to complain of constant pain in the orbit. A more exten-
sive operation was then proposed, and was consented to by the parents.
The conjunctiva was opened horizontally on the temporal side, and the
tendon of the external rectus muscle divided, and the eye turned strongly
towards the nose. The finger was then introduced, and almost immedi-
ately felt a tumor, which seemed to occupy the apex of the orbit, and to
be firmly attached to the outer wall of the orbit far back. It had no ad-
hesions to the eyeball, and was easily detached from the orbital tissue and
sheath of the optic nerve, but was with great difficulty separated from the
periosteum on the outer side of the orbit. In doing this the sac-wall was
ruptured far back, and a quantity of ill smelling pus came out, and the
tumor collapsed. The sac-wall was then carefully removed, as far as pos-
sible, and the little finger being introduced, discovered a small patch of
denuded bone far back on the outer wall of the orbit. There had evidently
been a focus of periostitis, or perhaps of osteitis with caries, and an abscess
had developed in the orbital tissue. The dead bone was scraped as thor-
oughly as possible, the cavity thoroughly washed out with a sublimate
solution (1–2000), and a loop of carbolised silk inserted for drainage.
The case did remarkably well. Some suppuration occurred from the
orbital tissue, and from the suture points which united the tendon of the
external rectus to the sclera, but this ceased within the first week. The
eyeball gradually receded within the orbit, and in two months scarcely
a trace of the operation was left. There has been no return of the orbital
trouble, but the child has had a rather severe osteitis in the right ankle
joint, from which he eventually recovered.
CASE XII. A young woman, K. M., twenty-one years of age, was
brought to me on January 12, 1885. Three months before, she began to be
troubled with epiphora in the left eye, and very shortly after, she noticed
a small tumor along the orbital margin, just beneath the lower lid, and at
about its middle. It was painless, and occasioned no annoyance. This
has increased in size, and now begins to push the lower lid forward. On
careful examination, the tumor could be plainly felt in the orbital cavity,
lying along the floor of the orbit beneath the eye, and extending up slightly
upon the inner wall. On being questioned, the patient stated that for
more than a year she had suffered from a pain in the cheek, just beneath
TUMORS OF THE ORBIT. 121
the orbital margin, which was dull in character, but never severe, and she
had considered it a neuralgia. The teeth were examined, and several were
found badly decayed, with large cavities. The nose and nasal meatus were
also examined, but nothing specially abnormal found. A diagnosis was
made of tumor of the orbit, with the possibility of its origin in the max-
illary antrum, and subsequent perforation of the floor of the orbit. Both
eyes were normal in every respect. The patient was advised to have the
growth removed before the vision of the eye became affected, but declined
all interference. In two weeks she came again, and a great change in her
appearance had occurred. The growth of the tumor had been very rapid.
The eyeball was displaced upwards and outwards, and vision was reduced
to #}. The lids were swollen, and protruded perceptibly. The growth
covered the floor of the orbit, extended over the inner wall, involved the
orbital plate of the ethmoid, and had spread over the lower edge of the
orbit, and down upon the anterior surface of the superior maxilla. She
was then eager for an operation, although she was told that in all proba-
bility the eye could not be saved. The nose and the pharynx were again
carefully examined, but nothing abnormal was found. On January 30th,
I enucleated the eye, and then found that nearly the whole orbit was filled
with the growth. It varied in consistency, being in some places hard, and in
others soft. In examining the floor of the orbit, the probe passed into a
cavity, showing that a communication with the antrum existed. The orbit
was then thoroughly cleaned out in the usual way, when a large opening
was discovered in the floor of the orbit, which extended nearly to the
orbital margin, and the growth could be seen and felt in the antrum. The
extra-orbital portion of the growth was then removed from the surface of
the upper jaw, and was found closely united with the periosteum. The
antrum was then emptied of its contents, and an examination showed that
the growth had not apparently extended into the nose. The cavity of the
antrum and the orbit were then carefully washed out with bichloride
Solution (1–2000), and the surface of the periosteum thoroughly scraped
and cauterised. The patient recovered rapidly, and went home at the end
of two weeks. She was told that the tumor would almost certainly return,
and that she must be seen at short intervals. I did not see or hear of her
for nearly a year, and then she came with a return of the growth just be-
neath the lower margin of the orbit, on the superior maxilla. There was
no sign of the recurrence of the tumor in the orbit, and the antrum was
empty, except for a considerable amount of thick, glairy mucus. The pain
in the upper jaw had appeared at intervals, but had not lasted long. The
external growth was removed through the lower cul-de-sac, the latter being
incised throughout nearly its entire length, and the lid depressed. After
the nodule had been dissected out, the bone was thoroughly scraped, and
then cauterised with the actual cautery. Considerable suppuration fol-
lowed this operation, and the lid remained everted for several weeks, but
eVentually this defect entirely disappeared. I saw this patient at intervals
for several months, but she then disappeared, and I have heard nothing of
her since. The growth in the Orbit, on microscopical examination, proved
122 NEW YORK STATE MEDICAL ASSOCIATION.
to be of a mixed nature. The denser portion of the tumor was pure sar-
coma of the small-cell variety ; the softer portion, together with the
growth in the antrum, was myxo-sarcomatous in character. It was impos-
sible to decide, from an examination of the tumor, and of the orbit and
antrum, where the disease originated, though the combined evidence was
rather in favor of the antrum.
CASE XIII. Early in March, 1885, a man, C. K., twenty-eight years of
age, came to me with a very incomplete and fragmentary history of
trouble in the orbit, on the left side. There had been a dull pain in the
orbit and left side of the head for some months, which was constant, but
never severe. Lately there had been some failure of the vision, and some
prominence on the eyeball. He had had two decayed teeth removed, one
from each jaw of the left side, but the pain continued. An examination
showed a very slight prominence of the eyeball, with W-##, clear media,
and a normal fundus. On the inner side of the left orbit, far back, a slight
elastic prominence could be felt. The naso-pharynx was examined, but
beyond a chronic catarrhal condition with rather profuse secretion, nothing
abnormal was discovered. The pain was now confined to the supra-orbital
region and root of the nose. There seemed nothing to do but to watch the
patient and await developments. One month later there was apparently a
slight increase in the elastic prominence on the nasal side of the orbit, and
a small trocar being introduced, a little yellowish, turbid fluid was
evacuated. During the next day it dribbled through the wound and
beneath the conjunctiva. That night the patient slept well, but towards
morning he woke up with a feeling of a severe cold in his head. In en-
deavoring to clear his nose he made several violent expiratory efforts, and
finally a quantity of gelatinous material was discharged through the nos-
trils, and he felt as if something had “given way in his eye.” He came to
See me early in the morning. The discharge was still coming from the
nose, and the ocular conjunctiva was swollen, and distended all round the
cornea, as in a case of extreme chemosis. The diagnosis was now some-
what easier. As a consequence of the chronic nasal catarrh, there had been
an accumulation of fluid in the upper nasal meatus, ethmoid cells, and
probably in the frontal sinus. As a result of the pressure, either one of
the fissures in the Orbital plate of the ethmoid had been widened, or the
bone itself had been worn away, thus forming a communication with the
Orbit, and the development of an apparent cyst in the orbit. This was
punctured, and the contents flowed out beneath the conjunctiva. The
violent expiratory effort had produced an enlargement of this opening in
the ethmoidal plate and the discharge of a large quantity of fluid into the
orbital tissue, as well as through the nose. I punctured the conjunctiva
in several places, and had the eye and conjunctival cul-de-sac irrigated
every two hours with a sublimate solution (1–5000), while the naso-pharynx
was frequently washed out with a Saturated solution of warm potassium
chlorate. The patient recovered without an adverse symptom, and vision
was gradually restored to the normal standard.
TUMC) RS OF THE ORBIT. - 123
CASE XIV. In the latter part of September, 1885, a gentleman, fifty-
eight years of age, came to me with the following complaint : In October,
1884, he began to have a dull pain in the left side of his face, near the ex-
ternal angle of the right eye, and over the molar prominence, which lasted
for some months. Thinking it might come from the teeth, he consulted
his dentist, who extracted the third and fourth molars from the upper jaw
on the right side, as these were badly decayed. The fangs of the fourth
molar had penetrated the antrum. For more than a month after the re-
moval of the teeth, there had been a slight offensive discharge into the
mouth from the alveolar opening into the antrum ; then this ceased, and
was followed by a more or less profuse purulent discharge through the
right nostril and into the pharynx. The dull ache over the molar promi-
nence still continued, and was supplemented by pain in the region of the
right frontal sinus. In June, 1885, the right eye was noticed to be on a
higher level than the left eye, and to be somewhat more prominent. He
consulted an oculist in a neighboring city, who told him that there was a
tumor in the orbit, and that the eye must be removed. There was at this
time no impairment of vision, but during the summer he began to have
vertical diplopia. When I saw him there was a slight difference in eleva-
tion of the two eyes, but no exophthalmos, and the right eye could be
moved freely in all directions. Shortly after his first visit, the purulent
discharge from the nostril, which had been very slight for some months,
became again profuse, and the right eye was restored to its normal posi-
tion, and the diplopia almost entirely disappeared. This induced me to
believe that the tumor was entirely in the antrum, and was in the nature
of an abscess, and I urged an operation. To this the patient objected, as
his condition was very comfortable, and the frontal pain had subsided.
I did not see him again until March, 1886. At that time the discharge
from the nose had nearly ceased, the right eye was displaced decidedly
upwards and somewhat outwards, and distinctly protruded from the orbit.
The diplopia was more marked than ever, and the pain over the molar
bone and frontal sinus was at times severe. The naso-pharynx showed
little abnormal. Vision in the right eye was still perfect, and the ophthal-
moscope gave a negative result. Influenced by my experience with a
former, very similar, though less severe, case, which I had transferred to
the care of a general surgeon, who operated on the patient with excellent
results, I urged an operation on the antrum through the mouth, and to
this the patient consented.
The alveolar opening at the root of the fourth molar tooth still existed,
though closed by mucous membrane. This I enlarged with small bone
forceps, first dissecting away the mucous membrane and gum. This was
followed at once by the discharge of an immense quantity of apparently
healthy pus. The antrum was then irrigated with a warm saturated solu-
tion of boracic acid, the irrigation being continued until the fluid returned
°lear. The cavity was then filled with a solution of sublimate (1–5000),
and the opening temporarily plugged. The nose and orbit were next care-
fully examined. Some of the fluid in the antrum escaped through the
124 JNETW YORK STATE MEDICAL ASSOCIATION.
nose. The floor of the orbit, which had been pushed upwards, had re-
ceded, and proved to be excessively thin, but apparently unperforated.
The plug was then removed from the alveolar opening, the sublimate Solu-
tion allowed to run out, and the antrum again irrigated several times with
the boracic acid solution.
The result was extremely satisfactory. There was no reaction, and the
patient rapidly recovered. A thin, semi-purulent discharge continued for
about two weeks, but the cavity was washed out daily, and at the end of
the second month the patient was discharged cured.
CASE XV. About the middle of May, 1886, agentleman, thirty-two years
of age, consulted me in regard to one of his eyes. About six months be-
fore, he had noticed a small nodule at the inner canthus of the left eye,
which at first looked like an enlargement of the caruncle. This slowly
increased in size until it projected outside the canthus, between the edges
of the closed lids. While in Europe he consulted a surgeon, who removed
the growth, together with the caruncle. It returned within two months,
and increased rapidly in size, occasioning great discomfort. When I saw
him the growth involved the entire inner canthus, including the conjunc-
tival folds, the ocular conjunctiva as far as the corneal margin throughout
its nasal half, and both culs-de-sac, and had extended deeply into the orbit
along the inner wall, being apparently closely connected with the perios-
teum over the lachrymal and ethmoid bones. The inner ends of both lids
were also infiltrated. The eye was limited in motility in all directions
except outwards. The media were clear, the fundus healthy, and vision
was normal. I advised a very complete and radical operation, viz.: the
enucleation of the eye, the removal of the entire contents of the orbit,
including the periosteum if necessary, and of the inner halves of both lids.
To this the patient would not consent, and went home, but subsequently
submitted to an operation by a local surgeon, the exact nature of which I
do not know, but it included the enucleation of the eye. The tumor again
returned within two months, and grew with great rapidity, so that less
than four months after the second operation, when he again consulted me,
the growth had filled the orbit, involved nearly the whole of both lids,
the cheek, the side of the nose, and temple. The left nostril was also oc-
cluded, though by what could not be ascertained definitely, but probably
by a prolongation of the growth from above. Inasmuch as nearly all the deep
bones of the face were involved, as well as the adjacent cavities, I declined
to operate, but removed a piece of the orbital growth for examination.
The patient returned home, and a fourth operation was done, but he died
within two weeks, of exhaustion. The microscopical examination of the
portion of orbital growth removed, proved it to be a small-cell sarcoma.
I subsequently learned that the family history of the patient on the mater-
nal side showed a distinctly cancerous tendency. His mother had had a
cancerous breast removed, and had subsequently died of a return of the
disease. A maternal aunt had died of cancer of the uterus, and so had
his maternal grandmother.
TUMORS OF THE ORBIT. 125
CASE XVI. In the latter part of December, 1887, a little boy, three
years of age, was brought to me. His case proved to be one of great inter-
est. About fourteen months before, the child had received an injury to
the left arm from a fall. The exact nature of this injury I could not as-
certain, but it was not a fracture. From this there resulted a tumor, which
involved the left upper arm, from the elbow to the head of the humerus,
and the glands of the axilla were infiltrated. Sometime during the summer
of 1887, the left arm was amputated at the shoulder-joint, and the enlarged
glands were removed from the axilla. The mother said that the tumor, on
examination with the microscope, proved to be a Cancer. Soon after the
amputation of the arm, the right eye was noticed to be more prominent
than the left, and the upper lid drooped. When I first saw the child, the
exophthalmos was forwards, downwards and outwards, and the infiltra-
tion of the lid was marked. The evidence of the presence of an orbital
tumor was unmistakable, and the parents were told of the probable malig-
nancy of the growth, and of its connection with the tumor in the arm. The
presence of the same trouble in the lid was inferred from its swollen, infil-
trated condition, and the hard sensation it gave when compressed between
the fingers. I advised that the orbit be emptied of its contents, including
the eyeball, that the upper lid be removed, and that the orbit be closed up
by a plastic operation. This advice was declined, and I heard nothing of
the child until four weeks later, when the father informed me that the
child was ill with pneumonia. Death followed on the third day, and I re-
ceived permission to remove the contents of the orbit, including the eye-
ball. The tumor had grown very rapidly, and was closely adherent to the
periosteum, and to the sheath of the optic nerve, so that the eye and the
tumor were removed together. The growth had also extended into the
sphenoidal fissure and over on the cheek. It proved to be a very was-
cular small-cell sarcoma, arising from the periosteum, and involving in its
growth the sheath of the optic nerve, the intravaginal lymphatic space
being filled with small round cells, similar to those in the main growth.
Nome of the tissues of the eyeball itself was invaded by the growth. I was
not permitted to make any further examination of the body
CASE XVII. I was consulted in March, 1889, by a gentleman, aged
forty, who told me that the vision of the right eye had been defective from
early childhood, although it could be somewhat improved by glasses, which
he sometimes wore. Three months before, vertical diplopia suddenly ap-
peared, preceded by a severe pain in the left eye, and the double vision
had persisted ever since. He thought also that the left eye was somewhat
more prominent than it had been. For the last six weeks the upper lid
On the left side had been swollen. When I saw him, the left upper lid was
turgid and seemed pushed downwards. The left eye protruded forwards,
downwards and outwards, but the motility was not greatly impaired ex-
Cept upwards. The media were clear and the fundus was normal in both
eyes. There was diplopia upwards, and to the right, for all large objects.
R. E. º. : with cyl.-D. 2.75 axis 90° = #} : L. E. #} : with cyl-
D. 0.50 axis 90° = #4. Just beneath the superior orbital margin on the
126 NEW YORK STATE MEDICAL ASSOCIATION.
left side, near the inner angle of the orbit, and reaching nearly to the outer
angle of the orbit, was an elastic, nodular mass, extending backwards
for some distance, and apparently closely connected with the roof of the
orbit. The naso-pharynx was normal, as was also the orbit on the oppo-
site side.
The patient was told that he had an orbital tumor, and that if an
operation were done at once for its removal, the eye might be saved.
He consented, and the operation was appointed for the next day.
The location of the tumor was such that it was necessary to displace the
eyeball downwards and outwards as far as possible, and this was done
without dividing any of the ocular muscles. The conjunctiva was divided
through the upper cul-de-sac, the incision extending the whole length of
the superior orbital margin. The adhesions between the orbital tissue and
eyeball, and between the latter and the tumor, were then carefully broken
through with the finger and a strabismus hook, which was easily done, as
none of the adhesions were firm. It was then found that the tumor in-
volved nearly the entire roof of the orbit, and extended as far back as
the finger could reach. It was flattened in the centre by pressure of the
eyeball, but was thicker on the temporal and nasal sides. It was very
firmly attached to the periosteum of the roof, and its dissection was ex-
tremely tedious. Great care had to be exercised to avoid wounding the
pulley of the superior oblique; and at the apex of the orbit, to avoid in-
jury to the optic nerve, superior oblique and superior rectus muscles.
After its removal, as much of the periosteum of the roof of the orbit
as could be reached was stripped off, and the underlying bone scraped.
The cavity was then thoroughly irrigated with a sublimate solution (1–2000),
the wound in the cul-de-sac carefully closed by a number of sutures, and
the eye bandaged. There was scarcely any reaction, but the infiltration in
the upper lid subsided very slowly. At the end of a week the eyes were
tested for diplopia, and it was found that the Superior oblique had been
injured during the operation, the relation of the double images to each
other being quite characteristic. This persisted for more than four months,
but eventually almost entirely disappeared. The eyeball resumed its nor-
mal position but slowly. This patient is still under observation, being
seen at somewhat long intervals, but there has been as yet no trace of a
recurrence of the disease, a period of three years and a half since the
operation.
The tumor was very carefully examined, and proved to be a fibro-Sar-
coma, with a very large preponderance of dense fibrous tissue, and but
comparatively few cells, which were of the fusiform variety. w
CASE XVIII. Early in April, 1889, a man was sent to my office with the
following history: He was twenty-three years of age, and apparently in per-
fect health, with unusually fine muscular development. Five or six weeks
before, he had first noticed a small lump in the lower lid of the left eye,
near the inner canthus. It was at first movable and painless, but increased
rapidly in size, became painful, and led him to seek advice. When I saw
him, the lower lid was swollen, reddened, and partially everted. The
TU MORS OF THE ORBIT. 127
growth had extended downwards and outwards over the superior maxillary
and malar bones, and backwards into the orbit, along the floor and inner
wall. It was irregularly nodulated, and the skin was freely movable over
it. The left eye was limited in motility inwards and downwards. Both
eyes were normal in every respect. It was impossible to determine by
examination whether the growth had begun in the Orbit or eyelid. I
gave an unfavorable prognosis, and told him the only advice I could give
him was to have an operation done for the removal of the tumor as soon as
possible, and that it would necessitate the loss of part of the eyelid, and
possibly of the eye itself. He agreed to do whatever I advised, and the oper-
ation was done on the second day following. The internal canthus was
split by a horizontal incision, extending to the bridge of the nose. The
lower lid was then split into an anterior lamina of skin and orbicular
muscle, which seemed to be healthy, and a posterior lamina containing the
tarsus, connective tissue and conjunctiva, as in the old Arlt-Jaesche opera-
tion for entropium. The incision was carried from the outer end of the
horizontal incision outwards to the middle of the lid, and then extended
vertically downwards to the level of the lower margin of the orbit. This
was done because the skin of the lid seemed healthy. The ocular conjunc-
tiva was then dissected free from the nasal half of the eyeball, being cut en-
tirely across along the lower orbital margin and inner side of the orbit, and
turned over on the cornea. It was then seen that to reach the extra-orbital
portion of the growth the lower lid must be divided vertically down to the
lower orbital margin, which was done, and the halves of the lid turned as
far as possible out of the way. The growth was not very adherent to the
underlying bone outside, and was easily removed by the Scissors and
forceps. Inside the orbit it was more flattened out and adherent to the bone,
especially along the floor of the orbit, and here the process of dissection
was much more slow. It extended about two-thirds of the way back into
the orbit, was closely attached to the periosteum, but not at all to the eyeball,
which was readily pushed out of the way. After nearly an hour's work,
the tumor was apparently entirely removed, and a careful examination was
then made of the floor and inner wall of the orbit, without discovering any
remains of the growth. The bone was then scraped, and the cavity in the
orbit washed out with a solution of mercuric bichloride (1–5000). The inner
half of the lid, consisting of skin and muscular tissue, was then cut away
and removed, and the vacancy filled by a flap of skin taken from the fore-
head and root of the nose, twisted on its base, and united with the inner
end of the outer half of the lid by suture pins and the necessary sutures.
There was considerable reaction on the next three days, but almost no sup-
putation, and the flap healed well, so that the patient was discharged from
treatment in about five weeks, with a very presentable lower lid. Nothing
more was heard from the patient for a period of eight months, when he
presented himself with an unmistakable return of the growth in the orbit
and eyelid. A very radical operation, including the removal of the eye-
ball, was the only advice I could give him, and this he declined. Nearly
a year later an operation was done in a distant city for the removal of the
128 JNETW YORK STATE MEDICAL ASSOCIATION.
growth which had attained enormous proportions. The nature of this opera-
tion was unknown to me, but it involved the removal of several large
pieces of bone, probably the superior maxilla and ethmoid. He recovered
from this operation, but died soon after from some cerebral complication,
and an autopsy was not allowed.
The tumor removed by me at the first operation contained but very few
blood-vessels, and proved to be a sarcoma of the spindle-cell variety, with
considerable fibrous tissue scattered through it.
CASE XIX. On October 4, 1889, a woman, thirty-five years of age, was
brought to me with the following history : For about a year she had suf-
fered from Severe neuralgia in the right side of the head and right orbit.
She had had defective vision in both eyes for four or five years. Four
days before I saw her, she suddenly discovered that she was blind in the
right eye.
An examination showed the following condition : The right eye pro-
truded straight forwards, and its motility was limited in all directions.
It resisted any attempt to replace it in its normal position, and any such
attempt was very painful. The iris was dilated and immovable. The
right eye protruded a quarter of an inch in advance of the left eye, but in
the same horizontal plane. There was an apparent infiltration of the
orbital cellular tissue, which was most marked along the floor of the orbit,
and upwards and outwards just inside the superior orbital margin. There
was a chain of enlarged glands on the right side, beginning at the pre-auric-
ular gland and extending down along the border of the sterno-cleido-mas-
toid muscle to the level of the thyro-cricoid region. The patient had had
repeated epistaxis for some months, together with a profuse purulent dis-
charge from the right nostril. An examination of the nose revealed an
hypertrophied and displaced inferior turbinated bone, but no visible
growth in the naso-pharynx. The patient complained of a constant pain
over the malar and superior maxillary bones.
A diagnosis was made of a tumor in the nasal meatus, orbit, and maxil-
lary antrum, with the strong probability of its origin in the antrum. Two
weeks later the growth along the floor of the orbit appeared at the inner
Canthus, where it felt like a hard though slightly yielding mass, and I
urged an immediate and radical operation. The right eye was entirely
blind ; the ophthalmoscope showed a neuro-retinitis or papillitis, in the
stage of atrophy. . The family consented to an operation, which was done
on October 9th.
So far as could be discovered, there was no external growth on the
cheek. The eyeball was enucleated in the usual manner, and the posterior
part of the Sclera and sheath of the optic nerve was found to be surrounded
and intimately connected with the growth in the orbit. On cutting through
the Optic nerve, a mass of the tumor was cut through and came away with
the eyeball. The floor of the orbit was found entirely absent, except a
narrow rim of bone along the orbital margin, and the antrum was filled
with the growth. The conjunctiva was then cut through at the culs-de-
sac, and with the entire contents of the orbit was then removed. The
TU MORS OF THE ORBIT. 129
inner wall, roof and outer wall of the orbit seemed to be intact, and the
periosteum was smooth. The growth did not appear to extend into the
optic foramen or sphenoidal fissure, and these facts seemed to emphasise
the probability that the tumor originated in the antrum. The communica-
tion between the antrum and nasal meatus was found much enlarged.
The growth was removed from the antrum, and the cavity thoroughly
washed out with sublimate solution (1–5000). Part of the inner wall of the
antrum and part of the nasal process of the Superior maxilla were then
removed, and the growth was cleared out from the nasal meatus. Small
pieces of the tumor and bits of the turbinated bones were removed in this
way, until it was possible to syringe freely from the antrum into the nose
and pharynx. A large amount of detritus was washed out in this manner,
until the lower and middle meatus were entirely free. A drainage tube
was then introduced through the nose, and the orbit dressed in the usual
way. The bony walls of the antrum seemed to be intact, except the roof,
which was entirely gone. In view of this fact, I did not deem it wise to
attempt the removal of the maxillary bone, as the patient was greatly
prostrated by the long operation. I told her family that the tumor would
probably return, and in a comparatively brief space of time; but in this I
was mistaken.
The patient recovered rapidly from the effects of the operation. The
orbit and antrum were irrigated twice daily for a period of three weeks,
but there was not at any time much discharge, and it soon changed into
a slight mucous secretion. At the end of two months, the periosteum
lining the antrum and orbit looked smooth and normal, and the patient
could breathe through the right nostril. There was no positive evidence
of a return of the growth till the November following, a period of thirteen
months. It then appeared in the nose from above, extending downwards
into the nostril, and also through the enlarged opening into the antrum.
She began to complain of severe frontal headache, which probably pointed
to an extension of the growth into the frontal sinus or ethmoid, or both.
I advised another operation, beginning in the nose, but did not urge it
Very strongly, as I regarded the case as hopeless from the first, and the
patient herself did not wish it. I watched the case to the end. The
growth gradually filled the antrum and orbit, extended into the ethmoid,
broke through the orbital plate of the ethmoid into the orbit, and also
filled the sphenoidal fissure. The growth in the nose was so extensive as
to obliterate both nasal cavities, and for the last months of her life, she
breathed entirely through the mouth. She finally died from pure exhaus-
tion, without any further head symptoms, nearly two years after the op-
eration. Her family would not allow an autopsy.
The tumor, on examination, proved to be a very vascular small-cell
Sarcoma, which had intimately involved the sclera and sheath of the optic
nerve, as Well as all the orbital tissues.
PARAPLEGIA.
By CHARLEs W. BROWN, M. D., of Washington, D. C.
November 16, 1892.
On March 2, 1892, I was called to see D–, a single
man, twenty-three years of age, a steam-fitter by Occupa-
tion. He had a good family history, and had never had
syphilis; previous to last February had always been
healthy. Early in February he contracted gonorrhoea,
and was treated by a homoeopath, without particular
benefit. On February 7th, while at his work in Charles-
ton, S. C., putting a covering on a steam boiler, he sat
upon the cold steel for the greater part of three days,
and each night before retiring, he had a chilly sensation
along his spine, followed by pain in his back. The third
night he had a decided chill, lasting for half an hour, but
he slept well all night, and the following day went to his
work as usual, but said his legs felt numb, and he was
obliged to make an extra effort to step over any object.
He made an attempt to climb up a short ladder to get to
his work, and could not raise his feet sufficiently to do
SO. He worked about the steamer all day, and walked
to his boarding-place in the evening.
The next morning he was unable to pass his urine,
and there was loss of sensation in both legs; but he
could walk about the room, with the aid of a chair, and
looking at each step to see where he placed his feet. A
surgeon was called, who emptied the bladder by means
of a catheter. On the fifth day after the numbness of the
limbs commenced, there was complete paralysis below
the last dorsal vertebra, and he was unable to move a
muscle of either leg.
He was brought to his home in Washington the sixth
day after he had the chill, and I saw him first on that
PARAPLEGIA. 131
day. His temperature was 104.5°, pulse 110, very weak
and small; he was not delirious, but despondent. There
was some swelling over the lower portion of the spine,
but no tenderness when firm pressure was made, at, and
above the line of paralysis. He suffered no pain, but
complained of a dragging Sensation, and of constriction
about the waist. Above the waist the power of move-
ment and the power of sensation were natural ; below
the waist, all the voluntary muscles were entirely para-
lysed, and the sensibility to pain, to tickling, to differ-
ences of temperature, as well as to touch, were com-
pletely lost. Pressure along the spine was felt above,
but not below the point to which the anaesthesia
reached, and firm pressure was borne without wincing.
The feeling of warmth produced by passing a sponge
soaked in hot water along the spine, was felt above, but
not below, the point to which the anaesthesia reached ;
and at the line of junction between the sensitive and the
paralysed parts, this feeling amounted to a burning. The
Same burning sensation was produced by passing the
Sponge around the body in the course of this line of
junction. No reflex movements were produced by tick-
ling the soles of his feet ; though when the clothing was
Suddenly thrown off his legs, the current of air produced
a slight reflex, the spasms of the muscles being sufficient
to be noticed by the patient.
The application of an electric current over the area of
anaesthesia, produced no reflex; he had no control of his
bowels or bladder; there was no priapism during the
time the paralysis continued ; the gonorrhoeal discharge
Was considerable; the introduction of the catheter pro-
duced no pain. There was a large bed-sore over the left
side of the sacrum, extending down on the nates. The
urine was alkaline, and had a strong ammoniacal odor.
His legs and feet were cold and oedematous.
Although the urine was drawn by the catheter at least
four times every twenty-four hours, there was a persist-
ent cystitis, which lasted for several weeks after he was
132 NEW YORK STATE MEDICAL ASSOCIATION.
able to walk. Mucus and pus came through the Catheter
in considerable quantities, and clogged the instrument So
that it was necessary to wash out the bladder nearly every
day for two weeks.
On the day of his arrival home, dry heat was applied
to his feet and legs, by means of heated woolen blankets,
and rubber bags of warm water. The nurses were
cautioned to be careful about burning him, but in Spite
of this warning, his father placed a two-quart bag filled
with very hot water near the soles of his feet, and during
the night in some way, the blanket which was placed
between the bag and his left foot, was taken out, and at
my morning visit, I found the sole of his left foot com-
pletely cooked from the heel to the end of the toes, and
when the slough came off, three weeks later, it exposed
the periosteum over a portion of the OS calcis, and the first
and second metatarsal bones. When the surface became
covered by healthy granulations, numerous skin grafts
were applied, and on July 15th, the ulcerating surface
was completely healed over, with but little contraction
of the cicatrix.
The gonorrhoea was treated by the usual means, and
in two weeks the discharge had ceased, and simulta-
neously there was the first slight return of Sensation in
the right foot and leg. On March 16th he could feel the
prick of a pin on most all the surface of both feet and
limbs. By the middle of April he was able to move the
toes of his right foot slightly, and from day to day the
improvement in motion continued, so that by May 10th
he was able to stand upright and walk about the room
by the aid of crutches. Since July 1st he has walked
without assistance, and from the middle of July has
done his usual work, his principal difficulty being with
the bladder. At times he cannot pass his urine, and then
there will be a few days in which the urine drips away.
I saw him a few days since, and he said he had had but
little difficulty in passing urine during the last ten days.
During the second week after the case came under my
PARAPLEGIA. 133
care, the temperature ranged from one to two degrees
below the normal.
I quote the following from Reynolds's System of Medi-
cine, Vol. I., page 964: “Acute myelitis affecting any
considerable extent of the spinal cord is, without doubt,
a very grave disorder. It may be fatalin fifteen or twenty
hours, and it is seldom that life is prolonged beyond the
end of the second week. Instances of recovery are On
record, it is true, but these are very few in number, and
of them there is, perhaps, no single one in which the
correctness of the diagnosis may not be impugned.
Even chronic myelitis is a very grave disease; for
though life may be prolonged, especially where the
disease is confined to the lower part of the cord, the
mischief once done seems to be in a great measure ir-
reparable. At the same time it is only right to say, that
of late years the results of treatment have been much
more satisfactory, and that it is possible now to hope
where there was little room for hoping formerly.”
From this it would seem doubtful whether this was a
case of myelitis or not, though the symptoms would cer-
tainly indicate it. The question of whether the gon-
orrhoea was a factor in the production of the paralysis
is important.
Brown-Sequard says: “Paraplegia may also be the
result of disorder or disease, beginning at a distance and
affecting the cord secondarily, beginning in the urinary
and genital organs more especially; of this there can be
but little doubt. The chief characteristics of that form
of reflex paraplegia which is associated with disease of
the urinary organs is urinary paraplegia, as it is often
called. Usually the paralysis is incomplete, both as to
degree and extent, some muscles being obviously more af-
fected by it than others; usually the paralysis is not asso-
ciated either with tingling, or numbness, or anaesthesia;
usually the bladder and rectum are only slightly impli-
Cated in the paralysis.” He also says: “Reflex par-
aplegia differs diametrically from the paraplegia produced
134 NEW YORK STATE MEDICAL ASSOCIATION.
by myelitis. In paraplegia from myelitis, the paralysis
is usually complete, and all the muscles are affected
equally; not so in reflex paraplegia. In paraplegia from
myelitis, the paralysis is associated with tingling, numb-
ness, or anaesthesia ; not so in reflex paraplegia. In
paraplegia from myelitis, paralysis of the bladder and
lower bowel is a marked phenomenon ; not so in reflex
paraplegia. In paraplegia from myelitis, cure, or even
improvement, is the exception ; in reflex paraplegia it is
the rule.’’ -
DISCUSSION.
DR. H. S. WILLIAMS, of New York county, said that he had been greatly
interested in the case described in the paper, and agreed with the author
that it was one of myelitis. He had seen recently a case, which proved
that the symptoms of myelitis are not so pronounced in some instances as
is commonly supposed. Its onset in his case was not unlike that described
by the author, and it terminated fatally in less than a week. During this
time, there was no marked impairment of sensibility, nor was there a
sign of paraplegia, as commonly described, and, therefore, the diagnosis
of myelitis had not been made ; yet the autopsy showed unequivocally that
this was a case of myelitis. The lumbar cord was chiefly affected. He had
been especially interested in the case, as showing to what extent micro-
scopical changes might occur, without affecting the transfer of the current
both above and below.
DR. BROWN, in closing the discussion, said that the treatment of his
patient in the early or acute stage, consisted in the administration of nux
vomica and the application of electricity, with attention to the condition of
the bowels and general health. Iodide of potassium was used after the
acute stage had passed.
THE QUESTION OF MATERNAL IMPRESSIONS.
By H. S. WILLIAMs, M.D., of New York County.
(Read by title November 16, 1892.)
In asking your attention to the mooted question of so-
called maternal impressions, I shall attempt no elaborate
or comprehensive discussion. I desire merely to glance
at the matter from a point of view which is usually neg-
lected. I will not take your time with an analysis of
alleged cases in point, but will at once assume that, inas-
much as equally competent observers draw radically dif-
ferent conclusions from these cases, they cannot properly
be regarded as demonstrative. This definite assumption
is necessary at the outset, because if a single unequivocal
case were on record, our discussion need go no further.
Science knows nothing of rules proved by exceptions.
But I know of no such case, and therefore assume that,
as regards the teaching of experience, the subject is still
subjudice. It seems at first thought a little strange that
this should be so, when one reflects that the question
has been, in a sense, on trial every time that a new being
has been born into the world since the race was young ;
but this is really another way of saying that the problem
is an extremely complex one. In truth, it does present
a Vast number of points for mistaken inference, and its
difficulties, as regards the application of rigorously sci-
entific tests, are very great ; and while I do not think
these difficulties insurmountable, I believe they have not
yet been surmounted. Hence, I feel justified in appeal-
ing to philosophy for an opinion, on a topic which induct-
ive science must ultimately settle.
The question before us is briefly this: In what meas-
ure, if at all, may mental states of the mother oper-
ate to alter the potentialities which enter into a new being
at the moment of conception ? This is, I believe, the
136 WEW YORK STATE MEDICAL ASSOCIATION.
question of maternal impressions, as usually considered.
But a moment's consideration will show that the ques-
tion as thus stated really involves two radically distinct
Questions: (1) To what extent may mental states of a
mother affect the foetus indirectly 7 (2) To what extent
may they affect it directly
The first of these questions, I desire to entirely exclude
from the present discussion. It is an interesting topic in
itself, and one worthy of more careful investigation than
has yet been given it, but it is not pertinent to my present
purpose. How much, or how little the foetus may suffer
from nutritional changes of the mother, from toxic con-
ditions of her blood, or from uterine anomalies, even
when these conditions result from mental states, does not
here concern us. The question which I wish to consider
briefly is: May mental states of a mother be directly
transferred, as such, with energising force to the foetus?
This is the real pith of the question of maternal impres-
sions. However much the other extraneous elements
may enter into it; however much, for example, nutri-
tional alterations may be referred to, it is always alleged
or implied whenever a supposed illustrative case is cited,
that an element of direct mental transfer underlies the
other conditions, and is, indeed, the essential element of
the question. I shall now consider only this alleged es-
sential element. For convenience, I shalluse the general
term “maternal impressions,” but bear in mind that I
intend it always in this restricted sense.
It needs no argument to show that a belief in maternal
impressions has been widely prevalent for centuries. It
was, perhaps, more generally accepted in the past than
at present, but it is by no means obsolete to-day ; in
fact, thousands of intelligent persons, lay and profes-
sional, still believe in it implicitly. The illustrative
cases which are cited in its favor, have, for the most
part, been drawn from the human race, but alleged
cases among the lower animals are not wanting—e. g.,
the famous case recorded in Genesis, of the striped
MATERNAL IMPRESSIONS. 137
Sticks and the spotted sheep. Among moderns also, the
belief is generally applied to lower animals as fully as to
the human race, and this application is strictly logical.
The great merit of modern biology is that it has taught
us to look on every organism as a member of an endless
series of organisms, all subject to the same general laws,
which are relatively few in number, but of universal
scope. We know of no innate organic capacity which
has an important bearing on organic development, which
is confined to any individual, species, or family. Now, this
capacity of mental transfer from mother to foetus, if it
exist at all, is certainly of far-reaching importance from
the standpoint of the evolution of the race; hence, we
are forced to conclude that, if it operates at all, it is not
confined to any single race of beings, and since the scale
of development is a theoretically unbroken one, it is
impossible to mentally fix upon any particular stage of
organic evolution at which this capacity became opera-
tive. If, then, this capacity exist at all, it must be
regarded as a general law, which though variously
modified in detail, operates upon every race of organ-
isms in the world. I think we cannot logically escape
this conclusion ; and hence, it becomes evident that the
alleged transfer of maternal impressions is not merely
an individual question, possibly of practical significance
to a few hundreds of the human race, in any generation,
but a far-reaching capacity, which, if it exist at all,
must necessarily influence the development of the entire
Organic system. We are viewing an alleged general bio-
logical law, and we may, therefore, properly consider
the question in the light of such known laws of develop-
ment as are pertinent, endeavoring to decide how far the
alleged law of maternal impressions is in harmony with
these known laws. To this end I shall emphasise certain
familiar biological truths, which it is important to our
discussion should be borne prominently in mind.
It is a familiar biological axiom that the chief function
of any Organism is to reproduce its kind. Everywhere
138 NEW YORK STATE MEDICAL ASSOCIATION,
above the protozoa, this reproduction is accomplished by
the union of male and female elements, each representing
in some mysterious way the potentialities of the being
from which it springs. The moment these elements
unite, a new and independent being is produced. The
details of this union are not essential ; it may take place
in the water, as in the case of a fish, or within the genital
canal of the female, as in most higher Organisms; the
result is uniform. The act of paternity renders the male
parent obsolete, but the mission of the mother is not yet
complete. The new being is at first absolutely helpless,
and Nature decrees that the mother shall aid it ; shall
shield it for a time, as far as may be, from the adverse
forces of the environment. The essence of this aid is the
Supplying of nourishment to the young Organism. The
new being may be placed in a lake of nutritious matter,
called an egg, and soon extruded into the outer world ;
or it may be supplied piece-meal with this nourishment,
being retained meanwhile within the maternal organism.
In each case the new organism is equally dependent upon
the maternal organism for its nourishment; equally inde-
pendent as an individual entity. The expulsion of the
new being from the genital canal of the mother, may
take place, as in case of the fish, even before the new
being comes into existence ; it may occur before develop-
ment has advanced beyond the first stage, as in the bird
and the lowest mammal; it may be accomplished when the
new being is further advanced, but still utterly helpless,
necessitating the employment of what might be termed
“a supplementary external uterus,” as in the marsu-
pials ; or it may be delayed until the new being has ad-
vanced far on the developmental road. These differences
are minor details of specific adaptation ; the underlying
law is everywhere the same, viz.: The maternal organism
must strive, at whatever hazard, to protect the new being
until it is able to battle for itself. To that end, her in-
stincts are changed ; she passes to a new stage of mental
evolution ; the law of self-preservation is supplanted by
MATERNAL IMPRESSIONS. 139
the law of race preservation, and for the first time in the
history of mind, a truly altruistic principle prevails.
To supply nourishment for the new being, is a drain
on the system of the mother; to protect it, her interests,
even her life, may be jeopardized; she is fulfilling her
last and highest function, and her interests are as noth-
ing compared with the interests of the new being ; until
it has been rendered self-protecting, her mission will not
be complete.
What is the meaning of all this? Simply that Nature
despises the individual, but loves the race ; and that
each new generation represents the farthest advance
along that line of unceasing progress, which is a part of
Nature’s plan.
In the light of these known laws of development, how
shall we regard the alleged law of maternal impressions?
We have before our mind’s eye an ovum; male and fe-
male elements have combined ; a miracle has been per-
formed ; a new being has been ushered into the world.
It matters not, in our present view, whether this new
being lies in an egg-shell or in a uterus ; it is an organic
unit, an individual, immutably differentiated from each
and every other being that is, or ever has been, or ever
shall be in existence. It has come into the world
endowed with certain potentialities, the accumulated ten-
dencies of hosts of ancestors; it has come to battle with
a host of adverse tendencies—the forces of the environ-
ment. These adverse powers are fully equipped and
ready for battle, while the powers of the new being are
as yet but potential. The battle would indeed be a dis-
astrous one for the new being were it left to its own de-
Vices; but Nature decrees that it shall have aid from
the maternal organism. All her instincts, habits, and
Capacities are made subservient to this end. All, did I
Say ? No, not quite all, if the theory of maternal im-
pressions be true; for one capacity then hangs unceas-
ingly as a menace over the head of the new being. If
this theory be true, the mother, even while she strives
140 NEW YORK STATE MEDICAL ASSOCIATION.
to protect and nurture the new being, may mutilate it
by an uncontrollable action of her plastic mind. Does
this seem consistent with Nature’s great, progressive
plan 2 Does it harmonise with the fundamental laws of
evolution ?
Of course the mother cannot protect the foetus abso-
lutely from the forces which play upon her, but her mis-
sion is to mollify their influence as far as possible. Can
we suppose that while doing this, in obedience to a
general law, she is made to constantly menace the foetus
through the operation of a subordinate law . If so, what
becomes of our belief that each law must be in harmony
with every other law throughout the universe ?
Suppose the mother to be a deer, and that as she
roams the forest, gathering nourishment for the foetus
she has been called upon to protect, a panther springs
upon her and lacerates her haunches ; but she escapes
with her life. Acting in true maternal capacity, she has
saved the life of her foetus; but we are asked to believe
that the pain and terror which that mother experienced,
may make an impress on the new being which will
cripple it for life. What conceivable purpose has been
served by such a mutilation ?
What is this mind which is said to stand with such
menacing and domineering power over each new being ?
In the modern view, as I understand it, consciousness is
held to be itself an incidental condition, important, of
course, in the history of each race, but never all-impor-
tant. A transitory State of consciousness, then, is a mere
incident within an incident ; a fleeting condition of such
insignificance that it is not permitted to govern the vital
functions of the being which experiences it. Much less,
then, can we suppose it to govern the vital functions of
another being. If we admit that a mental state may
have such power as the theory of maternal impressions
Supposes, consider for a moment what a far-reaching
capacity is predicated. It is the actual operation of
mind within another body; for, we have seen that the
MATERNAL IMPRESSIONS. 141
new being is an individual entity, even as it lies in the
uterus. But again, why should the Operation of this
alleged law be restricted to the child in utero *
If the life of the new being, as such, dates from the
moment of conception ; if the development of the foetus
from that moment is a steady development, in which
even the birth is merely an incident, how shall we fix
upon a time at which maternal impressions shall cease
to operate, if they ever operate at all ? If the human
foetus, for example, may be marked by a mental state of
the mother when it has lain two weeks or two months in
wtero, why may it not be similarly marked at three, six,
eight, or ten months, even though in the last instance it
is drawing its nourishment from the breast instead of
from the uterus : Some of the ablest advocates of the
doctrine of maternal impressions, have contended that
such impressions can operate only during the first few
weeks of human gestation. I maintain that there is no
philosophical reason for such limitation, or for any
limitation short of the full development of the young
organism. When the human child is two years old, it is
still as unequivocally dependent upon some other being
for its nutrition, as when it lay in the uterus. Its tissues
are still developing hourly, and it is probably the source
of far greater maternal solicitude, and the object of far
greater maternal love than at the earlier period. If the
maternal thought or emotion could directly affect it then,
I affirm that logical thinking demands of us to believe
that the same maternal mental states can similarly affect
it now, not perhaps in the same degree, but in the same
kind. Bear in mind, I have excluded from present con-
sideration, the indirect influence of altered nutrition, of
diseased blood, and of uterine anomalies. I speak here
Only of direct mental transfer, of what may truly be
termed, a maternal impression. If there be a weak link
in the chain of reasoning, which demands that the law
of maternal impressions, if law it be, shall operate upon
the new organism during its entire time of development,
142 NEW YORK STATE MEDICAL ASSOCIATION.
I am unable to detect that link. It would thus seem
that if this question of maternal impressions were dem-
onstrated, it would have a direct bearing on the alluring
problems of Theosophy, which so exercise the minds of
a certain class of philosophers to-day.
In this wider view, to which, as it seems to me, a
strict reasoning forces us, the question of a non-nervous
umbilical cord, on which much stress is sometimes laid,
is seen to be of no significance whatever. Indeed, even
in a more restricted view, I cannot see that we would be
greatly aided if nerves were found in the cord, and if
these were proven to connect with the nerves of the
mother. We know nothing of nervous currents oper-
ating, for example, with such force as to amputate mem-
bers ; and we are quite unable to conceive how the nas-
cent nervous system of the foetus could transform the
nervous currents of the mother into agents of such effi-
ciency. It is quite as easy to imagine the mental state
of the mother operating directly on the foetus—or rather,
the two things are equally inconceivable.
But the inconceivable is not necessarily the impossible.
It is not because we cannot understand this alleged law
of maternal impressions, that we must reject it ; it is
because we cannot make it seem compatible with other
and wider laws. Of what effect are the laws of heredity,
if, at any moment, a capricious consciousness—an inci-
dental condition Operating for a moment in an inconse-
Quential Organism—can overthrow its tenets? Natural
selection might have wrought its finest structure ; all the
forces of countless generations might have combined to
produce a faultless being ; but an accidental emotion
steps in and pushes aside all these cumulative forces.
Chance supplants law in the organic world. Such are
the philosophical bearings of the question of maternal
impressions, as I see them.
But let me hasten to add that I make no pretence to
speak with the voice of an Oracle. As I have thought on
this topic, an alternative possibility has all the time been
MA 7'EIRNAL IMPRESSIONS. 143
before me. Perchance, I have said to myself, all that
consciousness about which you talk is not an incident,
but the one thing paramount in the organic world; every
thought of the mother operates upon the foetus, pushing
it, for the most part, onward. The thought is alluring,
and argument is not wanting which might seem to sus-
tain such a view.
Since it might be said, the foetus cannot be absolutely
shielded from the forces of the environment, and since
the mind of the mother is an exemplification of these
forces, may not the maternal consciousness be one of the
channels by which the infant organism is made to enter
into the struggle for existence, just as nutritional states
of the mother are such channels 2 I think we must ad-
mit that such may be the case. But if so, biological con-
sistency demands that the forces of consciousness shall
be modified, not accentuated in their action on the new
being. When nutritional vicissitudes play upon the
mother, they affect her tissues first, and most markedly;
the tissues of the foetus later, and less markedly. Must
we not suppose that the same law applies to conscious-
ness, if that also be a channel of attack upon the foetus?
Yet the alleged cases of maternal impression suppose
this consciousness to be malevolently directed against the
foetus, with such a force as it never displays in its oper-
ation on the maternal organism itself. But, these cases in
which consciousness is alleged to act with such disastrous
efficiency are rare; may they not be perverted examples of
a general law, which ordinarily operates for the good of the
foetus? The animal organism is not perfect; it acts always
in obedience to law, but its actions may vary within limits,
Perverted actions, carried to the extreme of these limits,
may give us a glimpse of the operation of a law, which
Otherwise we could not recognise, though its operation
Were incessant. In this view, it must be supposed, if we
admit the operation of maternal impressions in a single
Case, that each incidental operation of maternal con-
Sciousness operates more or less efficiently upon the
144 NEW YORK STATE MEDICAL ASSOCIATION.
foetal organism ; just as we must Suppose that each nu-
tritional change of the mother in Some degree affects that
foetus. This point of view is doubly alluring, because
by its aid we can explain one of the great problems of
biology—the cause of the so-called Spontaneous varia-
tions on which the Darwinian hypothesis is based. The
hunted hare, longing for longer legs to aid her flight,
transmits that desire with energising force to the foetus
in her uterus; and so on, and on. A pleasing fancy, is
it not ? But I fear it is only a fancy. I cannot make it
seem consistent with what I know of organic law. Still
it shows another of the marvelous implications of this
question of maternal impressions.
I will not ask you to look further with me into the
mazes of uncertainty which encompass this question.
Instead, let me repeat, that whatever our theories may
seem to prove or disprove, experience must bring the
final verdict ; philosophy to-day is only the handmaid of
science. I have had no thought of settling definitely in
your minds, or in mine, this question of maternal im-
pressions, by an appeal to theory. What I have hoped
to do, however, is to show how vastly more important is
the question, than is commonly supposed. I have
touched upon but one of its phases, yet I have succeeded
ill, if I have not proven that we have here the key to
momentous physiological problems. It remains for us,
as physicians, to use that key. I know of no question
within the scope of medicine, on the solution of which
may hang so many important and far-reaching im-
plications. It seems to me, therefore, that it should
be the duty of every physician to fully explore the his-
tory of every suggestive case of alleged maternal im-
pression which comes in his way. A single seemingly
demonstrative case, in which the hereditary history, the
nutritional possibilities, and the actual facts of the
mental state alleged to have acted on the foetus had
been put to a rigidly Scientific test, would be not only a
unique case in medical annals, but a valuable contribu-
MATERNAL IMPRESSIOWS. 145
tion to biological literature, and, incidentally, to specu-
lative philosophy. I speak with due deliberation, when
I express the opinion, that a truly demonstrative series
of cases on this subject, would be the most momentous
single contribution to biology and psychology, which
has appeared since the dawning of the Darwinian epoch.
This, then, must be my apology for addressing you in
this theoretical vein. I thought if I could help to arouse
a widespread professional interest in this topic, I would
do a better service than by the presentation of any case
at my command, or by any practical discussion within
my knowledge.
10
CLINICAL CONTRIBUTIONS TO THE SUBJECT
OF BRAIN SURGERY.
By Roswell, PARK, M. D., of Erie County.
November 16, 1892.
It is my intention in the following paper to report and
comment upon certain personal experiences in the rather
new field of intra-cranial surgery, illuminated, as it has
been, by the light of recent researches, rather than to
endeavor to present any new aspects of the subject.
After a man has done a certain amount of this kind of
work, his experience and deductions become of value to
others, and the sole purpose of the present communica-
tion is to make it as helpful to others as possible. Nor
do I intend to touch upon all possible phases of the sub-
ject, but rather upon some of the more common cases of
this general character. This is not intended to be a
comprehensive or complete personal record ; the in-
stances reported are simply those selected from a much
larger number, because they appear to me to be of in-
terest. Hence the frequent use of the personal pronoun.
INTRA-CRANIAL AIBSCESS.
As is well known, abscess in the brain must be the re-
sult either of direct infection or of embolic disturbance.
The latter it is sometimes easy to trace ; explanation of
the former is frequently much more difficult. While it is
everywhere acknowledged that abscess in the brain may
follow external injury to the skull, it is usually difficult
to fully appreciate the minute mechanism of its produc-
tion, and although a collection of pus may be found
directly beneath and two inches below an external scar,
we may be absolutely unable to demonstrate the path
PRAIN SURGERY. 147
pursued by the agents which have produced it. In the
following case, which I shall briefly report, the path of
infection is made reasonably clear.
The case concerns a lady approaching elderly life, from whose upper
nasal passage on one side a nasal polyp was removed by Dr. Hinkel, of
Buffalo. At first she did well ; but, later, rather severe nasal symptoms
presented themselves, and at the expiration of about four weeks she devel-
oped brain symptoms, and became unconscious. In this condition, Dr.
Putnam, together with Dr. Hinkel, diagnosticated a probable brain abscess,
and, with these two gentlemen, I saw her, and fully concurred in their
diagnosis. In this comatose condition there were no localising symptoms
whatever, and it was by inference, rather than by any safer guide, that we
decided to explore the frontal lobe. Accordingly, without an anaesthetic,
I raised a frontal flap, and made a good-sized trephine opening about 2.5
cm. above the orbit, on the side from which the polyp had been removed.
After opening the dura, which appeared normal, I used the needle of an
exploring syringe, and passed it in in several directions, once quite through
the falx and 3 cm. into the other hemisphere, searching for pus. Upon
the fourth or fifth attempt it was found directly back of the trephine open-
ing, and at a depth of about 3 cm. The abscess cavity was then freely
opened, and 12 c.c. of fresh pus were evacuated. The cavity was drained
with rubber tubing, and the wound closed and dressed.
The patient never recovered consciousness, but died the following day.
Examination was fortunately permitted, and it was found that on the
other side, in almost the exactly corresponding locality, was a similar col-
lection of pus of about the same amount. The point of my needle must
have gone within a very short distance of it, although it was completely
missed.
Here was a case similar to others that have been noted,
where the surgeon is deluded into contenting himself
with the discovery of one brain abscess, while more or
less narrowly missing others in its neighborhood. At
the same time, it must be said that there was absolutely
nothing about the case to lead to a suspicion of trouble
Other than that discovered, which seemed ample for an
explanation of the symptoms presented.
The case is also of pathological interest, since it gives
a clinical demonstration of recently discovered anatomi-
Cal facts concerning the lymph-vascular connection
between the nasal region and the encephalon. It more-
OVer indicates a possible source of danger in operations
Within the nasal cavity.
148 NEW YORK STATE MEDICAL ASSOOIATION.
HAEMORREIAGE.
One of the most complete demonstrations of the forma-
tion of clot, and the proper measure for its removal, that
I have ever seen, was the following:
In February, 1889, a young man in an adjoining town was injured by
a falling board, which inflicted a large scalp wound near the left parietal
eminence. He was stunned, but quickly recovered consciousness, and was
attended by a local physician, who showed himself not keenly alive to
modern practice in this regard, and who sewed up the scalp wound with-
out any of the precautions at present customary. He was then put on the
train, and sent to the Buffalo General Hospital, which he reached in the
evening. On his arrival at the station, where he was met by the ambulance,
it was noted that he used his right arm, but that during the quarter of an
hour spent in the removal to the institution, he lost the use of it. When he
entered the hospital he was able to talk, but within half an hour he lost
his power of speech, and within an hour was completely aphasic, with right
brachial monoplegia. I did not see him until the following morning, when
the house-staff had him ready for operation. His condition had not grown
worse during the night. Naturally, the diagnosis was that of a clot pres-
sing upon certain centres, and the indication for operation was most plain.
After anaesthetising him, I found considerable external injury of the soft
parts, with apparently local signs of infection. After such cleansing and
disinfection as was possible, I found a depressed fracture, about the size
of a nickel five-cent piece.
The trephine was applied at a point over the arm and speech centre, and
a considerable portion of slightly depressed bone was removed, its inner
table being considerably splintered. There was no laceration of the dura,
which, however, was dark in hue and bulged into the wound. Upon
making a small incision, a piece of clot was shot out from the dural wound,
and literally projected to a distance of fifteen or eighteen inches, showing
the extent of intra-cranial pressure. Enlarging the incision, a considerable
quantity of clot, fully two tablespoonfuls, was removed with probe, spoon,
and irrigating stream. A number of small brain fragments were also ex-
truded, showing that there had been laceration beneath the unbroken
dura.
His condition was not materially changed by the operation, and three
days later the wound was found united without any pus. On the follow-
ing day, however, his temperature quickly rose, the flap bulged somewhat,
and upon removing some stitches, considerable pus was discharged. It
will be sufficient to state, in this case, that the patient manifested no im-
provement, but became weaker, and died some three weeks later; and that
upon autopsy, three deep abscesses were found, apparently in the path of
motor conduction, which would probably account for the fact that no new
localising Symptoms developed themselves.
JBRAIN SURGERY. 149
This was clearly an instance of primary infection of a
head injury, which subsequent endeavors were powerless
to avert, and illustrates very forcibly the general state-
ment, that the fate of such cases is really in the hands of
the man who first attends them. A corollary is, that if the
first aid rendered is not based upon aseptic principles, the
case is usually thereby placed beyond the pale of surgical
help.
Another case of haemorrhage of different character and
happier termination is the following:
A lad of fifteen was, in June of the present year, struck on the right
side of his head by a wagon; he was unconscious for a time. There was no
distinct scalp wound, only some bruising and ecchymosis. He was at-
tended first by Dr. Schladermund, later by Dr. Dorr. With these gentle-
men I saw him, six days later. In the meantime, no motor or localising
symptoms had developed, but on the previous day his temperature began
to rise, and he had become very peevish and restless, although he was up
and about the house. I could easily feel a flattened and depressed area
back of the right parietal eminence. After shaving the scalp, it was found
ecchymotic over and back of the ear. On raising it, the periosteum was
found separated from the underlying bone, and an irregular, V-shaped,
linear fissure with depression, was found. The trephine was applied 5 cm.
away from the ear, on a line from the meatus to the vertex. Immediately
upon raising the button of bone, I came upon a very firm extra-dural
clot in which organisation had begun, and which, after cutting away a
large amount of bone, I found to cover an area 6 by 10 cm. (equal to 60
Sq. cm.), and to be at least 14 cm. thick in its central portion. So tena-
cious was it, that it was removed with considerable difficulty. After its
removal, the brain did not at once rise to its proper level, and I did not
think it necessary to open the dura. The wound was closed without
drainage, and rapid and perfect recovery ensued.
I have seen many large, flat clots, inside and outside
the dura, but never before had thought it possible that
a clot of this size and thickness could form, with so little
mental, psychical, or motor disturbance.
FRACTURES.
The following cases of aggravated and fatal fracture
Seem to me worthy of mention:
The first, was that of a middle-aged man who fell upon a slippery side-
Walk, and struck upon the back of the head, although his head did not
150 NEW YORK STATE MEDICAL ASSOCIATION.
receive the full violence of the fall. He was unconscious from the time of
the injury, and was brought to the hospital. He was operated on in the
evening, a few hours after his injury. At this time he was profoundly
comatose, in a rather bad condition generally, with a scalp wound upon
the right side of the head, and evident depressed fracture. Without an
anaesthetic, a large flap was raised, and revealed an astonishing condition
of multiple fracture extending in all directions, the fragments being more
or less interlocked until disturbed, after which, the more I picked out, the
more dislocated did the others become, and it seemed as if the skull were
cracked into a number of pieces. After commencing the operation there
seemed to be no indication as to just where to stop, except the strength of
the patient. The longitudinal sinus had been penetrated by a spicule, and
bled viciously on removal of the little fragment. So much blood was lost
before this could be effectually closed, that I hastily discontinued further
attempts, and bent my energies to getting him off the table alive. He died
shortly after the dressings were completed. His skull was thin, the bones
seemed rather brittle, but this was the most extensive fracture following a
common injury that I have ever met with.
A second case of this character was that of a man of forty, who, on the
4th day of April, 1892, fell from a height not exceeding five feet, and was
found unconscious. Accounts differ as to whether a stone fell with him,
and struck his head, or not, but at all events there were no perceptible
bruises on that or any other part of the body. On the morning following
the injury he was up and about the house, walking, using his hands, but
not talking, only replying by an inarticulate murmur to questions, i. e.,
with aphonia. The evacuations were attended to naturally. During the
third night following the injury, he became hemiplegic on the right side,
and the next morning was comatose. I saw him with Drs. Harrington and
Niemand, and found the right side absolutely paralysed, and that he pre-
sented all the Ordinary signs of compression, save that the pupils responded
to light. On careful palpation no tumor could be detected, or any ex-
terior evidence of fracture.
The conjunctiva of the right eye was suffused, but not that of the left.
As a last resort, operation was undertaken to see if the brain pressure could
be relieved. A very little chloroform was required. A large 5 cm. trephine
was applied over the left motor area, rather low down, and this, in spite
of the fact, that now that his head was shaved, we could see a faint linear
ecchymosis behind the opposite (right) ear. Even now, before exposing
the bone, we could detect no near, certain sign of fracture, although frac-
ture at the base was suspected. The skull was of average thickness.
After removing the button of bone, the dura appeared a little darker than
natural. It was opened, and it was seen that there was some laceration of
the brain substance. The most striking feature was the markedly increased
intra-cranial pressure. On further exploration, a little clot was removed
from beneath the dura, but the pressure increased. I then passed the
needle of an exploring syringe in the direction of the lateral ventricle. At
a depth of 6 cm. I found fluid blood, and removed 12 or 15 c.c. with the
BRAIN SURGERY 151
syringe. I then passed a director down alongside the needle, and evacu-
ated more than 30 c.c. of semi-fluid blood. After its removal, the pressure
was so reduced that the cortex subsided below the proper level, and he at
once began to move his right arm. I then passed a catgut drain into the
ventricle, and closed the dura and external wound. He displayed little or
no signs of shock, but died four hours later of pulmonary oedema. A hur-
ried autopsy was made, and upon removing the calvarium, it was found
that there was complete diastasis of the longitudinal suture, extending well
down anteriorly and posteriorly, and that the halves of the skull were al-
most ready to fall apart. Their level, however, was not altered, and with
all the work I did upon the skull during the operation, no such fracture as
this was suspected. A line of fracture was also found running down
toward the right ear, below the ecchymotic spot above noted. There were
several small clots just beneath the dura, scattered over the surfaces of
both hemispheres, and upon the right side some plastic exudate. At the
base, especially of the right anterior fossa, was considerable thin clot. In
the left hemisphere, about an inch beneath Broca's centre, was a firm clot of
the size of a grape. Numerous minute haemorrhages bespoke the extensive
lacerations inflicted upon the brain.
Here, again, Surprise is excited, that so many and
such lesions can occur, with so slight immediate signs
and results.
A few years ago, alluding to trephining for intra-
cranial haemorrhage, Hutchinson said, that “the modern
annals of Surgery do not contain any cases of haemor-
rhages in which life has been saved by trephining for
this state of things.” This statement was put on record,
although at the time numerous cases were in print, which
completely disproved it, and of which its writer seemed
to be ignorant. At present, that surgeon must be con- .
sidered as reprehensible, who fails to open the skull in
every case where indications of early or late haemor-
rhage are met with, aside from the localising symptoms
Commonly looked for. It is stated that a high temper-
ature, coming on suddenly, with slow, stertorous respira-
tion, diminishing consciousness, and hemiplegia, after
an interval of consciousness, may be regarded as con-
clusive evidence of haemorrhage from the middle menin-
geal artery. Of the brilliant results which have followed
the diagnosis and exploration of such cases, surgical
literature is full. The essential advance made, has been
152 MEW YORK STATE MEDICAL ASSOCIATION,
in systematising the indications, and popularising the
Operative attack. The most progressive surgeons, more-
Over, are coming to the conclusion that even in cases of
mild haemorrhage, it is best to trephine, in order to avoid
the risks of a small clot retained in the cranial cavity.
Indeed, Horsley, to whom we owe so much, is on record
as claiming that every case of fracture of the skull should
be trephined. For my own part, and so far as the danger
of the Operation is concerned, I can only say, that so far
as I know, among my own cases, in never a single in-
stance has the essential danger of a patient been enhanced
by trephining or other operative attack; and I desire to
ally myself with those who consider that trephining,
properly done, adds scarcely any appreciable danger,
while it offers a most important prospect of relief, and
One which no conscientious surgeon would willingly dis-
regard, or deprive his patient of.
IBRAIN TUIMOIRS.
With intra-cranial solid tumors I have had compara-
tively small experience. In one case, referred to me by Dr.
Putnam, where we regarded a tumor as certainly present,
but were unable to decide positively whether it was cor-
tical, or located along the deep paths of conduction, I
made an exploratory operation, which proved of no avail,
and, in fact, ended fatally within forty-eight hours.
In another case, referred to me by the same gentleman,
we were both convinced of the presence of a tumor, but
regarded it as inaccessible. After watching the patient's
suffering for a long time, we decided to operate, purely
for the relief of tension, and I trephined her, doing prac-
tically nothing but removing a large area of bone, yet
with complete relief of her distressing headache, which
relief continued up to the time of her death from the nat-
ural consequences of the disease. I have seen quite a num-
ber of cases of brain tumor with reference to operation,
but have, in most of them, declined to operate; while in
BRAIN SURGERY 153
those in which I was willing to do my part, the patients
have declined the proffered relief. A somewhat perplex-
ing case came under my notice not long ago, in the per-
son of an elderly woman, who fell down-stairs and struck
her head, and who, a few days later, became comatose,
and developed a peculiar sighing respiration, with fre-
quent hiccough. I was invited by Dr. Diehl to see her
with reference to operation, but could see no operative
indications. She died the following day, and on autopsy,
there was found acute meningitis of ordinary type. On
lifting up the lower surface of the brain, in its removal,
a peculiar condition of the lower surface of the cerebel-
lum was observed, and after its removal, a cluster of
cystic growths was found, which were attached a little to
One side of the middle line, upon the lower surface of
the cerebellum, where they had made depressions into
which they seemed to fit. One of these was of the size
of a Small grape, two of the size of large peas, and there
were several quite small ones. They had a peculiar
pearly sheen, were cystic in character, although their
Walls were quite thick, and upon minute examination
proved to be cholesteatomata. We learned that during
the last few months of her life, the patient had developed
a frequent, though not constantly staggering gait, and
that she at times complained of giddiness and vertigo.
FPILEPSY.
No discussion of brain surgery nowadays, in which the
Surgical treatment of epilepsy has been disregarded, has
been noted in recent surgical literature, and for very ob-
vious reasons. My own experience in this direction has
been, I imagine, like that of most other surgeons—i.e., a
Very mixed and contradictory one. I have had some very
brilliant results, and, I think, a few positive cures; on
the other hand, I have operated without noticing the
slightest permanent improvement. In no distinctly
epileptic case has any harm been done by the operation,
154 NEW YORK STATE MEDICAL ASSOCIATION.
unless there be included in this category, two cases of
linear craniotomy to be spoken of later. If I may be
permitted to state my present opinion concerning the
Surgical treatment of epilepsy, it would be about as
follows: That there are certain cases in which prognosis
is very favorable; that there are others in which the
Operation must be regarded as an absolute experiment,
albeit upon scientific principles ; and still others which,
although accompanied by focal symptoms or other feat-
ures which ordinarily necessitate operation, we must
regard as absolutely hopeless ; and that it is seldom
possible to designate to which class a case belongs until
the Operation is tried. But I think this statement ought
to be tempered by another, to the effect that surgery
alone, is rarely, if ever, sufficient, and that it must be
accompanied and followed, and, perhaps, even preceded,
by medicinal and dietetic treatment ; and that this feat-
ure of these cases is too often disregarded. To this
second statement should be added, perhaps, a third, to
the effect, that when operating for pronounced epilepsy,
we have to combat not only a somatic lesion, but an
epileptic habit, so to speak, and that a mere removal of
the lesion is not necessarily, nor always, enough to break
up the well-formed habit ; that it is this which calls for
the long-continued post-operative treatment which often
causes discouragement and carelessness, and, finally, in-
attention and absolute disappointment. I firmly believe
that if those who operate frequently for epilepsy, would
steadily follow their operations with the other measures
above alluded to, and keep them up for five years, at the
expiration of that time, much better results would be
reported. This refers not only to cases of head injury,
where the conventional Operations about the skull are
performed, but also to peripheral irritations in other
parts of the body, necessitating various other operations.
Of purely head or brain cases of this character, I will
only call attention to two or three. One was a case oper-
ated. On in 1884:
BRAIN SURGERY 155
A man, twenty-three years of age, who, when a boy, fell into the water
and struck upon a submerged timber. He was unconscious for two days
afterward, later on developed epilepsy, and was afterward in the hospital
on Ward's Island. He escaped from there when they proposed operation
to him, and was eventually picked up in a fit on a Buffalo street, and sent
to our hospital. Upon admission, he was having at least one fit every day;
there was a distinct depression on one side of the median line ; and the
overlying skin was very sensitive. The operation was on December 6,
1884; the bone was very thick (2 cm.), with external depression, but none
of the internal table could be made out ; the external sensitive area was
excised. For some days he was violently disturbed, then showed ma-
terial improvement, and during the last ten days of December, he had no
fit, save that upon the last day of the year, he had several. Respiration
became so embarrassed as to call for artificial aid. A few days later he
was sent to the almshouse, where he had a number of seizures, during one
of which a pail of cold water was thrown over him. He quickly recovered,
and had no more while there. He left the institution in May, was reported
as not having had any fits in three months, but since has not been heard
from.
The first case attempted in this country in accordance
with principles of cerebral localisation, was a patient upon
whom I operated November 16, 1886 : *
The patient was a man of forty-seven, who more than a year previously
had been thrown and dragged upon the ground. Four hours later he be-
came unconscious, although there was no external violence to the skull,
and remained so for sixty-eight hours, when he gradually recovered. He
developed nearly absolute aphasia, his vocabulary being limited to perhaps
half a dozen words. His right arm was also paralysed and cold. His
epileptic condition developed four months after his injury, and became
Very pronounced. His lesion was diagnosticated as cystic degeneration of
a clot, and its position correctly determined. Upon trephining it was
found, as expected, only perhaps larger. A cyst was discovered with a
capacity of 40 c.c. of fluid, and measuring 10 by 3 cm. It was dissected
Out, and the patient made a perfect recovery from the operation. His
epileptic and aphasic condition, however, have since then only in small
measure improved. This latter condition I can explain by atrophy of the
third parietal convolution, due to pressure of the cyst. For the former, I
can give no more Satisfactory explanation than in any such case.
Three or four similar cases where cysts have been ac-
curately diagnosticated and indicated either by localising
Symptoms, or by external scars, have been operated upon
* Wide Trans. Cong. Am. Phys. and Surg., vol. i.; paper by the writer.
156 NEW YORK STATE MEDICAL ASSOCIATION.
after much the same fashion, with results, in every case
encouraging, but in no case, completely satisfying. It
has seemed that in every case the cyst had existed long
enough to produce atrophy of the underlying portion of
the hemisphere, with permanent loss or disturbance of
its proper functions.
In one case operated upon last year, I had an expe-
rience with haemorrhage which may be of interest and
encouragement to others. It was one of those instances
of traumatic, Jacksonian epilepsy, with a scar near the
middle line of the scalp. The operation was without
incident until the dura was opened, and adhesions found
between it and the cortex. These were tough and firm,
and in the endeavor to remove the adherent portion of
the cortex, Some unusually large veins or abnormal con-
nections with the longitudinal sinus, were severed, and
the bleeding became serious and even alarming. I finally
succeeded, to my perfect satisfaction, however, in check-
ing it, by packing with iodoform gauze, the tampon of
which I retained in situ by the pressure of the overlying
skin flap, which was restored to its place after inserting
Secondary sutures of silk, which were left long, and tied
by a bow-knot. Two days later I untied the knots, lifted
up the flap, removed the tampon without a particle of
haemorrhage, restored the flap to place, utilised the
Secondary sutures for its retention, and got beautiful
union by first intention. This patient went home very
much improved, but during the hot weather of the past.
Summer was, they write me, injudicious, and had some
return of his old trouble, the seizures never being of SO
Serious a character as before, and being quite controll-
able So long as he takes bromides and borax in ordinary
doses–a line of treatment which I have urged him to
continue indefinitely. *
Last Spring, at the meeting of the Surgical Association
in Boston, Dr. Beach, of that city, presented to the Asso-
ciation a case operated upon for traumatic epilepsy,
where, in order to prevent the re-formation of adhesions
BRAIN SURGERY 157
between the dura and the other tissues, he had inserted
a piece of thin gold foil, carefully sterilised, with appar-
ently the best results. Following his example, I have
twice operated in the same way, cutting out with a
pattern, a piece of dentist’s foil a little larger than the
bone opening, and fitting it in, after closing the dura,
between it and the margin of the bony defect, then
closing the Scalp wound over it, all without drainage.
There has not been the slightest disturbance of any
Kind, and the progress of these cases, so far as I have
been able to judge of them, or to hear, has been very
encouraging.
This measure (insertion of gold foil) I now intend to
introduce and recommend in recent accident cases, where
trephining is practiced for depressed fractures, etc., for
the purpose of preventing adhesions between the scalp
and dura.
In another case, a young lady with Jacksonian epi-
lepsy, where the aura usually commenced in the arm,
and where there were noticed also what my colleague, Dr.
Putnam, has been recently the first to call attention to,
viz.:-sleep-movements in the same arm—I last spring
exposed the arm centre, determined its exact location
with the faradic coil, and excised the same, as ac-
curately as I could, to the depth of 1 cm. Perfect
primary union took place, but the result has been dis-
appointing, there having been only slight amelioration
Of symptoms. In her case, however, we have had to
Contend with peculiar gastric symptoms, dilatation of
the stomach, etc., which seem to have had a marked in-
fluence in depriving her of the benefits to have been
legitimately expected from such an operation. More-
Over, she has a peculiar idiosyncrasy, in that she cannot
take bromides in any form without intense bromism;
her body showing many scars of ulcers produced in the
attempt to bring her under the influence of the drug.
158 NEW YORK STATE MEDICAL ASSOCIATION.
PSYCHOPATHIC EQUIVALENT OF EPILEPSY ; DEMENTIA
IEPILEPTIC A.
Under this head, recent writers have included cases,
not of distinct epileptic type, but of paroxysmal, emo-
tional, and epileptiform character, the attacks coming
on sometimes with, and sometimes without aura or other
premonitory symptoms. I have operated upon three
well-marked cases of this character within the past few
months.
The first, was a man, thirty-one years of age, who, on July 20, 1891,
was kicked in the left side of the head by a horse, and who some time later
was found unconscious. He was carried into the house, and was aroused.
He had never had any paralysis. Three days later he began to act strangely,
and soon became willful and almost violent. He developed erotic
tendencies, and grew rapidly worse so that he could not be kept at
home. On July 28th, he was sent to me by Dr. Krehbiel, of Yorkshire
Centre. At this time the patient was difficult to control and mildly mani-
acal. On July 29th, I found a depressed area on the left side, near the
parietal eminence, a little anterior to it, yet he had absolutely no motor
symptoms. At this point there was an H-shaped scar. Immediate opera-
tion was done under chloroform. Beneath the Scalp I found a depression
about the size of a half-dollar, around which Ichiselled so as to entirely lift
and remove the depressed portion. The bone was well comminuted; there
was a small clot beneath the bone, but none beneath the dura. The bone
was not replaced, and the wound was closed without drainage. He made
a rapid recovery ; returned home in one week with his mind nearly clear,
and with his disposition as it had been before his injury.
My second case was a man of forty-five, who, when a young man, had
had an extensive compound fracture of the skull, and who for a while was
under the observation of the late Dr. Gray, of Utica, who advised against
operation in accordance with the practice of that day. Of late years the
man has developed distinct epileptiform seizures, followed by violent ma-
niacal attacks, during which he was positively dangerous, so that his fam-
ily lived in constant fear; moreover, his disposition and temper seemed to be
gradually changing under this stress, and it got to be a question whether
he should submit to an operation or be sent to an asylum. He was placed
in my hands by Dr. Putnam for operation. This was performed during
October, 1891, the depressed bone being removed, adhesions separated, and
a portion of the scar exsected. The change in this case for the better has
been most marked, and most gratifying. While it is too much to say that
he has not had a single seizure since the operation, they have been reduced
to very mild and very rare attacks, and I believe it is now some months
since he has had anything which could be called a fit. In temper and dispo-
sition he is also quite his old self again.
PRAIN SURGERY 159
A third case is one very recently operated on, so that I cannot report
final results. The patient was a man of about thirty, who, when five
years of age, sustained a bad compound fracture of the left side of the
skull. He was so profoundly unconscious, that for two or three days abso-
lutely nothing was done for him by the physician in his community. He
got married some twelve years ago, and since his marriage has had nearly
weekly attacks of faintness, but never any of a convulsive character. These
have been followed by sullenness, and by manifestations of quick temper,
which have greatly alarmed his family. Inasmuch as there was about
the head, at the site of the old injury, a dense, and depressed Scar, I as-
cribed his nervous symptoms to the remote effects of the injury, rather
than to those of his marriage. In his case, I completely dissected out
the scar, trephined and removed a small circular depression of bone, in-
serted a piece of gold foil, slipping its edges beneath those of the bone, and
closed the wound as usual without drainage. Up to the moment of pub-
lication, this case has steadily improved.
LINEAR CRANIOTOMY, OR CRANIECTOMY.
My experience with this new and radical procedure
has been sufficiently varied and interesting, not to say
important, to justify a report of each case. I will give
them in the order of their occurrence.
CASE I.—J. W., three and one-half years of age, was referred to me by
Dr. Crego. As a baby, he was restless and “jerky,” and when nine
months old had convulsions of the entire body. As he grew older he
would sometimes fall in some of them. These slowly assumed the con-
ventional epileptic type, and by the time he was three years old, or in
March, 1891, were perfect examples of grand mal. They also increased in
frequency and severity. At that time he began staggering in his gait, and
his left leg grew weak. Soon after, the leg showed relative decrease in
length and size. His temper became violent and uncontrollable, his epi-
leptic seizures more and more frequent, and durin g the twenty-four hours
previous to the operation, he had between thirty and forty distinct and
severe seizures. Though he was by no means an imbecile, his mental de-
velopment was retarded. His skull seemed relatively small for his age,
On June 21, 1891, I operated at the General Hospital. A long incision,
One inch to the right, and parallel with the middle line, was made from
the forehead to the occiput. With cutting bone forceps I excised a strip
of bone 2 cm. wide, from the line of growth of the hair in front, nearly to
the occipital protuberance behind ; then, detaching the scalp for the pur-
pose, I excised a narrow strip of bone over the fissure of Rolando on the
right side, down nearly to the temporal fossa. The wounds were closed
Without drainage. During the ensuing twenty-four hours, shock was
SeVere, and he had several violent epileptic seizures, but he has had none
160 NEW YORK STATE MEDICAL ASSOCIATION.
since this first day. His irascibility has subsided, his general health and
intelligence have improved, and he now runs, plays, acts, and talks just
like other children of his age.
CASE II.—Minnie R., four years of age, was referred to me by Dr. Put-
nam. This was a case of congenital microcephalus and imbecility. The
parents were healthy, and the family history was good, the previous chil-
dren being sound. This girl had scarcely ever spoken a word, and mani-
fested no more intelligence than an infant of three months. Her fontanelles
had closed very early. She led a vegetable sort of existence—without dis-
turbance of function. Operation here seemed much less hopeful than in
the previous case ; it was, nevertheless, undertaken, July 13, 1891. An
incision was made 3 cm. to the left of the middle line, from a point 4 cm.
above the left superciliary region, to the occipital protuberance. A strip
of bone was excised much nearer to the middle line, After removing it,
the scalp was pressed away on the left side, and a strip excised over the
Rolandic fissure. I then made a distinct incision over the right Ro-
landic fissure, and excised another strip of greater length, the three
lines of defect having a common meeting-place. The central grooves were
cut with forceps, the lateral grooves with chisel. There was no great
haemorrhage, and the wounds were closed without any provision for drain-
age. The child nearly collapsed after the operation, and for two days
required constant attention. The after-results in this case have been prac-
tically nil. There has seemed to be a perceptible improvement in intel-
ligence, and the child has appeared a little more alive to what is going on
about her, but this is about all that can be said.
CASE III.-W. K., eighteen years of age, was referred to me by Dr.
Crego. From an early age the patient's mental development has been very
disappointing. He is physically large and well developed, but mentally
shows scarcely more intelligence than a child of two or three years. At
the age of about five, he first showed epileptic manifestations. His seiz-
ures were then few and far between. They gradually increased in fre-
quency, until now he has several in one day, and rarely goes a few days
without any. His temper is usually good, but at times he is excessively
willful. The upper portion of his cranium is relatively small, though not
conspicuously so ; the muscles of his right side are somewhat atrophied ;
and it seems that his epileptic fits have been somewhat more violent on the
right side than on the left. His personal habits are good, as is also his
family history. Dr. Crego and myself both thought that an extensive
cranial opening might give relief, and the experiment was proposed and ac-
cepted by the father. The operation was done October 20, 1891. A long
incision was made to left of the middle line. When I endeavored to make a
longitudinal division of the skull, commencing with a common amputating
saw, I found that the bone was very thick. I then applied a trephine over
the motor area, and, through the opening thus made, with chisel and
gouge-forceps removed a portion of bone, some 5 cm. in diameter, and in
shape like a spherical triangle. Through a small opening in the dura I
BRAIN SURGERY. 161
found there were no adhesions, but that the arachnoid and pia were suc-
culent and oedematous. I started to make a longitudinal excision of bone,
but finding the same to be 1 cm. thick, desisted from this attempt, and
tried to make simply a large relief opening. The wound was closed with
catgut, and an ice-bag applied outside the dressing. At 6 P. M. he was
somewhat restless, and had a fit. This condition became more marked,
and by midnight, in spite of considerable morphine and other sedatives, he
was convulsively restless and violent, and required both a strait-jacket and
chloroform. At 4 A. M. he died of exhaustion.
CASE IV.-J. M., fifteen years of age. All the children of this family
were rachitic. The patient was healthy until he was three years old ; then
his nurse used to frighten him, and he grew to be very nervous and timid.
He soon began having fits every night, and this continued until he was
thirteen years old, when they occurred in the daytime also, and he soon had
as many as thirty to forty fits every day. During one of these, he fell and
broke his elbow, which is now partially anchylosed. He also cut his fore-
head to the bone. For the last two years, he has been lying most of the
time helpless in bed, and has had to be fed. His symptoms, mental and
convulsive, seemed to occur in cycles of about three weeks each. During
the first week of the three, he would be noisy, the second, he would be
weeping and wailing, and during the third, apathetic and almost uncon-
scious. He rarely spoke. On November 2, 1891, he was brought to my
clinic in this third stage, and it seemed impossible to arouse him. He
took mechanically most of what was put into his mouth; his bed was con-
stantly soiled ; his arms were nearly always in the athetoid condition, and
Sometimes his legs were similarly affected, and any little disturbance would
bring on a mild seizure, during which his arms were drawn up over his
head. There were no scars over his motor areas. On November 7, 1891,
the operation was performed in the clinic. A long incision was made to
the left of the middle line, and after a first opening with the trephine, along
Strip of bone, 1 cm. wide and 13 cm. long, was removed, just to the left of
the longitudinal sinus. The operation had to be discontinued because of
collapse. The patient stopped breathing, nearly died on the table, and
Was revived with great difficulty. The wound was closed as rapidly as
possible. He seemed better the same evening, but next day the athetosis
Continued ; he became uneasy, and died of shock, twenty-six hours after
Operation.
CASE W.—S. P., nine years of age. This patient was of Russian-Jewish
parentage, his father being an educated man, and the other children
healthy. He presented a defective skull development, especially over the
left frontal lobe; was imbecile and epileptic; had seizures coming on about
every five days. His forehead sloped backward so as to give him some-
What the appearance of one of the Aztec children. Mentally he was an im-
becile, muttering half a dozen words, and staggering about the room, but in
disposition good-natured and even confiding. He was operated upon Novem-
ber 14, 1891, in my clinic. In this instance I varied the Ordinary procedure,
11
162 NEW YORK STATE MEDICAL ASSOCIATION.
in that I laid up a W-shaped frontal flap, its apex reaching nearly to the
vertex of the skull, its extremities extending nearly to the external angular
processes. Then a small trephine was applied on each side of the middle
line; the opening thus made was connected across the longitudinal sinus,
and then two strips of bone excised in a direction parallel to the Scalp in-
cisions, by which considerable “spring” was given to the frontal bone,
and the fragments of others attached to it. The operation proceeded without
incident, and the first dressing was not made until eight days later, when
perfect union was found. The immediate effects in this case were not
very pronounced; his seizures, however, became less frequent and less
severe, and when he left the hospital a few weeks later, he had lost his stag-
gering gait, and his various actions and attempted speech showed much
more fixedness of purpose than was previously the case. But the results
at the end of a year, in his case, have astounded me. He has had no fit
for three months, and within a week or two was exhibited again at my
clinic. He came up to me, and publicly asked in clear and distinct tones,
whether he could go to school. I held some conversation with him before
my class, in order to show that he was capable of rational thought, and
rational, and even accurate conversation. In addition to this he has de-
veloped physically, and his face now has a really intelligent expression,
whereas a year ago it was expressionless.
CASE WI.—C. S., twelve years of age, of Warren, Pa., was sent to me
by Dr. Baker. This child was also an imbecile, speaking but few words,
being at times irascible, and having frequent epileptic seizures. There
was partial paresis of the left arm, although she used it more or less. In
her case there was great asymmetry, there being a decided depression over
the right side. She was operated on the same day as the previous case, at
a special clinic given for these two cases, and a strip of bone about 1 cm.
wide was excised to the right of the middle line, extending well backward,
and forward into the frontal bone. The dura was not opened. At the
first dressing, one week later, perfect union of the wound was found, and
a light dressing only was applied. A few hours later she got restless, and
tore this off, and then picked the wound open so that it gaped for its whole
distance. It was immediately re-dressed, after disinfection with hydro-
peroxygen, but healed the second time by the slower process of granula-
tion. During the few weeks of her stay in the hospital, she improved a
little. A letter from Dr. Baker, dated October 25, 1892, nearly a year
later, states that “she is no better now than she was before operation. For
the first three months after operation, there was a marked lessening in the
number of paroxysms, but for the last three months the convulsions have
been both severe and frequent, she having several daily. She is in much
the same condition mentally that she was before operation.”
From the foregoing reports it will be seen that I have
had six cases of this general character, two of which
were promptly fatal, two of which have been practically
BRAIN SURGERY. t 163
unaltered, and two of which have been brilliantly suc-
cessful beyond all expectation. Of the two fatal cases
I can only say, that they belong to a class of patients
about whom in general we feel that death is vastly pref-
erable to such a life, and while I think the second case
might have been benefited had he survived the shock, I
regard the first as essentially and absolutely hopeless in
every respect. Save in a purely personal sense, I have
no regret for the operation, which was freely assented
to by the parents. In fact, in every one of these cases,
the parents have been made fully aware of the difficulties
and dangers, and have in every instance said that they
would rather lose their children, than see them live in the
condition in which they were at the time of the operation.
The two cases where no result has been noted, I sup-
pose, must be regarded as belonging to the class of cere-
bral atrophies which have been stigmatised by Dr. Starr,
as essentially hopeless. In both these cases, the princi-
pal regret of the parents is that their children survived
the operative ordeal.
Of the two successful cases, any man might well feel
proud, as having contributed to such marvellous changes.
They are of themselves sufficient reward and justification
for a score of unsuccessful cases, and lend an element of
hope in similar instances, of which the profession should
not be deprived.
CASE VII.-Since writing the above, I have operated upon an infant of
fourteen months, who was born during a natural labor, of a healthy
mother, who had borne other healthy children. My little patient showed
no ordinary signs of rickets, but her fontanelles closed very early, and she
showed scarcely any more sign of intelligence than a vegetable. She
Seemed to recognise the difference between light and darkness, to have the
Sense of hearing reasonably acute, and to be in good physical condition.
Her principal evidence of life and activity, was her constant crying at night.
In this instance the father said to me, with tears in his eyes: “Do all you
can, and be sure to do what you think is enough, without stinting opera-
tion ; for I would rather bring the child away from the hospital in a coffin,
than in this condition.” The operation was done in the same way as in
Case V., but the child, who stood the operation well, collapsed, and died
suddenly the same evening.
164 NEW YORK STATE MEDICAL ASSOCIATION.
Without prolonging this paper to too great an extent,
I desire, before closing, to invite your attention to a few
conclusions, the results of my deliberate convictions and
reflections upon this kind of work.
1st. We have not yet learned the possible limits of
brain surgery, so called, nor the possible limits to which
we may with reasonable safety interfere with the func-
tions of the brain or its component parts. Final knowl-
edge in this respect will come, probably, rather through
clinical experience, than through experimental inves-
tigation.
2d. I have had a number of brain cases whose history
shows that at the time of reception of the injury, the
symptoms were so serious and severe as to lead the medi-
cal attendants to consider the case hopeless, so that prac-
tically nothing was done. I wish to say all I can to con-
demn this apathetic course, and to urge that the most
desperate case be attended to at once, with the same at-
tention to detail, as though it were quite hopeful in its
outlook.
3d. In many of my own cases, and my experience is
like that of many others, the mental or other disturbance
that has finally led to operation, has been allowed to
run along, often for years and years, and patients have
been brought to the surgeon only as a last resort. This
course is as unwise in these cases, as when we deal with
malignant disease, and the profession generally should
learn that prognosis would be very much more favorable
in Such cases, were they operated upon when these dis-
turbances first make their appearance.
4th. Personal experience has convinced me that when
I have erred in operating for epilepsy or psychic dis-
turbance, it has been rather on the side of doing too
little than too much. For instance, in one of the cases
alluded to under the caption “Epilepsy,” in which no
improvement was manifested, I am now sorry that I did
not take out so much of the arm centre as to produce, at
least, temporary paralysis of the arm. In other words,
DISCUSSION. 165
I have never regretted doing too much, but in several
cases, have regretted not doing more than was done.
5th. I wish again to insist upon the necessity of long-
continued medicinal and dietetic treatment after these
cases have passed out of the hands of the surgeon.
DISCUSSION.
DR. JAMEs W. PUTNAM, of Erie county, said that the paper contained
many cases which he had himself had the opportunity of seeing and study-
ing, and consequently it was to him especially interesting. He concurred
fully with the conclusions of the author. Operations for epilepsy, al-
though not holding out much encouragement, should not be discontinued,
for improvement has often been seen one or two years after the operation, if
vigorous medicinal treatment had been kept up. In the case operated upon
by Dr. Park, one year ago, the patient had frequent and severe attacks,
and was vigorously treated with the bromides before operation, but with-
out benefit. At the operation, a piece of depressed bone was removed, and
after a vigorous use of the bromides, the attacks became very much less
frequent, so that now, the interval between the attacks is about thirteen
months. Some of these cases have proved more amenable to treatment
with the bromides after operation, than before. One of the cases referred
to in the paper, was operated upon because the patient suffered from very
severe headaches, which were looked upon as one of the symptoms of
what was considered to be a cerebral growth. The symptoms, however,
were not sufficiently severe in themselves to make it seem advisable to
operate for the removal of the tumor. The operation was done with a
view to relieving the pressure, and this was accomplished by the removal
of a considerable portion of bone. The patient no longer suffers from the
severe paroxysms of pain. We should, therefore, bear in mind the value
of trephining in cases of brain tumor, even though we have no idea of re-
moving the tumor. Regarding the first case reported in the paper, he dif-
fered a little with the author, in saying there were no localisation symptoms;
for, although there were no positive ones, there were negative ones—cer-
tain psychical disturbances, so that she would forget what was said to her,
and her vocabulary became reduced to a very few words. There were
also disturbances of mentality, pointing, though not positively, to trouble
in the frontal lobe.
DR. F. W. Ross, of Chemung county, said that he only desired to em-
phasise the remarks made by the author, regarding cases which seemed to
be almost hopeless. He recalled two cases of traumatism in the frontal
region, in which it was decided that an operation was almost useless; yet
at the operation, a large clot was removed from the brain, and the patients
recovered with only loss of the function of one eye. Within the past week,
a man who had received a very severe crushing injury in the frontal region,
Was Sent to the hospital, twelve hours after the accident. He had been at-
tended during this interval by a surgeon from outside. On admission, his
166 NEW YORK STATE MEDICAL ASSOCIATION.
pulse was almost imperceptible, and he was unconscious, but his respira.
tions were fairly regular. The speaker re-opened the original wound, and
found it full of dirt ; there was a depression of the parietal bone. Tre-
phining was performed, the depressed bone elevated, and the blood clots
cleared out. This man died, and the speaker felt that the untoward result
was largely due to the negligence of the first surgeon ; for, in all cases of
injury to the brain, we should operate promptly, and as carefully as though
we fully expected the patient to recover.
THE PRESIDENT said that when we considered the few recoveries which
took place, as compared with the numerous operations which have been
performed for epilepsy, we must certainly admit that the results are not
very brilliant, but they are still sufficiently encouraging to warrant con-
tinued efforts in this direction, in the hope that the experience so gained may
lead to still better results. As had been said, the great obstacle to success
is the habit of epilepsy, unless that habit is directly produced by the pres-
sure of spiculae of bone, or something of that character. He thought, also,
that many of the cases which had been claimed as successes, had been re-
ported too soon after operation, and that results which, at first, seemed to
be most brilliant, would ultimately prove to be far different. The only
conclusion to be drawn, however, is the one given in the paper, viz.:--the
necessity of continuing the bromide treatment, with especial attention
to dietetics; for, as a rule, physicians are careless as to this matter of diet,
and the physician himself is often responsible for the continuance, or the
severity of the fits. He recalled the case of a yonng man who had the
status epilepticus, and had such continued fits that his friends were called
in to see him die. After coming out of this status epilepticus, the speaker
had inquired into his diet, and had learned that he was inclined to eat
everything that was on the table, and to eat excessively. After restricting
him to a milk diet, there was no return of the 8tatus epilepticus, and even
the epileptic fits decreased markedly in number, and his whole general
condition improved. The treatment with the bromides was of course con-
tinued, and he is now in a far different condition from that previous to the
restriction of his diet.
DR. JoHN CRONYN, of Erie county, said that the remarks of the pre-
ceding speaker on the subject of prematurely reporting these cases, had
recalled to his mind the first case which he believed had been operated
upon for traumatic epilepsy. In 1846, the then professor of physiology
and anatomy at the University in Toronto, performed an operation on a
young man who was an epileptic maniac in the asylum. A cicatrix was
found pressing upon the cortex, and was removed. For seven and a half
years afterwards, he remained perfectly well, and was intelligent. At the
end of this time, he was returned to the asylum as bad as before the opera-
tion. This goes to prove that immediate improvement is not to be relied
upon as a proof of the permanency of the cure. This subject is still 8wö
judice, but the operation should not be abandoned until the matter is
definitely settled.
A PLEA FOR THE EARLY EXTIRPATION OF
TUMORS.
By John W. S. Gouley, M. D., of New York County.
Movember 16, 1892.
At what period of the development of a tumor is its
extirpation justifiable . The answers to this question for a
long time have been divided between early and late sur-
gical intervention and non-intervention. Some surgeons,
at home and abroad, have favored and do now favor
early extirpation even in the case of benign tumors, but
many advise non-interference so long as tumors are
small, painless, stationary, or of slow growth.
The observations of experienced clinicians indicate
that malignant tumors sometimes have a long period of
latency, and that they often begin as benign tumors,
which are stationary for years or grow very slowly, and
then increase with the greatest rapidity. Such seems to
be the progress of some of the mammary tumors, notably
certain adenomata, which occasionally lead astray the
medical adviser respecting prognosis; for, the diagnosis
having been made and the tumor growing slowly, its
removal is condemned, or deferred until perhaps the
disease has already become malignant. The recent ad-
Vances in pathology and in surgical procedures, are very
likely to induce the majority of surgeons to modify their
views in relation to the indication for operative inter-
Vention. -
If it were generally known among intelligent people
that many innocent tumors sooner or later become malig-
nant, and that malignant tumors often simulate benign
tumors, and remain quiescent for a great while, the suf-
ferers would unhesitatingly consent to the removal of
168 NEW YORK STATE MEDICAL ASSOCIATION.
these morbid growths in their inception, long before the
possible advent of serious mischiefs, or when the cure
might be effected by minor operations which would
leave the smallest scars, especially in such parts as the
face, neck, arms, or hands. -
In the discussion of the initial question, the following
points will be considered: (1) The relative frequency of
malignant and benign tumors; (2) The liability of the
transformation of benign into malignant tumors; (3) The
impropriety of delaying operative interference ; and (4)
The advantages of early operations.
1. The testimony of careful observers tends to show
that the malignant exceed the benign tumors in frequency,
and also that many malignant tumors remain stationary
and seemingly harmless for one, two, six, eight years,
or even for longer periods, then increase rapidly, and
soon contaminate the system. Several modern writers
have analysed tumors on a sufficiently large Scale to give
some notion of the relative frequency of malignant and
benign tumors. Mr. W. R. Williams's analysis of 11,100
cases of tumors shows fifty-three per cent. to be can-
cerous, and of these, twenty-four per cent. to be cancers
of the breast. Dr. S. W. Gross cited 649 cases of mam-
mary tumors. Of these 649 tumors, 587 were malignant
and only 62 were benign. Of the 587 malignant tumors,
530 were carcinomata and 57 were sarcomata. Of the 62
benign tumors, 48 were inomata, 2 were adenomata, and
12 were cystomata. This excess of malignant over
benign tumors noted by Dr. Gross corresponds with the
observations of nearly all pathologists; but the propor-
tion of adenomata stated by him is very small as com-
pared with the experiences of other observers, although
he afterward spoke of 5 adenomata examined by himself
and of 13 examples which he had collated, making 18
additional cases. Among Mr. Williams's 11,100 tumors
are 280 cases of breast adenoma to 68 cases of breast Sar-
coma, and 1,439 cases of breast carcinoma—in all, 1,781
cases, with about sixteen per cent. of adenomata ; while
EARLY EXTIRPATION OF TUMQRS. 169
among Dr. Gross's cases there are 587 malignant tumors
and 20 adenomata, making in all 607, with only about
three per cent. of adenomata. -
Sir Astley Cooper, who first described adenomata of
the breast under the name of “chronic mammary tu-
mors,” regarded this disease as common, and reported a
series of illustrative cases in his work on the breast.
These were cases of circumscribed adenomata. “upon,
rather than in the breast,” the diffuse adenomata being
those which are viewed as so rare by Broca and other
writers. Is it not possible that this great rarity of dif-
fuse adenomata may be more apparant than real, and
that many of the excised carcinomata may at one time
have been diffuse adenomata ? This question can be
definitely settled only when great numbers of breasts
shall be excised much earlier than heretofore, or as
soon as the first traces of disease can be discerned. If,
then, it should be shown that diffuse adenomata are very
frequent instead of being very rare, it would be fair to
infer that most of the tumors formerly excised as carci-
nomata had probably begun as diffuse adenomata, and
that something like prophylaxis of carcinomata might
be effected by the early excision of diffuse adenomata.
In such cases the entire breast would necessarily be re-
moved, while in circumscribed adenomata the breast
would be saved.
Respecting the age of individuals affected with adeno-
mata as compared with that of cancerous subjects, Broca
has compiled a very interesting table of cases reported
by Lebert, Velpeau, Bauchet, and Rouyer. This table
Comprises 152 cases of tumors. Of these 152 cases, 62
Were cancers of the breast ; 90 were adenomata, and
of the 90 adenomata, 70 were of the mammary, 11 of
the parotid, and 9 of the palatine glands. Before the
age of twenty there were 6 cases of mammary adenoma,
8 cases of parotid adenoma, 3 cases of palatine adenoma,
and no case of mammary cancer. From the age of
twenty to twenty-five there were 17 cases of mammary
170 NEW YORK STATE MEDICAL ASSOCIATION.
adenoma, 1 of parotid, and 1 of palatine adenoma,
and no case of mammary cancer. From the age of
twenty-six to thirty there were 9 cases of mammary
adenoma, 1 of parotid and 1 of palatine adenoma, and 1
case of mammary cancer. From the age of thirty-one to
forty there were 20 cases of mammary adenoma, 5 cases
Of parotid adenoma, 3 cases of palatine adenoma, and 12
cases of mammary cancer. From the age of forty-one
to fifty there were 15 cases of mammary adenoma, 1 case
of parotid and 1 case of palatine adenoma, and 21 cases
of mammary cancer. From the age of fifty-one to fifty-
five there were 3 cases of mammary adenoma, none of
parotid or of palatine adenoma, and 12 cases of mam-
mary cancer. Beyond the age of fity-five there were no
cases of mammary, parotid, or palatine adenoma, but
there were 16 cases of mammary cancer.
Among the interesting features of this table are the
following: There are in it no cases of cancer up to the
age of twenty-five, 1 case between twenty-six and thirty,
and 12 cases between thirty-one and forty, so that up to
the age of forty there are only 13 cases of breast cancer
to 52 cases of breast adenoma, while from the age of
forty-one to fifty-five and upward, the high figures are
reversed, and there are 49 cases of breast cancer to 18
cases of breast adenoma. This is in corroboration of the
statement of Sir Astley Cooper, and of other observers,
that circumscribed adenoma of the breast occurs with
greatest frequency in early life—i. e., between the ages
of fifteen and thirty, while carcinoma is rarely devel-
oped before the age of forty.
Mr. Thomas Bryant, in his work on the diseases of the
breast, gives the following analysis of one hundred cases
of mammary “adenofibroma'' observed by him, illus-
trating the ages at which they occur:
“Twenty-seven cases were first discovered between
puberty and the age of twenty—i. e., during the devel-
opmental stage of the breast's life.
“Thirty-five cases appeared between twenty-one and
FARLY EXTIRPATION OF TUMC) RS. 171
thirty years of age, or during the period of functional
perfection.
“Twenty-two cases appeared between thirty-one and
forty, during the period of its maturity.
“Thirteen cases appeared during forty-one and fifty,
and 3 cases appeared in women over fifty, or during the
period of its functional decline.
“Forty-six of these cases occurred in single women,
39 in the married and prolific, 15 in the married and
sterile.”
The question of the influence of sex upon tumor for-
mation need not be discussed, as it is unnecessary to the
purposes of this plea, but it may be of incidental interest
to state the conclusion arrived at by statisticians, which
is that of all cancers, sixty and even seventy per cent.
occur in females.
Another item worthy of note is the rate of mortality
from malignant tumors as compared with other diseases.
In the discussion on tumors held during the fifth annual
meeting of the New York State Medical Association, Dr.
Alfred L. Carroll, formerly secretary of the New York
State Board of Health, answered the question, “What
is the rate of mortality from malignant neoplasmata as
compared with other diseases 3 '' and based his answer
upon an examination of the mortuary statistics of the
State of New York for the years 1885, 1886, and 1887,
and said: “In these three years the deaths from all
causes certified in the State at large amounted to 264,161.
Of these, 6,262 were reported as due to ‘cancer’—1 in
every 42.2, or a little more than two and a third per
cent.” Dr. Carroll’s computation gives a percentage of
mortality from cancer only a little lower than that of the
late Dr. William Farr, which was based upon the anal-
ysis of millions of deaths from all causes.
Aside from the consideration of the relative frequency
of malignant and benign tumors, their discrimination,
clinically, is often so difficult that surgeons are justified
in advising immediate extirpation, and in relying upon
172 NEW YORK STATE MEDICAL ASSOCIATION.
the microscope to insure the diagnosis and establish the
prognosis.
2. The liability to the transformation of benign into
malignant tumors has long been recognised, but the his-
tological demonstration of the phenomenon is modern.
It has happened that some tumors have been excised
during their transition from the benign to the malignant
type, and that this metamorphic process has been verified
by microscopical examination of different parts of the
growths. But so far it has not been possible to deter-
mine the precise time of the beginning of the transfor-
mation.
The clinical evidence that tumors, retaining the char-
acters of benignity for a number of years, often suddenly
acquire those of malignity, does not appear to have been
questioned, and many surgeons, such as Broca, Werneuil,
Richet, Labbé, Klebs, Billroth, Sir James Paget, Mr.
Bryant, Dr. Gross, and others, have made valuable con-
tributions in the establishment of the law of metamor-
phosis of tumors. Among the early observations of the
transformation of tumors were those of Sir Astley
Cooper, who, in commenting upon “chronic mammary
tumors,” said: “Although these tumors are not in their
commencement malignant, and they continue for many
years free from the disposition to become so, yet if they
remain until the period of the cessation of menstruation
they sometimes assume a new and malignant action.”
While both the diffuse and circumscribed adenomta tend
to carcinomatous transformation, those adenomata which
contain an excess of fibrous tissue tend to sarcomatous
transformation. The existence in the same breast of cir-
cumscribed and diffuse adenoma has been verified by
Broca. The coexistence too of benign and malignant
tumors in the same individual and even in the same
Organ has frequently been demonstrated, and examples
thereof have been given by several authors. The writer
has observed a sufficient number of breast tumors with
long periods of latency, to warrant him in thinking that
FARLY EXTIRPATION OF TUMC).R.S. 173
most of these may have been Originally adenomata, and
that probably many carcinomata begin as diffuse ade-
nomata. Benign circumscribed adenomata of the breast
recur after extirpation in a considerable proportion of
cases, without, however, causing general infection ; but
those adenomata that have become malignant are soon
followed by general infection, while most of the adeno-
mata of internal Organs are malignant from the begin-
ning.
Modern writers on tumors agree that not only circum-
scribed adenomata, which so often remain stationary for
a long time, but most of the other benign tumors are
liable to become malignant. Thus, warts, moles, and
other growths upon the face or body have been observed
to undergo cancerous metamorphosis many years after
their appearance. The late Dr. A. C. Post cited the
case of a patient who had a mole that underwent car-
cinomatous transformation forty years after it had been
first noticed, and advocated the removal of “morbid
growths which seem to be in themselves capable of no
harm.” Fibrous tumors are often transformed into
Sarcomata. Primary sarcomata are said to be rare,
particularly in the breast, for, in the majority of in-
stances, they are believed to begin as fibrous tumors
which, remaining stationary for variable lapses of time,
finally undergo sarcomatous transformation. In myxo-
mata and myomata, an accession of sarcomatous element
is not infrequent, the tumors so metamorphosed being
Commonly named myxosarcoma in the one case, and
myOSarcoma in the other case. Lipomata are some-
times metamorphosed into myxomata and sometimes
into sarcomata. Some years ago the writer extirpated
a large lipoma, nearly half of the bulk of which had
undergone sarcomatous metamorphosis.
It is well known that when mammary adenomata be-
become malignant, such epithelial hyperplasia as may
Cause carcinoma does not always occur, for it sometimes
happens that the regressive metaplasia is in the con-
174 NEW YORK STATE MEDICAL ASSOCIATION.
nective tissue framework of the acini and tubes, Sar-
coma being the result. This sarcomatous element
generally invades the tumor only in part, and consti-
tutes a variety and not a new species, as for instance,
the so-called adenosarcoma, the malignant transfor-
mation occurring in the fibrous tissue, which is, per-
haps, already in excess and not among the epithelia of
the acini or of the tubes. So long as a tumor retains a
comparatively high degree of organisation it remains
benign, but when its constituent tissues are disturbed
there is apt to be an accession of tissues of a low grade
of organisation, and the tumor becomes malignant ; the
lower the organisation, the greater the malignity.
3. In setting forth the reasons why it is believed to be
improper and unwise to delay operative interference for
the cure of tumors, it may be well to include a brief state-
ment of the principal methods of general and local treat-
ment from time to time employed. Many surgeons, ever
since the beginning, of this century, have tried in vain
both the general and local treatment of benign and of
malignant tumors.
The general treatment has consisted in the adminis-
tration of mercurial preparations, of potassium iodide,
of purgatives, of hemlock, of red-clover tea, of thuya
and hydrastis tinctures, of Chian turpentine, or of alka-
line solutions, all to no purpose. There is no trust-
worthy evidence that a single case has ever been cured
by these or by any other drugs. Those who stubbornly
rely upon exclusive general treatment in the manage-
ment of tumors, only imperil the lives of their patients,
for, thus allured, the sufferers temporise until it is too
late.
Local medication leads to no better end, but is still
resorted to by many because it has been advocated by
Some eminent surgeons who scarcely imagined what
might be the extent of the mischief indirectly caused
by this advocacy, although it was not without qualifi-
cations, and although most of them had afterward ac-
EARLY EXTIRPATION OF T'UMORS, 175
knowledged the failure of local treatment by poultices,
plasters, unguents, leeches, ice, etc., and had finally
advised excision as the most rational mode of cure. Un-
fortunately, by the majority, the first statement only
was read, copied, quoted, and acted upon without
discrimination. The qualifications were unheeded, the
repudiation was unnoticed, the evil of this essentially
temporising management increased, and the consequen-
ces were disastrous. Plasters, unguents, arsenical pastes,
nostrums of all kinds, continue to be used, much to
the detriment and suffering of the afflicted.
Mechanical compression was for a long time in great
vogue, and is even now occasionally employed in the
treatment of tumors, and is effected by means of ad-
hesive-plaster strips, compressed Sponges, tight bandag-
ing, etc. More than seventy years ago, its advocates
went so far as to devise special instruments to compress
breast tumors. Sir Astley Cooper recorded a case of
mammary tumor treated by compression—at first, for
several months, with adhesive strips, and afterward with
a pressure instrument which “was worn during four
months without advantage.” The tumor then increased
with great rapidity, and in the course of six months was
excised, when it had attained a weight of nine pounds.
Broca has resorted to compression in some cases of mam-
mary adenomata, and reported their diminution, and even
believed that some of them had disappeared after a few
Weeks of compression, but the cases were not afterward
Observed long enough to decide the question of cure.
The effect of compression was supposed to be absorption
of the tumors, but there is no proof of such absorption
of tumors. Cyst formation is known to be very common
in tumors of the breast. Steady compression applied to
these tumors sometimes causes a marked diminution of
their bulk, and this diminution is generally owing to
absorption of the fluid contents of the cysts, while the
Solid substance of the tumors remains intact. Soon after
the cessation of the compressing force, the cysts fill again,
176 NEW YORK STATE MEDICAL ASSOCIATION.
and then the tumor structure is liable to grow with in-
creased rapidity.
For a century past, eminent teachers have promulgated
the idea that so long as a tumor is causing no apparent
mischief, and shows no disposition to increase in volume,
it should not be excised. This precept, regarded by
many as conservative, is commonly followed to the
letter in the management of new growths, even by some
of the recent writers on the subject. Citations might be
greatly multiplied, but brief extracts from two modern
teachers will suffice. Dr. S. W. Gross, who advocated
without qualification the early excision of breast adeno-
mata, seems to have made an exception in the case of
fibrous tumors, for he says: “As fibrous tumors are abso-
lutely innocent, if their true nature be determined, they
may be let alone; but my advice is that they be extir-
pated if they begin to grow.” It seems strange that
the doctor should have sanctioned temporisation in this
case, as he was known to be a strong believer in the lia-
bility of the transformation of fibrous tumors into sar-
comata. It is often so difficult, at the bedside, to
determine the character of small mammary tumors, that
the risk of waiting until they begin to increase is such
that those countenancing this delay assume an unen-
viable responsibility, for sudden increase in bulk of solid
tumors is not unlikely to be the beginning of carcinoma-
tous or of sarcomatous transformation. Mr. Bryant, in
speaking of benign tumors of the breast, says: “It is
not, however, necessary to remove every tumor of this
kind as soon as it is discovered, for it may grow so slowly,
and be so little in the way, as to render its removal a
matter of small urgency. . . .” If the law of metamor-
phosis of tumors, which fixes no particular time for the
beginning of the transformation of benign into malig-
nant growths, is valid, the non-intervention implied by
Mr. Bryant is scarcely safe. Those who uttered this
precept of expectancy, and the others who accepted and
followed it, do not appear to have given good reasons
FARLY EXTIRPATION OF TUMC).R.S. 177
why a tumor which is stationary and apparently harm-
less, but liable to metamorphosis, should not be removed.
In accordance with the light thrown of late upon the
natural history of tumors, it is proper to inquire if this
precept can be regarded as truly conservative.
The well-known fact that any solid benign growth is
liable to become malignant should be sufficient to induce
surgeons to condemn the arbitrary expectancy which is
so generally counseled, and which so surely leads to
disaster. Even if a particular tumor increases without
showing signs of malignity, there can be no advantage
in waiting until it shall have attained a great size, as
the larger the tumor the more formidable the operation
for its removal. The advice that a morbid growth should
not be removed because it is stationary and causes no in-
convenience, does not seem to be founded on Sound prin-
ciples. Because it does not produce present inconvenience
gives no surety that it will not, sooner or later, cause the
greatest distress, if only from its increase in size or its
interference with a vital function ; but the liability to
malignant transformation is what is most to be dreaded.
Therefore, as a general rule, it may be considered unwise
to allow any accessible tumor to so increase in size as to
be damaging to the individual, or, if it be stationary,
to wait until it is metamorphosed before proposing an
Operation for its cure. The true spirit of conservatism
is manifested by advising the removal of a morbid
growth when it is benign, when it is small, when it is
Stationary, when the operation for its eradication is
trifling in comparison with what it must be when the
tumor has attained a great size, or when the neighboring
lymph glands are implicated. The modern improve-
ments in inducing anaesthesia, simplifying surgical
procedures, and insuring asepticism of wounds, ren-
der operations safe as compared with those of former
times, so that no serious harm need now be apprehended
from the extirpation of most tumors. Morbid excres-
Cences of all kinds, being worse than useless to the
12
178 NEW YORK STATE MEDICAL ASSOCIATION.
human economy, should be treated like foreign invaders,
and removed before they become too mischievous.
4. Some of the advantages of the early extirpation of
tumors have incidently appeared in the discussion of the
first three points, but their reiteration seems proper in
the conclusion of the answer to the initial question.
There can be no reasonable doubt of the advantage of
excising a small tumor believed to be malignant, even if
this be owing only to the ease with which the operation
can be executed, or to the slight degree of violence in-
flicted upon the parts as contrasted with the magnitude
of the procedure needed for the ablation of a growth
which has attained great dimensions, or which has in-
fected the adjacent lymph glands.
For a long time past there has been a prevailing belief
that extirpation of a quiescent malignant tumor only
serves to stimulate the extension of the disease. But
this belief does not appear to have been founded upon
trustworthy clinical observations or pathological data.
It is undoubtedly true that any incomplete cutting oper-
ation upon a malignant tumor, or its partial cauterisation
with silver nitrate or arsenic, only serves to stimulate its
extension, but complete extirpation, including the adja-
cent connective tissue, fascia, and lymphatics, does not
leave behind any disease to be extended. Recurrence of
the disease in this case would take place after cicatrisa-
tion of the wound, and would be by new cell-proliferation
and not by extension. External cancerous tumors have
been excised, and in the course of a few weeks the patients
have died of internal cancer; but in these cases, if the
internal had not antedated the external disease, the met-
astatic process had surely begun before the operation,
and would scarcely have occurred had the tumor been
excised five or six months before.
The main question, however, relates more particularly
to the early excision of benign tumors, of those of doubt-
ful character, and of the potentially malignant tumors
during the earliest period of their stage of benignity. It
EARLY EXTIRPATION OF TUMC).R.S. 179
is in respect to the propriety of early excision of these
several tumors that surgeons still differ in Opinion. Since
it appears, from analysis of the observations of Surgeons
of long and vast experience, that a large proportion of
benign tumors in time become malignant, and that most
malignant tumors have a stage of benignity, there should
be no hesitation in advising the extirpation of these
tumors as soon as discovered, and this advice may be
regarded as the very essence of conservatism and of
prophylaxis.
From a purely aesthetic point of view, it is of no little
consequence to minimise scars resulting from the excision
of tumors of the face, neck, arms, or hands, particularly
those occurring in the gentler sex, and this can be best
accomplished by the timely removal of such morbid
growths as are likely to increase to the extent of greatly
disfiguring the patients. It should, however, be noted
that almost any scar is better than an ugly tumor.
During the spring of 1892 the writer excised a super-
ficial, circumscribed, ovoid, and lobulated mammary ade-
noma of two years' standing and only an inch and a half
in mean diameter, from the upper and inner part of the
left breast of a young lady of twenty-one. The wound,
two inches in length, healed primarily. The scar is so
situated as not to be visible when a low-necked dress is
worn. The operation was performed thus early with the
view of minimising the scar and with due regard to pro-
phylaxis. For many years past the writer, like others,
has adopted the practice of excising such tumors as soon
as discovered, and he has no doubt that thus many
growths have been nipped in the bud, which in time
Would probably have become malignant.
The naevi that appear upon the faces of infants,
though benign, often grow so rapidly as to constitute
serious disfigurement, and to require operations which
leave extensive scars. If before these little vascular tu-
mors COver a space of more than two or three millimetres
they are promptly destroyed with the thermo-cautery,
180 NEW YORK STATE MEDICAL ASSOCIATION.
the ensuing scar is likely to be almost imperceptible.
The operation is completed in a few seconds and the
pain is very slight. 4.
The greatest mischief arises from temporisation in the
case of small epithelial growths upon the lips. The ad-
viser, perhaps uncertain as to the nature of the growth,
waits until he can be sure of the diagnosis, suggests
local remedies or sometimes even cauterisation with
nitrate of silver, which causes the most rapid extension
of the disease. There is then no doubt as to the char-
acter of the growth, for the ambient lymphatics are
already involved. The tumor is excised, but too late,
and the disease soon recurs. Any tumor of the lip Of
doubtful character should unhesitatingly be removed.
As a general rule, the subsequent dissection and micro-
scopical examination of the tumor shows the operation
to have been justifiable. Early excision is the surest
means of obtaining a long period of immunity from re-
currence. In the experience of the writer, excision of
labial epitheliomata has given immunity from recurrence
varying from five to sixteen years. In some of the cases
the operation was not performed as early as it would
now be done, but they were all apparently free from
lymphatic involvement. In a case of nasal epithelioma
the exact period of immunity could not be determined.
The patient was last seen nine years after the operation
and was then well.
The period of immunity from recurrence of the disease
after operation is very variable even in the same species
of tumor, and is doubtless influenced by the time of the
operation ; the earlier the operation the greater the
chances of prolonged immunity. In carcinoma the
average period of immunity is stated by some observers
to be three years and a half, and by others seven years.
The extremes are three months and forty years. The
writer has reported cases in which the periods of
immunity varied from seven to forty years. A little
reflection upon these facts naturally leads to a cautious
FARLY EXTIRPATION OF TUMC) PS. 181
prognosis in a large proportion of cases. As soon
as a tumor recurs, when it is still small, painless,
and apparently harmless, it should be extirpated. The
moral effect of this timely operation is generally good,
bodily comfort is thereby promoted, and life is pro-
longed. It is therefore wise to operate as often as the
tumor recurs. Dr. Valentine Mott reported a case of
recurring “malignant sarcoma’’ of the side that had
been extirpated fifteen times in twenty-three years. For
the first twenty years eight operations were performed
upon the man, and the intervals of freedom from the
disease averaged three years. During the remaining
three years of his life seven operations were performed,
and the intervals averaged four months. Dr. S. W.
Gross recorded a case of recurring sarcoma excised by
his father twenty-three times in four years. The
woman was alive and in good health ten years and nine
months after the last operation. Mr. Bryant cites a case
of lipoma over the left hip, “atrophic carcinoma, '' of
the left breast, and sarcoma of the right breast in a
Woman sixty-four years of age. He removed the right
breast, and in about six months there was a recurrence
of Sarcoma in the scar. In the course of four years and a
half from the first operation the disease had recurred in
all sixteen times, and sixteen operations were performed
for its cure. At last accounts the patient’s general con-
dition was good. The carcinoma of the left breast and
the lipoma of the hip were not excised. The annals of
Surgery of all countries contain reports of cases of
undoubted malignant tumors, after whose excision the
periods of immunity from recurrence have varied from
ten to thirty-five years.
Malignant tumors of long bones or of their periosteum,
such as sarcomata, demand the most prompt and radical
Operations. Nothing less than the amputation of a limb
offers the slightest chance for any prolongation of the
period of immunity from recurrence of the disease. Cir-
Cumscribed tumors, however, in the soft parts of a limb
182 NEW YORK STATE MEDICAL ASSOCIATION.
may sometimes be enucleated without impairing the
usefulness of the limb ; and, if the operation be per-
formed at the earliest period of the manifestation of the
disease, there may be no recurrence for a long time, or
there may be a permanent cure, as in the case of a benign
fibrous tumor.
According to the observations of many experienced
surgeons, the average duration of life is a little less than
three years from the first appearance of the tumor in
cases of breast carcinomata that have not been subjected
to any treatment. Does this not indicate the wisdom of
prompt action in the great majority of cases, since the
shortest average duration of life after operations which
were not performed during the stage of benignity of the
tumors is three years and a half, and since it has been
shown that early operations afford the best chance for
many years of immunity from recurrence %
Very large tumors are now rarely seen in comparison
with the great numbers recorded before the introduction
of ether, nitrous oxide and chloroform as anaesthetic
agents. The dread of surgical operations was formerly
so great that patients were ready for the use of any
means proposed rather than the knife, although many of
the modes of treatment employed were cruel in the ex-
treme, far exceeding any torture that could have been
inflicted with cutting instruments. At length, when
every method of cure failed and the tumor had attained
great dimensions or was in a state of ulceration, the
knife was used as the last resource, sometimes success-
fully, but generally without avail. The excision of
breast tumors of fifteen and twenty pounds weight, and
of fatty tumors of twenty and thirty pounds, was not an
uncommon operation. Fibrous tumors weighing one
hundred pounds and more were then often excised.
Thanks to the several modern modes of inducing anaes-
thesia, the patients of to-day need have little fear of the
knife, for they are assured that they will be rendered
insensible to pain during and for a time after operation.
JARLY EXTIRPATION OF TUMC)RS. 183
O
The surgeon, conscious that he is inflicting no pain, is
then able to give his whole attention to the work in
hand, and performs the operation in accordance with the
recent improvements in surgical procedures and with the
best modes of insuring asepticism of the wound.
The categorical answer to the initial question is, that
at the earliest period of the development of any acces-
sible tumor its complete extirpation is not only justifi-
able, but should be regarded as an eminently conservative
and equally humane act,
The results of the examination of the four points pro-
posed for consideration in the discussion of the initial
Question, may be summarised as follows:
1. Malignant tumors exceed benign tumors in fre-
Quency.
2. The malignant tumors comprise epitheliomata, Sar-
comata, and internal adenomata.
3. Among the bening tumors, myxomata and external
adenomata often recur after excision, but do not infect
the system.
4. There is no solid benign tumor that may not become
malignant.
5. No means are known by which can be ascertained
the precise time of the beginning of metamorphic action
in tumors.
6. Most malignant tumors have a stage of benignity.
7. Excision of potentially benignant tumors in the
early epoch of their stage of benignity is likely to effect
a permanent cure, or, at least, to prolong greatly the
period of immunity from recurrence of the disease.
8. In the excision of malignant tumors, the greatest
Care should be taken to remove as much of the ambient
tissues, including fasciae and lymph glands, as is com-
patible with good judgment.
9. General treatment of tumors has no value except
as an adjuvant of a surgical operation, and is often
indirectly injurious, leading the patient to expect a cure
184 JWE W YORK STATE MEDICAL ASSOCIATION.
by persevering in the use of drugs, and thus allowing
the disease to make rapid progress toward a fatal end.
10. Local treatment of tumors, by means of escharotic
plasters, pastes, or powders, is the most fruitful in evil
of all the devices for the torture of the afflicted. The
plaster, paste, or powder causes the greater part of the
tumor to slough, but there is enough left behind for the
most rapid extension of the disease. The effect of the
escharotic is, therefore, only to till a soil where new
growths sprout like so many seed cast upon rich loam.
11. Compression is delusive in the case of tumors con-
taining cysts, and is directly hurtful by exciting the
rapid growth of most tumors.
12. Expectancy, even in the case of benign tumors, is
as unwise as meddlesome medication.
13. There should be no waste of time in endeavoring
to make a precise diagnosis of a particular morbid
growth, for, after its excision, the microscope reveals the
nature of its constituent elements, and assists in the
establishment of the prognosis, which is the question of
greatest importance to the sufferer.
14. What is known of the great fatality of tumors of
long Standing, should induce surgeons to advise the com-
plete removal of all accessible morbid growths as soon
as detected, no matter how seemingly trivial or harmless;
Such as, Small glandular, fatty, fibrous, and vascular
tumors, wens, warts, moles, etc.
15. As soon after excision, and as often as a tumor
recurs, it should be removed, so long as there is any
possibility of insuring cicatrisation of the wound, even
by skin-grafting.
16. Medicinal treatment after the excision of malig-
nant tumors, is of much value, even if it consists only in
the administration of reconstituent medicines.
DISCUSSION.
DR. CHARLES PHELPs, of New York county, said that it seemed to
him one of the curiosities of medical science, that demonstrated facts
should be made the subject of discussion. He did not think there was any
I) ISO/USSION. 185
question about the transformation of tumors being a thoroughly estab-
lished fact, and this being the case, there should be no question about the
propriety of the early extirpation of all tumors, especially in consideration
of the fact that with our present methods of antiseptic surgery, very few
operations in the whole range of surgical procedures are, in themselves,
at all dangerous. The experience of each could doubtless furnish many
instances where the removal of tumors has been neglected with disastrous
results, and he could not see how any surgeon of experience could believe,
teach, or practice, that tumors should be allowed to grow to a certain size
before their removal. There is no more danger of extension because of the
thorough removal of the original growth, than there would be if it had
been allowed to remain. Dr. Gouley's paper was exceedingly important
and valuable, and one likely to be of service to the profession at large, who
were still sufficiently conservative to cling to the old idea, that while
tumors are causing no disturbance they should be left alone.
DR. Josh PH BRYANT, of New York county, said it was the duty of every
One dealing with malignant growths, to embrace this opportunity, after
the forcible presentation of the subject by the author, to express them-
Selves, not only as to their own belief on the matter, but to solemnly pledge
themselves to act on the proposition. There can be no question that if the
diagnosis were made more promptly, and less sentiment regarding the
presence of tumors in the human economy, were exhibited, both by their
possessors and by their family physicians, the death-rate following opera-
tions on such growths would be very greatly decreased. Every one who
has been in practice any length of time has met with this feeling, and has
Seen the strenuous efforts made to keep the fact of the presence of a tumor
a Secret. Unfortunately, the physician too often encourages this senti-
ment, instead of urging the person to have the tumor removed, if it be at
all accessible. Quite recently he had advised an exploratory incision in
the case of a young lady with a mammary growth, the exact measures to be
adopted at the time of operation, to depend largely upon the physical
Characteristics of the tumor and its association with the gland. Of course
the young lady objected strongly to the removal of the tumor, because she
feared permanent disfigurement, but when assured that the history of the
grOWth did not indicate malignancy, and that probably only a portion of
the gland would require removal, she submitted gracefully; the growth
Was removed, and found to be an adenoma. If this had been permitted to
go on, the chances are that it would have become, in time, actually malig-
nant, and eventually the whole breast would have been sacrificed. Again,
a lady came to his office with a large, fibrous tumor located in the lower
end of the femur, between the quadriceps and the bone. It was removed,
and found to contain six small isolated spots of beginning sarcomatous
change. When this change began no one could tell, but it is probable that
it commenced at that time when the history showed there had been an in-
crease in the rapidity of growth. When one considers our ignorance of the
time when constitutional infection takes place, it is evident that great risks
186 NEW YORK STATE MEDICAL ASSOCIATION.
are assumed by delaying operation. He would not say that we should at
Once remove small naevi or “mother's marks,” in infants, as we know that
such growths often rapidly disappear of themselves; but in the event of
their increasing in size, he would certainly remove them as soon as he could
convince the parents of the propriety of such a procedure. The earlier
malignant growths are removed, the more certain their permanent expul-
sion from the system ; and the later they are removed, even though this
appears to be thoroughly done, the Sooner will be their return, and the
more malignant will be the secondary manifestations. He desired to ex-
press his approval of the paper, and to say that every physician who has
patients with tumors, should avoid aiding them in concealing the fact, and
should never enter into any sentimental consideration about whether they
are, or are not malignant, but advise at once and most emphatically the
prompt removal of the growth.
REMAIRKS ON A NEW METHOD OF INTES-
TINAL ANASTOMOSIS.
By BENJAMIN M. RICKETTs, M. D., of Cincinnati, Ohio.
Movember 16, 1892.
(From the Stenographer's Notes.)
Dr. Ricketts said that in a paper read by Dr. J. P.
Murphy, of Chicago, before the Mississippi Valley
Medical Association, three weeks ago, the author de-
scribed a new method of making intestinal anastomoses,
both lateral, and end to end, and of performing cholo-
cystotomy by the use of a little “button” which he
had devised for this purpose. The idea involved in its
construction is taken from a popular form of glove fast-
ening, in which one portion fits into the other, like a plug
into a socket. In the device under consideration, this
“plug’’ is, of course, made with a central opening. It
is made in sets, of three different sizes, by Haussman &
Dunn, No. 220 Madison street, Chicago. A button of
the proper size is selected, and the gut clamped with a
pair of phimosis forceps, secured with rubber bands.
This prevents the escape of the intestinal contents. The
gut is then simply puckered up around the button, by
means of a thread, one-half of the button being thus
Secured in each portion of gut, so that when the portions
of gut are joined together, this button is on the inside,
and can therefore slough away, and escape through the
intestinal canal. Dr. Murphy began operating according
to this method, last April. He has successfully per-
formed one operation on a woman, for gall-stones, leav-
ing the stones, in the bladder, and allowing them to pass
Out afterwards. The gall-bladder will contract, and expel
them, so that there is no danger of their being left there.
188 NEW YORK STATE MEDICAL ASSOCIATION.
Since the reading of this paper, the speaker had been
engaged in experimenting with the button upon dogs.
Two weeks ago, he made an end-to-end anastomosis of
the colon, in a large mastiff, and he had brought enough
of the gut from this animal with him, to enable him to
demonstrate the method of doing the operation. He
thought this method would revolutionise this kind of
surgery, and would also be extremely useful in cholo-
cystotomy, as instead of occupying from two to two and
a half hours, it could be done in a few minutes, and
thus much shock avoided. The button, which he had
with him, was made of brass, but of course it could be
made of aluminium, or other suitable metal.
Dr. Ricketts then demonstrated the method of using
the button in making an end-to-end intestinal anasto-
mosis.
A REPORT OF SOME CASES OF COMPOUND
DEPRESSED FRACTURE OF THE SKULL.
By GEORGE D. KAHLO, M. D., of Indiana.
November 16, 1892.
It was my intention when accepting the invitation of
your Association to present a paper before this meeting,
to make simply a clinical report of the cases of compound
depressed fracture of the skull which came under my
care, during a service as house-surgeon at the Harlem
Hospital, New York. Through the courtesy of Drs. T.
H. Manley and C. B. White, visiting surgeons at the
hospital mentioned, I have, however, been permitted to
embody in this report statistics regarding all the cases
Of this kind which have been treated at that institution
since its opening in 1887. I have endeavored, therefore,
to make these histories as brief as is commensurate with
an accurate statement of the symptoms which they pre-
Sented, and will conclude with a few remarks upon what
appear to me to be the special points of interest to be
gathered from all.
CASE I. A boy, seventeen years of age; admitted to the hospital May 25,
1891. While standing on a scaffolding supported from the top of a two-story
building, he fell to the ground, a distance of about ten feet, pieces of the
broken cornice and bricks striking him as he fell. At the time of his
admission, there was complete loss of consciousness, but he was not
Comatose. There were signs also of quite a profuse haemorrhage from the
right ear, but the bleeding had entirely ceased. A large haematoma was
found covering nearly the whole of the right side of the skull, and there
Were two Small scalp wounds, each about a quarter of an inch in length
near the seat of the lower and posterior angle of the parietal bone. There
Was no paralysis, the pupils were equal and responded quickly to light.
Palpation of the scalp gave distinct crepitation over a considerable area.
After the administration of an anaesthetic, and shaving and cleansing the
Scalp, I made a semicircular incision, its convexity downwards, extending
from about the centre of the coronal suture to a point corresponding with
190 NEW YORK STATE MEDICAL ASSOCIATION.
the articulation of the occipital with the parietal bones. Upon elevating
the periosteum, I found a fracture radiating in every direction, and involv-
ing almost the entire right parietal bone; it extended anteriorly to a point
just above the supra-orbital arch of the frontal bone, posteriorly and below,
into the mastoid process and petrous portion of the temporal bone. There
was another line of fracture extending upward and backward into the
upper and posterior angle of the parietal bone of the left side. There were
in all seven different fragments, two of which were entirely detached; one
at the lower and anterior portion of the parietal bone, rectangular in shape,
measuring about three-fourths by one and one-half inches, and the other,
just above and posterior to it, triangular in shape, about an inch in its
longest and three-fourths of an inch in its shortest diameter. The latter
was depressed at its lower and posterior border about one-fourth of an
inch ; the others, with two exceptions, were in their normal positions, and
these were slightly elevated upon one side. With a periosteal elevator,
the depressed fragment was elevated and removed, and where there was
any over-riding of the edges, these were adjusted to the normal contour of
the skull. The other fragment which was detached, owing to its large
size, I allowed to remain in the position in which I found it. The dura
mater had not been injured at any point, and after irrigating the parts
with sterilised water, and the introduction of a few strands of horse-hair for
drainage, the wound was sutured together with silk, taking up the perios-
teum with the scalp. A rubber ice-helmet was now applied. A few hours
later, his condition, which, up to this time, had been one of great restless-
ness, changed to that of active delirium. He tossed his head about, cried
out incessantly, and became more and more maniacal during the next three
days, and required to be restrained in bed throughout the whole of the
first week. After the third day, there were no manifestations of violence, but
he talked constantly, night and day, and in a very rambling and incoherent
manner, evidencing the most varied delusions and hallucinations. At times
he seemed to recognise friends who visited him, but he was not at all rational.
The dressings were changed the day following his admission, and the
drainage removed. Fresh dressings were also applied at frequent intervals
thereafter, sometimes as often as three or four times a day, on account of
the great restlessness of the patient. The wound healed by first intention,
and all dressings were discontinued after the eighth day. Beyond the
treatment already mentioned, calomel was occasionally administered and
the catheter was passed at regular intervals during the five days in which
there was retention of urine. The greatest difficulty was experienced in
controlling the delirium. He was given potassium bromide in twenty-
grain doses, at intervals of three hours, with no apparent effect, and mor-
phine, unless administered hypodermically and in large doses, was scarcely
more efficacious. I next tried a hypodermic injection of one-eighth of a
grain of hyoscyamine. The first dose showed no effect whatever, but on
repeating it after an interval of four hours, I was much astonished at the
sudden development of what at first appeared to be serious symptoms of
the toxic effect of the drug. The pupils were widely dilated, there was a
FRACTURES OF THE SHOULL. 191
dark-red efflorescence on the skin, a rapid pulse, marked increase in the
frequency of respiration and in the delirium. I immediately administered a
hypodermic injection of one-sixth of a grain of morphine, which was fol-
lowed in a short time by a quiet sleep of about four hours, and a gradual Ces-
sation of the symptoms mentioned. The following day I ordered a mixture
containing in each dose twenty grains each of sodium and ammonium bro-
mide, and five minims of the tincture of opium. This was repeated every
four hours, and gave the best results. The dose was gradually reduced
and the intervals extended, until the fourteenth day, after which no seda-
tive of any kind was found necessary. His condition at this time was that
of acute dementia. He would sit up in the ward and appear quite rational
at times, but would quickly return to his rambling talk. He was then put
upon a general tonic, and his condition, both mental and physical, showed
signs of daily improvement until the date of his discharge, which was on
the seventeenth day. It was not until about a week later that his mental
faculties were entirely restored. Since that time, with the exception of an
occasional headache for the first few weeks following his discharge, he
has suffered no ill effects from the injury.
CASE II. A boy, seven years of age. He fell from a third story win-
dow to the pavement, a distance of about thirty feet. When admitted, he
was unconscious, and there were signs of a profuse haemorrhage from the
right ear, but there was no paralysis or inequality of the pupils. There
was a scalp wound about one inch in length, two inches above, and on a
line with the right external angular process of the frontal bone, through
which the fracture could be distinctly felt. An anaesthetic was adminis-
tered, and, after shaving the scalp, I enlarged the wound to about double
its original length, and then made a second incision of about equal length,
at right angles to it, beginning at its posterior angle and extending
upwards towards the median line. Upon lifting the flap, I found a
fracture beginning about one and a half inches above the centre of the
right orbital ridge, extending back through the frontal and parietal bones
for about two inches, making a curve downwards toward the ear in its
course, and then turning abruptly in the direction of the median line to a
point about one-fourth of an inch from it. The only point of depression
Was at the lower and posterior angle of the inner fragment, which was
depressed fully one-third of an inch. I then chiseled away a small por-
tion of the outer fragment, and with a periosteal elevator, raised the de-
pressed fragment until both were on the same plane. The wound was then
irrigated with sterilised water, two strands of coarse catgut being intro-
duced for drainage, and then closed with interrupted silk sutures which in-
cluded both the scalp and periosteum. The ear was packed with iodoform
gauze, and the usual surgical dressings applied. The application of an ice-
Cap Was the only treatment he received beyond the re-dressing of the wound,
Which was done on the fourth and eighth days; after this, no dressings were
required, as the wound had healed by first intention. The patient returned
to consciousness immediately after coming out of the ether. The second
192 NEW YORK STATE MEDICAL ASSOCIATION.
day, there was marked ecchymosis over the right eye, and a day or two
later, it was noticed that he had developed internal strabismus of the same
eye. He had no rise of temperature, and his convalescence was rapid and
uneventful. He was discharged on the eleventh day.
CASE III. A man, thirty-eight years of age, was struck by a brick which
had fallen from the fourth story of a building, a distance of about forty-five
feet. The blow knocked him down, but he quickly regained his feet, and at
the time of the arrival of the ambulance surgeon, presented no symptom of
fracture. There was a lacerated wound about two and a half inches in length,
extending transversely across the vertex near the articulation of the occip-
ital with the parietal bones. A triangular fracture was easily made out,
its apex pointing anteriorly. The sides of this triangle were each about
one and one-fourth inches long, and the base line about three-quarters of
an inch in length. The latter corresponded to the line of articulation of
the occipital and parietal bones, being about one-fourth of an inch anterior
to it ; the other two sides were in the right and left parietal bones respec-
tively, crossing the great longitudinal sinus in their course, but involving
rather more of the right side than the left. There was a depression of
fully one-fourth of an inch at the apex of the triangle, but none at the base.
Dr. Manley, who saw the case at the time of admission, inclined to the
opinion, that as the fracture was immediately over the longitudinal sinus,
thus involving some risk from haemorrhage, and there was an entire ab-
sence of constitutional symptoms, operative interference, at least for the
present, was inadvisable. Accordingly, nothing was done beyond shaving
the scalp, and applying dressings, the wound being kept open by packing
with gauze. The patient was allowed to go home the same day, and he
returned at intervals to be dressed. The wound, however, did not entirely
heal, and there remained a small sinus through which a slight amount of
purulent matter continued to discharge. About three months later he re-
turned to the hospital for an operation, which was performed by Dr. Man-
ley, under local anaesthesia, produced by injecting into the soft parts one
hundred and twenty minims of a one per cent. Solution of cocaine. An in-
cision was made, two and a half inches in length, extending from the
upper portion of the occipital bone on the left side, to the right parietal
bone ; this was crossed by a second incision, at right angles to it, of about
equal length, the fistulous opening in the scalp marking the point of inter-
section of the two incisions. Necrosis had taken place in the depressed
fragment, and had extended to the adjacent bone. The depressed frag-
ment was now removed, and the borders of the parietal bone which had
become involved, were chiseled away until only healthy structure was
visible. The external wound was closed, catgut inserted for drainage, and
the patient discharged on the same day, with instructions to return to the
hospital to have the wound dressed. He has since entirely recovered.
I wish especially to emphasise the following points in
connection with the histories of the foregoing cases.
FRACTURES OF THE SHOULL. 193
In the first case, the extent of the injury, the duration
of the delirium, the toxic effect produced by the admin-
istration of hyoscyamine, and the rapid subsidence of
these symptoms on the administration of morphine, are
points of special interest. In the second case, the restora-
tion of consciousness and disappearance of all symptoms
immediately following the operation, the development of
ecchymosis and internal strabismus, and the rapid re-
covery, are the important features. In the last case, the
marked depression of bone without any symptoms of
cerebral compression, and the prompt healing of the
wound after the removal of the necrosed bone, three
months subsequent to the injury, are worthy of note. I
wish also to call attention to the fact, that in the second
and third cases there was an entire absence of symptoms
of concussion following the use of the chisel, and that in
all three cases only sterilised applications were employed.
At the close of this article will be found a statistical
table of the fifty cases of compound depressed fracture
of the skull which have been treated in the hospital. Of
these,
43 occurred in the male, and 7 in the female.
16 were 10 years old or under,
17 between 10 and 20,
6 between 20 and 30,
9 between 30 and 40, and
2 over 40.
The frontal bone was involved in 20 cases,
The parietal in 25 cases,
The occipital in 10 cases, and
The temporal in 14.
In 9 cases, there was also fracture at the base.
18 were on the left side, -
27 were on the right, and in
5 both sides were involved.
In 18 cases the fracture was compound and depressed.
In 26 it was comminuted.
5 were gun-shot injuries, and
1 was a stab wound.
The dura, or brain substance, was involved in 20 cases, and paralysis
Was only present in 6; in 3 of which it was a primary, and in 3 a secondary
Symptom.
13
194 NETW YORK STATE MEDICAL ASSOCIATION,
Of the total number, all but 6 were operated upon ; in 18 the chisel was
employed, in 10 the trephine, and in 1 the Hey’s saw. The 15 remaining
cases were comminuted fractures, the fragments of which could be adjusted
with the use of the periosteal elevator or forceps, and did not involve the
loss of bone tissue.
Thirty-two of the number recovered, which would show a mortality of
36 per cent., or, exclusive of the 9 cases in which there was also a fracture
of the base, this would be reduced to 18 per cent. Of the cases in which
there was no injury of the dura or brain substance, the rate was 263 per
cent., and of those in which one or both of these formed a complication, it
was 50 per cent. In no single instance is it recorded in the history, that
death could be directly attributable to the operation itself, and only one of
the 6 upon which no operation was attempted, recovered.
The points which have especially impressed me in the
compilation of these statistics and the conclusions to be
drawn from them, I would state as follows:
1st. The comparatively slight danger of the operation
itself if proper antiseptic precautions are observed.
Roberts' says that “the rate of mortality should not be
greater than in amputations of the finger through the
metacarpal bone.” -
2d. The necessity of early operation in all recent
cases of compound depressed fractures of the skull,
whether there be symptoms of compression or not, unless
there is shock or some other contra-indication. Stimson”
states that “the percentage of recovery in early opera-
tive interference is high compared with tardy operation,”
and cites a case similar to the last one whose history I
read, in which there was injury to the great longitudinal
sinus without brain symptoms. This he treated by im-
mediate trephining, and the removal of about three
square inches of bone, with perfect recovery. Erichsen,”
in speaking of this class of cases says, with one excep-
tion he has never seen a case recover in which a com-
pound depressed fracture of the skull occurring in the
adult, has been left without operation—one is included
in the foregoing tabulation. •
* Roberts: Operative Surgery of the Brain, page 15.
* Treatise on Fractures, page 248. -
* Moses Gunn : Transactions Am. Surg. Assn. Vol. I., p. 85.
FRACTURES OF THE SHOULD. 195
I scarcely need call to your mind the many evil conse-
quences of procrastination in these cases, for it is familiar
to you all, that the injury to the internal table is in a
vast majority of cases greater than that to the external,
and I quote from Briggs," as saying that “the great
danger in depressed fractures is not compression, but in-
flammation set up by displaced fragments of bone;” and
Erichsen” also says “the presence of depressed and spicu-
lated fragments pressing upon the dura mater must
inevitably and speedily induce encephalitis.” Besides
this, there is in a large proportion of cases, necrosis of
the fragments, and, occasionally at least, the formation
of Osteophytes at the line of union between them.
To the teachings of the authorities mentioned, might
also be added another quotation from Roberts,” in which
he says: “Without a knowledge of the true state of af-
fairs, treatment is empirical; and the risk to subsequent
mental health or to life, is too great to permit reliance
on empirical treatment when a knowledge of the true
condition is obtainable with the slight danger that per-
tains to antisepsic surgery.” One point which has im-
pressed me in the history of the foregoing cases and in
Studying those in the table, is the absence of symptoms
of compression. This is often cited as the indication for
operative interference, and while believing of course that
the presence of such symptoms would point most emphat-
ically to the necessity for operation, I do not think that
their absence should in any way be regarded as contra-
indicating it.
3d. With reference to the different operations em-
ployed in the condition under consideration, it will be
remembered that in eighteen cases elevation of the de-
pressed bone was performed by the use of the chisel, and
In ten with the trephine. The rate of mortality in these
Cases Was eleven and one-ninth per cent. in the former, and
* Annals of Anatomy and Surgery, Vol. II., p. 69.
* Ibid.
* Roberts: Operative Surgery of the Brain, page 23.
196 NEW YORK STATE MEDIOAL ASSOCIATION.
forty per cent. in the latter, although, as I have said, in no
single instance do the hospital records give as the cause
of death, the operation itself. As may be inferred from
this comparison, my own preference is for the use of the
chisel. This opinion is of necessity largely the result of
my own experience, but I would quote the following au-
thorities for the position taken :
Gerster' expresses the opinion that “the trephine is al-
ways an inadequate instrument, and that its use is fraught
with danger to the dura.” He employs the chisel and
replaces the removed chips. The substitution of the
chisel for the trephine was also strongly advocated by
the late Professor von Volkmann.”
The objection is offered by the opponents of this
instrument, that its use, especially when the force is
applied with the mallet, is very apt to produce serious
symptoms of concussion, and in proof of the severity of
this plan it is claimed that, “while the force of one blow
may be insignificant, the result of a number in succes-
sion is proportionate to the aggregate of all.” Keetley *
states that this objection only holds good in old people
with very atheromatous arteries ; and I beg again to
direct your attention to the entire absence of this symp-
tom in the history of the cases which form the subject of
this paper. No note of any such unfavorable conse-
quence is made in any of the hospital records in which
this operation has been performed.
Leaving out this objection, I think it will be granted
that it at least possesses the advantage of minimising
the extent of bone tissue to be removed, and in my
opinion, its use in inexperienced hands is attended with
less difficulty and with less danger of injury to the
dura. When there is much comminution of the frag-
ments, and these can be easily replaced with the forceps
or periosteal elevator, this plan of treatment would of
1 N. Y. Med. Journal, Feb. 21, 1891.
* Berliner klinische Wochenschrift, Dec. 16, 1889.
° Med. Press and Circular, London, Dec. 31, 1890.
FRACTURES OF THE SHOULL. 197
course recommend itself to all. In those cases where
the object is to cut a hole of considerable size in the skull,
as in operations for tumor of the brain, epilepsy, etc.,
the trephine is obviously the proper instrument to be
employed; but in the vast majority of cases of linear
fracture with depression, I believe that a very small piece
may be chiseled from one fragment which will enable
one with the periosteal elevator or other instrument to
elevate the depressed portion with scarcely any loss of
bone tissue; and Ithink it is especially indicated in those
cases in which it is only necessary to cleanse the fissure
from any septic material which may have obtained lodg-
ment there.
In conclusion, permit me also to say a word with refer-
ence to the advantages of an aseptic over an antiseptic
operation. The tendency of the present day to use
sterilised water and sterilised dressings in preference to
antiseptics is, I think, especially applicable to brain
surgery; for, with careful cleansing, the wound may usu-
ally be made almost aseptic, and there is less danger
of irritation to the dura. I would, however, make an
exception in those cases in which, from the nature of
the injury, there seemed to be a special liability to the
development of Suppuration, and, of course, in latent
cases in which this condition already exists.
ź
H -: p3 ºf
3 P 2 3
SIDE OF § o º #:
SEX. AGE. BONES INVOLVED. HEAD. CHARACTER, PARALYSIS. º : z \operation. RESULT.
2 * : 3
z. o sº tº
Male. . . | 2 |Frontal. . . . . . . . . . . . . . . Right. Comminuted
(also fracture base)|Absent. . . . . . . Yes. |None. . . . . . . Died.
Female. || 3 |Parietal and Frontal. . . & & & & & & Left hemiple-
gia. Disap-
peared (after
5 weeks)....| Yes Chisel . . . . . . Recovered.
Male. . . | 3 |Temporal, Parietal and * -
Occipital. . . . . . . . . . . & C Comminuted. . . . . . . . Absent... . . . . . { { PerioSt’l ele
Vator. . . . . Died.
Male. . . 4 [Parietal. . . . . . . . . . . . . . . Left. Compound depressed & 4 No. 6 & Recovered.
Female.| 4 |Occipital... . . . . . . . . . . . & & Compound depressed
(also base). . . . . . . . . “ { { & 6 Died.
Male ... 4 |Frontal. . . . . . . . . . . . . . Right. Compound depressed £ & { % Trephine. ..] Recovered.
Female...| 4 & & Left. Comminuted. . . . . . . & & Yes Periost’l ele-
Vator . . . . . Died.
Female... 4 & 4 Right. Comminuted
(also base). . . . . . . . & & No. |None . . . . . . Died.
Male. . . | 5 |Frontal and Parietal. . . & & Comminuted . . . . . . . . & & Yes. Periost’l ele-
vator... . . . . Recovered.
& 6 7 Temporal, Parietal and
Frontal * * g e º ſº & & Comminuted
(also base) . . . . . . . . & & No. Hey’s saw. .. & &
4 & 7 |Frontal and Parietal...] Right. Compound depressed|Internal stra-
bismus se c- -
Ondary. . . . . . & & Chisel. . . . . . Recovered.



É
Male. . .
Female..
Male. . .
Female..
Male. . .
& &
Temporal, Parietal and
Frontal. . . . . . . . . . . . . .
Parietal . . . . . . . . . . . . . .
Parietal and Temporal
Occipital and Parietal.
Frontal. . . . . . . . . . . . . . .
Occipital and Parietal..
Frontal, . . . . . . . . . . . . . .
Frontal and Parietal...
Temporal. . . . . . . . . . . . .
Frontal. . . . . . . . . . . . . . .
Parietal and Temporal.
Parietal. . . . . . . . . . . . . .
Frontal, Parietal and
Temporal. . . . . . . . . . .
Temporal and Frontal.
Occipital. . . . . . . . . . . . . .
Frontal and Parietal...
Temporal and Occipital
Right & Left
& &
Left & Right
Right.
Left.
Right.
Left.
Left.
Right.
Right & Left
Right.
( &
& 4
Left.
Right.
Left.
Left.
Comminuted. . . . . . . .
Compound depressed
Compound depressed
Comminuted. . . . . . . .
Compound depressed
Comminuted. . . . . . .
Comminuted
(also base). . . . . . . .
(Also base and other
injuries). . . . . . . . . .
Comminuted
© o 'º e º 'º e
Compound depressed
Comminuted. . . . . . . .
Gun-shot. . . . . . . . . . .
Compound depressed
Comminuted. . . . . . . .
Compound depressed
Comminuted
tº º ſº gº tº e º º
& 4
& 4
Compound depressed
Gun-shot... . . . . . . . .
Stab wound. . . . . . . . .
Right.
Compound depressed
Internal stra-
bismus se c-
Ondary . . . . .
Absent... . . . . .
Absent. . . . . . .
Abscess of
brain.
No.
Yes.
Trephine....
PerioSt’l ele-
Trephine... .
Periost’l ele-
Vator. . . . .
& 4
4 &
Chisel... . . . .
& &
Vator. . . . .
Trephine. . . .
Chisel. . . . . .
Trephine. . . .
Periost’l ele-
Vator. . . . .
Trephine. . .
Chisel. . . . . .
Trephine. . . .
Periost'l ele-
Recovered.
Died.
Recovered.
Died.
Recovered.
Died.
Recovered.
Died.
Died.
Recovered.
4 &
& 4
& 4
Died.
Recovered.
& C
& 4
( &
Died.
Recovered.
& &
Died.
Recovered.

§
H 4 gº tº
; : Så
###
p: F.
SEX. AGE. BONES INVOLVED. * CHARACTER. PARALYSIS. à Q : 2 |OPERATION. RESULT.
2 * : 3
: o 3 pd
Male 23 |Frontal. . . . . . . . . . . . . . . Right. Compound depressed|Absent . . . . . . No. 1Chisel. . . . . Recovered.
& 4 25 |Temporal. . . . . . . . . . . . . Left. Comminuted ... . . . . . & & Yes. Periost’l ele-
Vator. . . . . Died.
{ { 28 Temporal and Parietal. & & Comminuted. . . . . . . . & & No. Trephine....| Recovered.
& & 28 |Frontal . . . . . . . . . . . . . . ( & Gun-shot. . . . . . . . . . . Nasal primari-
ly; secondary
- ptosis. . . . . . Yes. Chisel... . . . . & (
& & 32 |Occipital and Parietal...] Right. Compound depressed|Absent ....... No. None . . . . . . . & 6
& 4 33 Temporal. . . . . . . . . . . . . & 6 Gun-shot... . . . . . . . . . & & Yes. Chisel. . . . . . “ (,
{ % 34 |Frontal. . . . . . . . . . . . . . . & C Comminuted. . . . . . . . § { No. Trephine . . . { {
& & 35 |Temporal. . . . . . . . . . . . . ( & & 4 & & Yes. |Forceps.. . . . { %
{ % 36 Temporal, Frontal, Pa-
rietal, Occipital . . . . . Left. Comminuted
(also base). . . . . . . . . • & & Chisel. . . . . . Died.
{ { 38 Parietal. . . . . . . . . . . . . . . Right & Left|Compound depresse & 4 No. { % Recovered.
* { 39 & & Right. Comminuted. . . . . . . { { O. & & 6 &
{ { 39 & & Left. Compound depressed & & Abscess of
brain. |None. . . . . . . Died.
& 4 40 |Frontal. . . . . . . . . . . . . . . Left. Gun-shot....... . . . . . & & Yes. Chisel. . . . . . Recovered.
& 5 51 Parietal. . . . . . . . . . . . . . . Left. Comminuted. . . . . . . . Right hemiple-
- gia secondary No. & & & &
& 4 60 & & 4 Comminuted
(also base). . . . . . . . Right hemiple-
gia primary.| Yes. |None... . . . .
Died.

THE ACHIEVEMENTS OF AMERICAN SUR-
GERY.
By FREDERIC S. DENNIs, M. D., of New York County.
November 16, 1892.
MR. PRESIDENT AND GENTLEMEN OF THE NEW YORK
STATE MEDICAL Association : My first and pleasing
duty this evening is to acknowledge with profound re-
spect the distinction which has been conferred upon me
by this Association. To be selected as the orator of the
evening is an honor which the writer most keenly ap-
preciates.
In thinking over something to say upon this anniver-
sary, it has occurred to me that no subject could be
chosen so peculiarly fitted to this occasion, and so well
adapted to this Association and to the time in which we
live, as a review of the achievements of American sur-
gery. At no time, and at no place has this subject ever
been fully discussed with these limitations. The advance
of Surgery in general has been reviewed from time to
time in connection with medicine; but an attempt to
consider the advance of surgery, which is purely Ameri-
Can, and to trace its influence upon the nations of the
World, is a subject which is worthy our consideration.
The debt of gratitude which the world owes to Ameri-
Can Surgery is great, and though much has been done by
other nations older than America, I shall endeavor to
demonstrate that American surgery eclipses all other na-
tions of the world in regard to original research, in the
introduction of new methods of treatment, in the perfec-
tion of older methods, in the inauguration of a complete
ambulance system, and, finally, in regard to tangible
results. The subject is vast, the study of it is fraught
With great interest, and the result of the investigation is
most gratifying.
202 JNEW YORK STATE MEDICAL ASSOCIATION.
Before considering in detail any of the triumphs of
American surgery, it is necessary to bear in mind the im-
portant fact that our country is but still in its infancy as
compared with other countries, and, therefore, any com-
parison might appear greatly to the disadvantage of the
younger country; but, nevertheless, taking into consider-
ation this most important fact, the writer will endeavor
to prove that the achievements of American Surgery chal-
lenge the admiration of the world.
In these days of Columbian celebration, the rise and
progress of the American nation from 1492 down to the
present time, has been studied and recognised and eulo-
gised. The achievements in every walk of life, the innu-
merable inventions, the wonderful discoveries, the mag-
nificent results, have all been considered, and the sum
total is unparalleled in the history of nations.
In a period of four hundred years, great work has been
accomplished, and to-day we stand before the gaze of the
world as a nation exemplifying the truest type of Chris-
tian civilisation. While all this progress has been
reviewed and considered during the period of the four
hundred years, the work of American surgery can only
be reviewed during the past one hundred years, since
previous to that time American surgery was character-
ised by no discovery, or distinguished by no invention,
or known by any tangible results.
The Science of surgery in this country made no im-
pression upon the world until the beginning of the pres-
ent century, and the mighty works which it has wrought
during the present century, command respect and esteem
from every quarter of the globe. When the nineteenth
century had dawned upon us, in the long list of brilliant
men who had made the surgery of the world famous, the
name of no American appeared upon that honor scroll ;
but from colonial days down to the present time the
names of Americans shine forth in bold relief. What
our country has achieved within this period of time is a
worthy subject for our study and reflection.
ACHIEVEMENT'S OF AMERICAN SURGERY. 203
Without doubt, the progress which American surgery
has made, is due in great part to the dissemination of her
medical literature, to the formation of medical libraries,
to the organisation of hospitals and laboratories, and
to the foundation of medical schools. Let us consider
for a moment this subject, since its importance demands
attention.
The great dissemination of medical literature is made
apparent by a reference to Billings's statistics, which
show that in the United States, at the beginning of the
Revolutionary War, there was only one medical book,
three reprints, and about twenty pamphlets by American
authors; while to-day there are over six thousand medical
books and reprints, and innumerable pamphlets. There
are over three hundred and fifty books and pamphlets
written and published annually by American writers, to
say nothing of over five thousand journal articles con-
tributed each year by our countrymen.
In surgery, there were only three books by American
authors prior to 1844, while to-day the surgical writings
by American authors fill the shelves of every library upon
the face of the earth. It has been demonstrated that in
Surgery alone, in 1879–80, there were written forty-five
Surgical books, and one thousand seven hundred and
Seventeen journal articles. This is almost twice as many
Surgical books as were written in England during the
Same period, and many more journal articles. It can,
perhaps, be made even more forcible, by stating that in
1879–80, there were written ten thousand three hundred
and thirty-four medical books and journal articles in the
United States, while during the same time in England,
the other English-speaking nation, there were written
Only seven thousand four hundred and seventy-six books
and pamphlets. In addition to this, many of our medical
text-books have been translated into other languages and
have been adopted as standard text-books in foreign
medical Schools. In 1879–80, there were published more
medical journals and transactions in the United States
204 NEW YORK STATE MEDICAL ASSOCIATION.
than in Great Britain, France, Germany, Italy, or Spain,
and during these two years the total number of original
articles in medical journals, and transactions, exceeded
those of any other nation in the world. The wide dis-
Semination of medical literature has been one important
factor in the advancement of surgical knowledge in the
United States.
At the beginning of the Revolutionary War, there was
one public medical library. It belonged to the Pennsyl-
vania Hospital, and it contained about two hundred and
fifty volumes ; to-day, there are over one hundred
thousand medical works in medical libraries in the
United States. At that time there were no hospitals, no
laboratories, no training-School for nurses, no medical
colleges; to-day hospitals crowd every city and large
town, while over a million dollars have been devoted
lately to the establishment of laboratories. There are
Over a hundred organised training-schools for nurses.
At that time there were in the United States about two
hundred medical men in practice, who had graduated
from foreign schools; to-day, there are nearly one hun-
dred thousand medical men distributed throughout the
length and breadth of this vast country, who are gradu-
ates of our own medical schools. At that time there
were two medical schools in the embryo; to-day there are
Over one hundred medical schools in the United States.
At that time there was one quarterly medical journal;
to-day America has the largest proportion of monthly
medical journals of all the nations of the world, and
nearly twice as many of all kinds as England, the other
English-speaking nation. One of the best instances illus-
trating the progress of American medical journalism,
is the enterprise of the MEDICAL RECORD in cabling the
entire transactions of an International Medical Congress
for the benefit of the American medical profession. At
that time there was scarcely a medical society in exist-
ence, to-day there are over one hundred recognised and
well-established State and County medical associations.
ACEIIETVEMENT'S OF AMERICAN SURGERY. 205
At the beginning of the Revolutionary War there was
not a single medical museum in this country ; to-day
there are over twenty large, well-organised medical
museums, containing in the aggregate, Seventy thousand
gross specimens, and for the maintenance of which over
$70,000 is expended annually, or one dollar a year for
the preservation of each specimen. This fact alone is a
convincing proof of the progress which American sur-
gery has made, since the establishment and use of a
medical museum is an index of the thoroughness of sur-
gical teaching and practice.
In 1820, Sidney Smith, the great literary genius of his
day, made use of the following phrases in the Edinburgh
Review) : “Americans have done absolutely nothing for
the sciences. . . . In the four quarters of the globe,
who reads an American book? . . . What does the
world yet owe to American physicians or surgeons Ž
What new substances have their chemists dis-
covered ''” I shall take this remarkable passage and
transpose it so as to form the different heads of my
address this evening, and thus reply to this challenge of
Sidney Smith. It will be my endeavor to demonstrate,
that American surgery, as a science, has done much to
contribute to the welfare of the human race instead of
“absolutely nothing.” I shall show that many nations
of the world “read American books; ” and, finally, I
shall point out what “new substances their chemists
have discovered,” and what the world owes to “Ameri-
can physicians and Surgeons.”
In reviewing the progress of surgery in general, there
are two things which must not be overlooked, since they
have been instrumental in bringing about this great utopia
in surgery. The first is the introduction of anaesthetics,
which has eliminated shock, and the second is the intro-
duction of antiseptics, which has eliminated sepsis. The
Science of surgery has thus eliminated the two great
Causes of death after surgical operations, viz., shock and
Sepsis. A new era now dawned upon the profession and
206 MEW YORK STATE MEDICAL ASSOCIATION.
the field of operative surgery was vastly widened, the
results were made uniformly certain, and new operations
were performed which hitherto were considered outside
the pale of legitimate surgery. These two beneficent
discoveries thus form the two pillars to the triumphal
arch. In the pursuit of our subject, it is most pertinent
at this point to inquire into the influence that this coun-
try has exercised in effecting these two great reforma-
tions. .
1st. The Introduction of Anaesthetics.=This great
event has cast a widespread influence upon the progress
of surgery. In 1842, Crawford W. Long, of Georgia, re-
moved a tumor with the patient under the influence of an
anaesthetic. No further attempt was made until 1844,
when Wells had a tooth extracted while insensible with
nitrous oxide gas. Morton, at the suggestion of Dr.
Jackson, anaesthetised a patient on October 16, 1846,
while Dr. J. C. Warren removed a tumor from the
patient’s neck. From this time on, anaesthesia, hitherto
a dream, now became a living reality.
This is neither the place nor the time for a discussion
as to the merits of the three men whose names are in-
timately associated with this great discovery. To Jack-
son, Morton, and Wells, in alphabetical order, the pro-
fession is indebted for this great boon to suffering
humanity. For our purposes to-night the work of each
of these men is duly acknowledged. No other nation
has succeeded in establishing a claim to this honor. It
rightly belongs to us, and the influence of this dis-
covery has had a most important bearing upon the rise
and progress of surgery. This discovery has been the
great divide, toward which, and from which, all the
advances in surgery throughout the civilised world have
been accomplished. It is but fair to claim that all the
influences emanating and flowing from this discovery,
should be attributed to it, and since this concession is
granted by the world, the progress which surgery has
made from decade to decade, owes its origin to an
AOHIEVEMENTS OF AMERIOA.W SURGERY. 207
American discovery. That it is possible to conceive that
anaesthesia might have been born in Some other country,
if its birthplace had not been here, is readily admitted,
but since this great agent for the relief of pain was dis-
covered here, to us properly belongs all the credit which
flows from it.
There is one sad event connected with the greatest
discovery for suffering humanity, and that is the melan-
choly termination of the life of each of the three men
associated with the discovery. Jackson died insane;
Morton died without worldly means; Wells became a
pauper, and was arrested in New York city as a crim-
inal, for throwing vitriol. He was sent to jail, and there
committed suicide by cutting his femoral artery. The
tragic termination of life in the case of Jackson, Morton,
and Wells, men to whom the world owes a lasting debt
of gratitude, is in marked contrast to the beneficent,
grand, and glorious work to which their discovery has led.
It is interesting to note in this connection, that Sir Edward
Jenner, the discoverer of vaccination, was awarded
$225,000 for his discovery, by an act of Parliament,
while by no act of the United States Government has
anything been done to perpetuate the memory of these
three men. The physicians of Hartford have erected a
statue to Wells, and to them are due the grateful thanks
of a nation, for their interest in preserving the memory of
their fellow-townsman.
It is not possible to form an intelligent estimate, or
eVen an adequate conception of the sum total of human
suffering and distress which has been prevented by the
introduction of anaesthesia. This American discovery
is the greatest contribution to surgery which has been
made by any nation in the world. To Sidney Smith's
interrogatory, “What new substances have their chem-
ists discovered 7” the answer comes thundering down
the ages—the greatest discovery of any chemist in the
World, is the American discovery of a substance to pro-
duce anaesthesia.
208 NEW YORK STATE MEDICAL ASSOCIATION.
2d. The Introduction of Antiseptics.-This wonder-
ful discovery, which has so largely influenced the prog-
ress of Surgery, belongs to no one nation exclusively.
In France, Pasteur made the discovery that putrefaction
was due to the presence of micro-organisms. In Scot-
land, Lister made the application of this science to
surgery, and to him is due immortal praise. In Germany
and in the United States, the further application and the
perfection in the technique were made. The subject of
antisepsis, therefore, has been an evolution in which all
countries have taken a part, and the complete consum-
mation of which has been participated in by all nations.
There are some remarkable facts connected with the early
surgery of this country as foreshadowing the introduc-
tion of antiseptics. For example, absolute cleanliness
was a characteristic feature of Mott's surgery. He was
scrupulously careful about washing his hands imme-
diately prior to performing any surgical operation, and
every instrument was thoroughly washed just before
use. The employment of animal ligatures in this coun-
try anticipated their general adoption as an essential
part of antiseptic technique of the present day. Dorsey,
in 1844, successfully ligatured large blood-vessels with
buckskin and catgut ligatures, and after him Hartshorne
employed ligatures made of parchment. Jameson used
ligatures made from deer-skin.
The use of the germicide, as an antiseptic, was want-
ing ; still the American surgeons in early times, cer-
tainly employed some of the meams which to-day include
an important part of antiseptic technique.
With this introduction, and also with a reference to
the influence of the discovery of anaesthetics and anti-
septics upon American Surgery, Ishall consider, in tracing
the progress or the achievements of American surgery,
1st, Surgery of the Bones and Joints; 2d, Surgery of
the Vascular System ; 3d, Surgery of the Great Cavities.
of the Body; 4th, Surgery of the Genito-urinary Sys-
tem; and finally miscellaneous operations and other
ACHIEVEMENTS OF AMERICAN SURGERY 209
topics which cannot properly be classified in the other
departments of Surgery.
1st. The Surgery of Bones and Joints.-The man-
agement of fractures has brought out the wonderful
mechanical ingenuity which is a characteristic of the
American mind. The application of the plaster-of-Paris
bandage in the treatment of fractures is one of the great-
est improvements of the century. To the perfection of
its technique, Fluhrer's work deserves special commen-
dation. The use of flexible, narrow strips of tin or zinc
in the management of fractures, was devised by Fluhrer
in 1872, with the object of securing immobility of the
fractured bones. The strips are not designed to act as
rigid supports, although incidentally, by their width
(one-quarter of an inch), they oppose edgewise resistance
to angular motion, when passing through or near an axis
of motion. Their principal effect is by virtue of their
inextensibility; not shortening or lengthening under
strain, when bandaged to the limb in the principal planes
of motion. They are roughened on each side by per-
forations, so that they may be securely held in position
by the retaining bandage. They are not designed to
Serve as an accessory strengthening of an immovable
Splint ; the strips themselves are the splint. The plas-
ter-of-Paris or other material incorporated in the retain-
ing bandages, gives to the provisional effect of the strips,
durability, which, of course, cannot be obtained by a
simple bandage.
In the application of the strips, the limb, in simple
fractures, is first neatly and evenly covered with some
material over which is applied a compressing plaster-of-
Paris bandage. The strips, placed in proper position
relative to the planes of motion, are bandaged to the
limb as far as the site of the fracture, and, from their flex-
ibility, adapt themselves to the varying contour of the
limb. The fragments are then accurately adjusted in
position, and as soon as the bandage is carried up the
limb, firmly retaining them in relation to the upper
14
210 NEW YORK STATE MEDICAL ASSOCIATION.
fragment, the immobility of the fragments is secured.
In this procedure, the adjustment of the fragments
in position is accomplished, while the outlines of the
limb, the principal guide to a correct co-aptation of
the bones, are unobscured by dressings, and the frag-
ments are immobilised in the shortest time. In the
treatment of fractures of the shaft of the femur, special
apparatus is necessary in order to properly apply the
strips, and for the construction of the pelvic portion of
the permanent splint.
The antiseptic treatment of Open wounds, having prac-
tically brought compound fractures into the class of
simple fractures, so far as relates to their treatment with
permanent apparatus, has thereby widened the range of
usefulness of the strips by the extension of their appli-
cability to the treatment of these injuries. In compound
fractures, the wound having been antiseptically treated,
the covering of the limb is made by an even sheet of
antiseptic material. The sterilised strips are retained
by another layer of this bandage. The fragments having
been thus immobilised in correct co-aptation, while the
outlines of the limb are distinct, the antiseptic dressing
can then be increased in bulk to meet the necessities of
the wound.
The work of Dr. James L. Little in the use of plaster-
of-Paris bandages must not be overlooked, since he uti-
lised this dressing for various fractures, and perfected
several dressings for special fractures, notably the pa-
tella. This plan has superseded all the clumsy methods
in vogue in other countries. Time will not permit of a
discussion of the manifold ways that this dressing can
be employed in the different fractures. It will suffice to
mention the present method of treatment of fractures of
the thigh, in order to afford the best illustration of the
growth and development of the plan now generally ac-
cepted.
If we start with Desault's splint, which was crude
and unsatisfactory, the first change that occurred Was
ACHIEVEMENTS OF AMERICAN SURGERY. 211
Physick’s modification, which consisted in making De-
sault's splint, which reached only to the crest of the
ilium, extend above to the axilla, and downward below
the foot, with a perinaeal band for extension and counter-
extension. In 1819, Daniell, of Georgia, introduced the
weight and pulley. In 1851 Buck still further modified
Physick’s splint, so as to do away with the perinaeal
band, and accomplished extension of the limb by the
weight and pulley, after the manner of its present use.
This was a great improvement in order to overcome
shortening. Van Ingen, in 1857, suggested the elevation
of the foot of the bed, to permit the body to act as a
counter-extending force. The co-aptation splints were
used by Buck, in 1861, so that the present complete and
perfect method is one that is the result of evolution, the
consummation of which has been accomplished by the
work of American surgeons. In 1827, Nathan R. Smith
adopted the principle of suspension in the treatment of
fractures, and the use of the sand-bag was introduced by
Hunt, of Philadelphia, in 1862.
Infracture of the clavicle, Sayre has originated a dress-
ing, which is not only unique, but which is accepted as
the simplest, most reliable, and most satisfactory of all
the different forms of apparatus. Moore has also de-
vised a very useful dressing for fracture of the clavicle,
consisting of the figure-eight (8) bandage.
Physick suggested the two angular splints for treating
fracture of the lower end of the humerus, and Gunning
and Bean, the inter-dental splint in the treatment of the
fracture of the lower jaw.
Dr. Oscar H. Allis first called attention to the patho-
logical condition found in fractures of the lower end of
the humerus, and suggested new principles in the treat-
ment, to prevent deformities.
In 1881, Mason devised a new method of treating frac-
tures of the nasal bones bypassing a curved needle under
the fragments, and elevating them.
In the treatment of fracture of the patella by the use
212 INE/W YORK STATE MEDICAL ASSOCIATION.
of the metallic suture, American surgery can claim the
operation, as far as priority is concerned, since Rhea
Earton wired a fractured patella in 1834, McClellan in
1838, Cooper, of San Francisco, in 1861, and after him,
Logan and Gunn. While American surgery cannot
justly claim the priority of this operation, as practiced
by Lister with the modern aseptic technique, she can at
least lay claim to having brought the operation to its
present perfected technique, and can point to the fact
that here, in New York, the operation has been per-
formed more times than it has been throughout the dif-
ferent countries of the world. In this city, the patella
has been wired over a hundred times by Phelps, Fluhrer,
McBurney, Bull, Dennis, and others, and while the
operation is not one to be commended universally, it is
an operation yielding brilliant results in suitable cases,
and in the hands of aseptic surgeons.
The first time that fractures of the lower jaw were
treated by the metallic suture, was by Kinloch, of South
Carolina.
In the management of un-united fractures, American
surgery stands pre-eminent. In 1802, Physick passed a
Seton between the ends of an un-united fracture of the
humerus. In 1830, or twenty-eight years after the oper-
ation, Physick obtained the specimen. The use of the
metallic suture was first successfully tried in 1827, by J.
Rearney Rodgers, in a case of un-united fracture of the
humerus. Perforation of the ends of the bones in an un-
united fracture of the tibia was accomplished in 1850, by
Detmold. In 1852, Brainard introduced the operation
of drilling the fragments. In 1857, Pancoast used the
iron screw to accomplish the same object.
In the management of compound fractures American
surgery has achieved remarkable results. The largest
tabulated collection in the personal experience of One
surgeon, is the list by the writer, of one thousand cases
of compound fractures, with a mortality from Septo-
pyaemia of one-seventh of one per cent. The best pub-
AOHIETVEMENT'S OF AMERICAN SURGERY 213
lished reports from Europe, are from Billroth, whose
mortality in compound fractures was three per cent. No
better idea of the onward march and steady progress of
American surgery can be formed, than by a consider-
ation of the fact that, before the days of antiseptic Sur-
gery, the death-rate was as high as sixty-eight per cent.
in the major fractures, and that now the mortality has
been practically reduced to zero.
The ingenuity of American surgeons cannot be better
illustrated, than by demonstrating to this audience a
splint made by Dr. Cotting, of Roxbury, Mass. Dr.
Cotting is a retired surgeon, who is now over eighty
years old, but who has kindly furnished me some inter-
esting facts in regard to the manufacture of, and use of,
splints for fractures. Dr. Cotting amused himself, one
day recently, in making this splint, such as was in vogue
years ago in New England. This splint is a model of
Yankee ingenuity, and one perfectly adapted to the
treatment of fractures. Besides the perfect adaptability
of the splint, its essential characteristic is, that it is
simple, and can be made by anyone, at any time, and in
any place. The perfect simplicity becomes apparent,
when it is considered that this splint itself was made
from a fragment of a piece of a millinery box, the iron
from a tub-hoop, the rivets from ordinary tacks, the cloth
and wadding from remnants in the house, and the paste
from flour and water. All of these requisites can be
found in any city house, or in a log-cabin in a remote
Wilderness. The application of the iron was effected, by
using as an anvil the head of a hatchet, struck into a
block, and a common house claw-hammer to rivet the
tacks, the holes for which were driven by a sharp-
pointed nail. Dr. Ira Allen, of Roxbury, Mass., about
half a century ago, suggested the use of iron in the con-
Struction of splints, and Dr. Cotting, at that time, made
Splints such as the one now on exhibition. This splint
has lightness, strength, and Simplicity, and possesses at
the same time every advantage that can be possibly
214 NEW YORK STATE MEDICAL ASSOCIATION.
claimed for any splint. This splint affords comfort to
the patient, and is capable of adjustment to any fracture
or to any diseased joint. The true germ of every useful
splint of the present day, is found contained in this
model. -
In 1878, Pilcher first pointed out the correct pathology
and treatment of fractures of lower end of radius.
Before dismissing the subject of fractures, the work of
Frank H. Hamilton must not be overlooked, since he
did more to systematise and to perfect the treatment of
fractures in general, than any other American Surgeon.
The work of Stimson likewise deserves the highest
tribute of respect. The saw devised by Shrady for per-
forming a subcutaneous section of the bone, is an in-
strument worthy of the highest commendation. Exci-
sion of the superior maxillary bone with the exception
of the orbital plate, was first performed by Jameson, in
1820. The complete excision of the superior maxilla was
first performed in this city by David L. Rodgers, in 1824.
Excision of the inferior maxilla was first partially and
successfully made, “without known precedent, or pro-
fessional counsel or aid,” by Deadrich, of Tennessee, in
1810. Jameson exsected nearly the entire inferior max-
illa in 1820, Mott exsected one-half of the jaw in 1821,
and Ackley in 1850; and Carnochan, in 1851, excised
the entire bone. Excision of the os hyoides was per-
formed for the first time, by Dr. John C. Warren, in
1803. Excision of the wedge-shaped piece of bone from
the tibia and fibula, with osteoclasis of the bones, to cor-
rect a deformity by an osteotomy, was performed by Dr.
John C. Warren, in 1820. In 1835, Barton devised an
operation which is still practiced for the relief of angular
anchylosis of the knee. The entire clavicle was excised
successfully for necrosis for the first time in 1813, by Mc-
Creary of Kentucky. The entire clavicle was again ex-
cised successfully for the first time, formalignant disease,
by Mott, in 1828. The entire scapula, three-fourths of the
clavicle, and the arm were excised for the first time, and
AOHIEVEMENT'S OF AMERICAW SURGERY. 215
also successfully, by Dixi Crosby, in 1836. This same
operation was repeated by Twitchell in 1838, by Mac-
Clellan in 1838, and by Mussey in 1845; and since then
to the present time, the operation has been performed
about twenty-five times throughout the world. The en-
tire scapula and the clavicle were removed successfully,
six years after an amputation at the shoulder-joint, by
Mussey, in 1837. Two-thirds of the ulna were excised
successfully by Butt, of Virginia, in 1825, and the olec-
ranon by Buck, in 1842, while the entire ulna was
excised by Carnochan, in 1853. The same operator ex-
cised the entire radius in 1854. Both radius and ulna
were excised by Compton, of New Orleans, in 1853.
Excision of the coccyx was first performed by Nott, in
1832, for the relief of severe and persistent neuralgia.
Excision of a portion of the rib by the trephine, for
affording drainage in empyema, was first performed by
Stone in 1862, and excision of a part of one or more ribs
for the same purpose, was first performed by Walter, of
Pittsburgh, in 1857. Removal of a disk of bone for
drainage in non-traumatic, diffuse, acute, suppurative
Osteomyelitis, was done in 1798 by Nathan R. Smith,
Who anticipated Brodie in the performance of this opera-
tion. Brodie's operation had reference to circumscribed
abscess of bone.
Besides these excisions for necrosis, suppuration, and
malignant disease, much credit is due to American sur-
gery for the part it has played in subperiosteal surgery.
One of the most remarkable specimens is the reproduc-
tion of the inferior maxilla by Wood, in 1856. This jaw
Was exhibited by Dr. Wiggin at the Berlin Congress of
Surgeons, in 1877, and Langenbeck, the authority on
Subperiosteal surgery, said, “that he did not believe a
Corresponding preparation really existed anywhere,” and
remarked, that “there was not another such specimen
in the whole of Europe.” This was indeed a fitting
tribute, from one of Europe's greatest surgeons, to the
genius of one of America's greatest operators. Wood
216 JNETW YORK STATE MEDICAL ASSOCIATION.
has also succeeded in reproducing many other bones in
the body by the application of the same principles of
subperiosteal surgery. These Specimens form a unique
group, and are carefully preserved in the museum which
bears his name. Thus it is evident, if the first success-
ful excision of the superior and inferior maxillae, the
hyoid bone, the entire clavicle, the entire scapula, the
ulna and radius, the coccyx and ribs; also trephining
for relief of osteomyelitis and the most perfect specimens
of reproduced bone, be subtracted from the sum total of
operative surgery upon the bones, there is little left
which is not the offspring of American surgery.
In the surgery of the joints, American Surgeons have
since accomplished brilliant results. In the management
of dislocations, they have contributed much to the sum
total of our knowledge. Physick was the first to per-
form venesection to cause muscular relaxation, in Order
to reduce a dislocation. This was a most valuable
means, to which resort was made prior to the introduc-
tion of anaesthetics.
McKenzie and Smith, in 1805, reduced a dislocation of
the shoulder of six months’ standing, by the employ-
ment of venesection. This patient had been to England,
and all attempts at reduction had failed, and upon his
return to Baltimore, the reduction was effected by re-
laxing the muscular system by blood-letting ad dele-
quium animi. This plan is now abandoned since the
introduction of anaesthetics.
John C. Warren excised the head of the humerus, to
restore the usefulness of it after an unreduced disloca-
tion of the shoulder-joint.
Wood practiced tenotomy with great success, in order
to reduce difficult dislocations of the major joints, and
also for dislocation of the peroneal tendon.
Before dismissing the subject of tenotomy, it is stated
in Cooper’s “Dictionary of Surgery,” that Gibson, in
1842, divided the straight muscles of the eye for the relief
of strabismus, several years before Dieffenbach, of Berlin.
ACHIEVEMENT'S OF AMERICAN SURGERY 217
In 1826, Dixi Crosby demonstrated the causes of failure
to reduce the dislocation of the thumb, and showed that
forced extension and pressure upon the base of the dis-
located bone would effect a reduction.
In 1855, W. W. Reid published his method of reduc-
ing dislocation of the hip by manipulation, to which
must be added the contributions of Smith, Gunn, Bige-
low, and Stimson.
In 1856, Dugas pointed out a most important diagnos-
tic sign, of great value in dislocation of the shoulder.
Bigelow pointed out two obstacles to reduction in hip-
joint dislocation.
Sayre is the American surgeon who is entitled to the
honor of having established Orthopaedic Surgery as a
separate school of Surgery in this country.
In the inflammatory affections of joints, American
surgeons have advanced the principles which to-day are
considered sound, and which are universally adopted.
Physick insisted upon absolute rest of an inflamed limb.
Harris, in 1825, first insisted upon fixation and extension
in the management of inflamed joints. Later on the
principle of fixation and extension was modified, so as to
permit the patient to be up and about ; Subsequently
this principle was carried out in the ankle and knee
joints by an instrument devised by Sayre, and in the hip,
by an instrument first invented by Davis, of this city,
previous to 1860, and since modified and improved by
Sayre.
There are other splints employed which are most use-
ful, notably those of Taylor, Shaffer, Ridlon, A. M.
Phelps, Gibney, and others; while the work of Whit-
man, Willard, Judson, Vance, Reginald, Sayre, and
Townsend, in this department of surgery, merits the
highest consideration. The invention of the plaster-of-
Paris jacket by Sayre, for the treatment of Pott's dis-
ease, in 1874, is one of the most important surgical
discoveries of the century. This same apparatus he
devised for the treatment of lateral curvature. These
218 NEW YORK STATE MEDIOAL ASSOCIATION.
cases of Pott's disease, which hitherto were consigned to
a distressing death, are now permanently relieved of their
sufferings, and are in many cases entirely cured. -
Excision of the hip-joint was performed as a syste-
matic operation, and successfully, for the first time in this
country, by Sayre, in 1854. To this same surgeon is due
the credit, of suggesting and carrying into execution, the
principle of free drainage in cases of empyema of joints.
In hydrops articuli, Martin, of Boston, in 1853, Sug-
gested equable uniform compression by means of an
elastic bandage, and Sayre has applied the same prin-
ciple by using compressed sponges. Martin, in 1877,
also employed the elastic bandage for the cure of chronic
ulcers of the leg.
In 1826, Barton divided with a saw the great trochan-
ter and the neck of the thigh, to relieve anchylosis of the
hip-joint; in 1830, Rodgers removed a disk of bone; and
in 1862, Sayre perfected the operation and introduced a
new principle, by removing a plano-convex wedge of
bone between the two trochanters, and making rotund
the end of the lower fragment, in order to form a new
and artificial joint.
In 1835, Barton removed a cuneiform wedge just above
the condyle, fractured the bone, and made the limb
straight, to relieve angular anchylosis of the knee-joint.
This operation is practically the Osteotomy of the pres-
ent time.
In 1840, Carnochan first operated for the relief of an-
chylosis of the lower jaw, by subcutaneously dividing the
masseter muscle. In forcing open the mouth after tenot-
omy of the muscle, he accidentally fractured the bone,
thus producing a false joint until the fracture united.
Carnochan conceived then the idea of excising a wedge-
shaped piece from the jaw, and establishing a false joint.
For the relief of this distressing condition, in 1873, Gross
excised the condyle and a portion of the neck of the bone,
and in 1875, Mears excised the coronoid and condyloid
processes, together with the upper half of the ramus.
ACHIEVEMENT'S OF AMERIOA.W SURGERY. 219
Wood, in 1876, cured a patient with fracture of the
cervical vertebra, associated with paraplegia and brachial
paralysis, by the use of the plaster-of-Paris jacket. The
patient, though completely paralysed, made an excel-
lent recovery, and was able to resume his work as a
carpenter.
2d. Surgery of the Vascular System.–In the surgery
of the vascular system American operators have made
most valuable contributions.
The innominate artery was ligated for the first time in
the history of surgery, by Valentine Mott, of this city,
on May 11, 1818. The operation was performed for the
cure of aneurysm, and the patient died. The operation
was essayed for the second time by Hall, of Baltimore,
in 1830, and again by Cooper, of San Francisco, in 1859.
Both of these cases terminated fatally. The artery was
finally tied successfully, for the first time, by Smyth, of
New Orleans, on May 9, 1864. This last operator tied
also the vertebral in the same patient, for the first time.
Thus, it is evident that the ligature of the innominate
artery was first performed in this country, and it was
first ligated successfully in America. And the artery
has never been ligated anywhere else successfully but in
this country.
Mott tied one hundred and thirty-eight large arteries
for the relief of aneurysm ; and no other surgeon in the
World has ever ligated so many vessels.
The primitive carotid artery was ligated for the first
time successfully, for primary haemorrhage, by Cogs-
Well, of Hartford, Conn., on November 4,1803. Abernethy
is credited with tying the primitive carotid first in 1798;
but his case died. The first successful case, therefore,
of ligature of the primitive carotid for primary haemor-
rhage, was in America, and Cogswell had no knowledge
of Abernethy’s unsuccessful attempt. Again, the primi-
tive carotid was first tied successfully for secondary
haemorrhage by Amos Twitchell, of Keene, N. H., in
1807, eight months prior to Sir Astley Cooper's famous
220 NEW YORK STATE MEDICAL ASSOCIATION.
case, which was supposed until lately to be the first upon
record. The primitive carotid was first tied in its con-
tinuity successfully, for the cure of aneurysm, by J.
Wright Post, on January 9, 1813. This same surgeon
again repeated the operation successfully on November
28, 1816. -
The two primitive carotids were first tied in their
continuity successfully, within a month’s interval, by
Macgill, of Maryland, in 1823. Mott tied both carotids
simultaneously in 1833, for malignant disease of the par-
otid gland. In 1823, Davidge first tied the carotid
artery for fungous tumor of the antrum. The primitive
and internal carotids were first tied simultaneously by
Gurdon Buck, of New York City, in 1857, and again by
Briggs, of Nashville, in 1871. The internal carotid was
tied successfully, above and below, for secondary haem-
orrhage, by Sands, in 1874. Carnochan tied both caro-
tids for the first time, for elephantiasis arabum of the
neck and face, in 1867.
The subclavian artery in its third portion was first
tied successfully, for the cure of aneurysm, by J. Wright
Post, of New York City, in September, 1817. The sub-
clavian artery in its first position was ligated for the first
time by J. Kearney Rodgers, in 1845. The case died, and
the vessel was not tied successfully until 1892, when it
was done by Halsted, of Baltimore. The operation was
for the cure of aneurysm, and the sac was dissected out
by the removal of the clavicle. This is the only case in
which the ligation of the subclavian on its tracheal side
has ever been successful, although unsuccessful attempts
have been made in other countries. -
The primitive iliac artery was first tied in America by
Gibson, of Baltimore, in 1812. The ligation was for the
arrest of haemorrhage following a gun-shot wound. The
patient died after the thirteenth day. Valentine Mott
tied the artery successfully for the cure of aneurysm, On
March 15, 1827. In 1880, Sands first tied the primitive
iliac for aneurysm of the left external iliac, by first
ACHIEVEMENTS OF AMERICAN SURGERY. 221
performing a laparotomy, and securing the vessel by
this procedure.
The internal iliac was first successfully tied for the
cure of an aneurysm, by Stevens, in 1812, and again suc-
cessfully by Mott, in 1827, and by White, in 1847.
The two internal iliacs were first tied simultaneously
for the cure of double gluteal aneurysm, by the writer,
in 1886, upon a patient of Carpenter, of Boonton. In this
case, a laparotomy was first performed. The patient
died of uraemia. The same operator has since tied suc-
cessfully the internal iliac for the cure of gluteal aneu-
rysm, for the first time by laparotomy, as a first step in
the operation ; and also the internal pudic branch of the
internal iliac artery for the first time successfully out-
side the pelvis, for the arrest of secondary haemorrhage
in the perinaeum.
The external iliac was tied successfully in 1811, by
Dorsey, and again successfully by Post, in 1814.
In 1794–95, Post placed a ligature around the femoral
artery for the cure of aneurysm, and the patient was
cured. Onderdonk, in 1813, tied the femoral artery suc-
cessfully for acute phlegmonous inflammation of the
knee-joint, and Rodgers did the same operation with suc-
cess in 1824. Carnochan, in 1851, tied the femoral artery
for the first time for the cure of elephantiasis arabum,
thereby inaugurating a new principle of treatment.
In May, 1821, Jameson ligated the externaliliac artery,
and Davidge, who settled in Baltimore in 1796, shortly
after this, first ligated the gluteal artery.
Thus, it has been shown that the ligation of the innom-
inate, the subclavian both in the first and third portion,
the primitive carotid, both primitive carotids simultane-
Qusly, primitive and the internal carotids, the primitive
iliac and the internal iliac, have all been tied for the
first time successfully in America; and further, that the
primitive carotid was first successfully tied for primary
haemorrhage, and also for Secondary haemorrhage, and
the primitive and internal carotids simultaneously tied
222 NEW YORK STATE MEDICAL ASSOCIATION.
for traumatic aneurysm, and the internal carotid for
secondary haemorrhage, and both internal iliacs simul-
taneously, in this country. In the surgery of the
arteries there seems little left to the credit of any other
country.
In addition to the various ligations already mentioned
for the cure of aneurysm, a variety of compression, known
as digital pressure, was carried into practice by Jonathan
Knight, of New Haven, in 1848. There are many modi-
fications of digital pressure. Wood utilised the bag of
shot, which was suspended over the patient, and by this
means, the pressure was effected by it, instead of by the
finger. In 1874, Stone, of New Orleans, first cured a
traumatic aneurysm of the Second portion of the subcla-
vian artery, by digital pressure upon the third portion
of the vessel.
Martin, in 1877, suggested the use of the elastic ban-
dage in the treatment of varicose veins, and Dr. Charles
Phelps the method by the multiple ligature of the veins
from the ankle to the Saphenous opening. He applies
some thirty ligatures to the limb, and the results of his
operation have been most satisfactory.
There has been much diversity of opinion as to whom
the credit belongs for the introduction of the Esmarch
bandage. In the public clinics of the Jefferson Medical
College, at the time of an amputation, the elder Pancoast
and Gross rendered the limb bloodless by elevating it,
and by the application of a roller bandage. This was
done before a tourniquet was applied. The value of this
procedure was not published, and to Esmarch is due the
credit of having adopted the principle, with the modifi-
cation of the elastic bandage, and having published it
abroad for the benefit of the profession.
In 1874, Woodbury, of Philadelphia, suggested digital
pressure of the common iliac, with the hand introduced
through the sphincter; and Wyeth has devised a method
of controlling haemorrhage during amputation of the hip-
joint, which deserves mention.
ACHIEVEMENTS OF AMERICAN SURGERY. 223
3d. Surgery of the Great Cavities of the Body—Sur-
gery of the Cranial Cavity.—In cerebral surgery, Ameri-
can surgeons have accomplished excellent work; but this
is not the place or the time to review the entire field of
brain surgery. Within a few years great progress has
been made in this department, but that part which has
reference to the work of American surgeons only concerns
us this evening.
Trephining for the relief of epilepsy was performed by
Dudley, of Kentucky, prior to 1828, with sixty per cent.
of permanent cures. Dr. Mason Warren trephined a
child for epilepsy in June, 1849, for the relief of acci-
dental idiotism. A case of cerebral abscess was opened
by Detmold in 1855, and pus evacuated from the lateral
ventricle. The lateral ventricle itself was opened by
Dennis, in 1889, for the purpose of removing a blood-clot
in a case of traumatic haemorrhage. There was no wound
of the soft parts, or fracture of the bone, to indicate the
place to trephine, and the diagnosis of cortical haemor-
rhage was made before the operation. This is a unique
case in the annals of surgery.
The brain substance itself has been explored by Fluh-
rer, who was the first to locate a pistol-ball within the
brain, by the use of his special probe. He extracted the
bullet by a counter opening made with a trephine. He
had also located by means of the probe, and extracted,
a bullet, which was embedded in the substance of the
brain, two and three-quarter inches. This operation was
followed by complete recovery.
In the removal of cerebral tumors, American surgeons
Cannot establish any claim for priority, and but little for
originality; but they can at least establish claim for hav-
ing had many cases of this nature, since nearly one-third
of all the cases operated upon have been by American
Surgeons. The work of Weir, Keen, Roswell Park, Mills,
Hearn, McBurney, Birdsall, Bullard and Bradford, Mar-
koe, Curtis, Charles Phelps, Deaven, Bryant, Lloyd, and
Hun deserve the highest commendation. American sur-
224 NEW YORK STATE MEDICAL ASSOCIATION.
gery would be ungracious not to acknowledge the work
of Starr, Mills, Seguin, Putnam, Spitzka, Gray, McDon-
ald, Sachs, Dana, Janeway, and Clymer, since these
neurologists have prepared the way for the work of the
surgeons. Trephining for traumatic meningeal haemor-
rhage, for pachymeningitis interna haemorrhagica, and
other like conditions, have been employed by surgeons,
who have reported the result of their operations.
In all probability, the most important medical event
which has ever happened in this country, or in the world,
was the conception, development, and birth of ovariot-
omy. To Dr. Ephraim McDowell, of Danville, Ky., be-
longs this great honor. In 1809, he was the first to per-
form this unique and Original operation, which has made
his name immortal. The far-reaching influences which
have proceeded from this step are incalculable. Dr.
McDowell is finally recognised as the originator of not
only one of the greatest operations in surgery, but also
as the author of an operation, the influence of which has
made it possible to develop the present wide field of
abdominal surgery. McDowell's work will live in the
memory of thousands in this land, and will be honored,
the world over, as long as time endures.
In 1821, Dr. Nathan Smith performed ovariotomy in
Connecticut, and without the knowledge that it had
been performed by McDowell; Smith dropped the
pedicle into the abdominal cavity, and thus made a great
advance in McDowell's operation. In 1823, Alban G.
Smith also performed an ovariotomy in Kentucky, and
David L. Rodgers, in New York, in 1829. All these
cases of ovariotomy were successful. It was seven years
after this last American operation, before ovariotomy was
first performed in England, and nearly fifteen years be-
fore ovariotomy was first performed in France. In 1870,
T. Gaillard Thomas first devised and performed success-
fully a vaginal ovariotomy. In 1872, Dr. Davis, of
Pennsylvania, performed successfully the same opera-
tion; he was followed in 1873 by Gilmore, of Alabama,
and in 1874, by Battey, of Georgia, and later by Sims.
ACEHIEVEMENTS OF AMERICAN SURGERY. 225
In 1872, Battey performed his first oëphorectomy,
“with a view to establish at once the change of life for
the effectual remedy of certain otherwise incurable mala-
dies.” This is an operation also of purely American ori-
gin, and has contributed much to the relief of human
suffering. - r
It has been urged, that while to an American surgeon
the credit is honestly due for the first performance of an
ovariotomy, other nations have perfected the operation,
and that more credit is due to-day to other nations for
the best results. Let us see how this statement accords
with facts. In 1857, the question of ovariotomy was
brought up for discussion at the French Academy of
Medicine, and only one surgeon considered the operation
as sometimes justifiable. Up to that time there had been
in America, ninety-seven ovariotomies, with thirty-four
per cent. mortality; in Great Britain, one hundred and
twenty-three operations, with forty-three per cent. mor-
tality; while in Germany there had been forty-seven
Operations, with seventy-seven per cent. mortality. Amer-
ican surgeons, therefore, not only obtained the best re-
Sults up to that date, but no American surgeon to-day
will concede that our results are inferior to those ob-
tained by surgeons in any other country at the present
time. Among American surgeons who are now contribut-
ing to the success of ovariotomy, may be mentioned,
Thomas, Lusk, Polk, Wylie, Mundé, Goddell, Kelly,
Homans, Price, Janvrin, Leidy, and Dudley.
Few men can realise the influence of McDowell’s first
OVariotomy upon the whole field of abdominal surgery.
It is indeed a sublime thought to consider, that a man
Was found with the courage of his convictions to do what
no man had ever done, and to operate within the noise
of the infuriated mob beneath his windows. This mob
Would have lynched him if Mrs. Crawford had died.
Having escaped the angry mob, he was pointed out as a
murderer by his fellow-colleagues, and was condemned
by the highest scientific authorities in Europe. In Amer-
15
226 NEW YORK STATE MEDICAL ASSOCIATION.
ica, therefore, under such circumstances and under such
conditions, the birth of the greatest operation in surgery
occurred—an operation destined to save in the future
millions of human lives.
The disapproval of this great operation of McDowell’s,
by the press, by the profession, and by the laity was pro-
nounced. The Medico-Chirurgical Review, speaking of
McDowell’s achievement, says: “A back settlement of
America, Kentucky, has beaten the Mother Country, nay,
Europe itself, with all the boasted surgeons thereof, in
the fearful and formidable Operation of gastrotomy with
the extraction of diseased ovaries.” All this vitupera-
tion was hurled at McDowell, but time, as the great arbi-
ter, has demonstrated that what was said in sarcasm, has
become a transcendent and mighty truth. The noble
character and the true grandeur of McDowell’s nature,
and his high and lofty ambitions, are illustrated by the
fact that he had performed three successful ovariot-
omies, operations never before undertaken by man, with-
out heralding the victories as triumphs of his personal
ambition.
In the early days of ovariotomy, McDowell and Na-
than Smith, the Atlees, Dunlap, Peaslee, Kimball, Sims,
and Thomas, have established and brought to the front
an operation, against which the most bitter and scathing
invectives have been aimed. These great men, who have
placed this operation upon a firm basis, deserve the grat-
itude of a nation, and of the world, since they have
thrown a flood of light upon this dark region of surgery,
which is now illuminated by the work of recent opera-
tors, whose successes are simply miraculous.
The operation of hysterectomy is one that was per-
formed very early in the history of this country, since
it has been ascertained that in 1813, Joseph Glover, of
South Carolina, removed the entire uterus, and the
patient made a complete recovery. This operation OC-
curred just four years subsequent to McDowell’s first
ovariotomy. Dr. J. Briggs also repeated the operation
ACHIEVEMENTS OF AMERICAN SURGERY. 227
in 1830, and Dr. J. M. Briggs is said to have performed
the same operation previous to 1830, the exact date of
which is unknown. Polk, of this city, has performed
hysterectomy with the largest percentage of recoveries.
In 1759, John Bard operated for extra-uterine preg-
nancy, and in 1791, the operation of gastrotomy for the
same condition was successfully carried into execution
by William Baynham, and again successfully in 1799, by
the same surgeon. Since then, the operation has been
performed frequently. In 1816 John King, of South
Carolina, removed a living child, in the case of an extra-
uterine pregnancy, by opening into the pelvic cavity by the
side of the vagina, and extracting the child with forceps.
In 1824, Jameson first incised the cervix uteri, and in
1870, T. Gaillard Thomas, and in 1876, Skene, of Brook-
lyn, both successfully performed gastro-elytrotomy.
In 1862, Emmet described a new operation in gynaeco-
logical surgery for the relief of lacerated cervix. This
Operation has contributed much to the relief of suffering
in those cases which hitherto baffled medical skill. He
also devised an operation for prolapsus of the uterus in
1869, one for displacement of this organ in 1874, one for
lacerated perinaeum and rectocele in 1882, and one for
the purpose of exploring the bladder on removing ure-
thral caruncle by a button-slit in the urethra.
To our countryman, J. Marion Sims, is due the great
honor of perfecting, in 1852, the operation for the cure
of vesico-vaginal fistula, and while the operation itself
Was not first executed in this country, it was so im-
proved and perfected here, that to-day, the operation of
Sims is the one universally practiced. Nathan Bozeman
has also devised an operation for the relief of this condi-
tion, by operating in the knee-chest position, with instru-
ments especially devised by himself. This operation has
Prevented much suffering and distress, which before the
Perfected operation of Sims, was considered as practically
*nourable. The same surgeon also devised, in 1856, the
99eration for prolapse of the uterus, and in 1857 for
228 JWEW YORK STATE MEDICAL ASSOCIATION,
the relief of vaginismus, and perfected the technique of
amputation of the cervix in 1859. t
In closing this brief sketch of American gynaecological
Surgery, it is obvious that it was an American Surgeon to
whom the honor of first performing ovariotomy is due.
Sir Spencer Wells is said to have added twenty thousand
years to the lives of British women, and by the same
process of reasoning, Ephraim McDowell, the Kentucky
frontier surgeon, has already added hundreds of thou-
sands of years to the lives of women throughout the
world. Our country has achieved its most brilliant
triumphs in this department of Surgery, and to American
surgeons belong the honor of not only first performing
nearly every important surgical gynaecological Operation,
but also of perfecting the technique of the less important
Surgical procedures. A most worthy compliment to
American gynaecological surgery is the fact, that one of
Great Britain’s most famous ovariotomists sent his son
to Our Shores to study and to perfect himself in gynaeco-
logical Surgery.
The Operation of Caesarean section has met with un-
usual success in this country. Lusk has operated five
times, with three successful results; the fourth case died
of intestinal obstruction, consequent upon a pelvic ab-
scess, due to Pott's disease; and the fifth died also of
Pott's disease. Kelly has performed the operation five
times, with four successful results. Thomas has oper-
ated with success; also Jewett, of Brooklyn; Price and
Noble, of Philadelphia; Garrigues, Coe, and Grandin, of
New York. Gibson performed Caesarean section twice
upon the same patient; once in 1835, and again in 1837.
The patient recovered from these operations, and lived
to the age of seventy-five. Kelly devised a new opera-
tion for the relief of retro-displacement of the uterus.
The operation was modified by Krug, in 1890, and also by
Dudley, of New York. E. C. Dudley, of Chicago, has de-
vised an operation for antero-displacements, and the same
Operator has also improved the Alexander operation.
ACHIETVEMENT'S OF AMERICAN SURGERY. 229
Newman devised his operation for shortening the round
ligaments in September, 1888.
Outerbridge, in 1889, devised a speculum for dilatation
of the cervix in cases of Stenosis, when sterility exists.
Laparotomy was performed by Dr. Wilson, in 1831,
for the relief of an intussusception. The patient was a
negro slave, and had suffered from intestinal obstruction
for seventeen days. The abdomen was opened, and the
intussusception found; it was then drawn out and re-
leased, and the patient made a complete recovery.
In 1792, Physick devised an operation for the cure of
artificial pouches in the alimentary canal.
In 1809, Physick was the first to ligate the eperon,
where an artificial opening had been made in the intestine
on account of pathological changes. In 1847, Gross urged
the excision of a section of the intestine, with suturing of
the divided ends, with a view to establish the continuity
of the canal, but the patient refused; in 1863, Kinloch, of
South Carolina, accomplished this result.
In 1834, Luzenberg laid open a strangulated hernia,
found it gangrenous, excised the mortified section of the
intestine, stitched the serous surfaces, and the patient
fully recovered. This same surgeon suggested, in 1832,
exclusion of light to prevent pitting in small-pox.
The operation of laparotomy for the treatment of pene-
trating gun-shot and stab-wounds of the peritonaeal cav-
ity, was the work of American surgery. Gross, in 1843,
and Sims, just before his death, suggested this method,
but these gentlemen never practiced it. It remained for
Dr. W. T. Bull to make the practical application of the
method, and to him is due the credit of this great ad-
Vance in Surgery. It is a source of national pride, that
laparotomy in penetrating wounds and visceral injuries
of the abdomen, was conceived, developed, and perfected
in America. The wide-spreading influence of this oper-
ation is felt in abdominal surgery, and much of the
present advance is the result of Bull's surgery. The
Work of Senn and Abbe in intestinal anastomosis also
deserves the highest praise.
230 NETW YORK STATE MEDICAL ASSOCIATION.
The operation for the relief of acute appendicitis is
clearly traced to the work of American surgeons. In
1843, Willard Parker, and later Gurdon Buck, did much
to explain the nature of these iliac inflammations; and
Sands cleared the way for the perfected operation of
McBurney, which aims to prevent these dangerous peri-
tonaeal inflammations, and to prepare the wound for
aseptic healing. Sands first operated with success, after
perforation had taken place, and general peritonitis was
present. To McBurney is due great credit for the per-
fection of this operation, which is now recognised
throughout the world as the best, safest, and most scien-
tific way of managing these varieties of Suppuration,
hitherto so fatal.
The operation of removing the appendix vermiformis
during the quiescent period, between relapsing attacks,
was suggested by Treves, of London, although the ap-
pendix was successfully removed in this country by the
writer, in 1887. In this case, the appendix was diseased,
Owing to adhesions to an ovarian tumor.
The first and only successful case of laparotomy for
the relief of perforation of the intestine during the prog-
ress of typhoid fever, was performed in this country,
and to Dr. Weller VanHook, of Chicago, is due the
credit of having first established an operation for the
relief of these cases, which hitherto were fatal.
Still another important discovery must not be over-
looked, and that is Senn’s insufflation of hydrogen as an
infallible test in the diagnosis of visceral injury of the
gastro-intestinal canal, in penetrating wounds of the ab-
domen. Senn has also made other valuable contributions
to abdominal surgery, and his work entitles him to the
gratitude of the profession. -
Laparotomy for the relief of purulent peritonitis, was
performed by Mears, of Philadelphia, in 1875. This
case was among the first, if not the first, where the peri-
tonaeal cavity was opened for the express purpose of
washing it out, and draining it like any abscess cavity.
ACHIEVEMENTS OF AMERICAN SURGERY. 231
The work of Abbe, Hartley, Curtis, McCosh, Briddon,
Lange, Stimson, Morton, and Vanderveer, deserves great
commendation.
In the surgery of the liver, American surgeons have
distinguished themselves. In 1867, Dr. Bobbs, of In-
dianapolis, was the first surgeon to perform the mod-
ern operation of cholecystotomy, which he did success-
fully, and removed fifty biliary calculi from an incision
into the gall-bladder. He was followed, in 1868, by Dr.
J. Marion Sims, who removed sixty stones from the gall-
bladder. To Tait, however, belongs the great credit of
perfecting the technique of this operation, and he stands,
to-day, pre-eminently the authority upon hepatic surgery.
Excision of biliary calculi by incision into the umbilical
vein, was performed by Dr. John C. Warren, of Boston,
in the early part of the present century.
In the surgery of the spleen, American surgeons have
a record of which they need not be ashamed. In review-
ing the literature of splenectomy, the case of Zaccarelli,
in 1549, may be excluded, Sir Spencer Wells says, as
apocryphal. The next authentic case is one by Quitten-
baum, of Rostock. This splenectomy was performed in
1826, and the patient died. But in 1801, a quarter of
a century previous to this case, Dr. Joseph Glover, of
Charleston, S. C., removed nearly the entire spleen and
Some Omentum, and ligated a branch of the splenic
artery. This was not, however, an extirpation of the
Spleen for any pathological condition. The spleen was
also removed for gun-shot wound, by Dr. Alston, of Texas,
about 1863, and the patient recovered.
What little has been done in the surgery of the pancreas
has been done by American surgeons. The literature of
the subject is contained in an elaborate brochure by Senn.
There have been only four cases of cysts of the pancreas
diagnosticated, and these were operated upon success-
fully by Senn, Tremaine, Bull, and Bozeman.
4th. Surgery of the Genito- Urimary System.–In the
department of genito-urinary surgery, a great advance
232 MEW YORK STATE MEDICAL ASSOCIATION.
has been made by the invention of instruments to facili-
tate and improve the technique. *
The cystoscope is an American instrument, having been
invented by Dr. John D. Fisher, of Boston, in 1824, while
Civiale and Heurteloup did not invent their instruments
until 1827. The cystoscope of to-day is one which has
been evolved from the general principle of Fisher’s
endoscope. Dr. W. K. Otis has perfected the urethro-
scope by the addition of a new electric lamp. Klotz has
also devised a cystoscope, which is in use at the present
time. Dr. F. T. Brown has devised a most useful urethral
speculum for the purpose of making topical applications
to the canal. The Gross urethrotome, Powell’s urethral
dilator, the dilating urethrotome, and the urethrotometer
of Otis, are instruments deserving of mention. The work
of Bumstead and of Van Buren, in this department of
surgery, has already a world-wide reputation. -
The operation of nephrectomy for the relief of malig-
nant disease of the kidney, is of American origin, since
it was first performed by Wolcott, of Milwaukee, in 1860.
British surgeons give the credit of this operation to
Simon, of Heidelberg ; but he did not perform his opera-
tion until 1869, or nine years after Wolcott’s operation.
Nephrectomy was first performed in America for gun-
shot wound of the kidney, by Keen, in 1887, and again two
months later, for the same condition, by Willard, and still
again for the same cause, by Price, successfully, in 1888.
The first successful operation for the relief of extro-
version of the bladder, was performed in this city by Dr.
A. L. Carroll, on April 13, 1858. Pancoast performed this
operation successfully the same year, and Ayers, in 1859.
All of these cases ante-date the British success of Woods
and Holmes, although there are two operative failures
reported by Cook and Lloyd, in London, in 1851. Lapar-
otomy for rupture of the bladder was successfully per-
formed by Walters, of Pittsburgh, in 1862; but to Sir
William MacCormac is justly due the credit of establish-
ing this operation. .
ACHIEVEMENTS OF AMERICAN SURGERY 233
In the plastic surgery of the urethra, another brilliant
triumph has been made by American surgeons. In 1892,
Dr. Samuel Alexander succeeded, for the first time in the
history of genito-urinary surgery, in a case of complete
epispadias in the female, in making a new urethra, the
retentive powers of which were perfect. There have been
twelve cases, in all, of complete epispadias, in none of
which heretofore has the urine been completely under the
control of the patient.
In 1795, Physick did an internal urethrotomy by a
concealed lancet, and Alexander Stevens, in 1817, was the
first surgeon in this country to perform external perinaeal
urethrotomy. He revived an operation which had fallen
into desuetude, at the close of the last century, because
of the great mortality which attended it. Prior to 1840,
the operation was performed in this country by several
surgeons; notably, in 1820, by Jameson ; in 1823, by
Rodgers; in 1829, by Warren ; and later, by several sur-
geons connected with the New York Hospital, among
whom may be mentioned Hoffman, Post, and Watson;
and also by Alden March, of Albany, and Wood, of New
York City. Without doubt the operation has reached
its present state of perfection through the labors of
Gouley, who suggested the whalebone guide, the tun-
neled catheter staff, and the beaked bistoury. The oper-
ation of Fluhrer, with his instruments, which are marvels
of mechanical skill and precision, has still further im-
proved the technique of external perinaeal urethrotomy.
The operation of supra-pubic prostatectomy was first
performed in this country by Belfield, in October, 1886.
This operation has been greatly improved upon by the
use of Gouley’s prostatectome, which facilitates the re-
moval of the gland.
In lithotomy, American surgeons have achieved bril-
liant results. McDowell did thirty-two lithotomies in
Succession without a death. Dudley performed one
hundred consecutive operations without a fatal case. In
1846, Willard Parker removed a calculus from the blad-
234 METW YORK STATE MEDICAL ASSOCIATION.
der by producing a recto-vesical fistula, and subsequently
performed this operation for the cure of chronic cystitis.
In 1861, Dr. Bozeman did this same operation to relieve
a chronic cystitis in the female. Physick did his first
Operation for stone in 1797, and in doing it, wounded the
internal pudic artery. This accident led to the inven-
tion of his needle for carrying a ligature around deep-
Seated vessels. In 1836, this same operator removed over
One thousand calculi from the bladder of Chief Justice
Marshall. These brilliant results in lithotomy are most
remarkable, when it is considered that there was a time,
in the medical history of this country, when a patient
actually made the pilgrimage across the Ocean, in order
to secure the services of a surgeon to perform lithotomy.
In lithrotrity, American surgeons have obtained re-
sults which compare favorably with the work of lithot-
rotists of other countries. Keyes has made Some great
improvements in litholapaxy, thereby reducing the mor-
tality of the operation. Among these may be mentioned
the evacuating tube, the alteration in the mechanism, and
other improvements in the technique of the operation.
To Henry J. Bigelow, of Boston, is due the credit of
having made important changes in the technique of lith-
otrity. In 1878, Bigelow pointed out the important fact
that a calculus could be crushed, and the debris removed,
at a single operation. This was a great step forward, and
litholapaxy of to-day is an operation of American origin,
since Bigelow devised a lithotrite for crushing the stone
and an evacuator for washing out the bladder.
Bigelow’s operation has been performed by Keegan
fifty-nine times in children, with one death ; and by
Freyer, forty-nine times, without a death. This, the
American operation of litholapaxy, has certainly won for
itself a fixed place in the annals of surgery.
5th. Miscellaneous Operations.—There are many mis-
cellaneous operations in surgery which are purely of
American origin, or they have been so improved in tech-
nique as to be properly claimed as American. The scar-
ACHIEVEMENTS OF AMERICAN SURGERY. 235
ification of the infiltrated mucous membrane in Oedema
glottidis, as suggested by Buck, and the removal of
polypi from the larynx by the same surgeon, who was
the first to do this in America, and the second in the
world, are worthy of record.
Frank Hamilton, in 1854, was the first to transplant
skin for the repair of ulcers. This operation he termed
anaplasty.
In October, 1842, Sayre made a free incision into the
chest in a case of empyema, and the patient made a good
recovery. Forty years ago, in a case of empyema, Oc-
curring in a tuberculous patient from the rupture of an
abscess into the pleura, Sayre raised the query—would
we not be justified in tapping as soon as the effusion is
discovered 3
In 1850, Dr. Henry I. Bowditch suggested and prac-
ticed paracentesis thoracis. Dr. Morrill Wyman, un-
aware of Dr. Bowditch’s operation, performed the same
Operation. For a long time in this country, as well as in
Europe, paracentesis thoracis was condemned ; but at last
the operation has advanced to the stage of full acceptance
by all surgeons. It is almost impossible to estimate the
number of lives saved by this operation, but it is very
great, and this operation forms an enduring monument
to the fame of these American physicians.
In 1844, John Watson performed oesophagotomy for
the relief of organic stricture of the oesophagus, and in
1886, Richardson demonstrated the accessibility of the
entire length of the oesophagus by digital examination,
either by gastrotomy or oesophagotomy.
In 1823, Milton Antony removed a diseased rib and a
large portion of lung tissue, and evacuated a lung abscess.
This is one of the first operations upon the lung.
In the surgery of the eye, much has been accomplished
by specialists, but they have done very little original
Work. The revival of old operations, the improvement
in the technique of existing ones, and the magnificent
results obtained by Agnew, Noyes, Knapp, Bull, Loring,
236 NEW YORK STATE MEDICAL ASSOCIATION.
Kip, Callan, and Roosa, characterise this department of
Surgery.
The introduction of cocaine as an anaesthetic, by
Koller, then of Vienna, but now of this city, is one of the
most important discoveries of the century, as is also Dr.
Leonard Corning's remarkable discovery of a method of
prolonging the cocaine anaesthesia, by making pressure
in such a way as to retain the drug within prescribed
limits. The discovery that water may act as a local
anaesthetic, was made in 1885, by Halsted, of Baltimore.
In the surgery of the ear important work has also been
accomplished. The removal of the ossicles by Sexton
and Burnett, the removal of the stapes by Blake, the
operation for correction of prominent auricles, by Keen
and Monk, the invention of the artificial leech by Bacon,
and the operation of trephining the mastoid cells, as per-
formed by Crosby, Alfred Post, Agnew, Buck, Knapp,
Roosa, Gruening, and Pomeroy, are among the chief
Operations.
In the surgery of the nerves the work performed by
Americans is most commendable. In 1869, Warren,
of Baltimore, excised the head of the humerus to re-
lieve severe brachial neuralgia produced by pressure
of the dislocated head upon the plexus. In 1876, Mears
subcutaneously divided the humerus, and thus produced
a false joint. In 1871, Sands excised a piece of the
brachial plexus for the relief of persistent neuralgia
of a traumatic character. In 1856, Carnochan excised
the second branch of the fifth cranial nerve beyond
Meckel’s ganglion, for the relief of tic-douloureux, and
two years later, Pancoast performed the same operation
in the pterygo-maxillary fossa. In 1863, Gross removed
the inferior maxillary branch of the same nerve. In
1873, Morton dissected out the perinaeal nerve for in-
tense neuralgia of the parts to which it is distributed.
This same operator cut out nearly two inches of the
Sciatic nerve to relieve elephantiasis, in a patient upon
whom he previously had performed Carnochan's Oper-
ACHIEVEMENTS OF AMERICAN SURGERY. 237
ation of ligation of the femoral artery. S. W. Gross,
for the first time in the history of surgery, excised nearly
two inches of the spinal accessory nerve, and performed
tenotomy of the sterno-cleido mastoid muscle, to cure
torticollis. In 1870, Dr. Sayre pointed out the relation
between paralysis and peripheral irritation as observed
in congenital cases of adherent prepuce.
The telephone is an American invention, which has
been applied to practical surgery. The author reports a
case of an intubation-tube which had by accident fallen
into the trachea, and which was removed by him, as soon
as the lodgment of it was made certain by the telephone
needle-probe devised by Girdner, of this city.
Amputations.—In this department of surgery, America
has nothing of which to be ashamed. She has not only
taken the initiative in the more important amputations,
but she has perfected methods devised by eminent sur-
geons in other countries. The first successful primary
amputation at the hip-joint was performed by a Kentucky
surgeon named Brashear, in 1806. The amputation was
successfully repeated by Mott, in 1824. Nathan Smith,
in 1824, was among the first, if not the first, to success-
fully and systematically amputate at the knee-joint, and
the technique of this operation has been perfected by
Markoe and Stephen Smith, of this city. The first suc-
cessful amputation of the ankle-joint in this country was
performed by Gross, in 1851. The operation had been
performed in 1842, by Syme, in Scotland. The first sys-
tematic amputation at the shoulder-joint was performed
by Richard Bayley, in 1762. The same operation was
also performed by John Warren, in 1781. The first suc-
Cessful amputation of the arm, with the clavicle and
Scapula, was performed by Dixi Crosby, in 1836. Amos
Twitchell and MacClellan performed the same operation
Successfully in 1838. Triple simultaneous amputations
have been successfully performed by Ashhurst, Ruckie,
Stone, Reid, Koebler, and others; while Wallace has
Successfully performed a quadruple amputation. These
238 NEW YORK STATE MEDICAL ASSOCIATION.
are among the curiosities of surgery, and illustrate the
preservation of human life, in face of the greatest danger.
Thus it is evident that American surgery has not only
taken the initiative, but has successfully performed many
of the major amputations; and when the number of them
is considered, what has been left for other countries to
claim in regard to this special field of operative surgery'.
In the invention of prothetic apparatus, the ingenuity
of the American mind has discovered a most wonderful
field of operation, since in no country can be found the
mechanism displayed in the aluminum manufacture of
artificial limbs. I know of patients who can walk well,
and even run, with two artificial limbs, and of one with
artificial hands, who is employed as a pharmacist, and is
able to weigh medicine on the most finely adjusted
balance.
Staphylorrhaphy was performed by Dr. John C. War-
ren, in 1820. The same year, it is just to state, the oper-
ation was performed in France, by Roux, but Warren had
no knowledge of Roux's method. It has been also stated
that this operation had been previously executed in
Poland; but no authentic statement is extant as to who
the surgeon was, or at what place or time the operation
was performed. -
Myotomy of the masseter muscle was first performed
by Schmidt, of New York, and he was followed by Mut-
ter, of Philadelphia. Both of these operations preceded
the work of Dieffenbach and Fergusson.
Excision of the tonsil was placed upon a safe and per-
manent basis, by Dr. Cox, of New York. This surgeon
invented, in 1820, an instrument which included the ton-
sil in a ring, and then cut it by a ring-shaped knife.
The guillotine principle, applied to the tonsillotome, was
an improvement upon this instrument. Previous to 1820,
the method of Desault was in vogue. This consisted in
tying off the tonsil, and permitting it to separate by a
process of Sloughing, which occupied six days.
The evolution of the present guillotine tonsillotome is
ACHIEVEMENTS OF AMERICAN SURGERY. 239
one of great interest. Dr. John C. Warren, of Boston,
about 1835, attempted to remove the tonsils of Mr. Caleb
Eddy's boy, and the instrument worked so unsatisfac-
torily that Mr. Eddy remarked to Dr. Warren, at the
completion of the operation, that this crude instrument
was “Sullivan’s Machine,” and that he would make one
for him, better adapted to the purpose. In order to ap-
preciate this terse and sarcastic remark, it is necessary
to recall some historical facts.
In the old Salem canal, the grass grew so luxuriantly
that it impeded the progress of the slow canal boats; and
Mr. Sullivan, the superintendent, devised a machine,
known afterward as “Sullivan’s Machine,” which con-
sisted of a sort of Scythe, which was set upon a frame,
and attached to the stern of the canal boat. As the
canal boat was hauled through the waterway, the grass
was supposed to be cut by the blade swung from the
stern of the boat. As a matter of fact, the grass was
simply pushed down in front of the knife, instead of
being cut by it.
Mr. Caleb Eddy, appreciating the mechanical defects
of this cutting apparatus, suggested placing the knife at
an angle, and then the grass was cut down as the boat
Was dragged through the canal. The guillotine tonsil-
lotome of the present day owes its efficiency to this in-
cident. I have been very much surprised to find how
many Surgical instruments have had a similar origin.
The American mind is wonderfully prolific in invention,
and has adopted, improved, and perfected many a sur-
gical instrument from the mechanics of every-day life.
In the departments of the throat and nose, American
Surgery has accomplished excellent results. The opera-
tion for the relief of catarrh by the use of the saws in-
Vented by Bosworth, and by Bucklin ; the removal of
polypi by the snare, devised by Jarvis ; Curtis's method
of curing nasal stenosis by the nasal trephine; the im-
provement of Elsberg's forceps by Beverley Robinson, all
deserve the highest commendation. In 1866, Cheever, of
240 NEW YORK STATE MEDICALL ASSOCIATION.
Boston, was the first surgeon to remove a carcinomatous
tonsil by an operation through the neck. The work of
Bosworth, Lincoln, Delavan and Chapman in this depart-
ment, also deserves special commendation. Tiffany, in
1878, removed successfully a naso-pharyngeal polypus,
by first depressing temporarily the two upper jaws,
having performed a prophylactic tracheotomy.
The operation of intubation is one that reflects great
credit upon American surgery. The dyspnoea of laryn-
geal stenosis depending upon the pressure of a pseudo-
membrane, or a stenosis the result of a chronic inflam-
matory thickening, are relieved by the introduction of a
tube through the mouth into the larynx. This is not the
place or the occasion to enter into the merits or demerits
of intubation of the larynx as compared with trache-
otomy; suffice it to say, that the awful dyspnoeal dis-
tress among children suffering from croup or diphtheria
has been in a large measure relieved, and the mortality
of the operation, based upon 806 cases, is 27.4 per cent.
This mortality is the result obtained from a list of the
cases furnished by many operators, while individual
operators have obtained as high as thirty-eight per cent.
of recoveries. Few can realise the wide-spreading in-
fluence of this operation for the relief of one of the most
dreadful of diseases. To Dr. Joseph O'Dwyer the en-
tire profession owes a debt of gratitude. “The perse-
verance, ingenuity, and originality shown in perfecting
the method merit our admiration.” Finally, I heartily
indorse the Sentiment expressed by Dr. Ingals, and join
“in acknowledging the nobleness of the profession at
large, which tolerates no secret method, but generously
donates to mankind every improvement in the healing
art. Among the latest, but not the least, may be classed
intubation, rightly considered as one of the great ad-
vances of medical discoveries.”
In considering this great discovery and invention by
Dr. O'Dwyer, the long list of brilliant operators who
have perfected and demonstrated the success of the Oper-
ACHIEVEMENTS OF AMERICAN SURGERY. 241
ation, deserve recognition, among whom may be men-
tioned Dillon Brown, who has intubated six hundred and
sixty-eight cases, with a little over thirty per cent. Of
recoveries; Waxham, Huber, Eichberg, Montgomery,
Gay, McNaughton, Pyne, and others, who have per-
formed many intubations with brilliant success.
In the investigation of malignant tumors American
surgeons have displayed great ability. The early work
of Warren, of Boston, was among the first attempts to
systematically collect and study neoplasms from a clinical
point of view. The writings of Gross upon tumors de-
mand more than a passing notice, while the contributions
of Shrady and of Mudd to cancer of the tongue, are most
exhaustive. The results after operation for carcinoma of
the breast, afford an example of what has been accom-
plished in this country, for the permanent recoveries have
now reached over thirty per cent., while fourteen per cent.
represents the best results in Great Britain. In sarcoma
the results are even more favorable. J. Collins Warren’s
method of examining a part of a tumor before operation
by his special instrument, is most useful and ingenious.
The work of White, in the surgery of the spinal cord, of
Watson, in concussion of the cord, of Westbrook, in
tapping the ventricle of the heart, of Gerster, Pilcher,
and Fowler, in the perfection of antiseptic technique, of
Dawbarn, in hypodermatic injection of serum in large
blood-vessels, as a substitute for transfusions—all de-
Serve special commendation. The writings of Agnew
and Ashhurst, which have widely disseminated surgical
literature, the investigations of Jarvis White upon the
Subject of asymmetry of limbs, the work of Yale, in
tuberculosis of joints and bone, and of Ranney, in the
ºy of the nerves, also deserve most honorable men-
lC)11.
In plastic surgery, American operators have been most
Successful in their work. The formation by Pancoast of
a nose from the forehead, by the modified Indian method,
the building of a nose from the phalanx by Sabine, and
16
242 NEW YORK STATE MEDICAL ASSOCIATION.
the treatment by Mutter of cicatrices after burns, are all
operations illustrating the versatile genius of the Ameri-
can mind. The plastic surgery of the mouth has been
advanced by Goodwillie, whose results in this depart-
ment of surgery have been presented to the profession.
In the invention, perfection, and manufacture of Surgi-
cal instruments, America eclipses the world. It was my
intention to collect for the purposes of practical demon-
stration, a sample of every surgical instrument invented
and made by Yankee ingenuity; but I was informed that
Over One hundred thousand dollars would not cover the
expenses of such an outlay. I have, therefore, been
obliged to abandon that project in full, and have arranged
to show as many as possible of the modern instruments
of purely American invention, in order that the members
of this Association can form some general idea of the
credit to which our country is entitled for their share in
the armamentarium of the surgeon. It is certainly a most
praiseworthy fact, that there is no operation in all Surgery
which cannot be performed by instruments invented in
this country and manufactured by American artisans.
This statement embraces a wide field, and an examination
of the array of surgical instruments will convince anyone
of the correctness of this opinion. It is but a short time
since the French imported surgical instruments were
almost a necessity; but nowadays the most perfect and
precise instrument is made in our own country, with
steel which eclipses that of any other nation. For work-
manship, for precision, for lightness, for durability, for
strength and beauty, the work of American artisans is
superior to those of any other country.
The impartiality of our countrymen has enabled us to
seize upon the best from wherever it emanates. Ameri-
can surgeons have gleaned the harvest from all nations.
During our colonial days, Great Britain and France were
foremost in the achievements of surgery, but their feelings
of hated rivalry and national jealousy precluded the pos-
sibility of their adopting anything good from one another.
AOHIEVEMENT'S OF AMERICAN SURGERY. 243
In late years, this same spirit pervaded France and Ger-
many. The want of reciprocity has hindered the advance
of surgery in both of these rival nations. As an illustra-
tion of this statement, I may cite the fact, that in 1823,
the writings of the great French surgeon Desault had
not yet been translated for the use of English surgeons,
while at that time, Dr. E. D. Smith, of South Carolina,
was engaged in the translation of this work for the ben-
efit of American surgeons. In the great triangle of
nations, formed by England, France and Germany, the
good of each remained within its own domain. America,
on the other hand, eagerly seized upon all the good from
these and other nations, and she appropriated to her own
use all principles, theories, discoveries, inventions, and
knowledge, and utilising these factors, she has made her
onward march illustrious.
With the wonderful adaptability of the American mind,
with its easy susceptibility in its early plastic condition,
these impressions have been made, and their results in
surgery are as enduring in their potential influence, as
the ocean which separates us from the Old World.
Finally, gentlemen, this brief review of the early and
present achievements of American Surgery, demonstrates
the fact, that our country has nothing of which to be
ashamed in estimating her share in the evolution of this
great science. Our contributions to surgery, in general,
are now matters of record for the study of all nations.
If what America has accomplished in the past be elimi-
nated from the sum total of the surgical work of the
World, there is little left to the older nations.
There are many things which explain the prominent
position which America has taken in the consummation
of this great work. Chief among them may be men-
tioned the innate courage which our Puritan ancestors
DOSSessed. The same undaunted bravery which spurred
the Puritans to cross the great unknown ocean, and to
Settle in the primeval forest for the purpose of exercising
their liberty, stirred them to great efforts on behalf of
244 JNETW YORK STATE MEDIOAL ASSOOIATION.
Surgery, and made them fearless and bold. The self-
reliance of the early settlers in this country, and their
manly independence were characteristics necessary to
win Success in the art of surgery, without which Ameri-
can Surgery would never have obtained the high place it
now holds in the estimation of the civilised world.
MEMORANDA, PRACTICAL AND SUGGESTIVE.
By H. D. DIDAMA, M. D., of Onondaga County.
November 16, 1892.
(a) EARLY ASPIRATION IN PLEURITIS.
Many cases of pleuritis, especially of the dry form,
where the quantity of effusion is small, get well with
little or no treatment. The patients, in these instances,
are usually blessed with excellent constitutions, and a
habitual vigor, which is elastic. In other cases, where
the attack is more severe, recovery also occurs under the
use of cathartics, diuretics, sudorifics and blisters, with
Or without total abstinence from water or other bever-
age; but convalescence is tedious, and recovery often
incomplete. Furthermore, in a large percentage of cases,
the therapeutic management just indicated fails entirely
to Secure a favorable termination, so that the thoughtful
medical attendant is sometimes perplexed to determine
whether the unsatisfactory course is due wholly to the
malignancy of the disease, or in part to the imperfection
of the treatment.
The consensus of modern medical opinion, as expressed
in books, is that after giving the remedies a fair oppor-
tunity, and a reasonably generous time to secure the
absorption of the pleural effusion, if the desired object is
not accomplished, or if the amount of the transudation
rapidly becomes so great as to imperil the life of the
patient, the effusion should be partially removed by the
Operation of peracentesis. The limit of this probation-
any period, and the danger-symptoms and signs which
should be manifest before instrumental interference is
justifiable, are variously set forth by different authors.
If the flatness on percussion does not extend well above
the nipple, and if dyspnoea be not very severe, ten days,
246 NEW YORK STATE MEDICAL ASSOCIATION.
to four or more weeks, would fairly cover the period
of waiting and watching proposed by conservative
experience. . -
For several years, a minority of physicians, including
the writer, have pursued a different course, with more
satisfactory results. They do not regard active cathar-
sis, diuresis, or diaphoresis as an essential or important
part of the treatment. Anodynes and strapping are em-
ployed while the pain is severe, and tonics, such as qui-
nine, iron, and strychnine, are administered, if the patient
—as he often, and she usually—is in a weak condition ;
and then, when with mitigation of pain, and some sub-
sidence of fever, percussion shows that fluid is present,
even if the amount does not exceed an estimated half-
pint, aspiration is performed.
The diagnosis is verified, and the depth of the trocar
puncture determined, by the hypodermic needle ; clean-
liness of skin and instruments is secured; and the oper-
ation, at this early period, is done while the patient is in
a sitting posture. No effort is made to leave a portion
of the effusion to be removed by absorbents. As a rule,
which has scarcely an exception in the practice of the
writer, a repetition of the operation is not needed ; the
lung expands, normal respiratory sounds reappear, and
the friction fremitus returns with exaggerated distinct-
ness. More or less pain or discomfort is felt in the af-
fected side, but convalescence is rapid and unattended
with great prostration, and the recovery is complete.
The experience of the writer has been reasonably exten-
sive. He has had at least forty original cases, where he
has performed aspiration early ; and the outcome has
been such that he has no inclination to resort to any other
treatment now known to him. He has been called to a
considerable number of cases where a diagnosis of a hep-
atised lung, or enlarged liver, or malign tumors had been
made, and also in consultation to several cases where an
early and correct diagnosis had been made, and the most
vigorous antiphlogistic and eliminative treatment had
MEMORANDA, PRACTIOAL AND SUGGESTIVE. 247
been pursued from the outset. In these cases, and in
these only, has he found the cautions laid down by the
authorities important.
In some instances, the lung, crowded or retracted to
the upper part of the chest, had become imprisoned by
adhesions, and even carnified, so that it could not expand;
while the heart was pushed or drawn over, so that its
pulsations were palpable and visible at the right of the
sternum. Only a portion of the fluid could be removed
without exciting violent fits of coughing, and not unfre-
quently, after a few days, a repetition of the operation
was demanded. In a few instances, where some of the
patients were young and previously healthy, pyothorax
was present, apparently, because an early operation had
been performed, owing to the reliance on authorised
medication, or because a faulty diagnosis had been made.
The supporting and alleviating treatment of pleuritis,
combined with early thoracentesis, seems to possess the
following positive and negative advantages: It is easily
and safely done ; it does not add to the local inflamma-
tion, but actually relieves and shortens it ; it is not
debilitating ; it removes, in a few minutes, a quantity of
fluid which could not be removed through the skin, kid-
neys, and bowels in many hours, days, or even weeks;
and it does all this without causing weakness and slow
recovery ; it prevents that carnification of the lung, and
those tender adhesions, which in late aspirations eventu-
ate in deformity of the chest, and haemorrhage into the
pleural cavity; it prevents congestion of the lung on the
unaffected side, and injurious dilatation of the right ven-
tricle; it probably secures exemption from empyema
In many cases; and, if it be true (as some active writers
vehemently claim) that every case of pleuritis is tuber-
cular, then this treatment, like the prompt removal of
the fluid in tubercular ascites, is decidedly the most
efficacious in preventing or arresting general bacillary
infection. In short, it averts death, and safely, easily,
Promptly and permanently cures the patient.
248 NEW YORK STATE MEDICAL ASSOCIATION.
(b) MINERAL WATERS, CRUDE AND REFINED.
An examination of the analyses of the various mineral
waters of the United States, and elsewhere, seems to
warrant the following statements:
1. Many of the waters, like those of Saratoga, Carls-
bad and Crab Orchard, contain a cathartic salt in such
quantity that from half a pint to a quart of the beverage
will act as an efficient laxative. One excellence of these
purgatives, is that they can be taken daily for an in-
definite period without injury.
2. The activity of a salt designed to move the bowels
is much impaired by excessive dilution. A Saline Solu-
tion, whose specific gravity is less than that of serum,
passes largely by Osmosis into the blood and out through
the kidneys, instead of drawing water from the circula-
tion and acting as a laxative.
3. Many, indeed most, of the really valuable natural,
crude, mineral springs contain ingredients which in
Quantity or quality are detrimental. The famous
Sprudel spring, and many others, whose active principle
is Glauber's Salt, have too large a percentage of lime.
The Saratoga waters possess too much sodium chloride,
as well as calcic salts. The aqueous beverage now
indulged in by Syracuse people at home (soon to be
displaced by the sparkling and bright Skaneateles Lake
water) is decidedly hard, but it contains only two and a
half grains of lime salts in a pint, while the Congress
and Hathorn contain respectively more than twelve and
fourteen grains. Apropos of these waters, it may be re-
marked, that the Congress has nine grains of carbonate
of magnesia, and fifty grains of common salt in a pint,
and the Hathorn has but three more grains of the mag-
nesium salt and thirteen grains more of the sodium
chloride; yet the genial and reverend Theodore Cuyler,
who summers at a sanitarium in Saratoga, ventures the
assertion, that “Hathorn water is as pungently drastic
as high Calvinism ; but the Congress Spring has a some-
MEMORANDA, PRACTIOAL AND SUGGESTIVE. 249
what milder quality—about like the modified Calvinism
recommended by the Revision Committee. Congress
water is about the right thing after all for a regular
morning potation.”
4. An ideal, artificial, refined mineral water, which
shall not contain objectional ingredients, and which shall
possess, in a concentrated form, all desirable qualities at
a reasonable price, can be manufactured by any capable
chemist.
Lithia Springs contain the material from which their
name is derived, in such minute quantity, that a person
must imbibe one or two gallons of the water to obtain a
medium dose of the medicine. The Virginia Buffalo
Lithia Springs have but two grains of lithium salt,
and thirty-nine grains of lime, in a gallon ; while an
artificial lithia water (called, funnily enough, “Hudor
water”) contains sixty grains of lithia in a gallon, with
all useless and faulty substances left out. So that this
One gallon, therefore, of this artificial product is equal
to a barrel of the Virginia water, when lithium is required
Or desired, and is immensely superior to the crude
natural variety.
5. But it is well enough to remember that no salt
of lithium is equal in its solvent power over uric acid
to the same quantity of citrate of potassium.
6. Waunted Springs which, like the Poland, and
Others, contain hardly any appreciable amount of any
mineral (the Poland having a total of about three grains
to the gallon, two-thirds of this being lime and silica)
may still be beneficial if used in the enormously large
Quantities directed and urged by their proprietors.
Their location may be where the air is invigorating and
germless; where the weary invalid is liberated from the
Care of business, relieved to some extent of the deceitful-
neSS-certainly of the plethora—of riches, and flushed
out every few hours with an amount of fluid for which
he never dreamed he had a capacity. Divesting himself
of prejudice, he would probably find that an equal quan-
250 NEW YORK STATE MEDICAL ASSOCIATION.
tity of pure water at home would (so far as the water is
concerned) be equally beneficial; and it is well to con-
sider that the pecuniary condition of the average patient
will not allow the luxury of a distant journey, and a
board bill of five dollars a day.
7. The notion that the natural heat of the earth
imparts to water any virtue which could not be derived
from solar or stove heat, has no scientific or experimental
foundation. Watrium iodidum is known to be a potent
weapon in the armamentarium of the Hot Springs medi-
cine-man.
The writer has never sent a patient to the National
Calidarium, but he has treated with satisfaction several
who have returned unbenefited from that popular, but
Somewhat compromising resort.
(c) COUGHING MADE EASY IN BRONCHIECTASIS.
A few years ago, at Skaneateles Junction, there
resided an old lady who had been for many months
troubled with a cough which her friends regarded as
consumptive. The cough was severe enough at all times,
but twice or thrice in twenty-four hours, there were
violent, long-continued paroxysms, attended with copious
and extremely foetid expectoration.
I recognised, as you all would, bronchiectasis. The
patient had not derived much benefit from the cod-liver
oil and numerous cough medicines which she had taken
faithfully in great abundance. Her appearance did not
denote the existence of tuberculosis ; and, under a
change of treatment, relief was afforded, the paroxysms
ceased, and the offensive odor disappeared.
Recently, Mrs. H., of C., about thirty-five years of
age, came under my observation. She had had bronchial
catarrh for a year and a half, and a few slight haemor-
rhages. After a time, the cough became paroxysmal, and
during these violent fits, which lasted without sensible
mitigation from sixty minutes to three hours, the copious
MEMORANDA, PRACTICAL AND SUGGESTIVE. 251
expectoration was so offensive that the windows had to
be kept open. The disease was thought to be tubercu-
lous, or cancerous ulceration, or gangrene of the stomach;
for vomiting was of frequent occurrence, and the odor of
the vomited material was also, as the patient expressed
it, “enough to knock anybody down.”
At my first visit, the patient was found weak and ema-
ciated, but without the tuberculous or cancerous facial
expression. The scent of the expectoration fairly justi-
fied the description given. The history showed that
enough food was taken, but that two or three times a
day it was all vomited, and that these vomiting spells
coincided with the severe spells of coughing. There was
some diarrhoea, but the odor of the alvine discharges
was entirely unlike that of the vomited material. There
was no gastralgia, and no tenderness in the epigastric
region. The diagnosis, of course, was uncomplicated
bronchiectasis, and the rationale of the symptoms was
Obvious. If the stomach had been involved, the stools
Would have possessed the peculiar odor of the sputa.
Nausea and vomiting, which were excited by the violent
Coughing and the repulsive smell, increased mechani-
cally the amount of the putrid material expectorated,
and this, mingled with the ejected food, perfumed the
Whole mass, and led to the mistaken diagnosis of gastric
ulceration or gangrene. -
Proper explanations were made, and encouragements
given to the intelligent patient, and a therapeutic plan
Was instituted, which included tonics of iron, strychnine,
Venice turpentine, Santal, et cetera, and the use, with a
Steam atomiser, of a deodorising spray.
Perhaps the most important element in the treatment
of this case, and the one at the Junction, was the
emphatic and iterated direction to cough downwards.
The usual and proper information was given to the
patient, that a pocket was formed in the tubes of the
lungs, and that when this pocket became filled and run-
ning over, as it did two or three times a day, the
252 NEW YORK STATE MED TO AL ASSOCIATION.
unpleasant and irritating material caused the terrible
fits of coughing. The walls of the pocket, it was further
explained, were so thick, that even the most violent and
long-continued attacks could not compress them enough
to empty the pocket entirely, and so a portion of the
putrid matter remained to contaminate future collec-
tions. Now by lying in bed, or on the lounge, the
patient was told, with one hand on the floor and the
head almost reaching there, the pocket would be
inverted, and the fluid would run out almost of itself,
and its expulsion would be hastened by a short spell of
coughing. The direction was given not to wait until
the pocket became wholly filled again, but to anticipate
this period by inversion four or five times daily.
The injunctions were obeyed; the result was favorable.
In five minutes, the pocket was emptied more com-
pletely than when she had formerly “coughed her head
off” for an hour or longer; the odor disappeared,
vomiting and diarrhoea ceased, the flesh came back; and
to-day, with the exception of a slight cough, and a few
mucous râles in the left infra-axillary region, the grate-
ful patient, who rides twenty miles to town every two
weeks for inspection, is decidedly convalescent.
It is proper to add, that the idea of coughing down
hill was derived from a small pamphlet, published nearly
fifty years ago by the poet N. P. Willis, who claimed
that he had cured himself of consumption by this origi-
nal device, and by horseback exercise. In all proba-
bility, his supposed consumption was bronchiectasis, but
his suggestion is none the less valuable ; and the writer
of this paper has known great, even if temporary,
relief and comfort to be obtained by this gravity treat-
ment, in cases of phthisis, when large cavities, and
excessively annoying coughs existed.
Only a week before this annual meeting, I was invited
to See a patient who had a cavity in the right infraclavic-
ular region, capacious enough to hold a teacupful of muco-
pus. He discovered that, while lying on his right side, he
MEMORANDA, PRAOTICAL AND SUGGESTIVE. 253
could sleep three or four hours with but little disturb-
ance, but that if—after this period of repose—he turned
upon his left side, a brief fit of coughing ensued. If he
attempted to sleep, lying on his left side, the cough was
incessant, and the Sputa Only moderate in amount.
Every one present can see without explanation, that
while in one position the Secretion accumulated, exciting
in the nerveless pocket little or no cough, till the reser-
voir was filled, and that on turning over, the irritating
material ran out by gravity into the sensitive bronchi,
and produced an easy cough, sufficiently prolonged to
secure thorough evacuation; in the other position, on
the left side, there was a continual dripping from the
abscess cavity, and a wearing cough which banished
sleep. Two mornings ago, as I learn, the patient, after
a prolonged sleep, which lasted all night, turned upon
his left side. The large amount of pus which had been
permitted to accumulate during this long period, poured
out suddenly into the tubes, and produced strangulation
and almost instant death.
It is respectfully submitted that this facilis descensus
treatment might be so beneficial in some cases of real or
Supposed gangrene of the lung, communicating with a
bronchus, that pneumonectomy might be unnecessary.
(d) THE INSURANCE SPONGE.
The Sponge is an animal; that question is settled; the
Vegetarians have ceased to claim it. Like the vanquished
party in the recent presidential contest, they surrendered
reluctantly, but they surrendered. “In its simplest
form,” so the naturalists inform us, “the sponge is
homologically a single animal with the internal structure
and function of a colonial organisation.” There are many
Varieties of sponge: the spongia equina is the horse sponge
of the bath-room; the spongia dura is the hardhead found
in America; the cup sponge and glove sponge are fine
Species used in surgery. All these are marine varieties.
254 NEW YORK STATE MEDICAL ASSOCIATION.
“None of them seem to be truly parasitic—that is,
capable of living upon the substance of other animals.”
But there are land sponges. These also are single
animals, with the structure and function of organised
colonies. Unlike the sea sponges, these land lubbers are
truly, and with emphasis, parasitic, that is, they do
actually live upon the substance, the juices, the circula-
ting medium of other animals.
The tramp is a Sponge—a combination of Spongia dura
and spongia eſ/wina. He has facial petrifaction united
with the peripatetic propensity of the walking delegate.
A sponge possesses the property of enormous absorp-
tion and retention ; but of its own volition it disburses
nothing. Firm compression is necessary to secure dis-
gorgement. Spongia cerebriform is is a common enough
species, but Spongia corda—the sponge with a heart—is
an exceedingly rare, but not inconceivable variety.
This, by natural gradation, brings us to the subject
under consideration.
A Life Insurance Company is a sponge. It belongs to
the family of octopeda or millipoda. It has a head-
centre ; grasping arms, which extend to immense dis-
tances; agents as suckers; and medicine-men as ten-
tacles or feelers. Through its agents it sucks into its
colonial meshes such an enormous surplus of nutriment,
that it permits its chief sucker to retain fifty per cent. of
the premium blood drawn from the veins of each newly
captured victim ; while its corpulent head-centre ap-
propriates an amount of this same vital fluid, which, if
transmuted into coin, would equal from ten thousand to
Seventy thousand ducats annually.
The tentacles decide as to the sanitary condition of the
victims. They receive scanty pabulum for their services,
which are, or should be, of the greatest value.
The judgment of other medical men (especially those
of recognised prominence) as to the ability and fitness of
the tentacles, is constantly sought by the head-centre.
The opinion desired may be of immense importance ; it
MEMORANDA, PRACTICAL AND SUGGESTIVE. 255
may ensure success, or ward off disaster; but the insur-
ance octopus Sponges the Opinion ; he disgorges no
ducats; he emits not even a worthless thank.
He propounds, in a circular, a series of questions as
to the age of the tentacle whom he purposes to employ,
when and where he was educated, his qualifications as a
diagnostician, the acuteness of his senses, especially his
hearing, the amount of his business; his shrewdness, his
mental and moral integrity, his ability to resist the
allurements of the willing victim, and the anxious
sucker ; his social and professional Standing ; and then
he craftily pretends that the valuable time spent in
answering fully these and many more Searching questions,
is for the sole benefit of the proposed tentacle ; while
at every moment he knows that the pretense is a false
one, and employed. Only to excuse Sponging the wished-
for information from the meek and complaisant physician.
More than this. He is guilty of the contemptible
meanness of promising that if the friendly tentacle shall
be maligned and betrayed, the gratuitous betrayal will
be guarded sacredly as “confidential.”
In the good time coming, slowly coming, some insur-
ance millipod may, by evolution or compulsion, emerge
from his spongy condition. Then he will send with his
circular questions, not only the generous two-cent post-
age Stamp, but a suitable fee for careful answers ; then
he will frankly acknowledge the truth, that the infor-
mation sought is for the protection of the organisation ;
then he will be independent enough and shrewd enough
to proclaim, that whatever other associations may sneak-
ingly do, his company is able and willing to pay, and
actually does pay, for all services rendered.
When this salutary transformation shall have been
effected, the busy doctor will no longer throw, with
resentful disgust, the insurance circulars into the waste
basket; but he will regard himself as the compensated
agent of a cordate and honorable association, which
deserves respect and success, and whose interests he will
gladly seek to promote.
ACUTE PLEURISY.
By FRANK S. PARSONs, M. D., of Northampton, Mass.
November 17, 1892.
The intelligent classification of an inflammatory affec-
tion of a serous membrane, and especially of the pleura,
is not an easy task. The terms “acute,” “subacute,”
and “chronic,” which have been applied to diseases of
that nature, are often subjects of much criticism, no
matter from what pathological lesions, or symptomatic
indications, they may be derived, and I can only hope that
I shall not fall into the common error of making them
more intricate.
The term acute pleurisy indicates an inflammatory
condition of the serous membrane lining the pleural
cavity, in which the height of the disease is attained in a
few days, ten at the most, and accompanied by an appre-
ciable rise in temperature.
It may be dependent on pre-existing disease or lesions,
or it may be an idiopathic disease.
Pathology.—Hyperaemia, or congestion of the blood-
vessels within the serous and subserous connective tissue,
causing swelling, redness, and oedema of the pleura, is
the first noticeable lesion of acute idiopathic pleurisy.
This congestion may be at first localised, and rapidly
extend, or it may, from the first, be quite general. Soon
the smaller and weaker capillary vessels rupture, pro-
ducing ecchymosed spots over the membrane, and, at
the same time, infiltration of the subserous connective
tissue occurs, with proliferation and detachment of
epithelial cells.
As the process progresses, the pleura appears studded
with fine granulations, in which appear embryonic cells.
A CUTE PLEURISY. 257
These tend to organise the newly formed connective
tissue into firm fibrinous bands, which are often found
stretching across the pleural cavity, in old cases, and
which constitute the so-called neo-membranes. Finally,
the congested serous membrane pours out a fluid,
resembling in all respects the plasma of the blood except
that it is more dilute. Red blood corpuscles and leuco-
cytes are to be found in the liquid, but in simple sero-
fibrinous pleurisy, the red globules are not in sufficient
numbers to cause any marked discoloration.
“Inflammation,” says M. Germain Sée,” “is a struggle
for life and not a destructive process; it is essentially a
vital phenomenon eminently reactionary against a mor-
bid agent.” He believes that micro-biology teaches that
inflammation is a strongly exaggerated physiological
process, a general struggle of the Organism against
microbic invaders. “The first step in this process,”
says he, “is leucocytosis, or the exaggerated production
of white blood corpuscles in the blood; and the second,
called phagocytosis, is the absorption and destruction of
micro-organisms by these leucocytes, showing the de-
fensive action of the latter.
The French supporters of the germ theory of disease,
believe that when microbes have penetrated the organ-
ism, the leucocytes increase, and that the condition
which brings them to the blood, carries them to the
point of excitement.
In acute inflammations there are three stages of de-
Velopment: first, vascular dilatation ; secondly, activity
and proliferation of endothelium ; thirdly, exudation,
With diapedesis of leucocytes. As a consequence of these
three stages, it is claimed, a great afflux of phagocytes
takes place towards the point of attack, both in puru-
lent, as well as catarrhal inflammations.
, Purulence is considered no exaggeration of inflamma-
tion, but due primarily to the action of the streptococcus
or Staphylococcus; and, although great numbers of
* Bulletin de L'Académie de Médicine, May 10, 1892, p. 680.
17
258 NEW YORK STATE MEDICAL ASSOOIATION.
phagocytes may be found, their defensive action is much
harassed by their deadly enemy, the pus germs. We
may conclude from the foregoing, if we are to accept
this doctrine, that inflammation is a physiological
process to develop phagocytes against microbes.
Anatomically, the pleura is a great lymphatic Sac, con-
tiguous with the arterio-pulmonary system, and natur-
ally deriving its serosity from that source. According
to the eminent French teacher, M. Guerin,” “pleurisy
is nothing else than lymphangitis.”
“If one injects the pulmonary artery,” says Guerin,
“with colored liquid, it will be found that the liquid
will appear in the polygonal ramifications of the lym-
phatics of the pleura.” Moreover, he has practiced on the
cadaver, injecting bullocks' blood in the same manner,
and finds that he obtains a serosity from the pleura,
which, if much force be used in the process of injecting,
becomes bloody, or red in color. If, on the other hand,
he injects a colored liquid in a subject who has suffered
and died from pleurisy, there will be found no coloring
matter in the meshes of the lymphatics, except those
which have not been affected by the inflammatory pro-
CéSS.
If this be true, we can readily see that when from some
cause the lymphatics of the pleura become congested
and Swollen, and the natural channels for the lymph
impeded, an oedematous condition of the subserous con-
nective tissue will arise, due to forced diapedesis of the
Serosity, and will cause the fluid to ooze from all parts
into the cavity.
If, then, the lymphatic stoppage be complete enough,
and the force behind sufficiently strong, there will be
more or less diapedesis of red blood corpuscles also,
hence the haemorrhagic pleurisy.
If we find leucocytes in the lymphatic exudation, does
that not offer the best explanation of the formation of
pus :
* Bulletin de L'Académie de Médicine, April 26, 1892.
AOUTE PLEURISY. 259
It has been stated that the serosity of acute pleurisy
does not differ materially from the plasma of the blood;
if drawn off, it will coagulate, often spontaneously ; if
beaten or whipped, it will show a deposit of fibrin ; and
the constituents are the same as the plasma of the blood,
differing only in their relative proportions. From the
fact that the aspirating needle often becomes clogged
with fibrinous flocculi, it is argued by M. Lanceraux,"
that these flocculi clog the openings of the lymphatics,
and by the thrombi thus formed produce a mechanical
hindrance to the exit of the effused fluid. Hence, in
some cases, according to this author, “one must wait
for the disintegration and absorption of the clot, before
any diminution of the quantity of the fluid by nature
takes place.”
I can see no reason for the opinion held by some
authors, that every pleurisy is dependent on lesions of
pre-existing maladies, and especially on tuberculosis.
Aetiology.—In considering the causation of acute pleu-
risy, one must of necessity admit that from an aetiolog-
ical point of view there are two general classifications:
those which are and those which are not due to any pre-
existing disease. -
At the present day, there are many and diverse opin-
ions concerning the production of idiopathic pleurisy ; in-
deed, there are those who would go so far as to say that
all pleurisies are tubercular in origin, and, hence, second-
ary, but this seems to me to be going farther than our
pathological researches would warrant. I doubt not, if
the chests of many persons, who to-day are in good
health, and have never been aware of having had pleu-
risy, were opened, we would find various traces of old
adhesions and other lesions of former pleurisies. It
must be admitted, therefore, that neither the microbe
nor any other one causative factor, will account for all
Cases of acute pleurisy.
* Bulletin de L'Académie, de Médicine, May 31, 1892, p. 661, et seq.
260 NEW YORK STATE MEDICAL ASSOCIATION.
While it is difficult to state with certainty that pleu-
risy originates in perfectly healthy persons, because
latent pathological lesions cannot be appreciated, we
know that it does occur in persons who to all appear-
ances are in good health.
M. Sée maintains that the aetiology of acute pleurisy
is always due to microbes, and that cold is simply a
stimulus to the activity and development of the micro-
Organisms.
Netter” claims that all forms of pleurisy are of microbic
origin, but that the microbes producing them are of
many different kinds.
M. Bechamp" says: “Microbes do not have so much
importance in acute pleurisy as some would have them,”
and he is certain that pleurisy may exist independently
of tuberculosis, from the fact that although at the age
of thirty he was seized with acute pleurisy, and treated
by the usual bleeding, blistering, and purging, he is still
alive at the age of seventy-six, and has not developed
tuberculosis. Furthermore, in support of this, both he
and Dieulafoy state, that many persons live ten or fifteen
years, or even longer, after the operation of thoracente-
sis, and do not develop tuberculosis. That exposure to
cold has a tendency to excite inflammations, and with
them acute pleurisy, there can be no doubt ; but whether
it causes pleurisy directly through its influence on the
nerve centres, or whether it acts simply as a stimulus to
organised germs, through whose activity the disease
originates, is still a much mooted question.
M. Tresbot" does not doubt that acute pleurisy in
horses is the direct result of an exposure to cold ; and he
says: “Ordinarily there is nothing in common between
sero-fibrous pleurisy in the horse, and tuberculosis
and that it is impossible to class sero-fibrous
* Bulletin de L'Académie de Médicine, May 10, 1892.
* British Medical Journal, June 2, 1890.
* Bulletin de L'Académie de Médicine, June 7, 1892, p. 793.
* Bulletin de L'Académie de Médicine, May 17, 1892, p. 758.
AOUTE! PLEURISY. 261
pleurisy in the horse with an eruptive fever; or indeed,
with any periodic disease.” On the other hand, M. .
Lanceraux' asserts, that “pleurisy should be rightly
classed among the infectious maladies, and exposure to
cold is nothing but an occasional exciting cause.”
If we should accept the pathological views of M.
Guerin, already mentioned, we might easily explain the
congestion of the blood-vessels by peripheral irritation,
and reflex action of the vasomotor nerves from exposure
to cold ; but this would not explain why such excite-
ment should be directed to the pleura in particular.
In a paper on “The cause of syncope in pleurisy,”
M. La Borde” has shown by experiment on animals, that
it is possible to produce a sero-fibrous pleurisy in a few
hours, by the action of cantharidin injected into the
blood. This leads me to ask, Is the causation of acute
primary pleurisy ever governed by the ingestion of cer-
tain articles of food just previous to an exposure to
cold ; and would the combination of these two factors
be sufficient to direct the inflammatory action towards
the pleura ; Purulent pleurisies are originally of micro-
bic origin, or are secondary to other diseases. Age and
debility are also important factors in their production.
It is doubtful if simple sero-fibrous pleurisies ever turn to
the purulent form without outside interference.
Secondary pleurisies occur from a variety of causes,
mostly from diseases microbic in origin. While it may
be rare to have pneumonia occur without some localised
extension of inflammation to the pleura, it is doubtful if
a general acute pleurisy, secondary to pneumonia, will
be found without numerous pneumococci.
In the same manner, the causation of pleurisy, during
an epidemic of typhoid fever, influenza, malarial fever,
rheumatism, or kindred diseases, is undoubtedly due
to the same influences which govern the co-existing
disease.
*Bulletin de L'Académie de Médicine, May 8, 1892.
* Bulletin de L'Académie de Médicine, May 17, 1892, p. 709.
262 NEW YORK STATE MEDICAL ASSOCIATION,
It is well known that pleurisy of an acute type may be
Secondary to tuberculosis; but, there is considerable
difference of opinion as to the percentage of cases arising
from this source. M. Sée claims" that sixty-eight per
cent. of all pleurisies are due to this cause. This seems
high, or else persons entirely recover from tubercular
pleurisy more often than from any other form of tuber-
culosis. Dr. G. G. Sears reports” four hundred and
fifty cases of pleurisy, thirty-nine per cent. of which
developed tubercular disease. Others claim that not
more than twenty per cent. of pleurisies are of tubercu-
lar origin.
Symptomatology.—M. Lanceraux, and other French
observers, consider acute pleurisy to be a well-defined
cyclical malady,” because its lesions are always found
unchangeable, and its evolution is as constant as that of
pneumonia or typhoid fever.
It may be classified, according to its pathological
changes, into three periods of evolution : (1) A period of
seven days, at the end of which the effusion reaches the
limit of its advance; (2) a period of seven days during
which the pathological lesions and the amount of effu-
sion appear to remain stationary ; (3) from the fifteenth
to the twenty-first day of the disease, during which time
an absorption of the inflammatory products, and of the
effusion, occurs.
Of course these divisions cannot be made absolute, but
we may confidently expect, at the end of the first period,
in uncomplicated cases, that there will be no further
effusion of fluid.
Each of these three stages has its respective symptoms,
but there is no marked transition from one to the other.
In a majority of cases, the first period of acute pleurisy
is ushered in with a chill, a more or less marked rise of
temperature, and pain in the affected side.
1 Bulletin de L'Académie de Médicine, April 19, 1892.
* Boston Medical and Surgical Journal, Feb. 25, 1892.
*Bulletin de L'Académie de Médicine, May 3, 1892.
A CUTE PLEURISY. 263
The pyrexia will generally determine the intensity of
the inflammation ; the temperature seldom rises above
102° or 103°F. unless the pleurisy is secondary to Some
other disease. The pain is usually circumscribed, Sharp
and lancinating, and is increased on motion, So that
the respiratory movements are restrained as far as pos-
sible by the patient. A dry, hacking cough is generally
present, but the pain it occasions calls for efforts at its
suppression. After a few hours, when the effusion ap-
pears, the pain moderates, or disappears. The pulse is
generally firm, and between 100 and 120.
As the disease progresses, dyspnoea is often developed,
and is most commonly due to an abundant effusion, to
compression of the lung, or to displacement of the heart.
Oedema and congestion of the lungs, capillary bron-
chitis, and rheumatic difficulties sometimes Occasion
dyspnoea when very little fluid can be found in the
cavity.
Irregularity of the pulse and cyanosis are grave symp-
toms, largely dependent on displacement or weakness of
the heart.
Syncope may, also, be occasioned in various ways.
The reflex action of pain is one of its chief causes, as may
be shown experimentally by electrifying some peripheral
Sensory nerve. Again, when the fluid fills the pleural
Cavity, and is suddenly drawn entirely away, the reac-
tion which follows may cause syncope.
Physical Signs.—On inspection, there is restricted
motion of the affected side, dependent in the early
Stages on pain, and later, on the accumulated fluid. In
left side effusions, there is frequently displacement of
the heart beat to the right of the normal line.
On palpation, vocal fremitus is lost over the fluid,
and, if the effusion be large on the right side, the liver
may be felt to be displaced.
On percussion, we find, at first, dullness over the
lower posterior portions of the chest, then flatness, as
the effusion appears and advances. Above the fluid, the
264 JNETW YORK STATE MEDICAL ASSOCIATION.
percussion note remains dull, while at its level, and
below, it is flat. It will be remembered that the level of
the fluid is not a hydrostatic one, but from the elasticity
of the lung, the level assumes a shape resembling the
letter S. Over the sound lung the vesicular resonance is
more or less exaggerated. Dullness is apt to remain for
a considerable time after the effusion has been absorbed.
On auscultation, the respiratory murmur is enfeebled
or absent, for the same reasons and in the same progres-
sive manner as the loss of resonance on percussion occurs.
Friction sounds are sometimes heard at the beginning of
the disease, but are more common at the close of the
third stage. -
Treatment.—In considering the treatment of acute
pleurisy we must recall its aetiological classification into
primary and secondary pleurisies.
In a recent discussion on the treatment of pleurisy,
the eminent French author, M. Hardy," said, that acute
pleurisy of sero-fibrous nature was no better treated to-
day than it was fifty years ago; and, except in purulent
forms, no better results were obtained now than then,
the death-rate at present being ten per cent., the same as
in the days of our forefathers.
This statement may astonish some of us who have
been taught to look upon acute pleurisy as a not very
fatal disease ; however, some statistics would seem to
bear out this opinion.
Let us, then, first consider the modern methods of
treatment, and later, compare them with those practiced
in the early part of this century.
The modern medical treatment of acute pleurisy con-
sists chiefly in the administration of antiseptics, anti-
pyretics, and evacuants.
Dr. Charles Talamon” has recently called attention to
the action of salicylate of sodium in pleuritic effusions,
claiming that it promotes the rapid absorption of the
1 Bulletin de L'Académie de Médicine, May 31, 1892, p. 776.
* New York Medical Journal, Jan. 2, 1892.
AOUTE! PLEURISY. 265
fluid. He thinks it has a direct action on the inflamed
pleura, for Rosenbach has proved by experiment that
the salicylates may be found in the serous cavities of the
body after their ingestion by the mouth in doses of
ten to twenty grains. Whether its beneficial action is
due to its antiseptic properties, or to its diuretic action,
is still an open question. That Salicylate of sodium may
be of use when the pleurisy is secondary to rheumatism
there can be no doubt ; but to depend on its success as a
germicide in the primary form, would be hazardous.
However, the salicylates certainly meet the indications
for an antiseptic, antipyretic, and diuretic.
The practice of injecting a solution of salicylic acid, or
other antiseptic, into the pleural cavity to combat the
microbes in the effusion, has been suggested, but the
treatment seems harsh and uncalled for, unless employed
in connection with surgical methods for the treatment of
empyema.
Antipyretics in acute pleurisy are only indicated, as
such, when the fever rises to 101° or over, and as the
fever seldom remains so high for any length of time,
their use is quite restricted.
Quinine may be advantageously employed in pleurisy
depending on malarial poisoning, and as a tonic during
Convalescence.
Antipyrine, or the other coal-tar derivatives, may be
useful in cases accompanied by hyperpyrexia ; but none
of these measures are calculated to reach the cause of the
disease, or modify its pathology.
The evacuants are administered in acute pleurisy with
a view to reduce the amount of effusion. Here the
diuretics are the most important. Digitalis may support
a Weak heart, but its action on the pleuritic effusion is
Small. Milk is often used as a diuretic, but is of doubt-
ful efficacy, except as a food.
Drastic or saline purgatives and sudorifics, not only
fail to reduce the quantity of fluid in the chest, but are
often dangerous.
266 NEW YORK STATE MEDICAL ASSOCIATION.
The chemical composition of ascitic fluid is quite differ-
ent from that of the serous effusion of pleurisy; the latter
is not simply serum from the blood, but blood plasma.
Of late, in the excitement of bacteriological investiga-
tions, the profession have been content to disregard the
teachings of their ancestors, and the good old methods
in vogue at their time.
We have regarded these diseases as cyclic in nature;
maladies which must run their regular course in spite of
all abortive treatment ; sicknesses which are caused by
micro-organisms over which we have no control; hence,
we must fold our hands and content ourselves with
relieving pain until such time as the particular germ has
loosened his grasp.
This is the ‘‘ expectant treatment” of to-day, and this
is the treatment eminent authorities hold out to us for
acute pleurisy. -
“The expectant treatment,” says M. Peter,” “is the
do-nothing treatment, and this is what many bacteri-
ologists practice. . . . . No physician has a right to
practice inactivity in these cases, when so much can be
done towards curing pleurisy if energetic treatment is
begun early.”
To allow a patient to become weakened by pain and
suffering, because pleurisy is a cyclic disease and should
terminate spontaneously in two or three weeks; or, be-
cause the pathological conditions are such that, by
deferring active measures, one may with impunity
puncture the chest and draw off a litre of fluid, is treat-
ing the wrong end of the disease.
A physician should strive to diminish the intensity of
a malady, if, indeed, he cannot shorten its duration.
What are the indications for treatment in acute
pleurisy % Briefly, they are, the relief of pain, the re-
duction of fever, and the arrest of effusion; or, in other
words, to treat the cause. Our ancestors had a rare
knowledge of these indications when they applied bleed-
* Bulletin de L'Académie de Médicine, April 26, 1892.
AOUTE! PLEURISY. 267
ing and localised vesications, which at once relieved the
pain and reduced the fever, and there was little or no
serous effusion found in their cases. By these methods
the pathological lesions were affected, and the cause of
the pain and fever reached.
Laennec said, in 1819, “If a plethoric subject had
pleurisy, he required bleeding.” While it is undoubt-
edly true that the pendulum of exsanguination in inflam-
matory diseases oscillated too far in the early part of
this century, and to the detriment of many ; is it not
also true that, at the present time, it has swung too far
the other way, and “expectant treatment” is employed
to the detriment of many ? I believe the antiphlogistic
treatment is indicated now in just as many cases of acute
pleurisy, as in the days of Our forefathers.
That the treatment may be carried too far, I do not
deny ; the judicious use of it at the right time is the
essential point. Pain is quickly relieved by the revul-
sive methods; probably by the removal of the congestion
and its baneful influences. At the present time, Opium, in
Some form, is employed for the relief of pain; but does
it lessen the congestion causing the pain, or simply dull
the sensibility to pain' -
Revulsives and antipyretics both lower the fever, but
Will the antipyretic drugs alter the pathological condition
Within the pleural cavity ?
Farther on in this disease we often employ puncture
of the chest to draw off the fluid ; but, have we not
allowed the malady to reach that point by neglecting at
the beginning to treat the cause efficiently
M. Peter goes so far as to say “that by revulsive
methods, early employed, one is able to prevent the
serous effusion in many cases; to arrest it, if the secre-
tion has begun to form ; and, finally, to absorb it, if a
small amount has collected.” Andral and Bouilland”
Cite thirty cases, in one year, treated antiphlogistically,
* Bulletin de L'Académie de Médicine, April 26, 1892.
8 Ibid.
268 NEW YORK STATE MEDICAL ASSOCIATION.
with one death, a mortality of three per cent. Of
seventy cases reported" in 1891, treated after the modern
methods, there were seven deaths, a death rate of ten
per cent. from acute pleurisy.
How should revulsion be employed in these cases 2
Bouilland used to bleed twice, and afterwards apply wet
cups and a large blister.
One might employ wet cups and vesication more
mildly, with equal success.
M. Peter” says: “What is remarkable in these cases
is the toleration of the system to these large bleedings ;
the rapidity with which the pain ceases, and the local
symptoms of pleurisy diminish.”
On the other hand, M. Sée” says: “Bleeding, after
doing so much harm, is springing up again insidiously
in many diseases ; it has no theoretical basis, and is
little better than empiricism.”
Can we learn anything from nature as to the treat-
ment of acute pleurisy % The inflammatory process
irritates the intercostal nerves, and causes pain; but in
consequence of this inflammatory action, evolves a fluid
which acts as a sedative to the injured nerves, and little
by little the pain subsides. As this fluid closely resem-
bles the plasma of the blood, is it not fair to assume that
nature bleeds her patient in the early stage of pleurisy %
It is generally held that blisters are useful adjuvants
to scarification, but some believe that cantharides pre-
dispose to the transformation of serous effusions into
purulent ones, especially in tuberculous patients.
There is no positive way to identify purulent pleurisies
from the serous variety except by explorative puncture,
but the indiscriminate use of the exploring needle—ten
or a dozen times, as recommended by some *—is to be
condemned.
* Bulletin de L'Académie de Médicine, April 26, 1892.
8 Ibid.
* Bulletin de L'Académie de Médicine, April 19, 1892, p. 597.
*Archives of Pediatrics, May, 1892, p. 353.
AOUTE! PLEURISY. 269
Thoracentesis.--This operation, though always to be
deplored, is often urgently demanded.
That aspiration, as first practiced by Bowditch, and
later, elaborated by Dieulafoy and others, is a simple
and harmless operation, there can be no doubt ; but as
practiced by the majority of general practitioners, with
no special attention to the cleanliness of trocar or
aspirator, it is a very dangerous operation.
All that is essential to the safety of the operation is
thoroughly aseptic instruments, especially the aspirating
needle, and some little skill in manipulation.
It has been held by some that after the operation has
been performed two or three times, a sero-fibrous effu-
sion becomes a purulent one. This may be SO. I do not
deny that it often happens, but it is rather the fault of
the operator and his unclean instruments.
As a rule, aspiration should not be performed in simple
sero-fibrous pleurisy until after the third week of the
disease, and then only as the fluid tends to remain
stationary and unabsorbed, unless there is urgent need
of interference to save life.
If the cause of the non-absorption of the fluid is, as
Suggested by M. Lanceraux, a stoppage of the lym-
phatics of the pleura by the formation of fibrous thrombi
in their orifices, we must wait until a disintegration of the
clot takes place before the fluid will be absorbed, and no
amount of aspiration will hasten the process of natural
absorption until that time has expired. This period of
disintegration is about the twenty-first day of the
disease. However, there are times previous to this
period, when life is threatened by the accumulation of
fluid in the pleural cavity to such an extent as to com-
press vital organs,
When this occurs, it becomes necessary to draw off a
Certain amount of fluid by aspiration, in order to relieve
the distressing symptoms.
When the fluid has accumulated, has progressed to
Such an extent that there is dyspnoea, more or less
270 NEW YORK STATE MEDICAL ASSOCIATION.
cyanosis, flatness on percussion over most of the affected
side, sometimes associated with bulging of the inter-
costal spaces, the patient is already in great danger.
There is no infallible guide to the best time for operating
in these cases, but percussion furnishes the most reliable
test, for by it we may arrive at an approximate estimate
of the quantity of fluid contained in the pleural cavity.
When the line of flatness has reached the second rib on
either side the chest, Dieulafoy estimates the quantity to
be about 2,000 grammes, and states that it is time to
operate. If, with this, there is dyspnoea and some
cyanosis, the operation should be immediately per-
formed.
If, as often happens after the early operative interfer-
ence, the fluid should re-accumulate, and the distressing
symptoms return, a second Operation would be impera-
tive, and probably later on, others would follow.
Only so much of the fluid should be removed in these
cases as will render the patient more comfortable, or
remove any danger of immediate collapse. The removal
of the entire amount of effusion at Once has caused Sud-
den death, due to the congestion produced by the sudden
return of the compressed and distorted lung to its normal
position.
Therefore, the fluid should be withdrawn gradually
through a fine needle, and not more than a third, or
perhaps a half of the total quantity of fluid in the chest
cavity removed at once.
It is better to perform the operation several times in
this manner than to have a fatal issue from the evacua-
tion of too great a quantity at once.
In purulent pleurisies, no time should be lost in evacu-
ating the pus, observing the same precautions necessary,
if by aspiration, as in serous effusions. In children with
purulent pleurisies, repeated aspirations are advisable
before resorting to more severe surgical methods; but
in adults, if a re-accumulation of pus occurs after One
aspiration, it is usually better to treat the empyema
AO: UTE! PLEURISY. 271
as one would an abscess cavity, and establish free
drainage.
Finally, I wish here to suggest a method of treatment
of pleuritic effusions, which I must frankly state is at
present only a theory. I refer to the employment of
electrolysis to cause absorption of pleuritic effusions,
just as it is used in the treatment of serous effusions
elsewhere. The operation might be appropriately called
“electrocentesis.”
I have not found any literature on the subject, but we
know electrolysis has been employed quite commonly in
Other serous effusions, such as hydroceles or other cystic
tumors with great benefit, in many instances, and why
should it not be equally beneficial in the serous effusion
of pleurisy %
Electricity hastens the absorption of fluid in cysts;
first, by its power to transform the watery elements into
gases, and secondly, by its direct stimulating effect on
the lining membrane of the sac.
Is there any reason to expect a different result from
a similar use of electricity in pleuritic effusions?
The technique of the operation would consist in thrust-
ing an electro-puncture needle into the effusion, applying
to the chest wall a clay electrode attached to the negative
pole of a galvanic battery, and in using a current strength
Of thirty to fifty milliamperes.
Care should be taken that the needle be not thrust
farther than just into the fluid, so that we get only an
action on the effusion and the costal pleura; otherwise
We might electrify some vital organ with very unpleasant
results.
From this application of electrolysis, we might reason-
ably expect more or less coagulation of fibrinous matter,
and absorption of the fluid portions of the effusion, in
proportion to the strength of the current, and the length
of time the current is allowed to pass.
This method of treatment would probably benefit those
Cases in which thoracentesis for any reason could not
272 NEW YORK STATE MEDICAL ASSOCIATION.
safely be performed, those in which there had been
repeated re-accumulation of fluid after aspiration, and,
finally, those of secondary nature, particulary those of a
tuberculous character. All the usual antiseptic precau-
tions should, of course, be observed.
DISCUSSION.
DR. F. W. HIGGINs, of Cortland county, said that in not a single case
which had come under his observation had he considered there was an in-
dication for venesection. This practice was theoretically good in strong
and robust people, but in the cases he had seen, the onset of the disease
had usually been insidious and without much pain; in Short they were
not of the sthenic type. He had been interested in the theory propounded
in the paper, that there must be some systemic cause not yet discovered,
and he was encouraged to believe that investigations in this direction would
yield good practical results.
DR. H. D. DIDAMA, of Onondago county, said that he had heard
nothing in the paper which had made him change the views which he had
expressed on the previous evening in favor of early aspiration in pleurisy.
Why not draw off the fluid when the acute symptoms subside, instead of
waiting from two to six weeks 2 Those who practice late aspiration are
the ones who have chronic cases of pleurisy, with carnification of the lung,
in many instances; and if the lung be much compressed, the other lung
must do the work, and this will lead to congestion and much subsequent
trouble. By early and complete aspiration, the lung is permitted to
expand immediately, and it is not necessary, as in the later operation, to
use a very fine needle for fear of producing severe symptoms. It was
long ago ascertained that diuretics, and diaphoretics, and cathartics, and
blisters are not useful in pleurisy, and yet these remedies are used still by
many. Tonic treatment from the start should be the rule; it is only
occasionally that sthenic cases are met with. Anstie recommended the
administration of the tincture of the chloride of iron in all cases from the
beginning, and he found that he had much better results from this treat-
ment than by the use of antiphlogistics. Strapping is a good treatment
after awhile, but anodynes, antipyretics, or other depressants are not
needed.
DR. JoHN CRONYN, of Erie county, indorsed all that had been said by the
preceding speaker. Plethoric individuals might be benefited by bleeding,
and the asthenic by cupping. When he was eighteen years of age, he had
pleurisy, and as venesection was then in vogue, he was bled, and after-
wards thirty leeches and a blister were applied ; yet in spite of all this, he
still lived and enjoyed good health. In the early years of his practice,
when he bled freely, and gave large doses of opium with calomel, he had
DISCUSSION. 273
scarcely any trouble with his cases of pleurisy, and he still held that as
soon as there is evidence of the subsidence of the acute inflammation, the
fluid should be removed, otherwise it would probably lead to a tubercular,
or at least to a chronic pleurisy.
DR. N. B. SIZER, of King's county, recalled a case in which he had
performed venesection at the Roosevelt Hospital. A man who had been
working for several hours in ice-cold water, suddenly began to shiver;
his temperature rose rapidly, and within a few hours he was delirious and
suffering from dyspnoea and severe pain in his chest. On admission to the
hospital, there were the usual signs of beginning pleurisy on each side, and
he was actively delirious. Venesection was performed, and all the symp-
toms promptly subsided, and he was discharged from the hospital on the
fifth day.
THE PRESIDENT remarked that the author's idea of promoting absorption
by the use of electricity was novel to him, and he hoped to hear in the
future a report on this method of treatment.
18
A CITNICO_PATHOLOGICAL STUDY OF
INJURIES OF THE HEAD,
WITII SPECIAL REFERENCE TO LESIONS OF THE
BRAIN SUBSTANCE.
By CHARLEs PHELPs, M. D., of New York County.
Movember 16, 1892.
Two years ago I read before this association, in the
course of a general discussion upon cerebral surgery, a
very brief paper upon cerebral contusions. Since that
time a very considerable number of cases of serious in-
juries of the head, almost all of which have involved
lesion of the brain substance, have come under my ob-
servation. They present so many points of interest and
importance that I have ventured to ask renewed atten-
tion to an extension of the same subject. In no depart-
ment of surgery are more problems yet unsolved, and in
no department are the results of careful study likely to
be of more absorbing interest or of greater professional
value.
Attention has been largely directed to cerebral localisa-
tion, and to certain surgical procedures founded upon the
indications it has afforded. Such operations upon the
brain have been conspicuously successful, and have been
justly reckoned among the triumphs of modern Surgery.
When guided by the disclosures of physiological experi-
ment and aided by the application of recognised aseptic
laws, operations upon the brain have been devised and
Successfully executed, which in the immediate past
would have been not only impossible but incredible. It
is equally true that these operations are still limited in
number and application. The instances in which brain
lesions can be accurately defined and located, and after-
&TUDY OF INJURIES OF THE HEAD. 275
ward made subject of operation with reasonable prospect
of success, are comparatively infrequent. The lesions
which are of such nature, so well defined in outline, or
so situated, in view of demonstrated localisation of brain
function, that their diagnosis can be made with reason-
able certainty, are few enough in the first instance ;
those which are within reach of the surgeon’s knife are
fewer still ; and those in which the patient ultimately
survives constitute but a small proportion of the origin-
ally scanty number. It is not strange, however, that
operations which invade the very penetralia of the human
organism should fascinate by their audacity, and that,
when successful, they should dazzle the modest workers
in more prosaic fields of labor. It is also possible that
the ardor with which the diagnosis and relief of local
leisons of the brain have been pursued, in the light of
functional localisation, may tend to distract attention
from those general pathological conditions which are of
So much greater frequency. The study of cerebral topog-
raphy, moreover, has been so much more effectively
prosecuted by the physiologist than by the pathologist,
that perhaps the results of clinical and pathological
Work have been practically if not theoretically under-
rated. It is certainly proper at the present time to more
generously supplement physiological experimentation
by both ante-mortem and post-mortem observations made
upon the human subject. For this purpose, cerebral
traumatism, which this series of cases illustrates, affords
peculiar advantages, since death results from the estab-
lishment of lesions in a previously healthy brain, and
Since it presents itself with sufficient frequency for pur-
poses of comparison.
The cases which I propose to subject to analysis are
one hundred and twenty-four in number, and, with two
or three exceptions, have been previously unreported.
They have occurred mainly in my service in two hospi-
tals, and in the last two years. They include all cases of
*Juries of the head which I have seen during the time
76 AVEW YORK STATE MEDICAL ASSOCIATION.
Specified, and if they are preponderatingly of one charac-
ter, they are probably still representative of the whole
class to which they belong. Wounds of the scalp have
not been included, because they are not only surgically
insignificant, but have no necessary relation to the deeper-
Seated injuries which it is proposed to consider. In a
previous paper upon a subject of an entirely different
character, I found it convenient to abstract the histories.
of the Several cases upon which it was based. I pursue
the same course in the present instance in order to afford
a means of verification of such conclusions and general-
isations as I may establish, and at the same time to make
record of a large amount of material which may be of
Service hereafter to students of the same class of injuries.
I shall not attempt a reading of these histories, but shall
leave them to appear in the archives of the Association
for future consultation. They are arranged in accord-
ance with the nature and result of the primary injury.
FRACTURES AT THE BASE.
CASE I. Male, forty-five years of age ; fell in the street ; admitted to
alcoholic ward; wild delirium, requiring mechanical restraint; haemor-
rhage from left ear; wound in posterior parietal region ; high temperature ;
coma; death in forty-eight hours.
Necropsy.—Fracture at the base, with complete separation of the left
temporal bone into its constituent parts—squamous, petrous, and mastoid.
Slight laceration of left parietal lobe at a point corresponding to seat of
external injury. At a corresponding point upon opposite parietal lobe
there was extensive laceration 3% x 1% inches in diameter.
CASE II. Male, forty years of age; said to have fallen from his truck;
no superficial injury; delirium, which was considered alcoholic; refused
treatment; delirium continued next day, and he committed suicide by
drowning.
Necropsy.—Fracture at base extending from left parietal eminence to
foramen magnum. Superficial laceration of right temporo-sphenoidal
lobe by contre-coup.
These two cases have been previously reported.
CASE III. Male, fifty years of age; fell from steps to sidewalk; scalp
wound in right posterior superior parietal region; haemorrhage from right
ear, and later from right nostril; coma; stertor; rigidity of all the limbs ;.
left pupil dilated. In twelve hours complete left hemiplegia supervened,
STUDY OF INJURIES OF THE HEAD. 277
and haemorrhage from right ear renewed. Stertor and rigidity disappeared,
and left pupil became normal. Unconsciousness and incontinence of urine
continued from time of admission till death from asthenia at the end of six
days.
Mecropsy.—Fracture at base, beginning at point of injury and extending
through right petrous portion and middle fossa to apex of opposite petrous.
Lacerations of left frontal and right temporo-sphenoidal lobes inferiorly
and laterally. Thick clot over left frontal and temporal lobes laterally,
growing thinner as it extended toward base and vertex. Whole brain
intensely hyperaemic. -
CASE IV. Male, twenty-two years of age; cause of injury unknown ;
compound depressed fracture external to right parietal eminence; semi-
comatose, irrational, articulation indistinct ; respiration continued slow
and irregular for three days. The depression was found on trephining to
be of the external table only. Two days after admission, complete
paralysis of extensors of right hand, paresis of right arm, and right facial
paralysis, involving both mouth and eyelid. All these paralyses afterward
varied in degree from time to time, and the mental condition varied from
rationality to noisy delirium. He was usually restless, and became un-
conscious for two days before death. Temperature on admission, 101°,
and remained above 100° for a week. Then declined to 99°–– during
another week. Two days before death it rose steadily from 103° to 109°.
Died in forty-five days.
Necropsy.—Fissure extending from point of depression into right
middle fossa. Subacute arachnitis and excessive cerebral hyperaemia;
Surface of brain at point of fracture unchanged, but beneath it was a large
cavity containing reddish semi-fluid material, and brown detritus from
Subcortical laceration.
CASE W. Male, thirty-five years of age; cause of injury unknown ;
Scalp wound over occipital protuberance ; patient under influence of drink;
Would not answer questions; grew stupid, and in three hours became
unconscious ; mechanical restraint necessary. Temperature soon after
admission was 102°, and in ten hours became 105°, receded to 101.8°, and
then rose steadily to 106.6°. He died twenty-nine hours after admission.
Necropsy.—Haematoma covered whole calvarium. No fracture of ver-
tex, but a slight fissure existed along the posterior border of the right
petrous portion of temporal bone from contre-coup. Thin coagulum and
fluid blood covered upper surface of both cerebra (meningeal contusion).
Lacerations of under surface of left frontal (large) and temporo-sphenoidal,
of inner border of right frontal, and of under surface of right temporo-
Sphenoidal lobes. The last was as large as a hickory nut.
CASE WI. Male, thirty-eight years of age; knocked down by a blow
upon the head from a club ; scalp wound in right parietal region. He was
stupid, and could not answer questions coherently. Left pupil slightly
dilated and eyes directed slightly to the right. Next day incoherent,
delirious, and had delusions and muscular tremor, pupils irregular, pulse
2.78. NEW YORK STATE MEDICAL ASSOCIATION,
frequent and intermittent. Temperature on admission 108°, five hours,
later 102°, rose to 106.2°. Died in twenty-four hours.
Mecropsy.—Linear fracture through whole length of right parietal, right
occipital, and petrous portion of temporal bone into middle fossa. Consider-
able laceration of under surface of left frontal and temporo-sphenoidal lobes.
CASE VII. Male, forty-five years of age ; fell upon the sidewalk,
striking the back of the head. Admitted after twenty-four hours. Oedema
under and about an old cicatrix behind the right ear, and underneath this.
an extensive comminuted fracture. Two pieces of bone were removed and
one elevated, and a large, firm epidural clot extracted as far as possible.
The patient was in a condition of stupor; pupils irregularly dilated ; artic-
ulation difficult; muscles generally rigid ; gait ataxic when he attempted
to walk; sensibility diminished, and urine incontinent. His condition
improved for four days after operation ; temperature decreased, mental
condition became clearer, and muscular rigidity lessened. There was
copious serous discharge from the right ear, followed by right facial paral-
ysis. On the fifth day temperature rose from normal, muscular rigidity
again increased, and he again became stupid. The next day he became
unconscious, and in an hour's time he had eighteen general convulsions,
and died the following morning. His temperature did not exceed 98.8°
ill the fifth day. On the morning of his death it was 105°.
Mecropsy.—Fracture at the base. The whole central portion of the
occipital, from the foramen magnum upward, and posterior portion of
both parietal and right temporal bones, forming an irregular circle two
inches and a half to three inches in diameter, were broken into large frag-
ments, two of which had been removed during life. The mastoid and
outer part of the petrous portion of the right temporal bone could be re-
moved by the fingers with the use of very little force. This line of frac-
ture ran through the tympanic cavity, so that, after removal of the outer
fragment, the carotid canal and aqueductus Fallopii could be seen in the
section filled with coagula. A large epidural clot was situated beneath the
occipital fracture, extending half an inch beyond its margin. A large sub-
dural clot filled the right inferior occipital fossa, extending, to the foramen
magnum. The cavity of the posterior part of the great longitudinal sinus.
was occupied by a thrombus, and its walls were infiltrated with blood.
There was a large, partially decomposed thrombus in the torcular Her-
ophili, extending through the right lateral into the petrosal sinus and inter-
nal jugular vein. The whole internal surface of the dura beneath the seat.
of the external haemorrhage was lined by a firmly coagulated clot, with
an inflammatory exudation around it. A portion of the surface of the
right occipital lobe posteriorly was softened, showed minute haemorrhages,
and was torn away in the removal of the dura. The meshes of the pia
mater over a large part of the parietal and occipital lobes posteriorly Were
distended with slightly turbid serum. There was a small laceration on the
under surface of each frontal lobe, and a larger one, three-quarters of an
inch in diameter, existed in the right cerebellum at a point corresponding
to the site of the thickest part of the subdural haemorrhage.
STUDY OF INJURIES OF THE HEAD. 279
CASE VIII. Male, seventy-six years of age; cause of injury unknown ;
admitted to alcoholic ward, and transferred to surgical service same day.
Patient unconscious from the time he was found in the street. Stertor;
muscles rigid on both sides; both pupils very strongly contracted, the left
one the more so. Scalp oedematous in right parietal region. Fissure,
extending from posterior and inferior part of right parietal into occipital
bone, discovered by incision. There was no change in the general symp-
toms up to the time of death, two days and six hours after admission. The
left pupil continued to be the more strongly contracted, and muscular
rigidity more strongly marked on the right side. Consciousness was not
regained. Temperature on admission, 100:4°; rose steadily to 103-8°;
post-mortem, 102°.
Necropsy.—Fracture at base extended to right jugular foramen, and
then turned backward to foramen magnum. Slight epidural and consid-
erable subdural haemorrhage at point where fracture began. Slight Serous
effusions into pia. Thrombus in torcular Herophili, extending into right
occipital sinus and through petrosal sinus into jugular vein. The whole
inferior surface of the brain covered with blood. Superficial laceration
along the anterior border of left temporo-sphenoidal lobe from median line
outward. Large clot could be seen bulging outward, behind a thin corti-
cal layer, along the whole length of external border of left frontal lobe.
Well-marked lacerations upon anterior border of both frontal lobes, and
also upon their inferior surfaces along the longitudinal fissure. Optic
Chiasm surrounded by a clot, which extended backward as far as anterior
border of the pons Warolii. Upon section along external border of left
frontal lobe, a clot of great size was disclosed, which occupied almost the
Whole substance of the left frontal and temporo-sphenoidal lobes, from the
third frontal convolution backward. This haemorrhage had broken through
into the lateral ventricles and thence into the occipital lobes, which were
also filled with great pools of fluid blood.
CASE IX. Male, forty years of age; fell into the hold of a vessel;
Semi-conscious when found; haemorrhage from both nostrils and from
right ear; regained consciousness next day; four days later, delirious and
irritable; back of neck rigid ; abdomen retracted. Cheyne-Stokes respira-
tion supervened. Temperature for seventy-two hours, 99-2° to 99.8°;
fourth day, 103.2°; fifth day, 104.8°. Death at end of five days.
Mecropsy.—Contusion over right mastoid revealed on raising the scalp.
Fracture at base in three fissures; extending from this point, two (fine)
*Cross petrous portion, and a third connecting them posteriorly across
occipital bone. Deep linear laceration, extending across inferior surface of
right cerebellum, near outer border. Subdural haemorrhage over whole left
Serebrum, superiorly and laterally; most copious in middle lateral region.
Laceration of antero-inferior border of left frontal lobe. White substance
of left cerebrum much congested, and with punctate extravasations
throughout its extent.
* CASE X. Female, eight years of age; fell two stories; partially uncon-
*8; left hemiplegia, and haemorrhage from left nostril; depressed
280 NEW YORK STATE MEDICAL ASSOCIATION.
fracture over left frontal eminence. Patient became irritable, and the bone
was elevated an hour later. Died within twenty-four hours.
Necropsy.—Coronal suture separated on the right side. A fissure ex-
tended through right parietal eminence and another through frontal bone.
Base fractured across body of sphenoid into left middle fossa. Other
fissures through right middle and anterior fossae, external to orbital plate.
Epidural haemorrhage on left side anteriorly and in temporal region.
Lacerations in right frontal lobe and in right fissure of Rolando, and in
left temporo-sphenoidal lobe.
CASE XI. Male, twenty-nine years of age; fell fifteen feet into the hold
of a vessel and struck on his head. Coma, stertor; left pupil markedly
dilated and right pupil contracted; paraplegia, haemorrhage from left ear
and nose and under left conjunctiva, and contusion over left eye. Died in
five minutes after admission. -
Necropsy.—Epidural haemorrhage, blood still fluid. Fracture extend-
ing downward and forward from behind left parietal eminence, across
petrous portion, through middle fossa, transversely across anterior fossa,
and terminating at inner extremity of lesser wing of right sphenoid.
Slight cortical haemorrhage on left side, and slight lacerations of under Sur-
face of left frontal and temporo-sphenoidal lobes.
CASE XII. Female, twenty-three years of age ; jumped from fifth
story window. Contusions of left hip and shoulder and over right parietal
eminence; slight haemorrhage from nose and left ear; temperature, 99.4°;
incontinence of urine and faeces; right hemiplegia. Death in two days.
Mecropsy.—Fracture extending from right parietal eminence to foramen
magnum, of right petrous portion entire length, and of left petrous for
two inches; laceration of left parietal lobe beneath parietal eminence.
CASE XIII. Male, forty-six years of age ; fell five stories. Coma,
stertor, pupils normal; pulse and respiration normal. Death in five days.
Necropsy.—Contusion over right parietal eminence; fracture extending
from this point downward and forward, anterior to petrous portion, and
through sella turcica; subarachnoid haemorrhage over both hemispheres
laceration of under surface of left temporo-sphenoidal lobe.
CASE XIV. Male, fifty years of age; knocked down by a blow in the
face and fell upon the back of his head. Patient became unconscious,
but shortly afterward walked to the hospital; contusion over right parietal
eminence; dazed; no other symptoms; walked home ; had severe pain in
the head for three hours after the injury, then became gradually uncon-
scious till four hours later, when coma was complete, and death occurred
at the end of another hour.
Necropsy.—Wound of lip and contusion of forehead; very fine fissure
of external table, beginning in right inferior occipital fossa and running
across right petrous portion; slight epidural haemorrhage about the middle
of the fracture; upon left side, large subdural extravasation upon lateral
border of parietal and frontal lobes, extending upward and also downward
into middle fossa; also some extravasation into pia and several slight
STUDY OF INJURIES OF THE HEA. D. 281
contusions of brain substance ; skull thin, and angles and processes upon
its inner surface unusually sharp and prominent.
CASE XV. Male, forty years of age ; cause of injury unknown.
Coma ; respiration slow and full ; right pupil dilated, left contracted ; re-
flexes lost; had been seen to move the left side ; pulse became slower and
breathing more labored. Died in nine hours and a half.
AWecropsy.—Contusion in left parietal region; fracture from this point
extending by two fissures into anterior and middle fossae ; large epidural
haemorrhage from rupture of left middle meningeal artery ; slight lacera-
tion of left parietal lobe at point where fracture began, and another upon
lateral border of right temporo-sphenoidal lobe.
CASE XVI. Male, fifty-five years of age ; fell upon the street. Uncon-
scious; respiration labored; left pupil slightly dilated; slight haemorrhage
from left ear; slight rigidity of left side. He was still stupid upon admis-
sion, but could give his name. Temperatue, 99°. Dilatation of left pupil
and rigidity of left side increased, and afterward there was complete par-
alysis of left lower extremity, while left arm remained slightly rigid ; left
hemiplegia was finally complete. He died in twenty-one hours. Temper-
:ature, 101°2°.
Necropsy.—Contusion of scalp over left occipito-parietal suture; skull
thin ; stellate fracture, originating about the centre of left parietal bone;
fissures extending upward, across base of occipital and along the upper
border of petrous portion of temporal bone into the middle fossa; sub-
dural haemorrhage covered right hemisphere ; under and lateral surfaces
of right temporo-sphenoidal lobe extensively lacerated; under surface of
both frontal lobes lacerated along the median fissure; these lacerations were
recent. Upon the under surface of the left temporo-sphenoidal lobe there
Was a deep laceration, irregular in outline, but about an inch in its several
diameters; there were also small and deep lacerations upon its anterior
border and upon the under surface of the left frontal lobe. All these
lacerations upon the left side extended through the cortex, contained no
recent clot, but were covered with a grayish-yellow viscid substance, and
Were bounded by a considerable area of yellow softening. They evidently
antedated the final and fatal injury. Section of the brain disclosed marked
hyperaemia.
CASE XVII. Male, fifty years of age; cause of injury unknown. Un-
90nscious; pulse, 66; respiration full and slow ; right pupil dilated, the
left contracted, neither one responding to light ; he had been seen to move
º: left side of the body; stertor supervened, and death occurred in eleven
Tholl|rS.
Wecropsy.—Contusion of left parietal region disclosed by incision ; two
fissures originated from this point, one extending into the anterior and the
other into the posterior fossa; large epidural clot from rupture of left
middle meningeal artery; general contusion; hyperaemia.
Case XVIII. Male, thirteen years of age; fell two stories. Haemorrhage
from right ear; unconscious; irritable when disturbed ; consciousness
282 NEW YORK STATE MEDICAL ASSOCIATION.
regained in thirty minutes; pulse 78, intermittent; temperature, 98°; de-
pressed fractures below right temporal ridge; elevated next day; three
fissures, one backward, one forward, and one downward ; dura incised ;
only subarachnoid haemorrhage; temperature, 101-8°. Next day patient
irritable and somnolent ; urine incontinent; temperature slightly increased
(102°). On second day after operation he was delirious, and temperature
rose steadily till evening, when it was 105'4°. On the third day the skin
was hot, and he was very restless and sensitive to external impressions;
his pupils were moderately dilated and reacted slowly. From this time he
was in deep coma; temperature varied from 104°-H in the morning to 105°–H
in the evening till death occurred on the evening of the Seventh day, when
it was 106'5°.
Necropsy.—Skull thin. No pus in the wound or in the small brain
cavity which had been disclosed by the ante-mortem operation when the
depressed bone was elevated. Subdural haemorrhage in the opposite (left).
occipito-parietal region. An effusion of thick green pus beneath the
arachnoid covered the lateral and superior surfaces of the right occipital
and parietal lobes, but did not extend forward to within an inch of the
cranial opening left by the ante-mortem operation. A subdural effusion of
similar thick green pus was co-extensive with the whole right inferior
occipital fossa. There was a deep laceration, an inch in diameter, upon
the lateral border of the left temporo-sphenoidal lobe, which involved the
subcortical tissue. At a point directly beneath the opening left by the
removal of the depressed bone, there was a cavity in the brain substance as
large as a hickory nut, which opened by its whole extent upon the cerebral
surface. As this surface was intact at time of operation, the cavity must
be ascribed to a direct subcortical contusion, not involving the superficial
laceration, and to a subsequent giving way of the cerebral cortex under the
influence of arterial pulsation, and in the absence of the normal repressive
force exerted by the skull and dura. The whole brain substance and
meningeal vessels were intensely hyperaemic, and there were numerous
minute extravasations from general contusion. There was no meningeal
or ventricular serous effusion. A fissure extended from the central point
of fracture through the petrous portion of the temporal and inferior
occipital fossa to the foramen magnum.
CASE XIX. Male, nineteen years of age; fell three stories through
a hatchway ; unconscious; irritable when disturbed ; pulse, 80; tempera-
ture, 100°; profuse haemorrhage from left ear, which continued twenty-
four hours, and was then followed by serous discharge. At the end of
twenty-four hours patient was still unconscious, pupils were largely dilated
and movable, and he had general convulsive movements, most marked in
the right leg. During the second day coma was more profound and gen-
eral convulsive movements ceased, but he had one prolonged general
convulsion, which was repeated on the third day, the movements being
most violent on the left side. The left pupil continued from the first day
to be more contracted than the right. Died in three days and six hours.
Temperature continued to rise from time of admission, and reached 107'2".
STUDY OF INJURIES OF THE HEAD. 283
Necropsy.—Large haematoma in substance of left temporal muscle.
Fracture extended from left squamous portion of temporal bone into mid-
dle fossa, and by a wide fissure along the anterior border of the petrous
portion to the sella turcica. Large epidural and subdural clots in left
middle fossa, Right cerebrum covered by a thin subdural coagulum. In
the left middle fossa diffuent brain substance clung to the dura as it was
removed. Large and deep laceration of the lateral border of the left tem-
poro-sphenoidal lobe and of the lateral border and contiguous inferior
surface of the right temporo-sphenoidal lobe. Small and deep laceration
at junction of right parietal and occipital lobes. All these lacerations
extended into the subcortical tissue.
CASE XX. Male, sixty-two years of age ; cause of injury unknown ;
found unconscious in an ice-wagon with his head lying on a cake of ice.
Contusion of left parietal region, and both eyes much ecchymosed. Sub-
conjunctival haemorrhage at outer part of left eye. Muttered incoherently
when disturbed. Slight temporary rigidity of right arm. Testless and
irritable all day, and roused sufficiently in the evening to give a name and
address, both of which proved to be incorrect. Condition underwent little
change till death—at the end of seven days and seven hours. Temperature
high on admission — 100°; in forty-eight hours, 104.8°; seventy-eight
bours later it receded to 101:2°; in forty-eight hours more it varied from
101° to 102°-H, and then rose steadily to 107°–H at the time of death.
Necropsy.—Skull thin ; fracture of left anterior and middle fossae, ap-
parently beginning with a comminution of orbital plate of left frontal bone
about its centre. At this point two or three small fragments were dis-
placed upward with fine divergent fissures. One fissure ran outward and
upward into left squamous portion of temporal bone; another ran back-
Ward from the crista galli through the bodies of the ethmoid and sphenoid,
through the optic foramen and along the anterior border of the petrous
portion; and the third ran through the right optic foramen into the
Squamous portion of the right temporal. The optic nerves were uninjured.
There was a little blood extravasated over right occipital and lower part of
right parietal lobes. The left frontal lobe was completely excavated by a
laceration which was bounded everywhere by a thin layer of unaltered
Cortex, except inferiorly, near the anterior border, where it was covered in
only by the meninges. It was separated from the ventricle by a thin
Septum of brain substance. This cavity contained commingled blood,
clot and brain detritus. There was also a laceration of the anterior two-
thirds of the external lateral border of the right cerebellum, and an extrav-
agation the size of a robin-shot existed in the centre of the right corpus
striatum. There was no clot anywhere at the base of the brain, and no
further lesions.
CASE XXI. Male, twenty-seven years of age; fell seventeen feet into
the hold of a Vessel, striking his face and stomach. Thirty minutes later
an Officer found him lying upon the dock, unconscious and bleeding from
* mouth and nose. In the interval which had elapsed he was said to
284 NEW YORK STATE MEDICAL ASSOCIATION.
have been excited and abusive. He was seen upon the dock, and twice
afterward during the night at the station-house, by ambulance surgeons,
who refused to take him to a hospital, because, in their opinion, he was
simply drunk and in no want of surgical treatment. The next morning he
was taken to court by two policemen. He was then conscious, and, in
their inexpert opinion, rational. He was unable to stand or walk, and was
carried between them on their arms into a street-car and into court. He
was duly sentenced for intoxication, but by an inspiration of somebody he
was halted on his way to the Island, and placed in the alcoholic ward at
Bellevue. A little later he was transferred to a surgical ward. At that
time he was weak, his pulse slow, and respiration labored. There was
much ecchymosis of the eyes, and the lids could be separated only with
great difficulty. There was subconjunctival haemorrhage of both eyes,
and the arms were rigid, more especially the right. Pupils normal. The
patient soon grew restless, and had muttering delirium, incontinence of
urine, and Cheyne-Stokes respiration. Temperature, 1048°. Depressed
fracture easily felt in right frontal bone. The same afternoon he was
trephined, and the fracture found to be stellate, with a depression an inch
by half an inch in diameter. The inner table was driven through the dura.
Pulse and respiration temporarily improved, but he grew weaker, and died
eight hours after admission to the ward. Temperature, 106°.
Necropsy.—I am indebted to the report of Dr. W. T. Jenkins, late of the
coroner's office. There was a linear fracture in the temporal bone, three
inches long, extending upward and backward from the anterior margin.
There was a stellate fracture in the frontal bone to the right of the median
line and an inch above the superciliary ridge. On the inner surface of the
skull the fracture extended across both orbital plates, through the ethmoid
and body of the sphenoid bone, and on both sides through the anterior
fossa and through the left middle fossa nearly to the petrous portion of the
temporal bone. The nasal bones were also fractured. These fractures
were nearly all comminuted. There was no considerable haemorrhage in
the cranial cavity. The upper surfaces of both hemispheres were lacerated,
especially at seat of fracture.
CASE XXII. Male, thirty-nine years of age ; fell from mizzen-top to
deck, and struck upon right temporal region; admitted half an hour later;
unconscious, and bleeding from right ear; stertorous breathing; pulse full
and bounding; lacerated wound in right parietal region. He had pulmo-
nary oedema, for which he had already been bled from the arm by the
ship's surgeon. Died in two hours.
Necropsy.—Haematoma over whole right side of the head. Six multiple
fissures of the base involving both sides and all the fossae. The primary
fissure, of five which were connected, began as a wide fissure behind and a
little to the left of the foramen magnum, and narrowed to a hair's breadth
as it ran forward to the right superciliary ridge. A sixth, and entirely
independent fissure, ran backward from the crista galli on the left side
through the optic foramen to the sella turcica. There were slight lacera-
tions of the under surface of both frontal and right temporo-sphenoidal
STUDY OF INJURIES OF THE HEAD. 285.
lobes, which occasioned slight Subdural haemorrhage. On the upper and
ateral surfaces of the hemispheres, especially the left ; and at the base, an
epidural haemorrhage of larger size existed in the inferior occipital fossae,
land pressed upon the pons and medulla.
CASE XXIII. Male, forty years of age ; found at foot of cellar stairs,
unconscious and restless, with a large lacerated scalp wound, which had bled
freely, and with several wounds of the face. When admitted to the alco-
holic ward on the diagnosis of ambulance surgeon of another hospital, was
still unconscious. The Scalp wound was in the parieto-occipital region, to
right of median line, and the most extensive face wound was over the right
malar bone. As he did not “clear up,” he was transferred to a surgical
ward four days afterward. He was then nearly comatose, quiet unless dis-
turbed, his pupils normal, and respiration slow and regular. Temperature,
102.2°; pulse, 96. Temperature next day was 104.6°, 103.6°, and 106°; and
on the morning after it was 105° and 107°, when he died without further
symptoms, five days and a half after reception of injury.
Necropsy.—Fracture at base, through petrous portion of left temporal
bone, extending to foramen magnum. Laceration of left temporal and
frontal lobes, with cortical haemorrhage.
CASE XXIV. Female, thirty-eight years of age; habitual criminal;
jumped from the third tier of the Tombs Prison to the flagging below,
thirty feet or more ; punctured wound in left occipito-parietal region; un-
conscious; haemorrhage from left ear; pupils moderately dilated, more
especially the left ; and vomiting persistent. Temperature, 98.9°. The
next morning the patient was conscious, rational, and the haemorrhage had
nearly ceased. In the evening she was slightly delirious, and the follow-
ing day required mechanical restraint till quieted by sedatives. Both
pupils became widely dilated, the left still continuing more dilated than
the right, and they were only slightly responsive to strong artificial light.
This ocular condition continued till her death. The abdomen was painful
and Swollen. Her mind remained clear, but apathetic, till the sixth day,
When she fell into a stupor. On the same day all the extremities became
paretic and partially anaesthetic. Up to this time the muscular power had
been normal. The paresis and anaesthesia were most marked on the right
side. The pulse was rapid, quick, and feeble. A day later the left foot
and right hand were less paretic, and her mind was clear, but the senses
blunted. She answered questions slowly and after an interval, and com-
plained of pain in the head. On the eighth day she was restless and irrit-
able, and had some right facial paralysis, while power in the left foot and
right hand was still further improved. The ninth day she was delirious
and unconscious. On the eleventh day she no longer moved or spoke, and
paid no attention to an explorative incision. On the fifteenth day she died
from asthenia. The temperature remained below 100° till the close of the
fourth day, when it rose to 103°. After that it varied from 100° to 102°–H,
usually was 101°-i-till the twelfth day, when it rose to 104°, and was from
108° to 104.5° till she died.
286 NEW YORK STATE MEDICAL ASSOCIATION.
Necropsy.—Head large and unsymmetrical, and skull thick. No lesion
of the scalp or of the bone before removing the calvarium. The occiput
was disproportionately large, and the right occipital fossae were much
larger than the left. The left, middle and anterior fossae were rather
larger than the right. A fissure began at a point in the squamous portion
of the left temporal bone, beneath the external wound, and, passing
through the anterior surface of the petrous portion, terminated in the
optic foramen. This fissure was not open, but the fragments were quite
movable. There was no epidural haemorrhage, but pressure was made
upon the facial nerve by interosseous haemorrhage as a result of the frac-
ture. There was no meningitis, and scarcely the usual amount of Serum in
the meshes of the pia. There were slight lacerations upon the under Sur-
face of the right temporo-sphenoidal lobe, and one somewhat larger upon
its external border, from which a moderate amount of blood had spread
upward over the occipital lobe, barely reaching the parietal. Upon Sec-
tion, the cerebral vessels were found to be distended with blood, which
flowed from the puncta vasculosa. The veins could be seen in congeries
and filled with coagula. The brain substance was softened and Oedematous,
so that the serum followed the knife. The ventricles were distended with
serum. Subsequent microscopic examination of the brain tissue in the
recent state disclosed no inflammatory changes. There was a considerable
extravasation of blood behind the peritonaeum on the right side, but no
injury of the viscera. There were no serous effusions in the cavities of the
body, and no chronic visceral lesions.
CASE XXV. Male, thirty-seven years of age. Cause of injury un-
known ; scalp wound in right posterior temporal region ; hemorrhage
from right ear; mental condition stupid, but consciousness retained ; in
continence of urine and faeces. The patient had been drinking to excess.
On the next day he had active delirium, with tremulous muscles and delu-
sions, and intervals of semi-unconsciousness. On the sixth day there was
general muscular rigidity, stertor, and muttering delirium. The right
pupil was slightly contracted, with slight serous discharge from right ear
and slight right facial paralysis. Unconsciousness followed. On the
eighth day there were two slight convulsions involuing both arms, the
face, and eyes. The face was drawn to the right and the eyes turned
upward. Paralysis of right arm and face succeeded, and a little later the
surface temperature of the left side was found to be 102°, while that of
the right side was normal. Rectal temperature, 105.6°, which soon de-
clined to 104.8°. Death two hours later. Post-mortem temperature, 106°.
The temperature varied from 100° to 102° till fourth day, then from 108°
to 104° to last day, when it was as noted above.
Necropsy.—Fissure across petrous portion of right temporal bone.
Large subarachnoid serous effusion. Thin cortical layer of blood cover-
ing whole of parietal and occipital lobes on both sides of the brain. Men-
ingeal vessels congested. Brain structure everywhere oedematous. Mi-
nute vessels filled with coagula. Fluid blood in anterior cornu of left
lateral ventricle. Laceration of upper and outer surface of right frontal
STUDY OF INJURIES OF THE HEAD. 287
lobe, and upon upper and outer surface and posterior border of left occipi-
tal lobe. A third laceration existed at the base of the brain upon either
side of the median fissure of the cerebellum. Neither of these lacerations
was larger than a walnut, and neither involved a rupture of the meninges,
though they all reached the surface of the brain.
CASE XXVI. Male, twenty-three years of age; thrown from a wagon.
The ambulance surgeon found him dizzy and feeling ill. He had no other
symptoms except a scalp wound in right temporal region, After admission
to hospital he was entirely conscious and dictated a letter. There was
haemorrhage from right ear and nostril. Temperature, 100°. No other
symptoms. Soon afterward he vomited blood copiously and became un-
conscious with stertor, and died in four hours from time of admission.
Necropsy.—Depressed fracture of right frotal bone an inch from median
line and just anterior to coronal suture, triangular in form with apex
extending to superciliary ridge. One fissure, originating in this depression,
ran through right orbital plate, and greater and lesser wings of sphenoid,
into middle fossa ; another one ran through Squamous into petrous portion
of temporal bone, terminating upon its anterior surface. There was an
epidural clot extending over lateral aspect of right frontal lobe into the
middle fossa. This portion of the frontal lobe was much flattened and
compressed. There was no subdural haemorrhage and no superficial lacer-
ation of the brain. There was a small effusion of blood in the meshes of
pia on either side of the medulla, behind the pons, parallel to the anterior
columns. The whole brain was hyperaemic, with a multitude of punctate
extravasations, and the minute vessels were filled with coagula. Upon
Section, a number of extravasations were found in the substance of the
pons, mainly in the transverse fibres, but some in the longitudinal fibres
of the crura. The smaller ones were of the size of a robin-shot. The
largest one was half an inch long by a quarter of an inch wide, and was
just below the surface on the right external border of its inferior surface.
CASE XXVII. Male, thirty years of age; cause of injury unknown ;
unconscious ; coma continued till death ; haematoma of scalp at vertex;
ecchymosis at base, right side; slight haemorrhage from right nostril;
Stertor; pulse, 130, irregular and weak ; temperature, 94°; rose to 102°
Some hours later; both eyes protruded and both pupils were dilated, left
pupil most markedly so; some rigidity of right side; died same day, eight
Or ten hours after admission to hospital.
Necropsy.—Fracture through petrous portion of right temporal into the
occipital bone and into middle fossa. No fracture of vertex. Epidural
clot in right inferior occipital fossa. Thin subdural clot over both frontal
lobes, especially over left, extending nearly to fissure of Rolando. Small
*Ceration of left frontal lobe on its under surface near anterior border.
CASE XXVIII. Female, forty-five years of age; fell ten feet upon her
head; Scalp wound in right parietal region; temperature, 98.8°. Twenty
*utes after admission left lower extremity became paretic, patellar re-
flexes lost. Three days later temperature suddenly rose from 99%+ to 102°.
288 NEW YORK STATE MEDICAL ASSOCIATION.
Next day patient became delirious. Evening temperature, 105.2°; fol.
lowing morning, 106°. Death five days after reception of the injury.
Necropsy.—Fracture beginning in squamous portion of right temporal
bone, extended through both anterior fossae, involving greater wing of
right sphenoid and both orbital plates. Subdural clot, the size of a
pigeon’s egg, Occupied the left middle fossa. Laceration of inferior sur-
face of left temporo-sphenoidal lobe.
CASE XXIX. Female, sixty-six years of age ; found unconscious at
foot of cellar stairs; supposed to have been thrown down. Scalp wound
in left inferior temporal region ; left malar bone fractured and left side of
face much contused ; coma, stertor, and frothing at the mouth ; moist
bronchial rāles; right pupil dilated, left pupil invisible from ecchymosis;
right upper extremity anaesthetic and soon became paralysed ; tempera-
ture, 101-6°. Three hours later the patient was apparently moribund.
On the following day she was conscious and rational, and the paralysis and
anaesthesia had disappeared ; the pupils were normal; urine incontinent ;
temperature, 99°--. For a week's time her condition remained practically
unchanged, except that her temperature gradually rose to 108°, and in the
last three days gradually fell to 100°, and that the subconjunctival
haemorrhage increased. Her mental condition was apathetic, and she
could be rarely induced to make a mono-syllabic answer to a question
asked. On the eighth day she suddenly became unconscious. Her tem-
perature rose to 104.8°, and within two hours fell to 102.8°. She became
weaker and died during the ninth day, her temperature having again risen
to 106°. Ten minutes post mortem it was 105.2°.
Mecropsy.—An open fissure extended through both tables of the bone
from a little above and to the left of the external occipital tubercle to the
left foramen lacerum posterius. There was moderate subarachnoid serous
effusion. There was an apparent laceration on the median aspect of the
left frontal lobe, the real character of which only became obvious upon
further examination. The interior of both frontal lobes was disorgan-
ised and destroyed, having been broken down by subcortical laceration.
On the left side the clot was very solid, and the external layers of fibrin on
its inferior aspect were partially decolorised. It had broken through into
the anterior part of the lateral ventricle and also through the cortex on
the median surface, involving for a space of half an inch the motor arm
area, and the sensorial centre below it in the gyrus fornicatus. It was this
which at first sight seemed to be an independent lesion. The clot in the
right frontal lobe, which was of equal size, had nowhere broken through
the cortex or into the lateral ventricle. There was no cortical haemorrhage,
although there was a deep laceration on the posterior border of the left
cerebellum. The interior of the brain generally was softened and reddened
in patches.
CASE XXX. Female, fifty years of years of age; no history; admitted
as case of apoplexy. Small lacerated scalp wound in left posterior parietal
region ; slight haemorrhage from both nostrils; patient unconscious ;
STUDY OF INJURIES OF THE HEA. D. 289
movements sluggish; left pupil dilated, right contracted; incontinence of
urine and faeces; face flushed ; visible pulsations of carotids; fine linear
fracture running toward the base discovered by incision ; temperature,
101°; at night, 101-8°; next day, 101-2° to 101°; then rose steadily to
106.8° on the next day, when death ensued, three days and a half after ad-
mission, without consciousness having at any time been regained. Post-
mortem temperature, 109°. On the last day of life, sensitiveness of the
corneae was markedly diminished and sensation was evidently blunted all
over the body.
Necropsy.—A fissure extended from left of occipital protuberance
through posterior fossa and petrous bone to foramen ovale. There was a
large, firm subdural clot, three fluid ounces by measurement, in the anterior
fossae, and a slight subdural haemorrhage into right posterior fossa around
the foramen magnum. A deep laceration extending below the cortex, on
the under surface of the left cerebellum, made an excavation three-quarters
of an inch broad from the posterior nearly to the anterior border. Another
extensive laceration deeply excavated the inferior portion of the right
frontal and extended into the external border of the right temporo-
sphenoidal lobe. Haemorrhage from the latter laceration reached the ver-
tex anteriorly and filled the fissure of Sylvius. Another laceration existed
in the middle portion of the gyrus fornicatus, filled with brain detritus and
coagulum, and extended through the cortex. This was oval in form and
half an inch in diameter. There was some general contusion of both
hemispheres, most marked in posterior portions.
CASE XXXI. Male, forty-five years of age ; thrown from a horse and
Struck upon his head. He was temporarily unconscious, but on the
arrival of the ambulance was able to stand, and said he felt very well. He
again became unconscious on his way to the hospital. His pupils were
Contracted and his pulse barely perceptible. He suddenly became cyanotic
and died twenty-five minutes later.
Necropsy.—Haematoma of scalp in left occipital region; blood fluid ; stel-
late fracture of calvarium with centre in left upper occipital region, and
With fissures extending downward into foramen magnum, forward into
middle fossa, and upward and laterally ; epidural clot in occipital region;
Subdural haemorrhage in inferior occipital fossa compressing the medulla;
extensive subarachnoid haemorrhage over temporo-sphenoidal and frontal
lobes on both sides, with laceration of inferior surface of right frontal and
temporo-Sphenoidal lobes, and in slighter degree of same region on the left
side.
CASE XXXII. Male, thirty-four years of age; struck by a brick falling
from the fourth story. Compound, comminuted, depressed fracture of
the right parietal bone extending into the base; haemorrhage from right
ear; patient conscious and without general symptoms; temperature,
100.4°, and became normal; depressed bone elevated; no injury of dura.
After twenty-three days subcortical abscess of brain developed, with left
hemiplegia and anaesthesia. Dura incised and abscess evacuated. Died
sixteen hours later. Temperature, 108°.
19
290 NEW YORK STATE MEDICAL ASSOCIATION.
Necropsy.—Fissure through whole length of anterior surface of right
petrous portion of temporal bone; no superficial cerebral laceration ; sub-
Cortial abscess cavity of small size, which had been evacuated ante-mortem
through the angular gyrus. This case is fully reported in the New York
Medical Journal, March 29, 1890.
CASE XXXIII. Male, thirty-three years of age ; cause of injury un-
known. Consciousness lost and never regained ; scalp wound in left
posterior parietal region; haemorrhage from left ear; both pupils dilated,
but the right contracted later; pulse, 60 ; muscles relaxed and later
became rigid. Death in twelve hours. Temperature on admission, 99-6°;
later, 98-6° to 100°4°; one hour post-mortem, 101-2°.
Wecropsy.-Semicircular fracture of squamous portion of left temporal
bone, with fissure extending into anterior surface of petrous portion ; deep,
well-defined laceration, laterally and posteriorly, of left temporo-sphenoidal
lobe, from which a thick clot extended over the occipital region; brain in
all its parts excessively hyperaemic ; on section, the surface was repeatedly
bathed in blood as it was each time wiped away; no punctate extravasation
Or coagula in minute vessels.
CASE XXXIV. Male, forty years of age ; said to have fallen down one
flight of stairs. Scalp wound in right occipito-parietal region ; haemor-
rhage from the nose and later occurrence of haematemesis; unconscious-
ness; stertor; pulse, 96 and full; respiration, 18; temperature, 100°; pupils
normal till just before death, when they dilated; restlessness; incontinence
of urine ; temperature rose gradually to 102°6° one hour ante-mortem.
Died in fourteen hours.
Necropsy—Linear fracture in right parietal bone and extending through
middle fossa and greater wing of sphenoid ; small epidural clot and larger
subdural clot beneath the site of fracture ; dura ruptured ; cortical lacera-
tion an inch and a quarter by three-quarters of an inch in anterior and in-
ferior part of right parietal lobe; another laceration involved anterior half
of middle temporal convolution on the same side. The whole brain Very
hyperaemic, most markedly so on left side posteriorly. In almost the
exact centre of the left cerebellum there was a laceration about the size of
a pea filled with fluid blood.
CASE XXXV. Male, forty years of age; fell six stories. Abrasion about
left eye; unconscious; pulse and respiration too rapid to be counted ;
temperature, 101°; both pupils strongly contracted ; rigidity of both
lower and the right upper extremities; temperature in articulo mort?8,
100'4”--; two hours post mortem, 99°-H and pupils dilated.
Necropsy.—No superficial injury upon any part of the body except the
:abrasion noted. An extravasation of blood existed below the scalp, COVer-
ing the whole left parietal region. Separation of coronal suture, left side,
from about its middle point, extending outward and terminating in a
fissure which, in the middle fossa, divided into two lines, one lost in the
greater wing of the sphenoid, the other at the petro-mastoid junction. No
epidural or subdural haemorrhages. Cortical haemorrhages from menin-
STUDY OF INJURIES OF THE HEAD. 291
geal contusion—one covering left frontal and parietal lobes superiorly and
laterally, another covering right parietal and occipital lobes on either side
of their junction. No laceration on the surface of the brain, or in any
part, except one three-eighths by one-fourth of an inch in the left corpus
striatum, subcortical, and at junction of middle and posterior thirds.
Excessive general hyperaemia. -
CASE XXXVI. Male, sixty-five years of age ; fell into the hold of a
vessel; haemorrhage from the ears and into subconjunctival tissue; con-
scious for twenty-four hours; both pupils dilated ; temperature high ;
died in twenty-four hours.
CASE XXXVII, Male, sixty years of age ; knocked down by a truck;
scalp wound in right posterior occipital region. A linear fracture run-
ning backward and downward was discovered by incision. Patient un-
conscious and restless. Pupils contracted ; pulse, 66; very slight move-
ments of right side of body; no facial paralysis; spoke only in monosylla-
bles. In a short time right hemiplegia became complete, pulse Weaker,
temperature lower, and there was a slight general convulsion lasting
about ten seconds. Four hours later coma was profound, pupils Small
and irresponsive, pulse and respiration very irregular, and restlessness
ceased. The patient was trephined over left motor area. The fissure was
found to extend downward behind the mastoid. Epidural haemorrhage
disclosed, and, after incision of dura, subdural haemorrhage. He died
three hours later, and eleven hours after reception of injury.
CASE XXXVIII. Male, forty years of age; cause of injury unknown;
contusions behind both ears; free haemorrhage from right ear, and during
the night from both ears and mouth ; pupils contracted ; pulse full and
Slow ; breathing labored ; temperature, 99.2°; became 105°. He did not
regain consciousness, and died six hours after admission.
CASE XXXIX. Male, twenty years of age; fell thirteen feet; large
haematoma in left posterior parietal region ; unconscious; oozing from
left ear and nose; pupils contracted, and eyes turned persistently to the
right; mouth drawn slightly to the right; breathing irregular; vomiting
free; extremities cold and muscles relaxed ; urine incontinent; tempera-
ture, 99.5°. Soon after admission haemorrhage from nose ceased, but con-
tinued from the ear. Patient could be roused partially but with difficulty,
became restless, and moved his right side rather less freely than the left.
Temperature, 101°. Two hours after admission breathing became stertorous,
and tonic spasms, beginning in the right arm, became general. Two at-
tacks of opisthotonos followed, and ceased after thirty minutes. Left
Pupil became the larger, while the right eye still turned to the right on
*posure. Temperature, 105°; pulse, 96; respiration, 32, and of the
Cheyne-Stokes Variety. An hour later coma was profound, with slow
and Stertorous respiration. Temperature, 106.6°. Respiration became
*Sufficient, four to the minute, and face cyanotic. Death occurred in
four hours. Pupils post-mortem were widely dilated.
292 NEW YORK STATE MEDIOAL ASSOCIATION.
CASE XL. Male, thirty years of age ; fell three stories to the pave-
ment; four ribs fractured on the right side; contusion over right eye,
and slight right subconjunctival haemorrhage; unconscious; skin cold
and moist ; pulse, 120; temperature, 100°. Pulse became weaker and
respiration more labored, and death ensued in five hours and a half after
reception of injury. No pulmonary symptoms. -
CASE XLI. Male, forty years of age ; cause of injury unknown ; ex-
tensive contusion over right parietal region; haemorrhage from right ear
and nose; unconscious ; stertor ; died in four hours and a half.
CASE XLII. Female, forty-seven years of age ; fell on the street in a
convulsion during a debauch ; had other convulsions before admission;
left side of head and eyelid much contused ; mental condition stupid ;
pupils normal ; breathing stertorous ; pulse, 108; convulsions continued
during the day and night ; no interval of consciousness. During the
morning a severe haemorrhage occurred from the mouth without previous
Warning. In the afternoon pulse and respiration became frequent. The
blood which came from the mouth was bright in color, non-aerated, and
Said to be more than eight ounces in amount. The next day the convul-
sions were diminished in frequency and were general, but more severe in
the right arm. No initial symptom noted. Both arms were rigid and
head constantly turned to the right. There were in all twenty-three con-
vulsions. Death occurred in thirty-eight hours. Temperature, one hour
after admission, 102-4°; morning of next day, 105.6°; later, 107.4°,
106.2°, 107.8°–the last, one hour before death.
CASE XLIII. Male, seventeen years of age ; fell one story ; large
haematoma on left frontal region ; unconscious till death ; haemorrhage
from nose, mouth, and left ear, and under conjunctiva of both eyes;
pupils equally dilated ; slight convulsive movements of right side SOOn
terminating in right hemiplegia, with rigidity of left side; death from
pulmonary oedema occurred in five hours; temperature one hour before
death, was 105'4°.
CASE XLIV. Male, thirty-seven years of age ; jumped from a fourth-
story window to the street while drunk; lacerated scalp wound in left
posterior parietal region, and fissure running from it into posterior fossa ;
both pupils widely dilated ; patient loud and abusive in language ; slight
left facial paralysis; incontinence of urine; pulse, 118, soon becoming
irregular and almost imperceptible. The patient became quiet, and a
little later comatose. Temperature, 97.6° by rectum. Three hours after
admission he had three clonic spasms of right arm at varying points.
Died in six hours after admission while under ether, given for reduction of
a dislocated hip.
CASE XLV. Male, thirty years of age ; struck by a falling ladder ;
haemorrhage from mouth and nose, and blood and brain matter exuded
from the right ear; both eyes protruded, the right eye the more so; both
pupils contracted and irresponsive to light; right facial paralysis; respira-
STUDY OF INJURIES OF THE HEAD. 293
tion stridulous. Right pupil soon began to dilate slowly. Temperature,
100°; pulse, 93. Patient remained unconscious till death, two hours after
injury.
CASE XLVI. Female, thirty-five years of age ; fell down stairs;
admitted next day, still unconscious ; ecchymosis in left posterior parietal
region; haemorrhage from left ear; left eye protruded; left pupil dilated.
Temperature, 101° ; pulse, slow. Vomiting profuse. Next day paresis
of whole right side; urine incontinent ; Some pulmonary oedema. On the
third day rigidity of the muscles of the back of the neck. Haemorrhage
from the ear continued a week, lessening in amount and becoming Serous
in character. Patient continued unconscious till death, at the end of ten
days, from asthenia. Temperature ranged from 100° to 102° till the morn-
ing of the eighth day, when it suddenly rose from 101° to 103°. From this
time it rose, with morning depressions, steadily to 107.4° on the day of her
death.
CASE XLVII. Male, thirty-five years of age; cause of injury unknown ;
found unconscious ; Small haematoma on left temple ; haemorrhage profuse
from both ears; evidence of previous haemorrhage from both nostrils;
pulse scarcely perceptible; stertor; pupils both equally dilated; complete
relaxation of limbs, and no response to peripheral irritation. Left facial
paralysis was developed two hours before death, which occurred in six
hours without restoration of consciousness. Temperature on admission
was 98.6°, rose to 99°-H; pulse, 64 to 128; respiration, 24.
CASE XLVIII. Male, twenty-four years of age ; fell down stairs; wound
over right eye ; haemorrhage from right nostril; coma ; stertor; pupils
contracted ; temperature, 98°5°; pulse, 120; no paralysis or muscular
rigidity ; reflexes normal; fracture of left thigh. Clonic spasm of left side
five hours after admission. Death in ten hours after reception of injury.
Hourly temperature, 100°, 101°, 102-4°, 102-4°, 103°, 104.4°, 105°, 106’4”.
Thirty minutes post-mortem, 108-8°.
CASE XLIX. Male, four years of age ; fell two stories, striking the
back of the head; small scalp wound just above external occipital protu-
berance; large haematoma above each ear; profuse haemorrhage from both
ears and mouth, and haematemesis; depressed fracture could be felt beneath
the wound ; unconscious; right pupil dilated ; neither pupil responsive ;
slight rigidity of muscles of right side. Temperature, 100.8° ; pulse and
º very rapid ; respiration became Cheyne-Stokes. Died in four
OUITS.
CASE L. Male, fifty-nine years of age ; fell two stories through an
elevator and struck his head; contusion about right ear and nose ; uncon-
scious for ten days; haemorrhage from right ear and nose and under right
Conjunctiva ; stertor; pupils irregular. At the end of a week restless,
and required to be kept in bed by an attendant. Discharge from ear
Straw-colored. At the end of two weeks patient entirely conscious. Ten
days later he walked a little and began to recognise people, and after
another ten days he was mentally recovered.
294 NEW YORK STATE MEDICAL ASSOCIATION.
CASE LI. Male, thirty-three years of age ; thrown from a truck and
received a blow upon the head ; scalp wound in left temporal region; pro-
fuse haemorrhage from left ear; pupils regular. He was semi-comatose,
but conscious and rational next day, and two days later became delirious.
Haemorrhage from the ear ceased on the sixth day, delirium continued a
week, and vertigo for upward of three weeks. No further symptoms were
developed.
CASE LII. Male, thirty-five years of age ; struck on the head by a
brick falling eight stories; not made unconscious; compound, comminuted,
depressed fracture at right temporo-parietal junction; squamous portion of
temporal much comminuted, and one large fragment driven into the brain ;
haemorrhage from right ear and nostril; right pupil contracted ; little or
no shock. He recovered with some deafness remaining in right ear.
CASE LIII. Male, thirty-five years of age; fell down stairs while
drunk; coma; stertor; haemorrhage from left ear, which continued
twenty-four hours; pupils contracted. Regained consciousness in twelve
hours. Five days later, left facial paralysis, both upper and lower face
involved, and food accumulated between cheek and jaw; ptosis, etc. No
loss of sense of taste. He entirely recovered from paralysis, and suffered
only from occasional vertigo.
CASE LIV. Male, nineteen years of age ; thrown from his horse while
riding, and struck on the back of his head; contused wound in right
occipital region ; profuse haemorrhage from right ear; pupils contracted;
unconscious till after his removal to his house, a distance of two miles. He
then had severe nausea and vomiting, and was somnolent for several hours.
The next morning his pulse and temperature were normal, and he suffered
from severe pain in the head, which continued for three days. Haemor-
rhage from the ear ceased at the same time. There was no rise at any time
in pulse or temperature. At the end of ten days there was still some pain
and tenderness on deep pressure just above and behind the ear. His
recovery was complete.
CASE LW. Male, forty-four years of age ; said to have fallen and
been struck by a plank ; admitted to alcoholic ward, and next day trans-
ferred to surgical service when he had partially recovered consciousness.
The left upper and lower extremities which had been rigid, had become hemi-
plegic and anaesthetic. There was an abrasion of the nose, a contusion of
the left eye, and a haematoma of the right posterior parietal region. Three
days later the left hemiplegia had become complete; movements from the
bowels were conscious but involuntary; bladder controlled ; temperature.
99°. His mental condition had been unchanged since he recovered con-
Sciousness. He answered questions rationally, and never varied in his ex-
planation of the manner in which his injury had been received. He talked
constantly and rambled in his speech. Upon incision, an open fissure Was
disclosed, which ran obliquely across the right parietal bone, from the an-
terior Superior angle, and into the occipital as far as it could be Conven-
ently traced. There was no depression. A large opening was made
STUDY OF INJURIES OF THE HEAI). 295
through the bone by trephining and use of the rongeur. An epidural clot was
found to extend from the coronal suture in front to the superior occipital
fossa behind, and from the median line to the middle fossa, and was an inch
and a half in thickness in its central portions. This clot, when removed,
measured four ounces and a half by volume, and left a large cavity, the
result of cerebral compression. The dura was apparently uninjured. As
haemorrhage was free from some inaccessible point beneath the bone, the
cavity was temporarily packed with gauze. Two hours after the opera-
tion he could move the left leg. Twelve hours later there was sensation in
the left arm. The next day sensation was perfect, movements of the left
arm still restricted, and movements of the bowels occurred which were con-
trolled. Temperature, 98°5°. The second day the brain had regained the
volume it had lost by compression, and his mental condition was apparently
normal. In four days he was in all respects entirely well, except for his
external wound.
CASE LVI. Male, twenty-three years of age ; thrown from his horse
and sustained a depressed fracture of the left frontal bone two inches above
the orbit. Partial loss of consciousness; haemorrhage from nose and
mouth ; pupils normal; skin pale and moist, and extremities cold; two or
three hours later projectile vomiting and haematemesis. There was slight
ecchymosis of the left upper eyelid before the vomiting ; after it both eye-
lids became excessively ecchymotic, and at the same time the outer half
of the left conjunctiva became filled with blood. The temperature was
usually about 99°, never above 100.5°. He had temporary amblyopia, and
no other results followed.
CASE LVII. Male, forty-five years of age; knocked down and beaten
about the head; lacerated scalp wounds in left fronto-parietal region;
Coma; haemorrhage from both nostrils; pupils normal; pulse, 100. He
recovered partial consciousness in one hour, and became excessively irri-
table; full consciousness returned next day, and he was removed from the
hospital.
CASE LVIII. Male, twenty-six months of age ; fell four stories; ex-
tensive Scalp wound in right occipital region ; repeated vomiting; haemor-
rhage from right ear. Three hours later he became restless, had clonic
Spasms upon the right side, and gradually lost consciousness. There was
apparent complete right hemiplegia; movements of the left side were
easily induced ; pulse, 130 and weak; breathing stertorous. Conscious-
ness gradually returned within twelve hours, and no paralysis remained.
There were no further symptoms.
tº CASE LIX. Male, thirty years of age; fell from elevated railroad to
sidewalk, striking upon left side of head and face; contusion over left eye;
semi-conscious; haemorrhage from right ear; pulse and respiration slow.
The next day patient recovered consciousness enough to discover that he
had become blind in the left eye. He responded slowly to questions and
slept most of the time. Ophthalmoscopic examination of the left retina
Was negative. The left pupil would not respond to direct exposure to
296 NEW YORK STATE MEDICAL ASSOCIATION.
light, but would contract with the other pupil on simultaneous exposure.
In the opinion of Dr. P. A. Callan, the blindness was due to pinching of
the optic nerve by a fracture involving the optic foramen. Fifteen days
later Dr. Callan found commencing atrophy of the optic nerve. Eight days
after the injury there was partial left facial paralysis, and the tongue
deviated to the right. He complained of pain over the left eye and be-
hind the right ear. A slight sero-sanguinolent discharge began to flow
from both ears, continued for some days, ceased, and reappeared from the
right ear. Temperature on admission was 99°, rose to 100°, and afterward
varied, usually from 99° to normal.
The patient, a man of unusual intelligence, stated, after his recovery,
that for five weeks after his accident he was unable to recollect the attend-
ant circumstances or anything that happened about that time or afterward;
that his mental condition was one of great confusion. After that period
his memory was restored and his mental confusion disappeared. His re-
covery was ultimately complete, with the exception of loss of sight of the
left eye.
The diagnosis made was ; Fracture of the frontal bone, commencing on
the left side, extending through the anterior fossae and through the right
middle fossa and petrous portion, involving the left optic foramen and
lacerating the pre-frontal lobe.
CASE LX. Male, forty-seven years of age ; knocked down by a blow,
and his head struck heavily upon the pavement ; slight contusion upon lip
and over right eye; pulse, 72; temperature, 100:2°; unconscious; stertor;
pupils normal ; soon became delirious and was unable to articulate. He
remained in a condition of stupor and delirium for ten days; required me-
chanical restraint. He was unable to articulate, and was dysphagic; at-
tempted to drink his urine. His mental condition and power of articula-
tion then improved for two weeks, though he developed left facial
paralysis, involving lower face; dysphagia disappeared. There was then
an interval of a few days, when he was irritable, restless, and disposed to
wander about the ward at night. His temperature varied from 100° to
normal, and was usually at the higher point. From this time he became
Quiet and conversed intelligently, though his mind wandered. He had no
recollection of his injury, of what preceded it, or of anything that occurred
afterward. He failed to recognise his location or to appreciate his sur-
roundings. His memory of more distant events was better, but still
defective. His laugh was vacant, and there was some perceptible loss of
power on the left side. He continued in a demented condition and inci-
dentally a dipsomaniac till his removal to an insane asylum within the last
month, two years after the injury.
CASE LXI. Male, twenty-two years of age; fell two stories and struck
right side of the head and face and right shoulder; contusions of those
regions and fracture of acromion; unconscious; haemorrhage from right ear,
and four hours later from the nose; regained consciousness in five hours;
haemorrhage from ear ceased in three days; temperature, 101° to 100”;
normal after four days.
STUDY OF TWJURIES OF THE HEAD. 297
CASE LXII. Male, twenty-two years of age ; fell three stories; contu-
sions of right side of head, face, and eye; haemorrhage from right ear and
mouth; unconscious; pulse slow and full (60); breathing labored; tempera-
ture, 101°; pupils normal. Respiration soon became easier, but the patient
was irritable and restless. He did not regain consciousness for five days,
during which time he continued to be irritable when disturbed, and was
not wholly rational for five days longer. Toward the end of the second
week his articulation became thick, and right lower facial paralysis became
evident. At the same time a swelling without discoloration of the left side
of the face, which had been present since admission, perceptibly increased,
but soon afterward disappeared. The facial paralysis persisted, and the
difficulty of articulation increased. His mental condition varied, but pro-
gressively deteriorated. There was slowness of perception and hesitation
in expression. His laugh was silly and his manner vacant. There also
seemed to be a sensory aphasia at a late period. In reply to questioning
about the manner of his accident, he would talk about taking a basket of
clams from Koster & Bial's. He might say “Koster & Bial's,” but was
quite likely to say “Koster and clams.” At the beginning of the second
month there was a sudden change. His mind in a day became clear ; he
knew where he lived and that he was in a hospital. He conversed ration-
ally about his accident and how it occurred. He lost his delusions and
rested quietly at night, though his speech was still a little indistinct and
his facial paralysis had not entirely disappeared. Temperature after the
third day was rarely above 99° and oftener below it. His recovery was
ultimately complete. .
CASE LXIII. Male, forty years of age; fell down five steps of a stair-
Way ; walked home ; haemorrhage from right ear; had two convulsions
next day and was then taken to the hospital; haemorrhage from the ear
still continued; stupid ; muttering; two other convulsions, most marked
On the right side, followed by mild delirium throught the night. No pre-
vious history of epilepsy or excesses in drink. Temperature, 101:2°.
Three days later patient was still stupid, said little and that incoherently,
and was delirious. Temperature had ranged from 101-2° to 100.6°. He
Was transferred to Bellevue, and there became wildly delirious for three
days, and then quiet and rational. Temperature, 98.8°. No further his-
tory noted ; no other Symptoms. -
CASE LXIV. Male, forty-two years of age ; cause of injury unknown.
Semi-conscious and drunk; haemorrhage from right ear which continued
eight days; membrana tympani ruptured ; violent mania for two days
and mild delirium two days longer; temperature, 100°. Four days after-
Ward he suffered pain in the head; had occasional delusions; his mental
Processes were slow, and his tongue deviated to the right; urine and
*ces incontinent. In the second week he became rational and only
Occasionally soiled the bed. His tongue still deviated. At the end of a
*9th he no longer had symptoms; even the deafness had improved.
Temperature second day, 103°; gradual decline to 99° in four days. After
Seventh day habitually normal to 99°.
298 NEW YORK STATE MEDICAL ASSOCIATION.
CASE LXV. Male, forty years of age; fell down a gang-plank. Un-
conscious ; haemorrhage from both ears, more from the right ; pulse, 100;
temperature, 100°. After some hours consciousness returned and he was
able to speak. Delirious through the night. On the next day his tongue
deviated to the right ; pupils dilated, left more so than the right; mind
still clouded ; temperature, 99.6°. Four days later he was rational. No
further symptoms.
CASE LXVI. Male, twenty-three years of age; walked out of a window
while sleeping, and fell three stories to a stone pavement below, striking
an iron fence on the way down. He remained unconscious for fifteen or
twenty minutes. On admission, there was a wound of the external right
ear. While this wound was being dressed a very profuse serous discharge
began from this ear and continued for several days. Pupils and respira-
tion normal; severe vertigo, aggravated on attempting to rise or on open-
ing his eyes; he vomited several times; pulse, 90 ; temperature, 99°. On
the fourth day he had upper and lower incomplete facial paralysis which
continued for a week's time. On the eighth day he had three epileptiform
convulsions, and one on the next day. The head and eyes were first turned
to the right, then the arms, and finally the legs were involved. On the
twentieth day he began to have severe pain in the right ear, and as the
mastoid region later became swollen and inflamed, it was trephined for
exploration, with negative result. The temperature but once exceeded
99°. The mastoid inflammation disappeared at once after trephining.
Recovery was complete.
CASE LXVII. Male, fifteen years of age ; kicked in the back of the
head by a horse. No apparent external injury ; profuse haemorrhage
from right ear; was moaning and restless; became delirious after a few
hours; afterward irrational and incoherent ; irritable ; temperature, 100°;
delirious or irrational for five days; temperature, 100° to 102° ; removed
from hospital in two weeks; temperature, 99°; still had delusions.
CASE LXVIII. Female, six years of age; fell two stories to pavement;
unconscious ; lacerated wound over right eye and haematoma ; contusion
of face ; severe haemorrhage from mouth and nose, and haematermesis ;
subconjunctival haemorrhage in both eyes; pupils dilated ; stertor;
respiration frequent ; temperature 99°; reflexes lost; incontinence of
urine and faeces; surface irritation caused violent convulsions; initial
Symptom in the eyes, continued twenty-four hours; also haemorrhage
from nose and mouth. After that time all the symptoms disappeared,
and patient was out of bed on the tenth day; temperature rose in three
hours from admission to 103.2°; fell to 98.6° on the second day.
CASE LXIX. Male, four years of age; struck by some falling object :
contusions over left frontal and right parietal eminences; haemorrhage
from mouth, nose, and both ears, and continued from left ear for five days;
unconscious; left pupil dilated; left facial paresis; temperature, 99";
somnolent forty-eight hours, but rational when roused ; incontinence of
urine and faeces; temperature, 100° on second day and 100:4° on third
STUDY OF INJURIES OF THE HEAD. 299
day; did not get below 100° till tenth day; pulse usually 120; symptoms
gradually disappeared.
CASE LXX. Male, forty years of age ; fell one story to pavement,
striking back of his head ; scalp wound in right occipital region; haemor-
rhage from left ear; left pupil dilated; soon became normal; unconscious;
partially restored in ambulance; on admission, restless and delirious;
temperature, 99.4°; pulse, 60; respiration rapid ; moved right side only ;
incontinence of urine and faeces. Temperature ranged during the first
week' from 100°–H to 101°; then became 99°–H in the morning, and at end of
second week became normal ; pulse varied from 62 to 54; required con-
tinuous mechanical restraint for four days, and at night for one month.
His mind underwent the typical changes (see remarks on diagnosis), and
became ultimately completely restored. -
FRACTURES OF THE VERTEX.
CASE LXXI. Male, fifty-two years of age ; fell backward and struck
back of his head, at the same time fracturing his left patella. At the hos-
pital to which he was taken, his head injury did not attract attention. He
was delirious on the second day and had a convulsion on the fifteenth, and
his condition was attributed to the alcoholic habit. Six months later the
patella was wired for non-union. His muscular rigidity under the anaes-
thetic was notable. His temperature the day following the operation was
99° until one o'clock P. M. Half an hour later, and without premonition,
he had an epileptiform convulsion which began in the face and became
general, and was followed by wild delirium. He had two other similar
Convulsions, also followed by wild delirium, and the last by a temperature
of 103°. The kidneys acted freely and the urine was normal. The wound
of operation was the seat of primary union. The temperature was normal
On the next day and so remained for fifteen days. At that time an attempt
Was made to coapt the fragments of the patella, which he had torn asunder
in his convulsions and delirium. This failed, and there was some subse-
Quent Suppuration which elevated the temperature for the next ten or
tWelve days to 99°-- and to 102°. The wound was then healed and the
temperature again became normal. At each dressing great muscular
rigidity and tonic spasm had been noted in the affected limb (left). Just
One month from the previous attack convulsions recurred, and were fre-
Quently repeated for thirty-six hours. They were all marked by the same
characteristics. Each one was preceded by great restlessness. In about
fifteen seconds this was followed by wide dilatation of both pupils. The
*uscles of the left side of the face began to twitch and the eyes deviated
to the left. The muscular spasm extended to the other side of the face,
then to the left arm and leg, and finally became general. The whole con-
Vulsion lasted about thirty seconds. During the day the deviation of the
*ft eye became permanent. The tendon reflexes were markedly increased.
After the convulsions ceased he became delirious, and died nine hours later.
300 WEW YORK STATE MEDICAL ASSOCIATION.
At the time of the seizure his temperature was 101'1", in twelve hours it
became 102°, in twenty hours 104°, in twenty-four hours 104.8°, and after-
Ward fell to 104°.
AWecropsy.—The knee-joint of operation was found to be free from in-
flammatory complication, and the wound practically healed. A depression
was discovered in the skull just above the external occipital protuberance
in the median line. This was confined to the external table and no lesion
of the brain existed beneath it. At the opposite extremity, however, of
the antero-posterior diameter, there was a circular laceration upon the an-
terior border of the right frontal lobe, and another laceration existed upon
the under surface of the left frontal lobe, upon the middle of the second
and third orbital convolutions, an inch and a half by an inch in diameter.
A still larger laceration of the base, at least three inches and a half by an
inch and a half in diameter, existed upon the right temporo-sphenoidal
lobe, involving a little of the first, and almost the whole of the second and
third convolutions. All these lacerations were distinctly limited, softened,
and of a brownish color, showing the considerable time which had elapsed
since they were inflicted. The whole right temporo-sphenoidal lobe was
greatly atrophied, indurated and pigmented. The pia, was thickened over
each laceration.
CASE LXXII. Male, forty years of age; cause of injury unknown;
found unconscious in bed; contusions of forehead and left upper eyelid ;
pupils regular and fixed ; right facial paralysis; both arms and right leg
rigid ; pulse, 96; respiration, 36. Twenty-four hours later, right arm
paralysed, but still rigid ; could not determine whether right leg was para-
lysed ; pulseless; died in thirty hours; temperature at admission, 102’6”;
twenty-four hours later, 105°.
Mecropsy.—Haematoma over whole left parietal region. Linear fracture
across whole length of parietal bone just above temporal ridge, recurving
upon itself posteriorly for a little distance. Large epidural clot beneath
the fracture, compressing and flattening the whole left hemisphere, and
forming an oblique plane. General contusion of the whole brain, which
was hyperaemic and studded with minute extravasations.
CASE LXXIII. Male, twenty-eight years of age; received a blow upon
the head from a falling elevator (lift); compound comminuted fracture of
right frontal bone; wound filled with clot and brain tissue ; opening in
the skull an inch and a half by half an inch in diameter. After cleansing
the wound a cavity was left in the frontal lobe as large as a Mandarin
Orange. The patient was semi-conscious, but mental condition soon be-
came normal. Pulse, 68; temperature, 100:2°. Womited frequently. At
the end of twenty-four hours he was rather heavy and somnolent, but
could be easily roused, and was rational. Two hours later he was found
in a comatose condition, with a temperature of 105.4°, and died soon after-
ward, twenty-seven hours from the time he received the injury.
Necropsy.—Two large fissures ran backward on either side of the skull,
one terminating in the parietal and the other in the occipital bone. There
STUDY OF INJURIES OF THE HEAD. 301
was no epidural haemorrhage. An irregularly shaped piece of the internal
table was detached and rested upon the brain just above the cavity noted,
but nearer the median line, and a subdural clot three inches in diameter and
half an inch thick was situated just posterior to it upon the right frontal
lobe. There was slight cortical haemorrhage in the left occipital region.
There was no lesion at the base. The cavity made by laceration of the
frontal lobe extended nearly to the lateral ventricle. The whole brain, in-
cluding the pons, optic thalami, and corpora striatà upon both sides, and
the cerebellum, was streaked with minute coagula, Some of which, an inch
in length, could be teased from the vessels.
CASE LXXIV. Male, thirty-two years of age ; fell thirty feet into the
hold of a vessel, striking upon his back. Unconscious ; pulse and respi-
ration slow ; stertor ; no other symptoms. Condition resembled that of
alcoholic coma. Next morning the temperature was 101-6°; evening, 101°8.
On the second day, A. M., 103-8°; M., 104.2°; P. M., 105.4°. Right hemi-
plegia and both eyes turned to the left. Pupils normal. Pulse feeble and
rapid. Respiration inadequate from pulmonary oedema. Still unconscious.
On the third day temperature, A. M., 106’4”. Death in sixty hours.
Mecropsy.—Separation of coronary suture from right frontal eminence
to its left external extremity. Not much epidural haemorrhage. Lacera-
tion of posterior extremity of left temporo-sphenoidal extending into occip-
ital lobe. Consequent subdural haemorrhage of moderate amount, involv-
ing left motor area and occipital lobe to the base. Another laceration
existed on the posterior border of the left cerebellum. General contusion.
CASE LXXV. Male, thirty-two years of age; fell from his truck. Con-
tusion of left parietal region ; unconscious ; irritable when disturbed ;
temperature 99°; pulse 60 and full ; coma continued for about a week
With temperature from 99% to 100°, then a period of irritability and mild
delirium which lasted two weeks longer. Mental condition after the first
tWO Weeks apathetic and weak. He answered questions rationally when
Spoken to, but rambled in his speeeh. He recognised his friends, but
Spoke only when spoken to and had some delusions. At the end of a
month he was transferred to Mount Sinai Hospital, and died there.
Necropsy.—Fracture found in left occipito-parietal region. Laceration.
CASE LXXVI. Female, twenty-three years of age ; suicidal gunshot
Wound through right temporal fossa; median line of vertex presented a
°onical elevation; haemorrhage considerable; patient unconscious with
Stertor; coma became more profound; temperature fell to 95°; pulse rapid ;
death in four hours.
Accropsy.-Scalp infiltrated with blood. Bullet entered frontal bone a
little above and external to right eye, penetrated the brain, passed inward,
*PWard, and backward, and impinged upon the inner surface of the skull,
*little to the left of the median line in the middle parietal region. It ele-
wated two little triangular pieces of bone which remained attached to the
P*ranium. The bullet then fell back into the brain. It had entered at
the anterior extremity of the fissure of Sylvius, traversed the right frontal
302 NEW YORK STATE MEDICAL ASSOCIATION.
lobe, just below the cortex and parallel to its curve, and then passed a
little backward and across the longitudinal fissure below the longitudinal
sinus, into the left parietal lobe ; after fracturing the left parietal bone and
falling back into its cerebral track as noted, it rested about half an inch
below the surface. The skull was very thick, and fissured from the point
where the bullet entered. There was little intracranial haemorrhage.
CASE LXXVII. Male, twenty-six years of age ; homicidal gunshot
wound in right temporal fossa; patient unconscious; pupils normal;
general muscular twitching ; coma became profound, and death followed
in twelve hours.
Necropsy.—Bullet entered just behind external angular process of right
frontal bone, traversed the right hemisphere nearly in its antero-posterior
diameter, just above corpus callosum, impinged upon inner surface of the
occipital bone, and, rebounding through the opening in the dura, fell into
the inferior occipital fossa. Considerable subdural haemorrhage.
CASE LXXVIII. Male, forty-two years of age ; suicidal gunshot
wound in right temporal fossa; patient unconscious; pulse, 70; no other
symptoms. He soon regained consciousness, and was rational, but his
mental processes were sluggish. He had syphilitic laryngitis and aphonia.
Temperature, 99°. An attempt was made to remove the ball next day,
the opening in the bone at about the right temporo-frontal junction having
been enlarged by the trephine. The track of the ball could be traced about
two inches and a half forward, downward, and inward, at which distance
a piece of bone, carried inward by the ball, circular and comprising both
tables, was discovered and removed. Considerable brain matter oozed out
during this exploration. The ball was not found. No reaction followed
the operation. The patient lived thirty days. His urine and faeces were
voided freely, but without attracting his attention. The discharge of brain
matter from the wound gradually diminished. At the time of his death
the external wound had almost entirely healed. The most notable symp-
tom in his condition was hebetude. He remained rational but quiet, list-
less, and taking no notice of people or things, and without interest in what
went on about him, with occasional intervals in which his mind seemed
brighter. The temperature ranged from 100°–H to 103.6°, and was usually
above 101°. *
Mecropsy.--The ball entered the brain about the middle of the third
right frontal convolution, and passed nearly transversely through the centre
of both frontal lobes, and lodged just behind the ascending arm of the
fissure of Sylvius on the left side, in the upper portion of the island of
Reil. Its track passed just above the anterior horn of both lateral Ven-
tricles, and above the corpus callosum, just involving the calloso-margi-
mal convolutions. On the left side the track was sharply defined, and
formed a cavity five-eighths by seven-eighths of an inch in diameter Con-
taining the ball surrounded by clot and brain detritus. This was separated
by the median fissure from the cavity on the right side, from which the
bone was extracted during life. Between the two cavities was a minute
piece of bone.
STUDY OF INJURIES OF THE HEAD. 303
CASE LXXIX. Female, eight years of age; fell three stories; conscious;
shock; compound comminuted depressed fracture of left frontal bone,
with laceration of brain and meninges; restless and delirious; died on the
third day; temperature on admission, 100:2°; rose to 104.6°.
Necropsy.—Cavity in left pre-frontal lobe filled with clot and brain
detritus. No considerable intracranial haemorrhage. General contusion
of brain substance with coagula in minute vessels.
CASE LXXX. Male, fifty years of age ; cause of injury unknown ; un-
conscious; pulse and respiration rapid ; temperature, 100°; both pupils
dilated ; died in four hours.
Necropsy.—Simple fracture of left temporal bone, squamous portion.
Deep laceration of right temporo-sphenoidal lobe, also of anterior border of
left temporo-sphenoidal, smaller and shallower. Whole superior surfaces
of both hemispheres covered by cortical haemorrhage.
CASE LXXXI. Male, sixteen years of age ; struck on the head by an
iron wrench ; scalp wound ; depressed fracture at right parieto-occipital
junction ; trephined and elevated ; no general symptoms; walking case ;
no injury of dura ; no subsequent symptoms.
CASE LXXXII. Male, thirty years of age; struck on the head ; com-
pound depressed fracture of left temporal bone at parietal junction ; tem-
porarily unconscious ; afterward dazed ; agraphia. Trephined and bone
elevated next day ; agraphia continued eight days; sensory aphasia on the
third day. Temperature on admission, 99°; next day, 103°; second day,
103-8°; became normal on eighth day; afterward varied from 99° to 102°;
for twenty days; did not again become normal till thirtieth day.
CASE LXXXIII. Male, thirty-three years of age; blow from a cleaver;
fragment of outer table of left frontal cut off and left hanging by the
periosteum, including the frontal eminence; condition irritable; wound
healed in four days; no subsequent symptoms.
CASE LXXXIV. Female, two and a half years of age; fell down stairs;
Compound depressed fracture of left parietal bone just posterior and
external to frontal eminence ; wound lacerated and contused. Three days
later, convulsion occurred, and she was admitted to hospital. Wound
Suppurating and sloughy. No general symptoms. Bone elevated.
Highest temperature, 102°. Discharged in twenty-eight days; readmitted
fourteen days later; subdural abscess; hernia cerebri; abscess in brain
°Vacuated ; hernia subsided, and patient discharged.
CASE LXXXV. Female, forty-two years of age; struck with a ham-
* Weighing eight pounds; several lacerated and contused wounds of
the Scalp, and a depressed fracture of the posterior inferior part of the
*ight parietal bone one-half by three-fourths of an inch in diameter, with a
fissure running forward ; haematoma over right malar bone and a contu-
Sion of the back of the neck; patient conscious, rational, and restless;
304 NEW YORK STATE MEDICAL ASSOCIATION.
pulse, 120 and full ; temperature, 99°; third day, 100°; fourth day, 104°.
Trephined and elevated ; some epidural clot removed ; dura tense and not
pulsating, and was incised ; small amount of blood and serum escaped ;
wound healed at once, and temperature fell gradually to 99° in the next
four days. Six months later, I was told by Dr. S. Douglass that he had
seen her at about that time. She was very nervous and excitable, and
complained that she was confused and “wrong in her head" ever since
her discharge.
CASE LXXXVI. Male, thirty-eight years of age ; was struck by a
bottle in middle of forehead ; he was dazed, but able to walk; compound
depressed fracture of right frontal bone extending into orbital plate, and
frontal sinus opened. Trephined and a piece of bone, an inch and a half
square, with a sharp edge, which had penetrated the cerebral substance,
was removed. The superior longitudinal sinus was torn, and haemorrhage
was controlled by pressure against the bone with one blade of a Langen-
beck's forceps. Sutured in position till the third day. The patient for a
time was irritable and delirious, requiring mechanical restraint. The
temperature was very uniform, varying only from 99% to 100°, when it
became normal.
CASE LXXXVII, Male, forty years of age ; knocked down by a blow
upon the head. When he recovered consciousness he walked into the
hospital. Compound depressed fracture posterior to left frontal eminence,
and piece of inner table driven in. Dura uninjured. No general symp-
toms. Temperature, 101° to 102” for six days, when it suddenly dropped
from 101° to normal.
CASE LXXXVIII. Male, fourteen years of age ; fell two stories; tem-
porarily delirious from fright and excitement, and then recovered and
walked home ; depressed fracture in right frontal bone near coronal suture;
elevated ; no subsequent symptoms.
CASE LXXXIX. Male, thirty years of age; gunshot fracture of right
frontal, one inch above the zygoma, ; considerable haemorrhage from wound
and beneath the conjunctiva; right eye protruded so much that the lids
could not be closed ; no mental symptoms; temperature, 99.5° to 104.5";
next day temperature 104°. The bullet-opening in the skull was enlarged
by the trephine, several loose pieces of bone removed, and the bullet felt
near the optic foramen. The eye was then removed and the bullet CX-
tracted through the orbit, the dura having been first incised. The roof of
the orbit was found to be much comminuted. Temperature remained
high, and delirium and illusions continued for three days. The wound
suppurated rather freely for the first month, and the patient often suffered
from headache, which was always relieved by changing the dressings. He
remained in the hospital for two months and was then discharged entirely
well. The temperature for the first ten days was 102” to 103°; for the
next twenty days, 100° to 101°; for the next ten days, 100°; and the next
ten days, 99° to 99"—H·. -
STUDY OF INJURIES OF THE HEAD. 305
CASE XC. Male, eighteen years of age; blow upon the head from a
hammer ; conscious; compound fissured fracture in left parietal region ;
no depression ; no Symptoms.
CASE XCI. Male, twelve years of age; ran into an iron post ; compound
depressed fracture of right frontal bone, encroaching upon coronal suture
in temporal region ; slight escape of brain-substance; elevated piece of
bone three-quarters of an inch in diameter; no general symptoms of cere-
bral injury. Had no subsequent symptoms, except for a single day fol-
lowing the operation, when he responded slowly to questions.
CASE XCII. Male, thirty-five years of age ; blow upon the head from
an earthen mug ; compound fissured fracture of external table of posterior
part of left parietal bone; no general symptoms.
CASE XCIII. Female, thirty-seven years of age ; struck by a brick
falling from a roof; compound depressed fracture of right parietal bone,
three-quarters of an inch from median line, double comminuted. One
fragment removed and the other elevated. No general symptoms either
before or after the operation.
CASE XCIV. Male, sixteen years of age ; thrown from a horse ; com-
pound depressed fracture of left frontal bone, just above superciliary
ridge; conscious and irritable ; temperature, 99.8° ; pulse, 60, full. A
piece of bone, an inch and a quarter by half an inch, completely separated
and driven in upon the dura, was elevated and removed under ether. Had
no Subsequent general symptoms except temperature, which for ten days
Was usually from 99° to 100°, and a somewhat irritable mental condition.
CASE XCV. Female, seven years of age ; fell one flight of stairs over
the banisters; struck her head ; unconscious; vomited. Became dull and
stupid on the second day; next day admitted to hospital. Haematoma in
left parietal region, and linear fracture, discovered by incision, confined to
left parietal bone. Temperature, 99°. No subsequent symptoms.
CASE XCVI. Male, thirty-two years of age; stabbed in the forehead
With a pocket knife. Three days later no general symptoms. Tempera-
ture, 99" to 100° ; pulse, 76. After incision, the knife blade could be seen
broken off at the level of the surface of the bone, an inch and three-quarters
above left supra-orbital ridge, and an inch and a half to left of median line.
A button of bone, which included the knife point in the centre, was re-
moved by the trephine. The point had penetrated the brain a quarter of
* inch. Dura incised and closed by suture. No subsequent symptoms.
CASE XCVII. Male, twenty years of age ; knocked down by a blow
from a heavy stick ; unconscious; linear fracture from just above left
*P*ciliary ridge, extending into parietal bone, and incised wound. No
8°neral Symptoms.
CASE XCVIII. Male, thirty-one years of age; struck by a shower of
bricks; Compound depressed fracture of right parietal bone. Trephined,
*d loose fragment of inner table, half an inch square, removed. No
8°neral symptoms,
20
306 NEW YORK STATE MEDICAL ASSOCIATION.
CASE XCIX. Male, twenty-six years of age; fell thirty-five feet from a
scaffold; had been temporarily unconscious. A fragment of the right
parietal bone, near its upper posterior angle, including both tables, had
been torn out and was missing, two inches by one inch and three-quarters
in diameter. The inner table was comminuted, and fragments pressing
upon the dura were removed. No fissures. Dura uninjured. No disorders
of sensation or other general symptoms. Temperature, 99° to 100°-H.
CASE C. Female, forty-five years of age ; fell down stairway at
elevated railroad station ; unconscious. Admitted after five days. Haema-
toma over left eye, which had been incised ; fissure, extending into frontal
sinus, could be detected through the incision. The only general symptom
was occipital headache for some days after the injury was received.
CASE CI. Male, eight years of age; kicked by a horse; compound
depressed fracture of right frontal bone, just above frontal sinus and near
the median line. Elevated on the fourth day. Dura uninjured. Opening
in the skull which remained was three-quarters of an inch in diameter.
Had no previous general symptoms. Temperature, from 99° to 99.8°;
after the operation, rose in twenty-four hours to 108°, and in forty-eight
hours to 104°. In the next five days it fell gradually to 99° and remained
99°–H for ten days following. Once during this time—on the fifteenth day—
some serum escaped from the wound at the time of dressing. On the twen-
tieth day some laudable pus escaped, also at the time of dressing, and a probe
was carried two inches and a half into the frontal lobe parallel to the orbital
plate. The next day the dura was incised to the extent of the cranial
opening, and from two to three ounces of laudable pus evacuated. The
probe could be carried backward two inches and a half parallel to the
cranial wall on the external aspect of the hemisphere, as well as two inches
and a half parallel to the orbital plate. The temperature at this time was
99.2° and pulse 96. There were no general symptoms, except a little mental
dullness or apathy and slight right lower facial paralysis. His general con-
dition was also becoming asthenic. The cavity was irrigated and drained
by tube. Temperature rose next day to 102°– ; became normal in a week.
Facial paralysis entirely disappeared in ten days. Discharge ceased during
the third week. Mental condition became normal, and nutrition rapidly
improved after the first few days. There was a fungus, not larger than a
hazel-nut which spontaneously disappeared. The external wound Was
entirely healed in little more than a month, and no symptoms of any kind
remained.
INJURIES OF THE ENCEPEIALON.
CASE CII. Male, forty-one years of age; fell upon his face; contusions
most marked on left side of face and eyes; violent delirium for two days.
Temperature, 103° to 104°. On the sixth day again became delirious, and
later unconscious and violently responsive to irritations. Temperature
was at no time below 100°, and was 103° just previous to death, which
occurred at the end of six days.
STUDY OF INJURIES OF THE HEAD. 307
Necropsy.—Haematoma and small scalp wound in right parietal region.
Thin cortical coagulum over left occipital lobe, extending into median fis-
sure. Subarachnoid serous effusion.
CASE CIII. Male, sixty years of age; pushed down three steps of a
stairway, and sustained minor superficial injuries. No head symptoms
till the fourth day, when he had four convulsions. There was one the next
day, and afterward they occurred with increasing frequency till his death
on the eighth day. Each one began by twitching of the muscles of the
face, with the head and eyes turned to the left, and these extended to the
left arm and finally to the left hand. The right side was not involved at
all. Temperature on admission, 100°; in twelve hours, 103°. From this
time it varied from 103° to 104° till six hours before his death, when it
became and continued 105°.
Mecropsy.—No lesion of scalp or skull. Subdural haemorrhage over
whole right cerebrum, and extensive laceration of right temporo-sphenoidal
lobe.
CASE CIV. Male, thirty-two years of age; fell upon the sidewalk; scalp
wound in left occipito-parietal region. Admitted to hospital ten hours
later. Conscious and rational, but dazed, and with extreme muscular
tremor. Two hours afterward the patient had a general convulsion.
From this time, during periods of about six hours, there would be a suc-
cession of convulsions, with intervals of unconsciousness or delirium, fol-
lowed by an equal period during which he would remain quiet and rational.
The convulsions were all general from beginning to end, without recog-
nisable initial symptom. Died in two days.
Necropsy.—Scalp wound, as previously noted. No lesion of skull.
Cortical haemorrhage on the right side of the vertex, from anterior border
of frontal lobe to posterior fissure of Rolando, and covering the temporo-
Sphenoidal lobe laterally and at the base. Deep laceration of right frontal
lobe, through the cortex, upon anterior and lateral borders, and extending
Well into the parietal region.
CASE CV. An unknown man was found in the street, leaning against
a fence in an upright position, dead.
Necropsy.—Haematoma over right side of the vertex; no lesion of the
skull; blood fluid and viscera generally much congested; area of contusion
and laceration over greater part of left frontal and temporo-sphenoidal
lobes; subdural haemorrhage over whole left hemisphere.
CASE CVI. Male, thirty years of age; found unconscious, and sup-
Posed to have jumped or fallen from a second-story window. Wound
over right eye and fracture of the nasal bones; coma profound ; stertor;
pupils contracted. On the two following days the temperature rose pro-
gressively from 101°-H on admission to 104.5°; pulse full, respiration rapid.
Patient could be roused by pressure on supraorbital nerve. On the third
day still deeper Coma, dysphagia, continued irritability, and restlessness,
*d temperaturestill 104.5°. Death at end of four days; temperature, 107-4°.
308 NEW YORK STATE MEDICAL ASSOCIATION.
JMecropsy.—No lesion of skull; no meningeal lesions; small cortical
haemorrhage over posterior part of left parietal lobe, and small laceration
of brain at parieto-occipital junction ; both cerebra hyperaemic.
CASE CWII. Male, forty years of age; fell down stairs. Admitted to
alcoholic ward and transferred to surgical service next day. Slight scalp
wound above right ear; comatose, but later could be roused sufficiently to
tell his name ; temperature, 103°4°; restless ; hyperaesthetic ; pneumonia
discovered ; died next day. -
Necropsy.—Left lung pneumonic ; lower lobe in second stage, upper
lobe in first stage ; no lesion of the skull; dura mater adherent to the
calvarium ; the left hemisphere on its upper surface was completely
covered by an organised false membrane, which also dipped into the
median fissure and covered its internal surface. This membrane was
divisible posteriorly into two layers; it was thin anteriorly, but fully an
eighth of an inch in thickness in its posterior part ; its upper surface was
smooth, non-adherent, and comparable in appearance to a section of raw
beef; its inferior or cerebral surface was smooth, velvety, non-adherent,
and could be raised without injuring the arachnoid ; it did not dip into
the sulci ; it was traversed by minute vessels and studded with some
fifteen or twenty grayish, caseous, and partially calcareous nodules, vary-
ing in size from that of a robin-shot to that of a buckshot. Similar
nodules were found in the basilar vessels, which were generally atheroma-
tous. No recent lesion of the brain was discovered, except general con-
tusion indicated by moderate hyperaemia and some capillary extravasa-
tions. -
His wife subsequently stated that he had never lost a day's work by
reason of sickness, and that he had never had even temporary loss of con-
sciousness or paralysis.
CASE CVIII. Male, fifty-seven years of age ; fell from his cab ; un-
conscious; large haematoma over left parietal region; respiration slow
and stertorous; double facial paralysis and cheeks flapping; complete right
hemiplegia and anaesthesia ; temperature, 99°. Trephined over left motor
area; dura pale, tense, and bloodless; no brain pulsation. After incision
of dura, serum escaped freely, and the quantity increased when the head
was so turned as to drain from the base. No blood clot found, Tempera-
ture at time of operation had risen to 103.4°; six hours later it had fallen
to 98-6°. The patient had regained consciousness and could articulate,
and gave his name and address. Hemiplegia not relieved. After twelve
hours, pulsation in the brain returned and he could speak rationally and
intelligently, though with difficulty. Two hours later still, he had a
slight convulsion, and death followed in four hours. The temperature
remained at 98.6° after the operation for fourteen hours, and it then rose
steadily to 104°6° just previous to death. The lower face continued para-
lysed and the respiration became frequent and insufficient.
Necropsy.—No lesion of skull; laceration of external border of right
cerebellum anteriorly, from which clot had formed about circle of Willis
STUDY OF INJURIES OF THE HEAD. 309
upon anterior part of pons and in transverse fissure in front of left cere-
bellum ; the vessels were atheromatous ; the interior of the left occipital
lobe was filled with clot which had completely broken down its structure ;
the left lateral ventricle was filled with blood which had broken through
the septum into the right lateral ventricle and also communicated with
the blood cavity in the occipital lobe.
CASE CIX. Male, sixty-three years of age ; struck by some part of
the machinery of his engine ; no general symptoms; temperature, 100°;
wound in posterior parietal region in median line and curving to the right ;
contusion over left parietal eminence ; temperature second day, 103.2° ;
delirious in the night; temperature third day, 101.8° to 101°; headache;
fourth and fifth days, temperature, 103.4° to 103°; no general symptoms;
sixth day, temperature, 106’4”, pulse, 140; restless and irritable, but
rational; weaker; died on the eighth day; temperature last two days
from 105° to 105'2°; post-mortem temperature, 104°. A few hours pre-
vious to death there was muscular rigidity of all the extremities, most
marked on right side and especially in right arm. There was perforating
ulcer of the cornea.
Mecropsy.—No lesion of skull or meninges; no haemorrhage; no lacera-
tions; cortex of brain and meninges hyperaemic ; brain substance moder-
ately oedematous and minute vessels filled with coagula; this condition
involved corpora striata, optic thalami, pons, and cerebellum, and was
most pronounced on left side and at the base; no minute extravasations;
both lateral and both inferior petrosal sinuses were filled with decolorised
thrombus, extending into jugular vein on the right side; the thrombus
Was colored only near the torcular Herophili.
CASE CX. Male, sixty years of age ; fell two stories to the sidewalk.
Contusion of left eye and slight contusion just above it ; temperature,
101'4”; delirium ; pupils and respiration normal; pulse, 114. Later symp-
toms: patient very irritable; cried out and tried to getaway when touched,
but replied rationally to questions; incontinence of urine and faeces;
delirium continued; died on the fifteenth day; temperature rose to 103.2°
On the fifth day and then fell very gradually to 100°. The day before
death it was 103.4°, was 103.8° five hours ante-mortem, and 104.2° one
hour post-mortem. General symptoms remained unchanged.
Wecropsy.—No fracture; subarachnoid haemorrhage over both hemi-
Spheres, forming a sheet which was thickest about occipito-parietal junc-
tion on both sides; some subarachnoid serous effusion in left frontal region;
8èneral contusion, which was most marked on left side; hyperaemia and
punctate haemorrhages.
CASE CXI. Male, forty-five years of age; cause of injury unknown;
found unconscious in the street and admitted to hospital after forty-eight
hours; contused wound in right parietal region ; muttering stupor; rigidity
of left arm; right hemiplegia, which was incomplete, but most marked in
*ight arm; pulse, 60; temperature, 101*. On the third day the rigidity of
the left arm was increased, and the paralysis of right arm was complete;
310 NEW YORK STATE MEDIOAL ASSOCIATION.
paralysis of right leg was nearly so; coma absolute; pulse, 128; tempera-
ture, 105°. Trephined over motor area and incised the dura. Pulsation of
brain absent at first, but soon returned in some degree. His movements
became freer, and he began to utter articulate sounds. Signs of sensibility
increased ; pulse, 108; temperature still 105°. Died next day.
Mecropsy.—Moderate subacute arachnitis over anterior two-thirds of
upper surface of right cerebrum ; laceration of left temporo-sphenoidal
lobe, excavating and filling with clot its whole interior structure. The
haemorrhage extended downward around the circle of Willis and upward
upon the cerebrum, mainly upon the occipital, but also in patches upon
the frontal and parietal lobes.
CASE CXII. Male, sixty years of age; found unconscious in bed ;
seemed to be in perfect health when he retired to his room on the previous
evening. He was heard moaning; no evidence of injury could be dis-
covered ; stertor; pupils normal; rigidity of right side ; pulse 120 and
weak; temperature, 100°. On the next day the right side was less rigid ;
the second day he was comatose; temperature, 103°2°, and he died.
Mecropsy.--No lesion of scalp or skull ; large amount of serum under
the arachnoid. There was a very soft elliptical area of disintegrated brain
tissue an inch and a half by three-quarters of an inch in diameter upon the
anterior part of the left occipital lobe, near the median fissure. There was
a similar area, smaller in size, on the under surface of the same lobe, but
with disintegration less advanced, and containing a clot not yet decolorised.
There was a red, firm clot beneath the latter, and deep in the substance of
the cerebellum, of more recent formation. The temporal artery was ather-
Omatous, but none of the basilar arteries was diseased.
CASE CXIII. Male, thirty years of age ; fell down stairs; conscious-
ness was lost, and only partially restored. He fell out of bed that night,
and again the next day, striking each time upon his right side. Admitted
to hospital that evening. No external evidence of injury except slight
contusion over crest of right ilium. Rational, but slow to respond to
questions; left pupil slightly dilated ; temperature, 99°. The follow-
ing day he again fell out of bed, and again the day after, always on the
right side, and there was a constant tendency to move to the right side
of the bed, which was quite level. Some left paresis and some difficulty
in Swallowing, which he referred to the left side of the throat ; transient
facial paresis. The amount of paresis and the condition of the left pupil
varied from day to day. His mental condition deteriorated ; he was stupid,
rambling in talk, delirious, apathetic, and had delusions. At first urine,
and later facces, were voided unconsciously. His temperature for ten days
was 99%+; it then began to rise and was 100°-|- to 101°; pulse usually
from 84 to 96, and respiration nearly normal. On the fifteenth day he was
trephined Over the right motor leg area, and a small subcortical cavity dis-
covered, from which half a drachm of yellowish fluid was removed. This
fluid was subsequently found to contain numerous leucocytes. There was
no marked change in his symptoms after the operation. Temperature was
STUDY OF INJURIES OF THE HEAD. 311
a trifle lower—99° to 100°–till the eleventh day, when it rose to 104°, fell
the next day to 100°, and rose again to 104°, when he died from asthenia on
the twenty-eighth day after his admission.
Necropsy.—Large subarachnoid serous effusion compressing frontal
lobes. General cerebral hyperaemia and many minute vessels filled with
coagula. The brain substance around the Small cavity discovered during
life was softened, stained a reddish-gray color, and it contained minute
extravasations.
CASE CXIV. Male, twenty-nine years of age ; was found unconscious
in Central Park. He was taken to a hospital, sent to court charged
with intoxication, and afterward admitted to Bellevue, still unconscious.
Small contused wound in right frontal region ; pupils slightly dilated ;
complete left hemiplegia and hemianaesthesia ; slight left facial paral-
ysis; temperature, 106°; pulse, 140; respiration accelerated ; convulsions
shortly after admission, which were repeated at frequent intervals; initial
symptom on the mouth and face ; arms and legs gradually involved ;
trephined over junction of right arm and leg areas by house surgeon; result
negative ; temperature two hours later, 107.4°, and three hours later still
he died in a convulsion. The ventricle was aspirated in the operation ;
temperature forty-five minutes post-mortem, was 109.4°.
Necropsy.—Brain and meninges excessively hyperaemic ; a small tumor
as large as a pea was found in right lower face area; the surrounding
brain tissue was disintegrated, forming a small cavity; no haemorrhages;
tle viscera were generally soft and congested.
CASE CXV. Male, thirty-seven years of age ; was found at the bottom
of a stairway with his feet uppermost ; unconscious; pupils contracted ;
muscular rigidity, especially marked in the legs; pulse rapid ; stertor;
died in two days without having regained consciousness.
CASE CXVI. Male, twenty-six years of age; thrown out of a wagon
and struck his head ; unconscious, but conscious on admission; contusion
in left parietal region; became irritable, and later comatose; died sud-
denly five hours afterward.
CASE CXVII. Male; struck by a cleat falling from aloft aboard ship;
large haematoma covering whole right side of the head; unconscious;
slight rigidity of left side; pulse full and slow ; died in fifteen minutes
after admission.
CASE CXVIII. Male, thirty-two years of age; struck with a shovel;
Contusion of the right posterior parietal region; pulse full and slow ; tem-
perature, 100°; pain in back of the head; dilatation of left pupil; rigidity
of flexor muscles of the arms; somnolence and restlessness. After twenty-
four hours patient became stupid and mildly delirious ; left pupil widely
dilated; urinated unconsciously; left arm only moved when irritated ;
Sensation slightly more acute on right side; dysphagia marked; left pupil
irresponsive to light. His condition varied from time to time for the first
*W9 weeks; left pupil more or less dilated and more or less irresponsive to
312 NETW YORK STATE MEDICAL ASSOOIATION.
light; mind obscured and apathetic ; some ptosis of left eye. After that
time his mind became clear, and he could intelligently describe the man-
ner in which he received his injury. Paralysis of the left external rectus;
optic nerve and retina normal; perforation of left tympanum and puriform
discharge; some left facial paralysis. He was discharged at the end of
two months. His ptosis and external strabismus had disappeared, and
there was only a perceptible trace of the paralysis of the lower face. His
left hemiparesis and anaesthesia were no longer noticeable. He was dull
and stupid, which his family said was his normal condition.
CASE CXIX. Male, twenty-five years of age ; fell from a truck, strik-
ing his forehead ; unconscious for twenty-four hours; slightly delirious
for two days; pain in frontal region after that time; temperature, 100°,
followed by mild dementia, which continued till his discharge.
CASE CXX. Male, twenty-one years of age; fell sixty feet down an
embankment; unconscious; afterward, violent delirium lasting a week;
then admitted to the hospital, still delirious, but more quiet ; suppurating
scalp wound external to right frontal eminence ; bone exposed ; also double
fracture of right inferior maxilla. The following day he had eleven epilep-
tiform convulsions within two hours. Each one began with twitching in
right hand and arm, extending to left arm and then to both legs, and finally
a general convulsion was established. Face not much involved, but eyes
deviated to the right. After these attacks he remained unconscious for
one hour; the right arm was then found to be anaesthetic, and with the
right leg paretic. The next day he had one similar attack, but he was
more rational afterward and recognised his paretic condition. On the next
day he had six convulsions within a little more than two hours, each one
beginning on right side of the face and extending to right side of the body
before becoming general, and the right arm was paralysed for five minutes
afterward. In the next few hours he had six others, one of which was
confined to right side of the face.
He was then trephined over left face area and the opening freely en-
larged. Dura tense and incised, but no lesion discovered. He was then
trephined through the exposed bone on the right side without result. No
further convulsions occurred. The next day he was entirely rational, and
it was discovered that he was aphasic. Some difficulty in articulation pre-
vious to the operation was ascribed to the fractures of the jaw. He had
both motor and sensory aphasia. Called his own name McNannold. He
was discharged at the end of a month. His wounds were entirely healed,
right arm still paretic, and mind clear. He had some hesitancy in Speech,
and the selection of words required a little time. His temperature ranged
from 99% -- to 101° during his whole convalescence.
CASE CXXI. Male, twenty years of age; cause of injury unknown ;
unconscious for a short time; scalp wound in left parietal region near the
mesial line, and a large haematoma just behind it in posterior parietal
region. He had no general symptom, except nearly complete paraplegia
with flaccid muscles and somewhat increased reflexes. There Was no
STUDY OF INJURIES OF THE HEAD. 313
evidence of specific disease, and it was possible to verify the fact that no
paralysis had existed previous to this recent injury. He was discharged at
the end of six weeks and could walk fairly well. The diagnosis was corti-
cal haemorrhage from direct contusion of the brain, extending from left
motor leg area across the median line into the corresponding area on the
right side.
CASE CXXII. Male, twenty-one years of age ; cause of injury un-
known ; found unconscious. Committed as drunk and disorderly, and
sent to Bellevue as a case of alcoholism. He again became unconscious
and was constantly crying out, but always a single phrase. He was rest-
less and hyperaesthetic, and the muscles of both sides were generally rigid.
There was a slight Scalp wound in right temporal region; incision dis-
closed no fracture. The day following he was more quiet and the muscles
were less rigid. Partial paralysis of the lower left face was developed.
He became rational, but apathetic. Then there were two days more of
active delirium, after which he again became quiet, but had delusions.
He was coherent in speech, though voluble, loquacious, and silly. He had
Sensory aphasia and agraphia, and his memory of recent events returned ;
he thought, however, he was born in September, 1891—two months
before. In notation, at dictation, he interpolated figures, thus—in writing
495, he wrote 490005. He could write two figures correctly, but not more.
After his discharge he returned to the hospital some months later, and was
noisy and excitable. Subsequent inquiry at the station-house made it
probable that he was not intoxicated at the time of his arrest. He remained
unconscious from early evening all night. When he was finally roused he
made strenuous efforts to speak. He was only able to say “Peter,” his
first name, which he repeated again and again, and evidently strove to give
his last name. Temperature, 100:2° on admission ; from 100° to 101° for
five days, then normal. After that time averaged 98.5° to 99.5°.
CASE CXXIII. Male, twenty-one years of age; cause of injury
unknown ; found unconscious in the street ; contusion of left eye and
Wound over superciliary ridge. On admission, he looked about with a
Vacant stare, but could not be induced to speak. Next day he had delu-
Sions and failed to recognise his family. His subsequent symptoms were
all mental. Memory of recent events lapsed. Never spoke except when
disturbed, then answered questions intelligently but mechanically. For
three nights he became violently delirious, and attacked his neighbor in
the next bed; then he became quiet again, and began to manifest some in-
terest in what passed about him. Two weeks from the time of his
admission his condition suddenly improved, and he began to remember
Some things which immediately preceded his injury. For the ensuing two
Weeks it was mainly noticeable that he never suggested or carried on any
Sustained conversation, and that he laughed much and without due cause
* the next and final two weeks of his continuance in the hospital, he
*sed to laugh inordinately or causelessly, and his memory seemed to be
restored in reference to matters up to the time he was hurt, and since his
314 NEW YORK STATE MEDICAL ASSOCIATION.
recovery of consciousness. The only abnormal indication in his appear-
ance was a slightly weak expression in his face. Temperature on
admission, 99.2°; afterward from 99° to 101°.
CASE CXXIV. Female, seventeen years of age ; fell three stories
through a hatchway; contusion of left occipital region; no fissure found
on incision. She was unconscious, with muscular rigidity of all the ex-
tremities, and was irritable when disturbed. She moved the right arm and
left leg only. Temperature, 100:2°. Delirious on the fourth day, and
noisy and excitable for several days afterward. There was left paresis and
dilatation of left pupil on the tenth day, and at the same time incontinence
of urine and faeces which continued eight days. Temperature was 100°–H
for the first five days, 99° – for next five days, and then became normal.
It rose on the thirteenth day from 99% to 103°5°, and on the next day to
104.5°. For the next ten days it was usually from 102° to 103°, at which
time she was removed from the hospital. She subsequently recovered.
She was of bad constitution, had inherited syphilis, was deaf, and had
interstitial keratitis in both eyes, with loss of sight in one from opacity of
COI’Ilea.
The following cases of idiopathic lesion are added to
illustrate simulated traumatism :
a. Male, fifty-five years of age ; fell upon the sidewalk, and, after rising
and walking a short distance, fell again. Upon admission he had a small
wound in the median line of the frontal region. He smelled strongly of
Spirits and was ascertained to be of intermperate habits. He was uncon-
scious from the time he fell until he died, seven hours later. He was rest-
less, and upon irritation had muscular spasm of both lower and upper
extremities. He had incontinence of urine and faeces, dilated pupils, and
Cheyne-Stokes respiration. No paralysis. , Temperature, 103.4°, 104°, and
105°. It was subsequently learned that the scalp wound was received two
days previously, and that the spirits of which he smelled so strongly had
been spilled upon him in an effort to restore him to consciousness before
admission.
Necropsy.—Chronic meningitis with great arachnoid opacity, but no
serous effusion. Basilar arteries extremely atheromatous. Both lateral
ventricles enormously distended with very bloody serum. Clot extended
through each posterior cornu. The right optic thalamus was swollen with
clot which also filled the third ventricle.
b. Male, seventy-one years of age ; said to have accidentally fallen from
a chair four days previous to admission ; no loss of consciousness; Subse-
quent delirium ; required mechanical restraint till his death, twenty-four
hours later; pupils contracted ; posterior cervical muscles rigid ; hyper-
aesthesia; retention of urine; temperature, 102°, 102°,+, 103°; pulse, 90
to 114.
Necropsy.—Abrasion of the nose. Duramater adherent to the calvarium,
and arachnoid to the brain. Little serous effusion. Some opacity of the
arachnoid. Meningeal and cerebral vessels hyperaemic. Cortex softened.
STUDY OF INJURIES OF THE HEAD.
The result of an analysis of the preceding cases may
be expressed in a brief
SUMMARY.
I. Fractures of the Base, - - sº
Recovered, - - – 21
Died, gº - - - 49
Number of necropsies, - sº mºs
II. Fractures of the Vertea, -*. -
Recovered, * - – 21
Died, - tº- - - - 10
Number of necropsies, - -
III. Encephalic Injuries without Fracture, -
Recovered, - - - - 7
Died, a- --> - - 16
Number of necropsies, - * . -
Total number of recoveries, - - 49
© ( & 4 { % deaths, - - 75
Total number of necropsies, -
INECTROPSIES.
I. Fracture of the Base.
Involving posterior fossae, -
6 & middle fossae, - -
middle and anterior fossae,
middle and posterior fossae,
anterior and posterior fossae,
all fossae, - -
Total number involving middle fossae,
& 4 & 4 “ posterior fossae,
anterior fossae,
Complications.
Laceration and resulting haemorrhage,
{ % “ general contusion, -
meningeal contusion,
& 4 & 4 { %
{ % & 4
124
70
35
31
10
23
13
58
sº
:
cº
• * * * *
&
3.16 NEW YORK STATE MEDICAL ASSOCIATION.
Laceration and thrombi, haemorrhages, - 2
{ % “ epidural haemorrhages, - 6
{ % “ meningeal contusion, epi-
dural haemorrhages, - 1
{ { “ general contusion, epidural
haemorrhages, - 1
Contusion and abscess, s - - 1
General contusion and epidural haemor-
rhage, * - * - 2
Meningeal contusion, - * - 1
35
From direct violence, - ºm - 31
“ contre-coup, - sº - 4
II. Fracture of the Vertea.
Involving frontal bone, sº - 4
C & parietal bone, - tº- - 1
{ % occipital bone, - - 1
& 6 parietal and occipital bone, - 1
( & parietal and frontal bone, - 1
€ 4 temporal bone, - * - 1
* 9
Complications.
Laceration and resulting haemorrhage, - 5
“ “ general contusion, - 2
{ % “ atrophy, * - 1
“ meningeal and general contusion, 1
General contusion and epidural haemor-
rhage, * - tº - 1
10
III. Injuries of the Encephalom, without Fracture.
Varieties.
Laceration and resulting haemorrhage, - 5
{ % “ meningeal contusion, - 2
( & ‘‘ general contusion, - 1
Meningeal contusion, - tº - 1
General contusion, - - - - 2
STUDY OF INJURIES OF THE HEAD.
317
General contusion and thrombi, - <-->
& 4
and meningeal contusion. - <-->
In Fifty-eight Wecropsies.
Laceration and resulting haemorrhage, -
& 4
{ %
© (
& C
{ %
“ general contusion, - sº
“ meningeal contusion, *
“ epidural haemorrhage, -
thrombi, and haemorrhages, sº
general, and meningeal contu-
Sion, *-*. - -
and atrophy, sº - *
meningeal contusion, epidural
haemorrhage, - -
General contusion, -- -
Meningeal contusion, - * =
General contusion and epidural haemor.
rhage,
General contusion and thrombus, - -
{ %
C & ‘‘ meningeal contusion,
Subcortical contusion and abscess, - -
Total number of cases in which injury was
received by
Contre-coup alone, gº * *-*.
Direct violence alone, sº – *
Contre-coup and direct violence, - *
Unknown, wº- -> º
Unrecorded, $º - º *
Pseudo-injuries.
Apoplexy, . ** * º
Arachnitis, - *E* sº
|
1.
:3
:
:
10
:
:
318 JNETW YORK STATE MEDIOAL ASSOCIATION.
In the majority of instances the subjects were males in
adult life. Vocation, the blundering helplessness of ine-
briety, and the homicidal passion, sufficiently account for
the influence of age and sex in the production of these
injuries.
Fractures.—It is a noteworthy fact that so many in-
juries of the head—nearly sixty per cent.—involve frac-
ture at the base. I have ranked as basic fractures all
those which have involved that region, even though be-
ginning at the vertex, because it is upon the implication
of the base that all the so-called characteristic symptoms
depend. In fact, fractures of the skull which do not
begin at the vertex are exceptional. I have found upon
necropsic examination but four cases in which fracture
at the base was not continuous with a fissure extending
from the point upon the vertex at which the violence
was inflicted. These four, which began and ended in
the base, were evidently from contre-coup. That they
were the result of violence acting directly upon the ver-
tex was proved by the history of the injury, as well as
by existent wound, contusion, or fracture. In neither
one was there the slightest reason to suspect that the
force was transmitted through the spinal column. The
greater frequency of fractures which extend to the base,
when compared with those which are confined to the ver-
tex, depends simply upon the fact that, under ordinary
circumstances, the physical properties of bone are such
that force, even when of crushing character, will not
expend itself wholly upon the point of impact, but will
extend to a considerable distance. That the fissure
extends from vertex to base, and not from base to Ver-
tex, is proved, even in the absence of a history, by the
mute evidence of the superficial injury, and by the nar-
rowing of the fissure as it passes downward. The ex-
planation of the fact that fracture through the middle is
more frequent than through the other fossae is equally
simple. The experiments of Aran have shown that when
any part of the vault is subjected to violence it is the
STUDY OF INJURIES OF THE HEAD. 319
corresponding part of the base which suffers. It follows
that the central or parietal region is the one most ex-
posed to violence, and it is corroborated by the results of
post-mortem examination.
Four cases, aside from those produced by contre-coup,
are of special interest simply as fractures. The first is a
separation of the temporal bone into its constituent parts
—squamous, petrous, and mastoid—in an adult male, the
result of an apparently inadequate cause. The specimen
was shown to this association two years ago. The
second was a comminuted fracture of nearly the whole
occipital, the posterior part of both parietal, and the
right temporal bones, in which the fragments were com-
pletely detached from each other. This, like the first,
was occasioned by a fall in the street, and was accom-
panied by extensive injuries of the brain, sinuses, and
membranes. The patient recovered partial conscious-
ness, and lived for a week’s time. The third involved
all the fossae on both sides from a fall from the mast-
head, and the patient survived two hours. This case I
believe to be the first on record in which all the fossae
Were involved in fracture. The fourth case was a wide
Separation of the coronal suture on both sides, occurring
in an adult without concomitant fracture.
The most practical comment to be made upon fractures
of the skull is that in themselves they are absolutely un-
important. It is only by their complications, immediate
Or remote, that they involve danger to life.
COMPLICATIONS OF FBAOTURES.
The complications of fracture are haemorrhages,
thromboses, lacerations, contusions, and paralyses. Their
derivatives are meningitis, abscess, and atrophy. All of
these may be produced directly from injury to the en-
9ephalon without fracture, with the exception of one
form of haemorrhage. If epidural haemorrhage ever
900urs without the intervention of fracture, I have never
320 NEW YORK STATE MEDICAL ASSOCIATION.
seen it in necropsies, or had reason to suspect it in re-
covering cases.
Fractures of the skull without complication are not
only without importance or consequences, but they are
devoid of symptoms. A simple fissure of the posterior
fossa would probably be unsuspected, for symptomatic
cervical ecchymosis is of the rarest occurrence. A simple
fracture of the vault is often overlooked in the absence
of pressure symptoms. In fracture at the base, dis-
placement of the fragment does not occur, or is insuf-
ficient to occasion trouble, and when the patient sur-
wives, union, of course, is without provisional callus.
The very general existence of complications, however,
often of the gravest character, has given fracture of the
base vicariously both an importance and a symptoma-
tology.
The encephalic lesions which complicate fracture in-
clude all those which occur independently, and there-
fore may be considered at once, from a double point of
view, as complications and as primary injuries.
HAIEMORREIAGES.
Epidural haemorrhage is perhaps the most character-
istic complication of fractures. In moderate quantity
from the Osseous or smaller meningeal vessels, it is the
usual source of the diagnostic haemorrhages from the
ears, nose, or mouth, and into the orbital and Subcon-
junctival tissues. In large amount, and as a source of
danger, it is derived from the larger meningeal vessels,
notably from the middle meningeal artery. In at least
two, and possibly four cases, it was the immediate cause
of death. In a third, involving fracture at the base, life
was saved by operation, although the clot removed
measured four ounces and a half by volume. Such a
case is in evidence that the brain-tissue is really suscept-
ible of compression.
STUDY OF INJURIES OF THE HEA D. 321
Subarachnoid or cortical haemorrhage is ordinarily
derived from laceration of the cortical substance, and is
often the direct cause of death, as well as of certain of
the precedent symptoms. From a laceration at the base,
whether of the frontal or temporo-sphenoidal lobe, it may
cover the whole Superior surface of one or both hemi-
spheres, and cause various localising symptoms which
accompany or precede those of facial pressure. From a
laceration of the occipital lobe or cerebellum, it may
cause immediate death from compression of the medulla ;
or the haemorrhage from the torn vessels of the brain,
even in extensive laceration, may be insufficient to
seriously modify symptoms or hasten the fatal termina-
tion. A moderate amount of cortical haemorrhage from
rupture of the vessels of the pia is also one of the results
of meningeal contusion.
Subdural haemorrhage I have found most frequently
to depend upon rupture of the arachnoid and escape of
blood from the meshes of the pia mater into the arach-
noid cavity. In a smaller number of instances its source
has been in the meningeal vessels. In a recent case there
Was rupture of the dura mater, and the blood was of
epidural origin. Cortical haemorrhage, however, is, of
all others, the one most frequently encountered. The
majority of lacerations reach the surface of the cortex,
and superficial haemorrhage results.
THROMBOSIS OF THE SINUSES.
The occurrence of thrombi in the sinuses of the dura
mater and base of the skull in three cases, under varying
Circumstances, is not in all of them susceptible of ade-
Quate explanation. In the first case, which, like the
Second, involved fracture at the base, the posterior part
of the skull was Subjected to crushing violence. There
Was extensive epidural clot, large subdural clot which
filled the right inferior Occipital fossa, and a firm cortical
*ot beneath the seat of fracture surrounded by an in-
21
322 NEW YORK STATE MEDICAL ASSOCIATION.
flammatory exudation. The surface of the posterior part
of the right occipital lobe was softened and the seat of
minute extravasations. There were small lacerations of
the inferior surface of both frontal lobes, and one of con-
siderable size in the right cerebellum, beneath the thick-
est part of the subdural extravasation. The wall of the
posterior part of the superior longitudinal sinus was
infiltrated with blood, and the cavity occupied by a
thrombus. A second large and partially decomposed
thrombus was situated in the torcular Herophili, and ex-
tended through the right lateral and petrosal sinuses into
the jugular vein. In the second case a simple fissure
extended from the right parietal bone into the posterior
fossa, terminating in the jugular foramen. There was
slight epidural and considerable subdural haemorrhage
at the origin of the fracture. There were several lacera-
tions in the anterior part of the brain, and on the left
side the interior of the temporo-sphenoidal and frontal
lobes was excavated and distended by a clot from a
haemorrhage, which had also broken through into the
lateral ventricles and occipital lobes and filled them with
fluid blood. There was cortical haemorrhage at the base,
which had surrounded the optic chiasm and extended to
the anterior border of the pons. The thrombus occupied
the torcular Herophili and extended through the lateral
and petrosal sinuses into the jugular vein. In the third
and final case there was no fracture, intracranial haemor-
rhage, or laceration. There was, however, general con-
tusion, with moderate oedema and distention of the
minute cerebral vessels with coagula. This condition
extended to the corpora striata, optic thalmi, pons, and
cerebellum, and was most pronounced at the base and
upon the left side. The thrombus was decolorised, and
Occupied both lateral and both petrosal sinuses. It ex-
tended into the right jugular vein, and was colored only
near the torcular Herophili. I have detailed all the
accompanying lesions, though I do not believe that they
were all related to the formation of the thrombi. In the
STUDY OF INJURIES OF THE HEAD. 323
first case the infiltration of the wall of the sinus points
to its laceration by direct violence as the first step
toward the coagulation of its contents. The portion of
the sinus in which it began was, moreover, directly
beneath the point at which sufficient violence was in-
flicted to comminute the skull, to rupture its membranes,
and to cause localised inflammation in connection with
the haemorrhage. The surrounding inflammation might,
at first sight, suggest an inflammatory origin, but the
absence of inflammatory products in the sinus wall cor-
roborates the view I have taken. It is more difficult to
account for the thrombus in the second case. There is
no positive evidence, but a possible clew exists in the
termination of the fissure in the jugular foramen. It
may be that some injury done to the vein led to the
beginning of thrombosis at this point. It had no evi-
dent relation to the other intracranial lesions which can
aid in Solving the problem. In the third case, the throm-
bus was the only localised lesion, and again a different
and conjectural explanation must be sought. There was
general contusion and general thrombosis of the minute
Cerebral veins. It is impossible to assume either that
Venous canals of such size should have primarily par-
ticipated in the effect of a general contusion, or that the
obstructing coagula should have extended secondarily
into the sinuses. It might more naturally be assumed
that the thrombus, which was already decolorised, was
an antecedent lesion which had led to the venous
obstruction and oedema of the brain tissue. There was,
however, no indication of previous disease, and the man
Was at his work when struck down by the blow which
Caused his death. These cases are pathologically in-
dependent of each other, and may have no significance
* Symptomatology or treatment. In another case I
Suspected thrombosis of the internal jugular vein, on
*Count of an oedema of one side of the face and neck,
but his recovery precluded a confirmation of my suspi-
ClOI). *
324 NEW YORK STATE MEDICAL ASSOCIATION.
I am unacquainted with any similar instances of trau-
matic thrombosis of these sinuses. They were uncon-
nected with pressure or any inflammatory process within
or without their walls, or with any dyscrasia of the pa-
tient. In the first and second cases I have been able to
suggest an explanation ; in the third case I am still with-
out definite Opinion.
LACERATIONS.
Lacerations and contusions of the brain are unques-
tionably first in frequency and importance among all the
injuries of the head. They play a part in all fatal cases,
and dominate the symptoms in almost all cases of recov-
ery. Even when death is the immediate result of haem-
orrhage or inflammation, or when, though life be saved,
the mind is lost, they still ride behind. In every fatal
case, with fracture or without, where necropsy has been
permitted, one at least of these lesions has been found
to exist. In every one in which necropsy has been de-
nied, as well as in every case of recovery, the interpreta-
tion of the symptoms in the light of what has been dis-
closed by previous post-mortem examination, has pointed
to the same conditions. They do not occur, however,
with equal frequency. While in fifty-eight cases there
were forty-eight with lacerations, there were but thirty
with marked contusions; or, differently estimated, there
were twenty-eight cases of laceration without noticeable
contusion, and but ten of contusion without laceration.
The lacerations may be single or multiple ; they may be
confined to the cortex, or extend a variable distance into
the subcortical structure; they may originate subcorti-
cally and completely disintegrate the interior of a lobe
without encroaching upon the cortex, or they may reach
the pia; they may lacerate the pia and rupture the arach-
noid, with or without diffusion of haemorrhage, or the
membranes may remain intact. In a large proportion of
cases the laceration will be with well-marked diffusion
of haemorrhage. Topographically, there is no lobe or
STUDY OF INJURIES OF THE HEAD. 325
convolution which may not be wounded. It will be seen
from the necropsies recorded, that the base of the brain,
especially upon the frontal and tempero-sphenoidal
lobes, suffers most seriously and most frequently, and
that the interior of the frontal lobes is oftenest the site
of extensive destruction. Several cases will be noted in
which the haemorrhage from a lacerated frontal lobe has
broken through the lateral ventricles into the posterior
regions of the brain. I present a specimen of small
laceration in almost the exact centre of the cerebellum
(Case XXXIV.). I have no record of laceration of the
optic thalami, fornix, velum interpositum, or corpus cal-
losum, though such injuries have been described. I also
present a specimen of laceration of the pons (Case
XXIV.). Instances of the laceration of the corpora
striata and gyrus fornicatus are included in the series
(Cases XX., XXIX., XXX., XXXV.). The general ap-
pearances of these lacerations have been noted by previous
writers under the name of contusions, and they require
but cursory mention. As they present themselves in
the cortex, they are simply lacerated wounds contain-
ing more or less coagulum with underlying shreds and
granular detritus of brain tissue. After the removal of
the coagulum the bottom of the wound is usually pulta-
Ceous, and stained with blood or of a grayish color. Some-
times the peripheral brain tissue is softened and dotted
With miliary extravasations, and sometimes it is of nor-
mal consistence and appearance. It is rarely the case
that there is not some resulting haemorrhage which in-
filtrates the pia, perhaps trivial in amount, perhaps suf-
ficient to thickly cover the base or vertex, and the lat-
eral aspects of the brain. The wound may be circular,
oval, or irregular in outline, not larger than a pea, or
Covering the whole extent of the inferior surface of the
temporo-sphenoidal lobe. In case of subcortical lacera-
tion, the lesion may be a simple extravasation of blood
*to the deeper brain tissue, as small as in the specimens
from the pons and central cerebellum which I have just
326 NEW YORK STATE MEDICAL ASSOCIATION.
exhibited, and either as harmless as it is trivial in extent,
or of deadly import. In another instance, as in more
than one of the necrologies which I have just recorded,
the whole internal structure of both frontal lobes may
be disintegrated and destroyed ; and when the clot and
mangled brain have been turned out, nothing but the
cortical shell remains. .
The subsequent changes which these wounds undergo
are not numerous. If of considerable size, death ensues
in the majority of cases before sufficient time has elapsed
to permit any change of importance. The end to be
hoped for, as in any wound with loss of tissue, is
cicatrisation. In an experience in the dead-house lasting
over many years, it has not been my fortune to meet
with an instance of such reparative process, yet I have
seen many cases of recovery where I am positive lacera-
tion had existed. There is a remarkable illustrative
specimen in the Museum of St. George’s Hospital, quoted
by Mr. Hewitt, in which two large lacerations of the
cerebrum, occurring without fracture, had cicatrised
after many years. The cerebral surface was excavated,
and the pia and arachnoid were carried over the depres-
sion, leaving a cavity filled with loose areolar tissue and
serum. The man’s intellect had been clear, and he had
suffered no cerebral symptoms.
If the patient survives, the process of reparation is
evidently slow. In certain cases in which old lacerations
were discovered after death from more recent injury,
there was no contraction of the wounds and no in-
flammatory changes of importance had begun. The
edges of the wounds were slightly rounded, and the
coagula which they contained were softened, and their
color had become rusty or yellow.
In necropsic cases of recent laceration, an interval
of from a few moments to one day, or several, has
probably elapsed. The appearances are practically the
same whatever the interval may have been. There is no
tendency to meningeal or visceral inflammation in any
STUDY OF INJURIES OF THE FIEAD. 327
cases which I have observed, with the exception of
the occasional formation of abscess from subcortical
laceration. As in the case of general contusion, with
profuse oedema and death after fifteen days, no inflam-
matory changes have been discovered, even upon careful
microscopical examination. In an exceptional case (Case
VII.), the temporo-sphenoidal lobe had been seriously
lacerated, and after the lapse of six months was the seat
of interstitial inflammation and atrophy.
CONTUSION.
Contusion may be regarded as occurring in three
forms—general and limited, affecting the brain ; and
meningeal, involving the membranes. The limited form
may be either cortical or subcortical. Any two or all
three of these may coexist in the same case.
Limited contusion of the brain differs from laceration
as a contusion elsewhere differs from a wound. There is
no palpable solution of continuity in the brain fibres, and
Consequently the haemorrhagic extravasation can only be
minute in quantity and of punctate or miliary form. In
reparation, only absorption, not cicatrisation, is required,
and recovery should occur in the major, and not, as in
laceration, in the minor proportion of cases. It is there-
fore less frequently met with in post-mortem observa-
tions. As in cortical or subcortical laceration, either
form of limited contusion occasionally results in abscess.
In the subcortical forms it may be difficult or impossible
to determine which one of the two is the responsible
lesion. I have very carefully described such an abscess
In a case reported in the Wew York Medical Journal,
March 19, 1890, and included in the present series. This
abscess, which complicated fracture at the base, and
two others complicating compound fracture of the ver-
tex, comprise the small proportion of cases which rep-
"esents the danger of this form of inflammation. In
the case first mentioned, though fracture at the base
328 NETW YORK STATE MEDICAL ASSOCIATION.
existed and made it technically one of that class, there
was also compound fracture of the vertex in connection
with which the abscess was formed. So we may properly
consider all the abscesses as complicating the latter form
of fracture. In all three cases the dura was carefully
examined at the time of accident and found to be unin-
jured, and after an interval of more than two weeks
without the occurrence of meningeal inflammation, the
abscess was developed. In each the external wound had
been healthy and had nearly closed. These data seem
to prove that suppurative inflammation of the brain sub-
stance is the result of primary injury of the brain itself,
and not secondary to meningeal inflammation extended
from the point of fracture. The time for cortical and
meningeal suppurations passed with the coming of aseptic
methods, and at the same time hernia cerebri practically
disappeared from the field of surgery. These cases,
however, show that compound fractures still sustain a
relation to deep abscess. It is not dependent upon the
extent of the attendant laceration or contusion, for that
is likely to be as great under other circumstances. It is
more probably due to exposure, for, though uninjured,
the dura and cortex may not be impervious to atmos-
pheric influences. The explanation of this subcortical
suppuration is, at all events, neither more nor less difficult
than that of subcutaneous suppuration upon the surface
of the body. The dogmatic assertion that traumatic
abscess of the brain never occurs except there has been
wound of the scalp or fracture of the skull is erroneous.
Though the cases which I record here conform to this
proposition, I am cognisant of at least two cases which
do not. One was a small parietal abscess which I saw
Some years ago; the other an abscess of enormous size
in the frontal lobe from a blow received in the ball-field,
without the occurrence of superficial injury of any sort
beyond moderate contusion. The latter specimen is
still in the Museum of the Carnegie Laboratory. The
important fact in connection with cerebral abscess at the
STUDY OF INJURIES OF THE HEA. D. 329
present day is, that it occurs from direct brain lesion
independent of injuries of the scalp, skull, or meninges.
General confusion of the brain is more frequent than
the limited form, but much less frequent than laceration.
I am accustomed to recognise it in three post-mortem
conditions: General hyperaemia, with or without
oedema, punctate or miliary haemorrhages, and throm-
bosis of the minute cerebral vessels. They occur separ-
ately or together. Examples of each are afforded by the
necropsies I have described, and the appearances they
present are sufficiently indicated in the enumeration of
post-mortem conditions which I have made. I will only
refer to two very recent cases (Cases XXXIII. and
XXXIV.) as well-marked instances of excessive general
hyperaemia from general contusion accompanying lacer-
ation, and to one other (Case XXIV.) in which death was
due to general contusion with oedema. The very mod-
erate hyperaemia, which often exists in connection with
other lesions, I have not specially considered, though it
may be of Serious importance.
Meningeal confusion, as a distinct complication, occa-
Sions haemorrhage and inflammation. Its relation to
general contusion of the brain is not closely defined.
The two conditions occur together or separately, and
Severity of One, when they are coincident, is not always
proportionate to that of the other. I may instance as
illustrative of this uncertain relation two cases—the one
of oedema to which I but just now referred, in which the
brain tissue was sodden and the ventricles distended
With serum, while the meningeal vessels were but
slightly congested and the subarachnoid Spaces notably
dry; the other, my single case of acute arachnitis to
Which I shall refer later, in which the whole subcortical
tissue was very markedly hyperaemic and the smaller
vessels filled with coagula. I do not regard simple
*ningeal hyperaemia as other than a factor in the more
*Portant lesion of laceration or general contusion,
With which it may happen to be associated.
330 NH|W YORK STATE MEDICAL ASSOCIATION.
Haemorrhage is of frequent occurrence. The vessels
of the pia are ruptured and the blood is effused ordina-
rily in a rather thin sheet over one or both hemispheres,
but may present itself in patches scattered over any part
of the brain. When the haemorrhage is more profuse
and the clot thicker, it can probably be traced to its
source in a cortical laceration. The coexistence of both
forms of cortical haemorrhage is not infrequent. If the
fact be fully recognised that cortical haemorrhages of
traumatic origin, unconnected with cortical laceration,
and without fracture as well as with it, are the result of
meningeal contusion, the subject will not require further
COmment. -
Traumatic arachnitis, so far as these records show,
does not result from direct injury transmitted through
fracture of the skull, nor from an inflammatory process
propagated from a cortical laceration. This complication
was once supposed to be the great danger to be feared
from injuries of the head, and when death ensued it was
always charged with the fatal result. An examination of
the fifty-eight post-mortem observations I have made,
discloses only seven cases in which it was possibly pres-
ent, and only five in which it was positively determined.
Two of these occurred in connection with fractures at
the base, and the remainder in simple injuries of the
brain in which no fracture existed. One of the former
was an acute arachnitis; the other six were characterised
by a Subarachnoid serous effusion. They all negative
the theory of direct violence, or of an extension of a
prior inflammatory process. The acute arachnitis (Case
XVIII.) was localised in the right and left occipital
regions, while the attendant fracture and subcortical
lesion were in the parietal region of one side, and
separated from it by an interval in which there was
no purulent effusion. General contusion was also pres-
ent. In the case of subacute arachnitis which compli-
cated a fracture at the base (Case IV.), the depressed
portion of the fracture which was in the vertex Was
STUDY OF INJURIES OF THE HEA. D. 331
confined to the external table, the local lesion was
subcortical, and there was evidence of general contusion.
In the five other cases, in which there was more or less
evidence of Subacute arachnitis, there was no fracture
at all; in three there was no laceration, but general
contusion or cortical haemorrhage from meningeal contu-
sion ; in one of the other two the subarachnoid effusion
was localised on the opposite side of the brain from the
site of the laceration ; and in the other, and last of
the series, the lacerations were old and considerably
antedated the immediate cause of death. There can be
no doubt that all of these were the result of menin-
geal contusion.
Paralysis.--Another complication which has been
Supposed to have been a direct result of fracture is
paralysis from bony compression of the cranial nerves.
This condition is represented in a single case. In this
there was compression of the optic nerve. There was
fracture extending through both anterior fossae, involv-
ing the left optic foramen, and pinching the optic nerve
at that point (Case LIX.). Loss of sight was immediate,
and Ophthalmic examination showed the condition of the
nerve and eye to be normal. Subsequent examinations
discovered progressive atrophy. The patient recovered,
but loss of sight was permanent. In other cases in which
loss of function occurred in parts to which cranial nerves
are distributed, as elucidated by post-mortem examina-
tion, the cause was found to exist in lesion of the
Cortical centres or in compression of the nerve by blood
effused into its intra-Osseous canal of exit. There is so
little displacement in fracture of the base that such
instances as the one detailed are probably of great infre-
Quency.
CONTRE-COUP.
I have called attention to the fact that fractures are
usually the result of direct violence, expending its force
upon the vertex or transmitted in continuity to the base,
332 NEW YORK STATE MEDICAL ASSOCIATION.
and that fractures by contre-coup are exceptional. Lac-
erations and contusions of the brain, on the contrary,
are almost invariably produced, either wholly or in part,
in this way. In the minority of cases in which some
encephalic lesion exists directly beneath the point at
which violence has been inflicted, there has usually been
further and more serious damage done to the brain in
Some distant part. There has been either laceration or
general contusion discovered in each case subjected to
post-mortem examination. If the cases of gunshot
laceration are excluded, and also those of general con-
tusion in which a question might arise as to the kind
of violence to which the lesion should be ascribed, there
are only five instances in which the violence inflicted
was exclusively direct. It is almost safe, therefore, to
assume in any given case that if a lesion of the brain
exists, it has been produced by contre-coup at a distance
from the seat of direct injury. A careful examination
of the cases cited shows this distant point to be al-
most always upon the opposite side of the brain, and
confirms all previous observations that it is likely to be
at the base, in the middle or anterior lobe. The reasons
which have been adduced to explain the frequent occur-
rence of brain injury by contre-coup, and its seat by
preference, have no relation to these necropsies and
need not engage our consideration.
(JONOUSSION AND COMPRESSION.
All traumatisms involving brain symptoms were for
many years classified as cases of concussion or compres-
Sion. The classification was undoubtedly simple and of
easy comprehension. If the intracranial space was di-
minished by the intrusion of bone, serum, extravasated
blood, or pus, it was compression. Otherwise all Symp-
toms were referred to a hypothetical vibration of the
brain within the skull, a merely functional disorder
produced by violence. Twenty years ago Mr. Prescott
STUDY OF INJURIES OF THE HEAD, 333
Hewitt described several forms of contusion, in which he
included lacerations, and questioned the occurrence of
concussion as a distinctively pathological condition
without the existence of anatomical change. Previous
to this time several observers had noted structural
changes in certain fatal cases, but had not regarded them
as either necessary or invariable. Some years later
Bergmann, in a clinical lecture, admitted the existence
of both concussion and compression, with an aetiological
difference, and insisted upon their clinical identity. He
attributed concussion to a direct injury from a single
impulse, modified by the elasticity of the skull, by
which the brain suffered a diffuse disturbance of nutri-
tion without appreciable lesion. He considered it a
suspension of cortical activity, followed by a stimula-
tion, and eventually by a depression of the medulla.
He recognised it as occurring in three degrees: 1. In-
volving paralysis of the cortex only ; 2. Paralysis of
the cortex and stimulation of the medulla ; 3. Paralysis
of both cortex and medulla, with brief and unobserved
medullary stimulation. Cortical paralysis was indicated
by unconsciousness; medullary stimulation by slowness
of pulse and increase of arterial tension; and medullary
paralysis by rapidity of pulse and decreased arterial
tension. In compression, he regarded the brain condi-
tion as being identically the same, and manifested by
the same symptoms, but due to change of cranial ca-
pacity and not, as in concussion, to change of cranial
form. Finally, he considered diagnosis as only possible
by the duration of the symptoms. This clinical lecture
was admirably translated by Dr. John C. Schapps, late
house surgeon at St. Vincent's Hospital, and appeared in
the Annals of Surgery in 1882. The views of Bergmann,
of which I have presented a résumé, are of great weight
and authority, and probably represent the cumulation
of thought and observation up to that time. I do not
know that very much of importance has been added
Since. I am quite in accord with his opinion that con-
334 NEW YORK STATE MEDICAL ASSOCIATION.
cussion and compression should be regarded as One, but
would go further, and, having consolidated the two,
would abolish them both together, so far as they are
terms used to express a pathological condition. The
difficulty with all explanations of concussion is that, of
necessity, they are largely theoretical. To account con-
clusively for unseen pathological changes, or to authori-
tatively deny their existence, requires that the syllogism
be very carefully constructed. In this instance, in every
fatal case where the clinical history has corresponded to
that of recovering cases, a carefully conducted necropsy
has revealed organic lesion. In all cases that have been
cited to prove that no post-mortem lesion exists, not one
has been observed with sufficient exactitude to make it
of the slightest statistical value. There is nothing in
analogy to warrant at the present time the assumption
that any fatal disorder terminates without involving
structural change. Even disorders of the nervous sys-
tem, long considered functional, have with closer inves-
tigation fallen more and more into line with Organic
diseases. It is tenable ground, therefore, to hold from both
negative and positive post-mortem observation, as well as
from general analogy, that brain injury produces struc-
tural change with the same certainty that it occasions
palpable symptoms. If the terms concussion and com-
pression be used to indicate a group of symptoms, or a
variation of pathological condition, it is objectionable,
both on the score of propriety and as being likely to lead
to erroneous diagnosis. If they be discarded, the form of
injury the patient has suffered in a given case—as lacer-
ation, general contusion, or fracture with haemorrhage
—is more likely to be accurately determined than if at-
tention be directed solely to a symptomatic condition
that may not clearly exist. If unconsciousness and vari-
ation of pulse be accepted as the sole pathognomonic
and invariable conditions of traumatism, there will still
remain many cases of uncertain status. Examples may be
cited from the foregoing necrologies in which, from the
STUDY OF INJURIES OF THE HEAD. 335
earliest moment at which the patient could be reached,
there was neither unconsciousness nor a typical variation
of pulse. There can be no doubt, however, that uncon-
sciousness is one of the earliest and most constant
symptoms of serious brain injury. The opinion that
consciousness resides in the cortex as a whole, and that
unconsciousness is paralytic or inhibitory, is confirmed
by the negative results of physiological experiment and
by the artificial production of cerebral anaemia. It
may properly be regarded, therefore, as symptomatic of
brain injury with diffuse effect, but not necessarily of
diffuse injury. The primary retardation and subsequent
acceleration of the pulse which have been experimentally
proved to be attributable to medullary lesion, are not as
constant, and are consequently of less symptomatic im-
portance. In a majority of cases, at the first moment
assistance can be rendered, the pulse is accelerated as it
would be in serious injury of other parts of the body.
The ambulance service is exceedingly rapid, so that if
the retardation of the pulse is so evanescent a symptom,
it has no great practical diagnostic value.
The temperature, which has not heretofore received
attention as an important factor in the genesis of symp-
toms or in the diagnosis and prognosis of brain injuries,
Seems to me of primary importance.
Analysis of the temperatures which have been re-
Corded in these histories, confirms the impression which
I formed early in my study of these cases—that an eleva-
tion of temperature was an early, continuous, and very
Constant symptom in all classes of head injury. I have
a record of temperatures in 45 cases in which the diag-
nosis was confirmed by necropsy, as well as in 10 other
fatal cases and in 28 cases of recovery, a total of 83 out
of 124 altogether. I think there can be no doubt of the
propriety of including the cases of death without ne-
Cropsy and the recoveries, since the diagnosis was in
each well established. I have a definite recollection that
* a Considerable number of other cases in which the
336 NEW YORK STATE MEDICAL ASSOCIATION.
temperature was carefully observed and recorded, but in
which the charts were unfortunately lost, that the aver-
ages were not essentially different.
Four cases, which proved to be fatal, were admitted
with subnormal temperatures—from 94° to 98°. In two,
a subsequent rise in temperature was immediate, con-
tinuous, and very considerable; in the other two, death
ensued in a few hours without reaction ; in all the pulse
indicated medullary paralysis, and the lesions were
afterward found to be extensive and severe. In six
other cases, the patient was not admitted to a surgical
ward till the second day or later after the reception of
the injury, so that the first temperature taken could not
be considered primary, but in each case it was then
notably elevated—from 101° to 104-8°. In one recovering
case of fracture of the base with epidural haemorrhage,
it was normal, and never exceeded 99°. In the remain-
ing seventy-two cases, without exception, the temper-
ature on admission was above normal. In the majority
it exceeded 100°, and ranged all the way from 98.8° to
106°. It would be difficult to trace a relationship be-
tween the character or location of the lesion and the
comparative elevation of temperature. The increase was
usually progressive, without much recession, and the
maximum was reached usually just before death, but
sometimes afterward. The highest temperatures at-
tained were 109° in one case, 108° in one, 107° + in eight,
106° -- in ten, and 105°,+ in nine ; in other words, in
twenty-eight cases it was above 105°. In eleven other
cases it ranged from 104°-H to 103°-H. In three cases the
post-mortem temperature was 108-8°, 109°, 109.4° respec-
tively. Sufficient data have been given to thow that in
probably no condition, except insolation, is the temper-
ature so uniformly high as in cases of encephalic lesion.
Unconsciousness, as an early symptom, sometimes fails
without apparent explanation in cases in which brain
injury is undoubted. A variation of temperature, there-
fore, is the one invariable symptom, and if the patient
STUDY OF INJURIES OF THE HEAD. 337
has rallied from immediate shock, it is always an eleva-
tion. Perhaps, like the retardation of the pulse, de-
pression of temperature may always be the primary
change, but, if so, like the primary pulse change, it is
too evanescent to be practically diagnostic. In many
trivial head injuries elevation of temperature is abso-
lutely the only symptom ever recognised. The symptoms
should be rated in order of constancy—elevation of
temperature, unconsciousness, and acceleration of pulse.
Since this elevation of temperature is a constant phe-
nomenon, whatever the nature of the lesion or wherever
situated, it would seem to be due to an affection of the
cortex as a whole, and not to special lesions of localised
heat centres. To this extent it might be comparable to
experimental results in the attempt to discover cortical
centres for Organic functions. To what degree and in
what manner the demonstrated heat centres are im-
plicated in the general cortical change, is not within the
Scope of this paper to discuss, nor within my province or
Competency to determine.
The primary effect of brain injuries may therefore still
be attributed to an affection of the cortex in its totality,
in accordance with Bergmann’s view, but manifested by
tWO symptoms in place of one—an invariable variation
in temperature and a nearly invariable loss of conscious-
ness. There is no reason to doubt that the medulla is
next involved, and the effect of its stimulation and sub-
Sequent paralysis have been too thoroughly demonstrated
to admit of question. The diagnostic value of the symp-
toms it affords, however, has not been apparent in these
histories. I have not quoted the pulse records, because
they have not been sufficiently characteristic to justify the
DeCeSSary expenditure of time and labor.
The post-mortem observations disclose in every in-
stance grOSS lesions in one or more regions of the brain
or its membranes, which give a material basis for the
Symptoms which preceded death, whatever may have
been the intervening processes which connected the
22
338 NEW YORK STATE MEDIOAL ASSOOIATION.
structural change with its outward manifestations. It is
for this reason that I would exclude the terms concus-
sion and compression from systems of classification and
descriptive histories of cases.
SYMPTOMATOLOGY.
The symptoms of injuries of the head, excluding those
which are casual and without diagnostic significance, are
fairly numerous. Fracture at the base has two symp-
toms peculiar to itself, and fracture of the vertex has
also two; the others are common to both forms of fract-
ure and to purely encephalic injuries. Those peculiar
to fracture at the base are, serous discharges from the
ears or nose, and haemorrhages from the ears, nose, or
mouth, and into the orbital, subconjunctival, or cervical
subcutaneous tissue. The characteristic symptom of
fracture of the vertex, aside from a possible local serous
discharge, lies in its perception by sight or touch. The
symptoms of encephalic injuries, as a class, whether they
occur independently or as complications of fracture, are
superficial injuries; peculiarities of temperature, pulse,
and respiration; unconsciousness; delirium ; irritabil-
ity; paralysis; muscular rigidity ; convulsions; anaes-
thesia and hyperaesthesia ; pupillary changes; and, in a
late stage, dementia. Other symptoms, as cephalalgia,
vomiting, vertigo, incontinence of urine and faeces, are
frequent, but of less clinical value.
The haemorrhages, serous discharges, and visual or
tactile detection of fracture are pathognomonic. The
haemorrhages occurred in twenty cases and the Serous
discharge in one, and the necropsy in each confirmed the
indication the symptom had afforded. In the fourteen
cases in which they were absent, the line of fracture in
each was found to be such as to preclude the escape Of
blood during life through any of the recognised chan-
nels. The direct evidence of fractured vertex was pres-
ent in five cases, including three of gunshot wound.
STUDY OF INJURIES OF THE HEA D. 339
There were simple contusions, large haematomata, or
wounds, perceptible in fifty out of the fifty-eight cases.
These superficial injuries were of great importance, not
only by affording positive proof that violence had been
suffered in cases where unconsciousness of the patient
and absence of history rendered such confirmation es-
sential, but by indicating the point at which it had been
inflicted. -
Sufficient has been said of variations of pulse and tem-
perature and of unconsciousness, and little need be added
in regard to peculiarities of respiration. In the majority
of cases it was simply rapid or normal, and the chart
records have not been transcribed for the same reason
that they were omitted in the case of the pulse. It was
occasionally slow, in some instances not more than seven
or eight in the minute, sometimes irregular or stertorous,
Sometimes of the Cheyne-Stokes variety, and in two or
three instances dependent in character upon the presence
of pulmonary oedema. As in case of the pulse symptoms,
I have been struck by the habitual absence of distinctive
respiratory indications of medullary implication in
Serious cortical disturbances. *
Delirium, or some form of mental impairment, is of
rather frequent occurrence. It sometimes replaces un-
Consciousness as the earliest noticeable symptom, and
Sometimes appears as a much later manifestation. It
may be violent and simulate alcoholic mania, or it may
be mild and coexist with stupor. The most characteris-
tic form of mental disorder which I have encountered in
Cases of head injury is that of nocturnal delirium, with
more or less mental disturbance by day, and in time
lapsing into permanent dementia as a termination, or
Sequel, of the traumatic lesion. It may follow at once
ºpºn recovery of consciousness, or it may succeed active
delirium. At night the patient often requires mechani-
Çal restraint, while during the day he answers questions
intelligently, is coherent in his speech, and may appear
entirely rational. His memory, however, is defective,
340 NEW YORK STATE MEDICAL ASSOCIATION.
or wanting altogether, in regard to all the circumstances
attending his injury. He has delusions and fails to
recognise his surroundings. He is prone to drink his
urine, and is often apathetic. His mind may finally
become clear, his memory of lost events return, and his
mental recovery be complete. In other cases his con-
dition becomes one of dementia, and some degree of
mental impairment is permanent. Such a condition as I
have described I presume is not novel to the alienist,
but I note it as a special characteristic of injuries of the
brain substance, not as a Sequel, but as a symptomatic
condition of recent lesion.
Another allied symptom is the sensitiveness to external
irritations observed in cortical lesions. It seems to be
not only a hyperaesthesia of the cutaneous surfaces, but
also a marked mental irritability. There is not only
exaggerated muscular movement from slight irritations
and disturbances, but the patient manifests great vexa-
tion and impatience, though apparently unconscious. It
is not usually followed by muscular spasm.
Convulsions, muscular rigidity, and muscular tremor
may also be classed as irritative symptoms. The first
and Second occur in a considerable number of cases, a
majority of which prove fatal, and upon necropsic ex-
amination, disclose haemorrhages and extensive lacera-
tions, and possibly general contusion. In the case of
atrophy of the temporo-sphenoidal lobe, already de-
scribed, convulsions were exceedingly severe; but they
followed operation, and a single one occurred fifteen
days after the original injury, so that it is by no means
certain that there was any aetiological connection
between the lesion and the symptom. It is fair to
assume that they are always evidence of serious lesion,
even when recovery follows. The few instances of mus-
cular tremor were in men addicted to drink, but not
intoxicated, and who died from the effects of extensive
structural changes.
Paralysis and anaesthesia, general and local, are reC-
STUDY OF INJURIES OF THE HEA. D. 341
ognised indications of traumatic, not less than of idio-
pathic, affections of the encephalon. In the present series
of cases they have occurred perhaps oftener than indi-
cated in the histories, since in so many instances con-
sciousness never returned. In this condition, paralysis
of the extremities and certain of the local paralyses—
facial, ocular, or even glosso-pharyngeal—can be recog-
nised ; but many others, as well as sensory disturbances,
remain hidden. The multiplicity of lesions, which is the
rule rather than the exception, is confusing. In testing
cutaneous sensibility the results are sufficiently contra-
dictory and unsatisfactory even under more favorable
conditions. Yet, despite all these difficulties, in two
cases of lesion of the gyrus fornicatus the observations
were productive of some result. In three cases of con-
jugate deviation, the necropsies afforded more or less
satisfaction according to the view taken of the location
of the cerebral centre. In a general way, however, while
traumatisms may in some instances be of service in the
Solution of various unsettled questions in cerebral local-
isation, such cases will probably continue to be excep-
tional.
The fact that defined lacerations are so largely situated
at the base of the brain, out of the region in which func-
tional areas have been located, still further diminishes
the chances that traumatism will aid much in perfecting
Cerebral topography. It is none the less important, in
all cases of profound unconsciousness, to examine criti-
cally for such forms of paralysis as are undoubtedly
recognisable, as well as for those, the discovery of which
is likely to be more problematical.
Pupillary changes are valuable positive evidence of or-
ganic injuries, but are less important as negative signs.
In a minority of fatal, as well as of recovering cases, I
have found the pupils to be abnormal—either variable,
unsymmetrical, dilated, or contracted. Unilateral dila-
tation is probably the most frequent deviation from the
*Ormal condition, and is likely to be associated with
9ther and more decisive symptoms.
342 NEW YORK STATE MEDIOAL ASSOOIATION.
I shall not stop to consider casual or remote general
symptoms, though, in connection with others more
characteristic, they sometimes acquire a value which is
not intrinsic. Vomiting, and incontinence of urine and
faeces are among the most constant symptoms encoun-
tered in head injuries; but the one is not less frequent
in peritonitis and pregnancy, and the other is quite as
common in a great variety of functional and organic dis-
orders of the brain which have no relation to traumatism.
There can be no doubt, however, of the value of such
indications when they occur under circumstances which
render traumatism probable, either by the history or by
the concurrence of more directly suggestive symptoms.
In the same connection, occipital headache might be
mentioned as so general in recovering cases of fracture
of the base with epidural haemorrhage, as to assume
almost diagnostic importance.
I have not specifically noted in the various cases the
symptoms which were not manifested, but with the
exception of temperatures, when unmentioned, they may
be regarded as absent.
The results of head injuries have been sufficiently indi-
cated as recovery, death, and dementia.
DIAGNOSIS.
The diagnosis of injuries of the head, as a class, is
always of interest, is usually practicable, and under
some circumstances is one of the most important in the
domain of surgery. Grievous error has entailed equal
disgrace upon the surgeon and suffering upon the patient.
These lesions are to be distinguished first from all other
morbid conditions, especially from those involving loss
of consciousness or delirium, and, secondly, they are to
be discriminated from each other. It is unnecessary to
enumerate or consider all those diseases which may
simulate their symptoms. The one of primary and para-
mount importance, and which demands most earnest and
STUDY OF INJURIES OF THE HEAD. 343
careful attention, is the coma produced by alcohol. Its
importance cannot be overestimated, not only because
it is the one with which the condition of traumatic coma
is most likely to be confounded, but because error in
diagnosis inflicts so much unnecessary suffering, addi-
tional danger, and possible disgrace upon the patient,
while it places the most serious responsibility upon the
surgeon. The number of instances in which injuries of
the brain have been mistaken for alcoholic coma, and
the patient left to die in the cells of a police station, or
committed to the alcoholic ward at Bellevue, or even sent
from a police court to a term of imprisonment, is inex-
cusably great. A large proportion of such cases which
came into my service at Bellevue, previous to the past
year, were transferred from the alcoholic ward. It is a
pleasure to acknowledge that within the year great
progress has been made in the acquisition of knowledge
among those who render first aid to the injured, even to
the extent of realising that an unconscious man with a
Scalp wound is not necessarily drunk, and that even a
drunken man may be so seriously injured as to require
hospital treatment. Unconsciousness and the existence
of Superficial injury of the head should, in any case,
arrest attention and awaken suspicion of brain lesion.
Coma ought not to be ascribed to alcohol, except by the
strictest process of exclusion. Symptoms which are
most likely to characterise different forms of head in-
jury should be sought seriatim. It should be remem-
bered, finally, that, even if the patient be intoxicated,
this circumstance should strengthen rather than allay
Suspicion of traumatism.
I believe the temperature affords the means of absolute
diagnosis. I have shown, from the histories I have
recorded, and upon which this paper is founded, that
Variation of temperature in head injuries is invariable,
and that in the exceptional instances in which it is de-
Pressed, the severity of associated symptoms will take
them out of the Category of doubtful cases. In alcoholic
344 JNEW YORK STATE MEDICAL ASSOCIATION.
coma, the temperature is subnormal, and I have found
this rule to be absolute. The one case which seemed to
be exceptional was reported to me as having a temper-
ature of 100°. Investigation proved it to be the result of
petit 'mal from Opium Smoking in a young prostitute of
the Chinese quarter who had not yet become accustomed
to her mode of life. I have made some observations to
determine the exact temperature in alcoholic coma. I
have succeeded in obtaining upward of twenty cases in
which coma was more or less profound, and the temper-
ature ranged from 96° to 98°, with a usually full and slow
or normal pulse, and the depression of temperature was
directly proportionate to the depth of the coma. I had
expected at the present time to have collected a larger
number of cases, but I have found my opportunities un-
expectedly limited. Whetherit be the quality of whiskey,
or the moral tone of the lower stratum of society which
has improved, I know not, but examples are no longer to
be had for the asking. I believe, however, the absolutely
uniform results in this number of cases makes it more
than probable that a larger number in the future will
corroborate the conclusion which has been reached.
In the diagnosis of apoplexy or non-traumatic cranial
haemorrhage, I have found that the observations of
Bourneville coincide with those more recently made.
They show that in the commencement of the attack the
temperature is subnormal, that it then becomes normal,
and remains at that point if the patient recovers, but if
he dies, it rises to a marked degree. In twenty-three
cases taken from an accessible record, of which seven
proved fatal, the temperature in two of the latter rose to
102° and 104°; in all the others, fatalities included, the
highest temperature was 100°-H. This is in marked Con-
trast to traumatic lesions in which the temperature Con-
tinues to rise from the depression, if one existed, and
remains elevated while the result remains in abeyance.
A case which suggests the occasional difficulty in the
diagnosis of idiopathic from traumatic lesion is that
STUDY OF INJURIES OF THE HEAD. 345
(Case CVIII.) of the man previously quoted, who was
seized with an apoplectic effusion into his lateral ven-
tricles and one occipital lobe, and fell from his cab,
causing a cerebellar laceration. There is still another in
this series very like it, in which a man after an apoplec-
tic seizure fell backward, and, like the first, lacerated his
cerebellum. In both cases the previous history was
known and it was possible to diagnosticate both lesions.
It is unnecessary to refer to uraemic coma, Opium
narcosis, hysteria, etc., as the diagnostic problems they
present are elementary.
The active delirium which may occur in the period im-
mediately succeeding the reception of a brain injury, is
sometimes very difficult to distinguish from that which
results from alcoholic excess. The difficulty may be
further increased by the fact that the subject is of known
intemperate habits, and very likely intoxicated when
first brought under observation. In those cases in which
delirium is the first symptom noted, and probably re-
places unconsciousness (as in Case I.), the condition be-
Comes very deceptive. In this instance we are not aided
by the temperature, which is almost always elevated in
alcoholic delirium, and the elevation may be, and often
is very great. I have within a few days seen a case in
Which, with quite extensive superficial injury of the
head, there was alcoholism to the verge of delirium, a
high temperature, a previous history of epilepsy, and
present epileptiform convulsions followed by facial
paralysis. The diagnosis, which excluded brain injury
and Which proved to be correct, was made from observa-
tion of the course of the temperature for the first
few hours. I am aware of no Single diagnostic sign
Upon Which dependence can be placed, and yet I have
*Ver seen a case in which it was not possible to make
the distinction between the two forms of mental disturb-
*nce. There are few head injuries in which there are
*ot at least one or two characteristic symptoms which
*n be detected if sufficient care be exercised in the
346 NEW YORK STATE MEDICAL ASSOCIATION.
examination of the case. It seems to me that there are
differences even in the character of the delirium which
may be recognised though not easily formulated.
The diagnosis from each other of the several injuries
which may be inflicted upon the cranium and its con-
tents, is fraught with difficulties. The lesions are likely
to be multiple and the symptoms to be equally referable
to either one of their number; the symptoms of circum-
scribed lesion are often lost in those from a diffuse
character, and similar results constantly ensue from
totally different causes. A more exhaustive study is
therefore requisite of the diagnostic value of individual
symptoms in their relation to each other, and to estab-
lished structural changes, than I have yet been able
to undertake. There are, however, well-established
facts, as well as strong diagnostic probabilities, which
are likely to multiply and to make diagnosis possible in
an increasing number of cases. Thus, it is well known
that certain haemorrhages positively indicate a definite
fracture at the base. A trivial injury of the vertex, and
One or two general symptoms may suggest its whole extent
and complications. Again, paralysis of an extremity in
a recent head injury will positively determine some
lesion of a definite portion of the parietal cortex on the
opposite side. In the absence of depressed fracture, and
with the knowledge that occurrence of laceration or
limited contusion at this point is unusual, the ascription
of the paralysis to haemorrhage becomes justifiable.
These conclusions are legitimate and founded upon
positive knowledge and logical inference combined.
There can be no doubt, I think, that greater diagnostic
significance will attach to individual symptoms in the
light of further pathological observation. As an ex-
ample, the present series of necrologies seems to show
that the peculiar mental conditions I have described are
usually preceded by lesion of the brain tissue, and if it
be of the membranes, that it is meningeal contusion with
inflammation. I have insisted upon the importance of
STUDY OF INJURIES OF THE HEA. D. 34?
temperature in the recognition of head injuries as a class.
I am not at present prepared to raise the question of its
diagnostic relation to individual lesions.
PROGNOSIS.
The prognosis may be first considered from the numer-
ical results. The total number of cases is one hundred
and twenty-four, of which forty-nine recovered, or nearly
forty per cent. The fractures at the base number seventy,
of which twenty-one recovered, or exactly thirty per
Cent.
The popular belief, and possibly the general profes-
Sional impression, is that this fracture is a peculiarly
fatal accident. I have already expressed the opinion
that fracture at the base is devoid of danger except for
its complications, but it is so often attended with grave
lesions of the brain and meninges that it is not strange
that by a species of metonymy it should come to stand
for the traumatism as a whole. -
It is difficult to estimate the comparative danger of the
Several lesions, from the fact that they are so generally
multiple, and altogether conspire to bring about the
fatal result. It is also true that the severity rather than
the form of lesion is to be made the basis of prognosis.
It may be, therefore, of no great practical importance to
attempt to infer from the necropsies the relative respon-
sibility of individual lesions in causing death in each
instance. So far as I may judge from comparisons of
Symptomatology with post-mortem appearances, when
Opportunity has been afforded, I believe death has di-
rectly resulted in fully fifty per cent. from laceration
and attendant haemorrhage. In the remainder it might
be chargeable to epidural haemorrhage, contusion, ab-
*SS, or arachnitis, though doubtless in every case some
other lesion was contributory.
The prognosis made from initial symptoms must depend
"Pon their general severity and upon the extent to which
348 NETW YORK STATE MEDICAL ASSOCIATION.
the vital powers are implicated. It sometimes happens
that the patient survives when the obvious extent of the
lesion has made recovery seem practically hopeless. A
fracture through both middle fossae, and one, probably
both, anterior fossae, might well put an end to hope, and
yet such a case (Case LXIX.) did recover. I find that
none of my patients have lived in whom the temperature
has risen to 105°, but in more than one that degree was
approximated. I am not at all certain it might not
exceed 105° consistently with recovery. A very high tem-
perature, or disturbance of respiration at an early period,
or muscular rigidity, is always calculated to excite the
gravest apprehension. The late prognosis presents no
difficulties, but it ceases to be of professional interest.
TREATMENT.
I propose to confine whatever I may have to say in
regard to treatment, to questions of operation. I omit all
reference to medication, as it involves matters of detail
for which time is wanting. I premise only a brief men-
tion of what may be properly designated adjuvants in
general treatment. The necessity of shaving the head,
which is conceded in cases with symptoms of marked
severity, is equally existent in every case in which there
seems to be a possibility of intracranial injury. It per-
mits the discovery of diagnostic contusions which are SO
Often disclosed only upon post-mortem examination. It
relieves the brain, in some cases at least, of a superin-
cumbent and thermogenetic weight, which is positively
contraindicated and is a factor of appreciable influence.
It facilitates the use of the ice cap, which in cases of high
temperature and delirium is an appliance of the highest
therapeutic value. I have found it so effective that I
desire to emphasise its importance. I have sometimes
been compelled to maintain its use for a length of time,
as whenever it was discontinued the temperature again
increased and delirium returned. The resort to a simple
STUDY OF INJURIES OF THE HEAD. 349.
form of mechanical restraint is often requisite for the
mere purpose of retaining the patient in bed. It inci-
dentally becomes at the same time a means of quieting
nervous excitement and of husbanding physical strength.
Trephining may be regarded with less apprehension by
the timid since the advent of aseptic methods. Its pro-
priety may now be decided simply in view of its probable
advantage, or its more probable futility. It may be
counted quite as safe as the use of the exploring needle
in suspected abscess, and safer than explorative laparot-
omy. I should not deem it necessary to insist upon this
point were it not that I am so often surprised by denials
of what I had taken to be conceded facts. If, as I am in-
formed, the temperature rises to a high degree after
craniectomy or trephining in children, it is so foreign to
my experience in traumatism that I am constrained to
attribute it to other causes than to simple perforation of
the cranium. I have often found it, on the contrary, to
be followed by a depression of temperature when no
result had been attained beyond the mere removal of the
button of bone. The incision of the dura, or the further
exploration of the brain, might be differently regarded,
for while trephining, done with due regard to time and
method, could hardly inure to the serious disadvantage
of the patient, uncalled-for and injudicious interference
With the intracranial contents might be positively harm-
ful. This possibility is not a contra-indication to going
further after trephining, if its propriety becomes evident.
In such cases I have always found the temperature
to rise as it does in injuries of the brain generally. In
the small abscess which I incised through the angular
gyrus, it rose, in the sixteen hours which preceded
death, from 102.2° to 108°. In the very large abscess in
the frontal lobe, upon which I operated only last month,
the temperature rose from 99.2° in twenty-four hours to
102.2°, and recovery is even now complete. I should ex-
pect an elevation of temperature in any case, but I should
not expect any serious results from incision of the dura
350 MEW YORK STATE MEDIOAL ASSOCIATION.
or brain per se. So far as subsequent danger or in-
convenience from hernia cerebri is concerned, I may
repeat a statement previously made, that in the Surgery
of to-day it has ceased to be an intimidation to the
surgeon.
I am quite of the same mind with those surgeons who
believe that this operation should be done in every de-
pressed fracture where elevation and thorough explora-
tion cannot be otherwise accomplished. I believe with
them that the absence of general symptoms does not
relieve the surgeon from the responsibility of operation.
This view was held by my former preceptors, the late
Dr. James R. Wood and Dr. J. W. S. Gouley, at a time
when to hold such opinion was almost an opprobrium.
It commended itself to my judgment then as it does
now. It is doubtful if such an operation has been known
to do harm when it has failed to do good. It is certain
that harm has come in more than one instance when,
because of the absence of general symptoms, it has been
neglected. It is impossible to tell in a depression of the
external table of moderate or perhaps insignificant
extent, what more extensive comminution of the internal
table may not exist. It is this possibility of even the
smallest bony spicula penetrating the brain and causing
serious nervous disturbance in the indefinite future, that
demands thorough examination of every cranial fracture.
It should be held obligatory on precisely the same
grounds as the examination and cleansing of a wound in
the external soft parts. The observance of such precau-
tion is free from danger; its neglect may lead to either
present or future serious complications.
If the depressed fracture is simple orits existence is in
doubt, there should be no hesitancy in making a suffi-
ciently free incision to determine the exact cranial Con-
dition. It is of very common occurrence that a large
haematoma exists in connection with diagnostic Symp-
toms of intracranial injury, and that there is no other
means than this of acquiring knowledge which may be
STUDY OF INJURIES OF THE HEAD. 351
of vital importance. If the result is nugatory, the inci-
sion, made under aseptic conditions, will be closed by
primary union. It is certainly better to have made many
fruitless incisions than to have allowed a single life to be
jeopardised by an undiscovered fracture.
In case the fracture proves to be a simple fissure, a
different rule of conduct will obtain. The probabilities
will be against the existence of depression of the inner
table, and after the fissure has been traced, with or with-
out incision, as far as practicable, or till it has become
narrowed to a line, the wound should be closed. If,
however, the general symptoms should indicate com-
plication, further exploration may become proper and
necessary.
The indications for trephining are wanting at the
present time in the great majority of cases which involve
intracranial lesion. If the existence of epidural haemor-
rhage is evident, and its location is accessible, the pro-
priety of operation is unquestioned. If the existence of
circumscribed lesion of the brain can be inferred from
local paralyses, anaesthesia, or muscular rigidity, or
from the initial symptom of convulsion, I think the pro-
priety of operation may be assumed. In the greater
number of cases, those in which only symptoms of diffuse
lesion can be recognised, the use of the trephine is en-
tirely empirical and without justification, unless under-
taken for special reason. If, in time, lacerations at the
base come to be diagnosticated with reasonable certainty,
it may then be proper to inquire whether their exposure
by the trephine or otherwise, disinfection, and drainage
Would be practicable and advantageous.
The accidental result of trephining, in at least two or
three cases, suggests its employment on purely medico-
legal grounds. I will instance the case (Case CVIII.),
already quoted as an example of mixed idiopathic and
traumatic lesions, of a man who fell from his cab after
* apoplectic effusion and secondarily lacerated his cere-
bellum. He was paralysed, anaesthetic, and absolutely
352 WEW YORK STATE MEDICAL ASSOCIATION,
unconscious. He was trephined, and a large amount of
serous fluid drained away from the surface of the brain.
His temperature fell in six hours from 103.4° to 98-69.
He became conscious, could articulate, spoke rationally
and intelligently, and gave his name and address. At
the end of fourteen hours his temperature again rose,
and he died. The possibilities of such a case are not less
practical than dramatic. The instances I have encoun-
tered of such transient returns to consciousness have
been sufficiently prosaic and unimportant. The very
next, perhaps, might disclose a criminal and avenge the
crime. In any one of the many homicidal assaults in
which the victim is found unconscious and the assailant
has escaped unknown, I believe it to be legitimate to
trephine for this direct purpose. Even temporary resto-
ration of the mental faculties might suffice the ends of
justice. The prospect of success is certainly not alto-
gether chimerical, for I have cited a case in which just
such a hypothetical result was absolutely attained.
The general principles of operative interference in cra-
nial fractures and encephalic injury may be recapitulated
and formulated as follows: Incision of the scalp, tre-
phining, incision of the dura mater, and perforation of
the brain, severally or together, should be resorted to
without fear or hesitation when indicated. Incision of
the scalp and trephining are devoid of danger and are
always justifiable for exploration, which in itself consti-
tutes an indication. Incision of the dura mater, and
incision or perforation of the brain are more serious
procedures, and should be made only when positively
indicated by the general symptomatology.
I have sketched as rapidly and systematically as pos-
sible in this paper the conclusions to be derived from the
series of histories and necrologies by which it is pre-
ceded. So far as they are confirmatory of previous ob-
servations, they will have the value which attaches to in-
dependent study. If in any particular they differ from
accepted teaching, the inclusion of the historical data
CORRIGENDA
At page 284, Case XXII., for “Six multiple " read “Multiple
fissures of the base (six in number).”
At page 290, third line from top, for “cortial" read “cortical.”
At page 298, Case LXVI., and wherever else in the paper the
words occur, for “trephined ” read “trepanned ” and for
“trephining ” read “trepanation.”
At page 304, fourth and fifth lines from the top, instead of
“next four days’ read “in the four days ensuing.”
At page 313 Case CXXII., for ‘‘ thus ” read “as.”
At page 321, eighth line from the top, for “facial,” read
“fatal.”
At page 336, eleventh line from the bottom, instead of “ in
Other words " read “or.”
At page 338, eleventh line from the bottom, for “less" read
“lesser.”
At page 346, ninth line from the top, after “from " add “one
Of.”
At page 349, thirteenth line from the bottom, for “positively
harmful" read “ of positive disservice.”
STUDY OF INJURIES OF THE HEAD, 353
will make it easy either to verify their truth or to refute
their error.
I beg to acknowledge my indebtedness to the courtesy
of my colleagues, Dr. J. W. S. Gouley and Dr. F. S.
Dennis, and also to the successive house surgeons at
Bellevue and St. Vincent's Hospitals, for their intelli-
gent co-operation in the work of observation.
28
THE AETIOLOGY OF GASTRIC ULCER.
By CHARLEs G. STOCKTON, M.D., of Erie County.
November 17, 1892.
The mucous membrane and the deeper structure of
the stomach may, from a variety of processes, suffer loss
of Substance, and properly enough these may be called
ulceration. Thus, from traumatism, corrosives, scalding
fluids, from tuberculosis, syphilis, scurvy, or from serious
blood changes, from extensive burns, from continued
pressure and other causes disturbing nutrition of the
part, ulceration may take place. However, for an ulcer,
Occurring most often in young women; which is usually
round, having about it healthy mucous membrane; its
margin being abrupt and clean cut, so that in old cases
it has a distinct punched-out appearance (as Rokitansky
aptly describes it); generally found alone, but occa-
sionally having one or two companions; located, as a
rule, on the posterior wall near the pylorus, and often
near the lesser curvature; almost invariably associated
with an excessive secretion of hydrochloric acid, and not
infrequently with anaemia; which is called the simple,
the solitary, the round, the perforating, the peptic ulcer,
and the ulcer of Cruveilhier, there has been suggested
no cause which is satisfactory, or which answers allim-
portant requirements.
It is not to be supposed that one can draw an uninter-
rupted and perfectly visible line of separation between
true round ulcer and all other forms of gastric ulceration.
It is probable that in many instances the processes are
so intermingled and confused that even the fullest
knowledge of the facts would leave differentiation in-
complete. Still, this fact must not be lost sight of, that
THE AETIOLOGY OF GASTRIO ULOER. 355
in the classical “round ulcer” no theory of aetiology so
far suggested has proved to be altogether satisfactory.
But before discussing this part of the subject, your
attention is invited to what we know of the causes of
gastric ulcer in general.
It is widely believed that the bacilli of tuberculosis,
passing through the stomach, may invade the intestinal
mucous membrane, and yet, this organism, while not
destroyed by the gastric secretion, has not been shown
to be a cause of local trouble in the stomach. Notwith-
standing this, there are now reported numerous authen-
ticated instances of tubercular disease of the stomach,"
and occasionally extensive ulceration of the mucosa is
See Iſl.
Syphilis, according to histological examinations made
by Guozot,” has been shown to be the cause of ulcer, and
Heller” thinks that syphilis plays an important rôle in
Congenital ulcer, of which a number of cases have been
reported.
The disintegration of neoplastic tissue can scarcely be
considered as ulceration of the stomach, although it is
Well known that cancer often finds its seat in the place
of a preceding ulcer. Albertoni," however, reports an
ulcer complicated with adenoma of the stomach, and
believes that the ulcer resulted from a previous growth
of this nature. Turner" describes a circumscribed super-
* Musser. Tuberculosis of Stomach. Philadelphia Hospital Reports,
1890, I., 117–124.
Hebb. Tubercular Ulcer of Stomach. Westminster Hospital Heports,
London, 1888, III., 155–158.
Coats. Tuberculosis of Stomach. Glasgow Med. Jour., 1886, 53–61.
Choosuek. Ueber Tuberculose des Magens. Wien. Med. Bl., 1882, W.,
197 and 233.
Kºhl Tuberculose Magen. Geschwilre. Kiel, 1889.
Guozot. Contribution à l'étude des maladies syphilitique de l'esto-
mac. Bordeaux, 1886.
8 Heller, Quoted by Steinman. Einige Fälle von Magengeschwilre und
Jugendlichen Alter. Kiel, 1890.
Albertoni. Jour. de Med. de Chir. et de Pharm. Bruxelles, 12, 20, 1890.
Turner. Trans. Path. Soc., London, 1884–5, XXXVI., 191.
356 ME}}W YORK STATE MEDICAL ASSOCIATION.
ficial slough of the gastric mucous membrane of a man
suffering from pyaemia following a fracture of the tibia,
and similar cases resulting from septic emboli are reported
at long intervals.
I have seen erosions of the gastric mucosa resulting
from extravasations of the blood into its substance, in
cases of purpura and scurvy, and, according to Wales,"
such lesions, and even distinct ulceration, are rarely
absent in the latter affection.
Quioroza” reports cases of gastric ulcer resulting from
dysentery, puerperal septicaemia, and typhoid fever,
and the author believes that the affection is the direct
result of numerous diseases of the body.
An interesting and ingenious explanation of the affec-
tion is that given by Wiktorowsky,” who maintains that
from chronic catarrh, the establishment of the chronic
interstitial process, up to perforating ulcer of the stomach
is but a continuous chain; but proof of this theory is
wanting. Nevertheless, Peter* and others hold that
round ulcer is the result of a preceding gastritis, and the
increased local temperature is mentioned as evidence in
that direction. It will be remembered that Cruveilhier”
held to the inflammatory origin of the disease. There
has been a general acceptance of the views expressed
long since by Virchow, that the ulceration follows haem-
orrhagic erosions resulting from disturbances of the cir-
culation; that “the interruptions of the circulation are
for the most part due to morbid conditions of the gastric
vessels, and particularly to a haemorrhagic necrosis of
the mucous membrane.” This hypothesis at once opens a
wide avenue for causative factors, and if it were not for
* International Surgery, Wol. I., p. 292.
* Études sur l'ulcere gastro-duodenal d'origine infectieuse. Paris,
1888. -
* Verhältniss der entzündlichen Processe zu den Ulcerosen im Magen
Virchow's Arch. f. path. anat. Berlin, 1883, XCIV, 542.
* Le Bul. Medical. Paris, July 12, 1890.
* Cruveilhier. Anatomie Pathol. du corps humain, Tome I., livraison
X., p. 1.
THE AETIOLOGY OF GASTRIC ULCER. 357
certain reasons, hereafter to be mentioned, the attempt
to point out a special process in the development of the
ulcer described by Cruveilhier would be profitless.
It is most natural and sensible to suppose that, given
a haemorrhagic necrosis of the mucosa, and the presence
of the active gastric juice, the part would become digested,
and the typical excavation, so well described by Roki-
tansky, would appear. This position is substantiated by
clinical observations, post-mortem discoveries and labo-
ratory experiments, so that one cannot deny that ulcers
are thus established. .
In 294 cases, Berthold' found diseases of the circula-
tory apparatus in 170, while Steiner reports such changes
in 71 cases out of a total of 110, finding particularly
endocarditis, end-aortitis, endarteritis. Thrombosis in
Various parts was demonstrated 48 times. Litten” saw a
perforating ulcer with a thrombus in the splenic artery,
and Janeway” describes a like case, where the ulcer was
directly due to a fibrinous plug found in the gastro-
epiploic artery. Provost and Cotard produced ulcerative
changes in various parts of the alimentary canal by intro-
ducing tobacco-seeds into the aorta, and other similar
experiments are on record ; and, as might have been
expected, Letulle” claims to have established the infec-
tious origin of the gastric ulcer.
By experimental means, haemorrhagic necrosis, and
later ulceration have been produced in dogs by several
investigators. Ritter" succeeded by poking a dog's
Stomach with a cane, and Decker reports like results after
feeding hot gruel to dogs. Quincke relates experiments
on dogs with gastric fistulae, in which the mucosa
Was injured by pinching, excision, or tying off small por-
* Statistischer Beitrag zur Kenntniss des Chronischen Magenge-
Schwires. Berlin, 1883.
* Berlin Klin. Wochenschr., 1880, XVII., 693.
* Trans. N. Y. Path. Soc., 1877, II., 1. -
* Revue Generale de Clin, et de Pharm., 1888.
* Z'tSchr. f. Klin. Med. Berlin, 1887, XII., 592.
358 NETW YORK STATE MEDICAL ASSOCIATION.
tions, by thermal irritation, and by caustics. . The ani-
mals showed no subsequent distress, and the digestion
was not impaired, but the ulcers disappeared after from
four to twelve days, although the repair was delayed
materially by rendering the dogs anaemic by bleeding.
Von Sohlern' thinks that the vegetable diets, by in-
creasing the proportion of potash salts in the blood, act
against the formation of ulcer, and mentions the infre-
Quency of the disease among vegetarian people. Silber-
man” repeated these experiments with modifications, and
reached the conclusion that ulcer might be caused by
arterial anaemia, venous hyperaemia, portal stasis, cir-
cumscribed haemorrhages, or reduced alkalinity, and sug-
gested that the hyperacidity of the gastric juice might
depend upon the lowered alkalinity of the blood.
Ulcers following blows on the abdomen in dogs" and
men “are reported, and it is well known that the condi-
tion is often seen after severe external burns."
Localised pressure, as a cause, is mentioned by Ras-
mussen," and M. Pettit" has recently described a fatal
case which apparently arose from pressure and rubbing
exercised by a bony protuberance on the inside of the
lower end of the sternum. -
Zielinski, of Warsaw, in a recent paper,” considers, as
a cause of gastric ulcer, the narrowing of the lumen of
the vessels of the stomach from traction made by enter-
Optosis.
Duodenal ulcer not infrequently follows external scalds
and burns,” and occasionally also the stomach is the seat
of like lesions;” and severe injuries of various kinds,
* Am. Jour. Med. Sciences. Philadelphia, April 1, 1889.
* Deutsche Med., Wochenschr. Berlin, 1886, XII., 592.
* Ritter Z’tschr, f. Klin. Med. Berlin, 1887, XII., 497.
* Wittneben. Ulcus ventriculi traumaticum. Hanover, 1886.
* Pitt. Tr. Path. Soc., London, 1886–7, XXXVIII, 140.
* Centralb. f. d. med, W’ssensch. Berlin, 1887, XXV., 162.
7 Le Bul. Med., Paris, September 4, 1892.
* The Satellite, January, 1892.
° (See Holmes' Surgery.)
19 Pitt. Tr. Path. Soc., London, 1886–7, XXXVIII, 140.
THE A.ETIOLOGY OF GASTRIO ULOER. 359
experimentally made upon animals," have been followed
by haemorrhagic necrosis in various parts of the body
and in the stomach, by ulcers.
Precisely how these changes are brought about is not
clear, and it is therefore not surprising that, as Niemeyer
has suggested, the nervous system may be a possible fac-
tor in the process. Indeed, it was with this in mind, that
Ebstein made the experiments just alluded to, which
were a part of a series of investigations undertaken to
show the relation which existed between certain severe
injuries and gastric ulcer. Repeating the well-known
experiments of Schiff, Ebstein reached somewhat different
conclusions; but in the main, both these investigators
agree that certain parts of the central nervous system
(optic thalam. pedunc. cerebri.) are competent to establish
ſulcus ventriculi. Similar results followed a half section
of the spinal marrow, and any great and often repeated
irritation of the sensory nerves led to quite uniform
changes in the gastric mucosa. Talma” was able to pro-
duce ulcer by exciting spasm of the muscular coat of the
stomach through prolonged stimulation of the left vagus.
He suggests that the so commonly present hyperacidity
may thus affect the pneumogastric. Apparently this
throws light upon the mystery of the relation between
external burns and ulcer, and is, at any rate, highly sug-
gestive of a possible nervous cause operating in clinical
Ca,SéS.
Whatever the exciting cause, the lowered alkalinity
of the blood, on the one hand, and the excessive acidity
of the gastric juice, on the other, are generally acknowl-
edged to be active contributing causes. Pavy" teaches
that the normal alkalinity of the blood successfully op-
poses ulcer, by preventing the auto-digestion of the
Stomach. This self-preservation on the part of that
* Ebstein. Arch. f. Exper. Path., Vol. II., p. 183.
le. Nederlandsch. Tijdschrift. voor Geneeskunde. Amsterdam, No. 24,
* Guy's Hospital Report, 1868.
360 MEW YORK STATE MEDICAL ASSOCIATION.
Organ has been shown not to be dependent upon this
condition, however, since Samuelson made the blood neu-
tral, and yet the stomach continued to resist its own
secretions. This fact throws discredit upon the theory
So long and Securely taught by Cohnheim', and we must
now conclude that in such investigations as those of Sil-
berman” the resulting ulcers were from some other change
in the blood besides the mere lowering of its alkalinity.
The views of Ewald” that the blood changes, to be
Operative, must be such as lower the resistance of the
living cell, are more acceptable.
There is apparently a close relation existing between
the lowered alkalinity and the hyperacidity. The
intimacy of the relation, pointed out by Pavy, has been
acknowledged by many. Grime" quotes fifty-three cases
Of ulcer, all of which had hyperacidity, and concludes
that it is due to the preceding chlorosis, and that with
these two conditions present, the slightest injury to the
mucous membrane may form the focus of an ulcer.
Riegel,” and his students, insist that a great excess of
hydrochloric acid is the invariable accompaniment of
gastric ulcer, and while this accords with my own ex-
perience, and undoubtedly is true of the classical ulcer,
there are undoubtedly cases, as shown by Ewald" which
are not only without hyperacidity, but even show hypo-
acidity. The importance of the acidity in delaying the
healing is, as Riegel states," very great, and that it has
a marked influence in establishing the lesion is most
probable; but the fact remains, that the ulcer may exist
and persist without hydrochloric acid, just as it may ap-
pear in those who have not an antecedent anaemia.
In view of the foregoing facts, necessarily stated in-
* Allgemeine Pathologie.
* Deutsche Med. Wochenschr. XII., Jahrgang., p. 497.
* Diseases of the Stomach.
* Lehre vom Ulcers ventriculi rotundum und dessen Bezichungen Zur
Chlorose. Amberg, 1890.
* Zeitcher. f. Klin. Med. Bd. 12, S. 434.
* Diseases of the Stomach, p. 230.
7 Deutsche Med, Wochenschr. Berlin, 1886, XII., 929.
THE A.ETIOLOGY OF GASTRIO ULOER. 361
completely and with brevity, it seems justifiable to Sup-
pose that while ulcerative processes, dependent upon
tuberculosis, syphilis, pyaemia, scurvy, and other Serious
dyscrasias, may proceed in the gastric mucosa, and while
simple anaemia with lowered alkalinity of the blood as-
sists the process, and hyperacidity of the gastric contents
greatly favors the change, there must still be some other,
as yet unknown cause, which, in a certain group of cases,
leads to the local necrosis, besides the accidental changes
from thrombi and emboli, such as have been cited above.
The reasons for this claim are: 1st, that the affection
shows itself particularly in adolescence, or before mid-
dle age, when there is the least probability of vascular
changes; 2d, that it appears most frequently in women,
who are less often subjects of arterial diseases than men ;
and 3d, because the ulcer selects for its site, with re-
markable frequency, the lesser curvature and posterior
wall of the stomach near the pylorus, a portion of the
economy which is not often invaded by emboli, and a
region of the stomach especially rich in anastomosing
vessels.
In a large number of cases, Buchmüller' found over
93 per cent. at the posterior wall near the lesser curva-
ture, and no certain cases under fifteen years of age. In
the Berlin statistics not one case was found under the
tenth year, and the greatest number between the twen-
tieth and thirtieth years. It is occasionally congenital,”
and one altogether exceptional case was found in a man
Said to be one hundred and twenty years old.” Greiss'
found from three to five times as many scars in women
as in men, and over 90 per cent. appeared on the pos-
* Pathol. Anatomie des Ulcus ventriculi et duodeni. Würzburg, 1889.
* Goodhart. Trans. Path. Soc., London, 1880–81, XXXII., 79.
Also Hecker, Monatsschr, f. Geburtskunde, VII.
Also Steinman, Einige Fälle von Magengeschwilr im Jugendlichen
Alter. Kiel, 1890.
* Eppinger, quoted by Welch, Pepper's System, Vol. II., p. 489.
* Greiss. Statistik, des runden Magengeschwilrs. Kiel, 1891.
362 JWH}W YORK STATE MEDICAL ASSOOIATION.
terior wall near the lesser curvature; and although many
of these appeared in middle, and a few in advanced life,
the beginning of the trouble was doubtless in earlier life,
as Leube has pointed out."
Statistics abound in similar statements, as may be
learned by consulting Welch’s splendid monograph in
Pepper’s System of Medicine.
From the foregoing facts, namely—the propensity
shown by the affection to select a certain site in females,
and to appear in early life—it has naturally led to the
Suggestion that this form of ulcer may take its origin in
Some unknown but definite neuropathic change, trophic,
VaSO-motor, or both. It has seemed to me remarkable
that this view has not gained more adherents, since by no
other evident hypothesis can these points in its natural
history be explained.
In reflection on the matter, it has occurred to me that
Somewhat analogous processes are to be witnessed in
other parts of the body, and that by using these as illus-
trations, some insight into the pathology of round ulcer
may be gained. For instance, the well-known proclivity
Of herpetic eruptions to attack particular points, under
especial conditions, is brought forward; and attention is
called to this common disease, which, depending upon
nerve abnormality, is found not only upon the skin, but
upon the mucous membrane of various parts, including
the mouth and throat, with a view to asking whether it
might not select for its appearance the pyloric end of the
stomach, and thus lead to ulcer.
Again, there is something most suggestive in that ex-
traordinary disease known as idiopathic haematoma
auris, which is seen not infrequently in the insane :
which invariably appears in the concha, rapidly reaches
maturity, and disappears only after destruction of tissue
and marked cicatricial deformity. It is interesting to
note that the affection has been seen occasionally in those
* Ziemssen’s Cyclop., Wol. VIII., p. 203.
THE ALETIOLOGY OF GASTRIO ULOER. 363
having no mental disease, or other known disability."
In a recent paper on this subject, Dr. H. G. Matzingar re-
fers to the complex nerve Supply of the ear, with especial
reference to the sympathetics, and concludes that othe-
matoma is a neuropathic affection, seen generally, but
not invariably, in those suffering from central nerve dis-
ease, in which the sympathetic system is seriously in-
volved. Why might not some similar process have for
its local expression the posterior wall or lesser curvature
of the stomach near the pylorus, than which no part of
the economy has a more complicated and involved in-
nervation ?
One is led also to think of the striking manifestations
in that curious affection, Raynaud's disease, with its
predilection for the fingers and toes; with its advancing
steps of Syncope, asphyxia, and necrosis of the parts.
It is not impossible that asphyxia of certain spots of the
gastric mucosa may occur from analogous causes, what-
ever they may be, and the tissue thus put to a disadvan-
tage, Would be well calculated to suffer erosion from the
active gastric juice.
If Morvan’s disease is not found to be a phase of syrin-
go-myelia, it also might be advanced as an instance of
local necrosis, something like that which may appear in
the stomach. - -
A few years ago I saw at the clinic of my colleague,
Prof. Roswell Park, a case of intense interest—a neurotic
girl, who had a series of painful and persistent ulcers
along the forearm and leg, following the tracts of certain
nerves. The parts bordering the ulcers were uninvolved,
and in every way healthy; the ulcers themselves suc-
ceeded the appearance of limited gangrenous spots; they
Yère deep, with abrupt walls, and were exquisitely sensi-
tive. They had for years resisted treatment by very
able men. Those on the arm were permanently cured by
Dr. Park, by a thorough stretching of the external cuta-
* Dr. Sparling. Med. Record, November 9, 1891.
364 NEW YORK STATE MEDICAL ASSOOIATION.
neous nerve. There was something about the appear-
ance of these ulcers which reminded one of the typi-
cal round ulcer of Cruveilhier, and it does not seem to
me absurd to suppose for the latter a somewhat similar
Origin.
Now, in concluding this view of the subject, it appears
natural to assume that the stomach, like other parts, may
suffer loss of substance from a variety of causes, but as
regards simple round ulcer, it must have a more precise
and definite aetiology.
Unquestionably, the impoverished condition of the
blood, leading to lowered resistance of “the living cells,”
and the persistent presence of hyperchlorhydria, must of
necessity put the tissues to severe strain ; but there is
wanted yet another factor. The object of this paper is to
suggest that, by the influence of Some process analogous
to herpes, or to idiopathic haematoma auris, or to Ray-
naud’s disease, or to herpetic gangrene,—some distinct
and persevering nerve perturbation, we may best explain
the recognised, but unaccounted for feature of the clin-
ical history as to location, age, and sex.
DISCUSSION.
DR. ZERA LUSK, of Wyoming county, said that in the early years of
his practice, a gentleman came to him complaining of a burning Sensation
in the epigastrium, and of indigestion. A diagnosis was made of gastric
ulcer. About two years later he was accidentally struck in the stomach
by the handle of a plow, and from the violent symptoms then present, a
diagnosis was made of rupture of the stomach. The man died, and owing
to certain domestic troubles it was deemed best to have an inquest, and a
coroner's jury was impaneled. An autopsy was made, and it was found
that the contents of the stomach had escaped into the abdominal cavity,
and examination of the stomach showed two round ulcers about one inch
apart—one nearly through the walls, probably as a result of the blow from
the plow, and the other a complete rupture, large enough to admit the
finger.
THE EXAMINATION AND COMMITMENT OF THE
PUBLIC INSANE IN NEW YORK CITY.
By MATTHEw D. FIELD, M.D., of New York County.
November 17, 1892.
As it has been suggested that the method of examina-
tion and commitment of the public insane in the city of
New York would be of interest, I have been induced to
write this paper.
After the passage of the law of 1874, Chap. 446," the
Commissioners of Public Charities and Correction of
New York City appointed special examiners in lunacy,
* $ 1. No person shall be committed to or confined as a patient in any
asylum, public or private, or in any institution, home or retreat for the
Care and treatment of the insane, except upon the certificate of two phy-
Sicians, under oath, setting forth the insanity of such person. But no per-
Son shall be held in confinement in any such asylum for more than five
days, unless within that time such certificate be approved by a judge or
justice of a court of record of the county or district in which the alleged
lunatic resides, and said judge or justice may institute inquiry and take
proofs as to any alleged lunacy before approving or disapproving of such
Certificate, and said judge or justice may, in his discretion, call a jury in
each case to determine the question of lunacy.
§ 2. It shall not be lawful for any physician to certify to the insanity of
any person for the purpose of securing his commitment to an asylum, un,
less said physician be of reputable character, a graduate of some incorpo-
rated medical college, a permanent resident of the State, and shall have
been in the actual practice of his profession for at least three years. And
Such qualifications shall be certified to by a judge of any court of record.
No certificate of insanity shall be made except after a personal examination
of the party alleged to be insane, and according to forms prescribed by the
State Commissioner in Lunacy (State Commission in Lunacy), and every
such certificate shall bear date of not more than ten days prior to such
Commitment.
$8. It shall not be lawful for any physician to certify to the insanity of
*Y Person for the purpose of committing him to an asylum of which the
Said physician is either the Superintendent, proprietor, an officer, or a reg-
ular professional attendant therein.
366 NEW YORK STATE MEDIOAL ASSOCIATION.
whose duty it should be to examine all cases who
should come under the care of the department, and, in
proper cases, make certificates of lunacy, and present the
same for approval before a judge of a court of record, as
required by the law, when the adjudged lunatics were sent
with such certificates to the asylums of the department.
This method has continued in vogue till the present day,
except that formerly the chief examiner held the posi-
tion of City Physician, and had charge likewise of the
city prison.
Such was the condition of affairs when I was appointed
examiner in lunacy for the department of Public Char-
ities and Correction, in November, 1882, my senior being
Dr. William L. Hardy, the prison physician. Within the
year, Dr. Hardy was relieved of all duties in the depart-
ment save those of examiner in lunacy, and Our func-
tions became, and have continued, independent. Upon
the death of Dr. Hardy in April, 1886, my present asso-
ciate, Dr. Allen Fitch, was appointed.
In the earlier days there was no special place for the
reception of the alleged lunatic, and he was examined
wherever he might be, in prison or hospital. Then all
the suspected insane were sent to Bellevue Hospital and
placed in “the cells.” These were two wards in the
basement of the building, one for males and the other
for females. In these wards were received not only the
supposed lunatics, but all alcoholics, violently delirious,
and refractory patients in the hospital, and frequently
criminal patients were sent there too for safe keeping.
I remember very well visiting “the cells” when an
interne of the hospital, at the time when all classes were
received. I was called as a surgeon, to see a wretched
woman who had received a fracture of the arm in a
drunken brawl, and who had been committed there as an
alcoholic. It was at night, and the light was dim, and a
little child scarcely more than three years of age was
clinging to the skirts of its mother, who was sodden with
liquor. As I examined the arm of the drunken mother,
EXAMINATION AND COMMITMENT OF INSANE 367
the beautiful, innocent, pleading face looked up to me for
mercy for her mother, and I could not but be gentle with
her for the child’s sake. I thought if the mother would
only look upon the child with but a tenth part of that
humanity and sympathy with which the child looked up
to me, what a different aspect the case would assume.
While this was taking place I could hear on all sides
the shrieks of fear from those in the delirium of alcohol,
and these cries continually excited the lunatic.
Long before this time the Commissioners of Public
Charities and Correction had recognised the necessity of
separating the insane from the alcoholic, and their per-
sistent application had obtained an appropriation for the
erection of a separate pavilion for the reception of the
supposed insane. .
The year 1879 saw the completion of the present recep-
tion pavilion for the insane at Bellevue Hospital. This
pavilion, erected on the grounds of the hospital, is a one-
story brick building, divided by iron doors into two
wards, one for males and one for females. Each side has
a corridor, lighted and ventilated from above, and con-
tains eight rooms for patients, besides an examination
room and a kitchen. The former contains record and
history books and a medicine and instrument chest ; in
the latter not only is the food received from the general
kitchen of the hospital, but special diet is prepared, as
the resident physician may direct; and here also the
Carving is done, and all dangerous knives are kept. One
room is set apart as a linen closet, where the bedding and
necessary clothing for the patients are kept. There is
also a lavatory, bath-room, and closets, separated from
the Ward by a passage which is ventilated and lighted by
Windows on either side, as well as by windows on either
side of the closets. The only criticism which can be
made concerning the pavilion is, that it might contain
more sleeping-rooms, and patients might be retained
longer under observation without overcrowding. The
Cells were, and still are, under the care of the house staff,
368 NEW YORK STATE MEDIOAL ASSOOIATION.
the medical staff dividing the service in looking after the
cells. When the pavilion was first established it was
placed under the same care, the house physician having
the supervision of the cells also having the care of the
insane admitted to the pavilion. The examiners passed
on the mental condition, and the propriety of commit-
ment or discharge, while the treatment of the patient in
the pavilion rested with the house physician, who had
no special training in the care of the insane, and who had
already sufficient work to care for the patients in his
regular service, where his interest and heart really were.
The oversight of the alcoholic and insane was an extra
and entirely secondary duty of a busy physician.
Soon after my appointment in November, 1882, Dr.
Henry W. Wildman, who had had several years' experi-
ence as assistant physician at the asylum on Ward's
Island, was appointed permanent resident physician at
I3ellevue Hospital, in charge of the pavilion for the in-
S&I16).
Dr. Wildman resigned in October, 1887, and was suc-
ceeded by Dr. Stuart Douglas, who had been assistant
physician at the City Asylum for over six years. Dr.
Douglas is still the resident physician.
In 1885 the general oversight of the pavilion was placed
under the charge of Dr. A. E. MacDonald, the general
superintendent of the New York City asylums.
You may now ask, whence come the patients? The
majority of those received at the pavilion are committed
to the care of the Commissioners of Public Charities and
Correction by the police justices, for examination as
to their sanity. The usual term for such commitment is
five days—why five days, nobody seems to know, except
that such has been the custom, and that length of time
is usually sufficient for the purpose.
The police justices commit for examination regarding
Sanity, such persons as manifest evidences of insanity,
VIZ. .
1st. Those persons who are arrested for petty offenses,
EXAMINATION AND COMMITMENT OF INSANE 369
the nature and manner of the occurrence indicating
an unbalanced mind ; 2d, those persons who interrupt
public meetings, or divine service, or who preach or orate
in public places, their conduct appearing to be irrational;
3d, persons making complaint before police justices, at
police stations, or other courts, to the District Attorney
or other public officials, of wrongs and persecutions, Or
of claims which appear to be imaginary ; 4th, where
citizens complain of persons who annoy them upon what
seem to be irrational pretenses ; 5th, persons who may
be found by the police wandering about the streets in
an aimless or purposeless manner, or acting in a strange
manner, or who are unable to give a rational account of
themselves ; 7th, those who have attempted suicide ;
and 8th, those persons who are brought before a public
magistrate, where the charge or testimony would warrant
the suggestion that the individual might be insane and
irresponsible.
It is not infrequent for police justices to commit per-
Sons for examination and to indorse across such commit-
ment—“To be returned to court if found not insane.” In
fact, police justices endeavor to be just, and to commit
no person for lesser crimes, when evidence is produced to
indicate insanity and irresponsibility, until the question
of Sanity has been passed upon by the city examiners.
In cases of grave crime they commit for trial, leaving the
Court of higher jurisdiction to determine the question of
Sanity and responsibility.
The Superintendent of the Poor, acting for the Com-
missioners, in cases which are made public charges, and
Where evidence is furnished that such person is insane
and requires care and treatment as an insane person,
gives permits for admission to the pavilion for examina-
tion. The examining physician for the department,
where admission is sought to some hospital, and where
his examination leads him to suspect insanity, gives per-
ºits for admission to the pavilion, for special examina-
tion regarding the applicant's sanity and fitness for
24
370 NEW YORK STATE MEDICAL ASSOCIATION.
admission to the city asylums, or other institutions of the
department. A certain number of patients are brought
by ambulance from residences, where the statement of
friends or conduct of the patient leads the ambulance
Surgeon to conclude that the patient is insane. Some are
Sent directly from police stations, without a commitment
from a police justice. These are usually excited, vio-
lent, or so sick that the police feel they are not justified
in retaining the individual at the police station for the
time required to obtain the formal commitment.
A few cases are admitted by the resident physician,
where patients are brought by friends with letters from
the family physician, or where the patient comes volun-
tarily, or consents to temporary restraint. Where the
patient is violent, dangerous, or very sick, the resident
physician feels justified in admitting to the pavilion
without the formality of a commitment by a magistrate ;
in other cases, it is his habit to recommend an application
to some police justice for formal commitment.
Patients are transferred from the regular wards of
Bellevue Hospital and from the alcoholic ward, but only
after the examination and approval of the resident physi-
cian of the pavilion, who indorses the card with his sig-
nature before the transfer is made. Patients are received
from other hospitals and institutions when brought to
Bellevue by ambulance. -
I have gone into this subject of admission to show the
precautions which are taken to prevent the temporary de-
tention of any improper case in the examining pavilion.
When cases of insanity develop at other hospitals or
institutions in the care of the Department of Public
Charities and Correction, by order of the general Super-
intendent it is the duty of the resident physician of such
institution or hospital to report the same to the exam-
iners in lunacy in writing, together with a history of the
case, and a statement that in his opinion the patient is
in such physical condition as to justify his or her trans-
fer to the asylum. The examiners are directed to visit
ExAMINATION AND COMMITMENT OF INSANE 371
such patients at the various institutions where they may
be, and pass judgment on the question of sanity and the
propriety of commitment to some of the city asylums.
The examiners prefer to make their visits separately,
and to arrive at independent conclusions, though they
have subsequently to unite in a dual certificate. Under
the present dual certificate we are in the habit of dividing
the work, and while one examiner makes out the cer-
tificates for the males, the other does so for the females;
we alternate each month.
The first examiner, after the completion of his exami-
nation, makes out, if he considers the patient insane, a
certificate, and makes oath to it before a notary public,
leaving the certificate in the notary’s charge. The second
examiner, if of the same opinion, signs the certificate
prepared by the first examiner, with such additions as
his examination may lead him to make ; then makes Oath
before the same notary, who acknowledges the certificate,
and in this form it is presented to the judge for ap-
proval. Should the two examiners disagree, as some-
times occurs, the case is referred to the resident physi-
cian, whose opinion decides the disposition of the case.
Discretion is exercised by the examiners, and by the
resident physician, in regard to the discharge of patients
to the care of friends and relatives. If the friends show a
disposition and ability to care for the patients, they are
usually discharged to their care, if they sign a contract
agreeing to properly provide for them. If the patient be
decidedly dangerous to himself and others we usually
insist that arrangements be made with some institution
for his proper care and treatment. All that is required
is a reasonable assurance that both the patient and the
Community will be properly guarded.
When once the patient is lodged in some institution
the examiners consider their responsibility ended. Of
Course, improper commitment or discharge would be still
ghargeable to them; beyond that, they could hardly be
held responsible. The examiners stand between the
372 NETW YORK STATE MEDICAL ASSOCIATION.
patient and the community; they must guard the welfare
of the patient, consider his right to enjoy liberty and the
pursuit of happiness, and at the same time, they must
guard and protect the community. -
A patient should be committed to an institution for the
insane for the following reasons:
1st. As the best means to insure recovery. Wealthy
patients may be as well or better treated at home, where
the home can be constituted an asylum for a single pa-
tient. In most of these cases, the only advantage gained
is the avoidance of the name asylum, and the benefits
accruing from the order and discipline of such an insti-
tution outweigh in very many cases all the advantages
of home treatment. In public cases, this mode of treat-
ment is usually out of the question.
2d. For the patients’ safety and well-being, they
must be protected against themselves and their own acts.
They must be guarded from suicide, self-mutilation, and
acts which result from a failure to appreciate their sur-
roundings—e.g., playing with fire, turning on gas, inter-
fering with poisonous or dangerous substances, expos-
ing themselves to heat and cold, walking into dangerous
places, and incurring the thousand-and-one risks which
demented persons are ever apt to do.
Very many, being unable to support themselves, suf-
fer, when at large, from lack of food, clothing, and shelter,
and are constantly being brought to the pavilion in the
most wretched condition. These patients are usually
fairly well off under supervision, and conduct themselves
well in asylums. Many have to be protected from ex-
travagance and waste of property, the result of delusion
Or lack of appreciation.
3d. For the protection of the community. The public
demands protection from acts of violence, and from the
dangers arising from the purposeless acts of the insane,
which threaten the public as well as themselves. Ladies
have a right to walk the streets without being accosted,
annoyed or frightened by lunatics, who fancy the ladies
EXAMINATION AND COMMITMENT OF INSANE. 373
are in love with them ; and the husband should be per-
mitted to enjoy his home without interruption and threats
from an insane person who imagines the wife is in love
with him, and that the husband has cheated him of his
rights. The lunatics who believe themselves kings,
queens, presidents, and heirs to thrones and property
are always dangerous, as well as those who have de-
lusions of persecution. Those who have hallucinations,
especially of hearing, are dangerous, for they are influ-
enced by their hallucinations. The voices which direct
the lunatic may never make him dangerous to the Com-
munity, but who can tell what the next communication
may be God may tell an Abraham to slay his son, and
never stay his hand. Simple Simon has wandered through
the streets for a generation, and is being jeered at by the
boys, as their fathers did before them ; but to-day he
turns, and with club or stone dashes out the brains of
Some innocent boy. It is now generally acknowleged to
be the duty of the community to care for the insane who
have not friends with means or the disposition to do so.
Public and newspaper criticism are largely due to igno-
rance, and a tendency to jump at conclusions without
fully inquiring into the method and care exercised, not
Only in the examination and commitment of the insane,
but their treatment in public institutions.
I believe that the citizens of New York City can take
pride in the methods employed in the examination and
Commitment of public insane, and the provision for the
Care of patients during such examination. The recep-
tion pavilion is in every respect a hospital, with a resi-
dent physician, and competent and trained attendants.
Unnecessary detention at police stations and prisons, and
the mingling of the insane with the criminal class, is
avoided. All patients transferred from the pavilion to
the asylum are accompanied by attendants of their own
Sex, Who remain with them until they are turned over to
the care of the asylum authorities. Opportunity is af.
forded in very many cases to obtain a history of the
374 NEW YORK STATE MED TOAD ASSOCIATION.
patient, and to consult with friends and allow them the
privilege of providing for the patients in other institu-
tions, if they have the means and disposition to do so.
The Superintendent of the Poor, Mr. William Blake,
visits the pavilion daily, and institutes investigation to
ascertain if the patients are proper public charges, and if
they be properly charged to New York county.
The following table will show the number of patients
received during the past four years, and their disposi-
tion : -
# 4 || ##| || 5 || ||
} { ; F : gº 2. ; F = p3 Q
SEX, É ##3 || 4 || ### à É
à || 3: ". . ; ; 35 # . ſº
3 || 3 || || 3: | # 3 | #
§ - || 35 | P: *
Male | 997 || 650 | 87 || 135 | 109 8
* |Female | 854 || 616 || 36 | 104 87 11
Male | 1,075 641 || 139 87 | 198 16
* |Female | "s43 | 625 46 63 93 12
Male | 1,066 || 658 || 71 | 193 135 12
* |Female | "sg0 | 601 || 37 70 103 14
Male | 1,138 || 724 56 187 || 144 16
* | Female | 866 | 671 23 54 100 17
TOTAL. 7,669 5,186 495 893 969 106
Total commitments - sº s gº 74.09 per cent.
& & & 4 to city asylums - - 67.62 “ “
6 & & 4 Other ( & tº- tº 6.47 “ “
{ { & © transferred to other institutions, 11.64 “ “
£ g ( & discharged - & - 12.63 ‘‘ ‘‘
( & & & died - tº * 1.38 ‘‘ ‘‘
The percentage of discharges, when I was first made
examiner, was over thirty-three per cent, but owing to the
greater care exercised in the admission of improper cases
to the pavilion, this percentage has gradually diminished
So that although the number of admissions has de-
creased but slightly, the number of improper admissions
has lessened very much. This is due very largely to the
EXAMINATION AND COMMITMENT OF INSANE. 375
oversight of a competent resident physician with in-
creased power.
In conclusion, I would state that every precaution is
exercised to prevent improper admissions to the recep-
tion pavilion, and that the examiners try to obtain his-
tories from friends of all patients, as to previous condi-
tion and conduct, and use this as independent evidence
in determining the true mental condition of individuals
who are presented to them for examination. We cannot
but take pride in the fact that very seldom is a case reg-
istered at the asylum as “not insane” (I believe but
three times in ten years), and never to my knowledge has
a discharged patient committed any outrage against the
community in that time. The nearest approach to this
was, when a mother was discharged to the care of a
daughter, and six weeks later both committed suicide.
In One other case, a man was sent to the alms-house, and
Some weeks later got into the river and was drowned.
Whether this was a suicide, or the act of a demented
person, is still a question. A large number of alms-
house inmates are mildly demented, and are acknowl-
edged to be so. These are the only evidences known to
the Writer, of misjudgment in the past ten years.
A female reporter was once sent to the asylum, and
much newspaper comment thereby aroused, so that the
examiners cannot now appear in court without the ques-
tion being asked them—“You once pronounced a sane
person insane, did you not ?” We are fallible. When
We are called upon to examine a criminal where there is
known to be a reason for simulating insanity, we are
naturally suspicious, and view the case in that light; but
Why should we look upon every admission to the pavilion
With suspicion and consider every person an impostor
The individual person referred to was duly committed by
a police justice for examination, and the matron of a
Home came and gave a history of irrational conduct on
the part of the patient, and alleged the existence of suffi-
°lent delusions to induce her to make the charge of
376 NEW YORK STATE MEDICAL ASSOCIATION. .
insanity before the committing magistrate. That person's
conduct was irrational while in the pavilion, as it was
before the examiners; she expressed inability to appre-
ciate her surroundings, and would give no account of
herself, and acted an inability to do so. There was no
more reason to disbelieve her conduct and answers than
that of any other patient. From her assumed conduct
she could not be cast upon the street, and no name could
be obtained of any friend, to whom she could be turned
over, or who could give any history of her. She was
simply a demented person to be cared for until friends
should appear, or until she should recover from her
apparent demented condition.
The examiners of lunacy in New York City are called
upon to pass judgment upon about two thousand cases
each year. This number embraces individuals from every
land under the sun. I have not unfrequently visited the
pavilion and found ten patients on a side, not a single
one of whom was able to speak the English language,
and for some of these it was impossible to find any inter-
preter. I can remember once one of the Commissioners
of the department tapped me on the shoulder, and point-
ing to a Chinaman, said: “Don’t send him to the asy-
lum, for no one will be able to say when he has cleared
up.” It must be borne in mind that most patients com-
mitted to the pavilion grasp the nature of the place, and
are at once on the defensive, and deny their delusions.
Even demented patients seem to grasp the situation, and
those who speak but little English at once deny their
ability to speak any but their native language.
We work under such disadvantages, yet we strive to
be just, not only to the patient, but to the community.
DISCUSSION.
THE PRESIDENT asked if the author thought the matron of the
Home had intentionally deceived him in the case of Nelly Bly.
DR. FIELD replied in the negative, and said she was honest, but
was herself deceived.
DISCUSSIOW. 377
THE PRESIDENT said he had a practical knowledge of the class with
which the author, as examiner in lunacy, had to contend. Some of the in-
dividuals committed to the State Hospital for the Insane, in Buffalo,
are unable to speak English, and no one can be found, in many cases, who
is able to interpret for them. To add to the difficulties of the situation,
their actions, even when sane, are often very different from what we are ac-
customed to observe in others. For instance, a Polish woman may assume
a sitting posture on the floor, cover herself with her dress, and show
an utter indifference to the usual proprieties of her sex ; and this may
continue for days and months together. Under such circumstances, it is
quite difficult to say when these people get better, if they have been
insane, and oftentimes it is only by diligently questioning their friends
that one is enabled to obtain a history of their true condition. The statis-
tics presented by Dr. Field, showing such few errors in their commitments,
are worthy of the highest commendation, for they evince a skill in diagno-
sis, far superior to ordinary practice in the diagnosis of disease. The
methods employed in New York City for the care of the insane are a cause
for congratulation, for they evidence a high state of public feeling in
regard to the interests of all concerned.
DR. FIELD said that the chief object in writing his paper was to advo-
cate the establishment of such reception pavilions in other places; for
so far as he knew, no other city in the United States had such a pavilion.
It is not a difficult matter for any large city to have a pavilion of this kind
connected with some hospital, thus taking these poor unfortunates away
from the surroundings of station-houses and like places. The reception
pavilion is also of material assistance to the examiners, as during the inter-
vals of their visits, the conduct of the patients is carefully observed by
skilled attendants.
THE PRESIDENT remarked that the Commission in Lunacy rarely visited
Buffalo without bringing up this question of the erection of a pavilion for
the insane, and the question of the erection of such a reception pavilion in
every county seat had also received consideration.
DR. L. J. BROOKS, of Chenango county, asked what proportion of
the diagnoses, made by physicians in the various counties who were not
experts, were found to be wrong after the arrival of the patients at the
asylum.
THE PRESIDENT replied that there were two common sources of error,
Viz.: first, certain alcoholic cases, who were seen while under the influence
of liquor; and secondly, cases of the morphia habit, in which there seemed
to be an actual necessity for commitment and restraint, for their own
good, but where, after awhile, they cannot be pronounced absolutely
insane. The first error can be avoided in many cases by keeping the
patient at home for several days under proper supervision. At the asylum,
only one or two each year are generally reported as “not insane,” and most
of these occur in criminal cases, frequently after an investigation by the
Court ; Sometimes after a report from the jury. In the present reports to
378 NEW YORK STATE MEDICAL ASSOCIATION.
the Commission in Lunacy, the asylum authorities are oblige to state the
number of cases “not insane,” the number of the victims of the morphia
habit, and the number of inebriates. The two cases reported last year as,
“not insane,” had been sent from the jail after a judicial decision as to
their insanity. The ordinary physician rarely makes a blunder in certi-
fying to cases of lunacy, and the speaker said his sole reason for referring
in his address to the diagnoses made by the general practitioner, was to
raise, if possible, the standard still higher, and to secure a more intelligent.
preparation of papers of commitment.
DR. F. W. Ross, of Chemung county, said that there was less reason.
for general practitioners making such mistakes, than the regular examiners
in lunacy, as the former were usually appointed, in these cases, by the
court, to make an examination, and usually obtained a correct history ;
while the examiners in lunacy commonly know nothing previously about
the case, and those brought to them for examination represent all nationali-
ties and languages.
DR. J. C. HANNAN, of Rensselaer county, said that in his neighborhood
there was a woman who had a drunken husband. When this man would
return from his debauches, he would abuse his wife, and he finally
threatened to send her to an insane asylum. This went on for a year
or two, when the husband employed two local physicians to examine
his wife, and these men pronounced her insane, a commitment was made.
out, and she was sent to a very well-known institution in the State. She
remained there six or seven months. Her sister came to the speaker and
asked him if he had any influence with the physicians of this institution, as
her sister was not in the least insane, and was constantly writing to her to:
try and get her out. After six or seven months, she was discharged as
Sane. In view of these facts, he would like to know why this woman was
detained, if she were not insane when admitted to the institution. Since her
discharge from there, she had nursed a patient for him, and she appeared
both physically and mentally in a normal condition.
THE PRESIDENT replied that the fact of her being discharged as same was
prima facie evidence that she was insane when admitted. Again, there
might have been much more in her history than was known to the
speaker, but which the physicians in the institution had learned subse-
quent to her admission.
MITRAL STENOSIS IN PREGINANCY.
By ZERA. J. LUSK, M.D., of Wyoming County.
November 17, 1892.
The question of matrimony among women having un-
mistakable organic disease of the heart, can admit of but
one answer, and that, emphatically in the negative.
Rarely is a physician’s consent or advice sought by the
contracting parties, for the very reason, in the first place,
that nearly always the disease is unsuspected, as there
are no rational signs denoting a perverted state of health;
and Secondly, if there were, the young Juliet would
prefer taking the chances of married life, rather than the
Opprobrium of ultimately evolving into that state which
bears the euphonius title of “old maid.”
Under the subject of cardiopathia and pregnancy, Dr.
Parvin' quotes Jaccoad as asking the question : “Has
the patient suffered from the cardiac lesion ?” If she
has never suffered, he sees no reason to forbid marriage,
but adds: “Her social condition must be considered.
If she has to work during pregnancy, then much is to be
feared ; but if she can be properly cared for, follow
medical advice, and pass the last half of her pregnancy
in almost absolute rest, she may marry.” Jaccoad
further relates a case in his private practice, where a
young lady had for eighteen months ardently desired
to marry, and that, had a negative answer been given,
mortal Syncope might have followed.
The fallacy of such an argument is too apparent. The
chances of mortal syncope following a refusal to permit
marriage, would be more favorable than syncope attend-
* “Annual of the Universal Med. Sciences.”
380 NEW YORK STATE MEDICAL ASSOCIATION.
ing the cardiopathic in the pregnant state. The aug-
mented duties of the married woman, the painful con-
Sequences following pregnancy and maternity, and the
alarming infant mortality, should be sufficient to dis-
Suade the most sanguine, and to clear all doubts about
entering the married state. It would be a great error to
assume that a woman could safely marry, if not suffering
at the time from the valvular disease. If stenosis of the
mitral valve be present, serious trouble will certainly
develop as soon as the heart is called upon to perform
the increased work incident to the last months of preg-
nancy. The demands upon the maternal system begin
about the six month, and subsequent to this time, great
changes continually occur. The enormous development
Of the gravid uterus with its intricate vascular apparatus,
as well as the growing foetus, call for an increased
amount of blood, the normal constituents of which are
undergoing change, the solids being proportionately
diminished. While there is an augmented supply of
blood, “the frequency of the pulsation of the heart re-
mains unchanged. For this alternate contingency, dila-
tation of the cavities becomes a necessity, and for the
same reason, arterial tension is increased.’” It is
evident that the heretofore weakened heart must begin
to show evidence of overwork.
Mitral stenosis is essentially a disease of women and
children, and the majority of cases owe their origin to
the rheumatic diathesis. It is sometimes dependent on
a form of chorea resulting from neurotrophic disturb-
ances. Loomis” asserts that such cases are confined to
children, and recover after a few years. Duroziez” dis-
Courages the theory that mitral stenosis, pure and simple,
is of rheumatic origin, and records eight cases occurring
in children, but adds: “They were subject to rheumatic
attacks later in life.”
* Lusk's Treatise on Midwifery, page 98.
* Pepper's System of Medicine, Wol. III., page 666.
"Annual of the Universal Medical Sciences, Vol. I., 1888, page 192.
MITRAL STENOSIS IN PREGINAWOY. 381
The object of this paper is not so much to discuss the
aetiology of mitral stenosis, as to consider the manage-
ment of such cases in actual practice. They are almost
always emergency cases, desperate in character, and
demanding the best energy and most prudent manage-
ment from the physician. Fortunately they are of rare
occurrence. In the last eighteen years I have had up-
wards of twelve hundred cases of labor, and out of this
number only two of mitral stenosis. There has been the
usual number of those who gravely assert that they have
heart disease and cannot take anaesthetics; also of those
whose physicians have accepted their statements with-
out making careful physical exploration, yet in whom a
careful examination fails to discover the physical signs
of cardiac disease. Sir Andrew Clark' describes six
hundred and eighty-four cases of valvular disease occur-
ring in his private practice, in the year 1887, and says
“that in a large majority of these cases the disease was
unsuspected.”
The symptoms of mitral stenosis are few, They are
described by Loomis as “mainly characterised by a loud
churning, grinding, or blubbering presystolic murmur.
It is of longer duration than any other cardiac murmur,
On account of the time required for the blood to pass
through the narrowed and obstructed orifice. It ends
With the commencement of the first sound. The apex
beat being synchronous with the purring thrill, the mur-
mur is heard with its maximum intensity a little above
the apex beat.”
CASE I. On May 5, 1890, I was called to see Mrs. R-, a primipara,
thirty-one years of age, well developed, and weighing about one hundred
and thirty-five pounds. Her environment was all that could be wished. I
Was informed by her husband that she was seven and a half months ad-
Vanced in pregnancy, and that she had been unusually well until about a
*onth before, when she began to have more or less nausea, and to suffer
from obstinate Constipation. I learned that her brother, who was a grad-
uate of the University Medical College of New York, but not at present
*&^ged in the practice of medicine, had occasionally seen and advised her.
* Ibid, page 667.
382 NEW YORK STATE MEDICAL ASSOCIATION.
Indeed, up to this time no other medical aid had been sought. I found her
sitting up ; her face was pale, and there was almost constant retching, with
occasional vomiting of whitish mucus tinged with bile. The stomach re-
jected everything taken, even water; her pulse was rapid and weak; res-
pirations hurried, tongue moist, and covered with brown fur ; breath
Offensive ; bowels had not moved for several days. She also complained
of sleeplessness. I advised an enema of warm Soap and water, a sinapism
over the epigastrium, and cracked ice as required. I also gave her, every
fifteen minutes, one teaspoonful from a mixture consisting of fifteen drops
of the fluid extract of ipecac to one-half glass of water. In my experience
this has often relieved the distressing nausea of pregnancy when other
remedies have failed. To the question whether she had any heart disease,
she gave a negative answer, and said if her bowels could only be relieved
she would be all right. I also left a powder of sulfonal to procure sleep.
On the following day her husband informed me that the enema had given a
negative result, but that the nausea had been relieved and she had rested
better, and was more cheerful. I was requested to consult with her
brother, Dr. Gouinlock, whose idea of the case was that “she has been
wearing very tight-fitting corsets, and is now paying the penalty.” As he
considered her symptoms due to pressure of the gravid uterus on the other
organs, he could suggest nothing to relieve her condition. I advised com-
pound cathartic pills to move the bowels, and a dessert-spoonful every two
hours of a mixture of one teaspoonful of bi-tartrate of potash in a glass of
water. I did not see her at this time, and not again until Friday evening,
the 8th, when I was hastily summoned. She was in bed; countenance
pale and pinched; pulse 130, rapid and weak; respirations, 38; constant
retching, marked dyspnoea, no oedema of the extremities. I advised a
hypodermic injection of one-fourth of a grain of morphia and one one-hun-
dred-and-fiftieth of a grain of atropia; but Dr. Gouinlock informed me
that the family were very susceptible to morphia, and objected to giving
more than one-tenth of a grain. I considered that her condition of extreme
prostration required more heroic treatment, and advised the doctor to re-
peat the dose until complete quiet was secured. No examination of the
heart was made at this time; patient was very restless, tossing about in
bed. Urine showed no trace of albumen. Dr. G. was left in charge during
the night. I was hastily called again about one A. M. because Mrs. K–
had “a sinking spell.” On my arrival I found her in extreme collapse; no
pulse at the Wrist, respirations slow and intermittent. I learned that she
had continued to be restless up to a few moments before the attack, and
that suddenly the body became rigid, and she had a general tonic spasm.
The heart was now beating tumultuously, and nothing but a churning
sound could be heard. At this juncture Dr. M. D. Mann, of Buffalo, N.
Y., was summoned by special train, and arrived in about two hours. In
the meantime I had administered chloroform with the result that the color
had gradually returned to the face, the heart action had become more
steady; the pulse appeared at wrist, and when spoken to the patient moved
her eyes. On examination of the heart, there was a loud presystolic mur-
MITRAL STENOSIS IN PREG WA. WCY. 383
mur, with an occasional clacking Sound ; on palpation, a distinct “purring
thrill” was communicated to the hand. Digitalis and brandy were given
hypodermically. Under this treatment her condition continued to improve
and things began to look more hopeful, when suddenly the eyes were
drawn upward and the head backward, and the whole body remained in a
tonic spasm for about two minutes. Respiration was apparently sus-
pended; the beating of the heart became loud and tumultuous; cold per-
spiration again appeared upon the face and extremities, and she had every
appearance of rapidly sinking. However, the muscles soon began to relax,
and under chloroform inhalation the heart became less tumultuous and
the color returned to the face. At this time I made a vaginal examination
and found the os dilated so as to easily admit the middle and index fingers.
Under chloroform, I dilated the cervix still more. Dr. Mann then arrived,
verified my diagnosis, and continued the treatment. About four A. M.
there was another spasm, lasting about one minute. She rallied slowly
from this. Dr. Mann continued the dilatation sufficiently to permit the
application of the Tarnier forceps, and soon delivered a still-born male
child. The mother did not rally, but gradually sank, and expired about
five A. M.
CASE II. Mrs. H., a well developed primipara, twenty-nine years of
age, had had one miscarriage at three and a half months two years before,
She was poor and obliged to work. She was seven months advanced in
pregnancy, and had done well up to two weeks before, when she had “a
fainting spell,” as she termed it, followed by nausea and vomiting, which
had continued up to the time I was called. She had also been troubled
with a hacking cough. Her tongue was covered with a moist brown fur;
the breath was very offensive ; bowels constipated ; the pulse 140 and ir-
regular. She also had dyspnoea and sharp precordial pain. On palpation,
there was a distinct purring thrill communicated to the hand, and diffused
OVer apex ; there was no increased area of dullness. Near the apex there
Was a loud and prolonged presystolic murmur, and the apex beat was
Synchronous with the purring thrill. Dr. Loomis' holds that mitral steno-
sis depends upon the existence of two physical signs, viz.: “The purring
thrill, and a loud, long, blubbering presystolic murmur.” The os was
found sufficiently dilated to easily admit the index finger. She was put
to bed, an enema prescribed, and one-sixth of a grain of morphia with
One One-hundred-and-fiftieth of a grain of atropia given hypodermically.
She was also given brandy and digitalis hypodermically, and on the fol.
lowing day, aromatic spirits of ammonia by mouth. On the morning of
the 13th, there was dyspnoea, the pulse was 120, the temperature 99° and
the heart's action less tumultuous. She continued to improve and on the
*5th I discontinued daily calls. I advised them fully of her condition, and
of the necessity of her keeping quiet. I was again hastily summoned on
the night of the 6th of January, and was informed by messenger that she
had been doing some light work, and found her in complete collapse; no
1 Pepper's System of Medicine, 3d vol., page:667.
384 NEW YORK STATE MEDICAL ASSOCIATION.
pulse at wrist, respirations rapid, and every indication of impending dis-
solution. Brandy and digitalis were given Subcutaneously, and chloro-
form by inhalation. Under the influence of the chloroform, reaction was
soon established. She had three slight attacks of syncope during the
night, but each time the inhalation of chloroform was followed by an ameli-
oration of the distressing symptoms. I saw her several times on the 26th,
and instructed the nurse about giving chloroform, if syncope threatened.
On the morning of the 27th the nurse reported that the patient had slept
some during the night, and had had only one attack of fainting. Her
pulse was 126, respirations 32, temperature 99°, and she complained of a
good deal of nausea and dyspnoea. She said she had felt no foetal move-
ments for two or three days. The os was found dilated so as to easily ad-
mit two fingers; there was a vertex presentation, but no evidence of foetal
life. In the evening her pulse was weaker, respirations 40 and labored,
and her temperature 99°8. The nurse reported that the patient had had
slight chills during the day. The OS was found already dilated to two
inches, and in about two hours there were regular uterine contractions.
Stimulants were given every two hours, and with the aid of a little chloro-
form I dilated the cervix, and delivered with forceps a female child, which
had evidently been dead for several days. After the tenth day convales-
cence proceeded satisfactorily, and she was able to be about and attend to
household duties in about six weeks.
Now, in the first place, both of these patients had
had attacks of rheumatism in childhood, but were not
aware of the existence of any cardiac lesion. The first
patient, suspecting that she had heart disease, had said
that she would not allow herself to be examined for that
trouble. I did not examine the heart at my first visit ;
I should have done so. “Experience sometimes teaches
dear lessons.” It matters not what the condition of the
pregnant woman, or at what period the physician is called,
he should always examine the heart, and so be pre-
pared for any emergency, or be in a position to prevent,
if possible, any complications arising from the existence
of a cardiac lesion. I was dissuaded from examining her
heart by the assurance that she had no such trouble, and
attributed her prostration to lack of sleep and to the
obstinate vomiting. The cases of Sir Andrew Clark
prove the fallacy of accepting the statement of patients.
Secondly. I believe that the only safe treatment prior
to the fifth month, when mitral stenosis is present, is the
production of abortion. Dr. Mann, who was present,
MITRAL STENOSIS IN PREGA WA WCY. 385
*
fully concurred in this opinion. In both cases there was
no impairment of health before the sixth month. It
is at this time that heart weakness begins, and even if
the pregnancy be allowed to proceed, the chances are
that the foetus will not survive the last two months.
Children, whose mothers are the victims of cardiac
disease, are often imperfectly developed, and are predis-
posed to untimely death.
Thirdly. The salutary effects of chloroform, cautiously
administered so as not to produce full anaesthesia, were
most perceptible. In both cases, the chloroform, when
thus administered, temporarily improved the pulse and
color of the face, and gave an opportunity for other and
more permanent medication.
Fourthly. If the sixth month is already past, the
patient must remain at perfect rest, under the constant
Care of a physician, and her husband or the nurse in-
Structed in the use of chloroform.
In answer to various questions, Dr. Lusk said that he
had used the word “syncope” in lieu of the word collapse.
He had meant to say that the patient was in collapse.
At this time there were only churning sounds of the
heart to be heard, but as soon as the inhalation of chlo-
roform began, this tumultuous action was greatly dimin-
ished, and her general condition improved very rapidly.
This good effect was noticed after each inhalation of
chloroform. The second patient was not so strong as the
first one, yet there was a decided improvement when she
Was Only sufficiently under the chloroform to feel the
Stimulating effect.
DISCUSSION.
PR. F. W. Ross, of Chemung county, said that he could not accept
the author's conclusions in regard to premature labor, for there is fully as
much danger in abortion as in allowing a woman to go on to full term. He
*alled one case of undoubted mitral stenosis which gave him much cause
for ºnxiety when he first saw her at about the sixth month of pregnancy.
Not Wishing to induce premature labor, he only cautioned her to notify
25
386 JNETW YORK STATE MEDICAL ASSOCIATION.
him immediately when labor began. When she notified him, he promptly
dilated the os, and by the aid of forceps, without assistance or anaesthesia,
delivered her of a living child, and she made a good recovery. Two and a
half years later, he attended her in her third pregnancy. As soon as the
pains began, he was summoned, and at once dilated the OS, and again,
without anaesthesia or medical assistance, delivered her of two living chil-
dren. She also made a good recovery from this confinement. One should
be careful about suggesting the induction of premature labor in any case
of cardiac disease, for, as a rule, these cases do well, even though present-
ing quite an unfavorable appearance.
DR. JoHN CRONYN, of Erie county, said that the histories of the cases
reported showed that, when young, they had suffered from rheumatism.
The long continuance of a condition like rheumatism must necessarily be
attended by hypertrophy of the right auriculo-ventricular opening on that
side, and mitral stenosis. The author did not mean “syncope,” but a
condition of collapse occurring with an irritable heart; and the reason the
chloroform acted so favorably was because it allayed this irritability. He
could endorse the whole treatment, except the use of digitalis. Digitalis
is a peculiar drug, and in mitral stenosis, with hypertrophy, he did not
think it was a good medicine. It did no harm in the author's case, because
he gave it along with brandy. 3.
DR. F. W. HrggiNs, of Cortland county, said that not long ago he had
had an interesting case in which abortion had occurred spontaneously five
days previously. When he first saw her, there was evidence of heart-
failure, but he could not detect any “thrill” or other evidence of mitral
Stenosis, and he made a diagnosis of fatty heart. In his opinion, the latter
months of pregnancy are the more dangerous, and, therefore, if labor can
be induced while the patient is still strong, the result is more likely to be
Satisfactory. In the case referred to, the woman was very anxious for a
child, and she was allowed to go on until the sixth or seventh month, when
labor came on spontaneously; yet, for a long time after her confinement, her
life was in great danger.
DR. LUSK, in closing the discussion, said that he stated in his paper that
about the sixth month there is an augmented supply of blood, and a greater
demand made upon the heart, due to the development of the foetus, and,
therefore, this is the most dangerous period. The physician who first as-
sisted him said that his wife had mitral stenosis, yet, although she had had
a baby every year for ten years, the speaker could not discover, on examina-
tion, any of the symptoms or signs of valvular trouble of the heart. Dr.
Mann said to him that he always recommended the induction of premature
labor where there was evidence of mitral stenosis, and though the mother
might live, the chances were one hundred to one against the child.
DR. S. T. ARMSTRONG, of New York county, called attention to the fact
that the author had particularly emphasised the evtent of the stenosis. He
was at present treating a lady who had been under observation for the past
ten years. Mitral stenosis existed before her first pregnancy, and, although
DISCUSSIOW. 387
she has been pregnant five times, the degree of stenosis is but little more
than it was when she first came under observation. She is not now under
treatment with cardiac tonics, and has never taken digitalis, so that had abor-
tion been attempted in her case, it would have served no good purpose.
The circumstances of the patient must of course not be overlooked. They
were such in his patient as to subject her at no time to any strain or anxiety.
She has been seen in consultation by several obstetricians, who agreed that
there was no indication for the induction of labor. Her last child is now a
healthy boy about sixteen months old. He had considered the case worthy
of narration, because it had been under observation for so long a time. In
some other cases, he had given chloroform without any more hesitation
than for any general surgical procedure. He agreed thoroughly with Dr.
Cronyn in condemning the use of digitalis, and in recommending brandy.
DR. LUSK said that he could not say that he got any effect from the dig-
italis in this emergency case; the good result was probably due to the
brandy and the Strychnia.
THE USE OF ELECTRICITY IN MIDWIFERY.
By OGDEN C. LUDLow, M.D., of New York County.
November 17, 1892.
It requires no very great stretch of imagination to
fancy the more conservative among you saying to them-
selves, as they glance at the title of this paper: “I sup-
pose some young enthusiast is going to try to make us
believe that electricity is capable of doing almost any-
thing in midwifery, and that our time-honored drugs and
instruments must be thrown aside, and Our Obstetric out-
fit reduced to a battery and a few electrodes.” If there
be any such here to-day, let me relieve their minds at
once by stating that it has been the aim of the author to
avoid the rosy-hued descriptions so often indulged in by
writers upon the medical uses of electricity, and to con-
fine his paper to a concise and scientific statement of
some points which his own experience has led him to
think may be of practical interest to his fellow prac-
titioners.
There are many occasions on which the resources of
the obstetrician are taxed to the utmost, and Our Science
has not yet become so exact that we can say, with cer-
tainty, that this or that remedy will be the appropriate
one for a given case. Even the physician of large ex-
perience, who has learned to make the most of what is
at hand, cannot afford to ignore any measure, however
trivial, which has been found helpful in practice; and it
is hoped, therefore, that the value of electricity in mid-
wifery will be judged, not by theory, but by the actual
test of experience. It is not an agent which will
suit every case, or which can be applied according to
mathematical rules; like other therapeutic measures, it
THE USE OF ELECTRICITY IN MIDWIFERY. 389
frequently fails, but, nevertheless, it possesses certain
important advantages which, in the opinion of the writer,
entitle it to a permanent place in the recognised resources
of obstetric art. Whenever the generic term “elec-
tricity” is employed in this article, it is to be under-
stood that it refers to faradisation, as this form of elec-
tricity is by far the most useful, as well as the most con-
venient for Our purpose.
For convenience in description, its more important
uses may be considered under three heads, viz.:
I. Its sedative action.
II. Its oxytocic action.
III. Its power to prevent and to control uterine
haemorrhage.
I. Its Sedative Action.—Happily, public opinion no
longer considers it improper to attempt to relieve the
sufferings of the parturient woman, and those physicians
who still persist in withholding remedies which are
known to mitigate the pangs of childbirth, do so, not
because they believe that woman is doomed “in sorrow
to bring forth children,” but from a deep conviction that
the administration of such drugs is not for the best
good of their patients. At our last meeting, I took occa-
Sion to express myself as heartily in favor of the judi-
cious administration of chloroform in most cases of labor,
but I recognise that chloroform has some disadvantages,
and I am sure that all of us would gladly welcome any
agent which, while exerting a marked sedative effect,
Would not interfere with the progress of labor, or tend to
produce post-partum haemorrhage. Such an agent is to
be found in the faradic current of electricity, but you will
be disappointed if you expect it to exhibit this action in
every case. I regret very much that my own experience
With faradisation does not permit me to endorse the
claims made for it by Dr. W. T. Baird, of Texas. In an
article written by him, and published in the American
Journal of Obstetries in 1885, he says that the suffering
can be as effectively relieved in the painful parts “as
390 NEW YORK STATE MEDICAL ASSOCIATION.
we would dare to relieve it with anaesthetics for any
great length of time,” and adds that he has never known
of a case in which it has failed to give all the relief
demanded by the patient. This is pretty strong lan-
guage, and is only applicable to some of the more strik-
ing cases which have come under my observation. In his
experience with electricity in midwifery, the writer has
met with the same uncertainties and disappointments
which characterise the action of other remedies, and he
has thus far been unable to formulate rules which would
be of much assistance in determining which cases are
most appropriate for its use. In Saying this, however,
he does not wish to be understood as implying that it is
more difficult of application than such remedies as chlo-
roform, morphine, and chloral; but only that in this
field, as elsewhere in medicine, empiricism must play an
important part. -
Dut, you ask, what are the special advantages, then, of
electricity over other remedies' In the first place, it is
useful where chloral or morphine is contra-indicated on
account of idiosyncrasy or debility, or where it is not
considered prudent to push these drugs any further. It
is also available where the stomach is too irritable to re-
tain medicine, and where it is inconvenient or impracti-
cable to resort to rectal administration. Faradisation,
unlike morphine or chloroform, does not interfere with
the progress of labor by stopping “the pains,” but, On
the contrary, excites more powerful and efficient uterine
contractions, at the same time that it quiets the general
nervous irritability. It also possesses the distinct ad-
vantage of not favoring uterine relaxation and haemor-
rhage, and its use, therefore, does not complicate sub-
sequent operative procedures under anaesthesia, should
these be demanded.
The manner in which the faradic current produces
sedation has long been a fruitful subject for specula-
tion, yet, up to the present time, but little is definitely
known about it. The older writers compared its action
THE USE OF ELECTRICITY IN MIDWIFERY. 391
on the nerves to that of counter-irritants upon disease
processes; or, in other words, they claimed that, by pro-
ducing a profound impression upon the nerves of sen-
sation, it prevented them, for the time being, from trans-
mitting the sensation of pain. More recently we have
been told that it probably causes anaesthesia by pro-
ducing a sort of rapid inward percussion upon the nerves.
That the number of vibrations of the current have much
to do with its anaesthetic effect has been admirably
shown in a recent paper, read by Dr. William F. Hutch-
inson, of Providence, before the American Electro-
Therapeutic Association. He has had constructed an in-
duction apparatus, in which the usual spring vibrator
has been replaced by a metallic ribbon, which may be
readily adjusted to vibrate in unison with any desired
note ; and his experiments upon the human subject with
the current from this apparatus have brought out the re-
markable fact that, when this ribbon sounds the note of C
major, or is vibrating about thirty-two thousand times per
minute, the maximum anaesthetic effect is obtained. So
marked was the anaesthesia that he was enabled, in one
instance, to open a felon without causing the patient any
pain whatever. I mention these experiments, not only
because they throw some light on the action of the faradic
Current upon the sensory nerves, but because they show
plainly that we cannot expect to obtain this exceedingly
useful effect of the current from every little induction
apparatus which we may happen to employ.
II. Its Oaytocic Action.—If there be one action of elec-
tricity more certain than another, it is its power to evoke
and stimulate uterine contractions; hence, in every case
of tedious labor in which the delay is due to feeble or
infrequent contractions of the uterus, or where, owing to
slight disproportion between the foetal and maternal
parts, unusual muscular exertion is required to deliver
the child, faradisation is indicated, and will usually
- render efficient aid. Not infrequently the exhibition of
its sedative action is immediately followed by a distinct
392 NEW YORK STATE MEDICAL ASSOCIATION,
advance, thus showing that, in practice, its Sedative and
oxytocic actions cannot always be separated. In persons
of sensitive temperament, a slight benumbing effect,
whether produced by drugs or by faradisation, is suffi-
cient to encourage the patient to “bear down '’ more
vigorously, and so make better use of the “pains” of
the second stage. One of the most beneficent properties
of electricity is exhibited in what may be termed its
“steadying effect” on “the pains,” by which is meant
that the uterine contractions, when severe and almost
incessant, are made less frequent and more efficient. It
is just here that one appreciates the importance of that
rest which is afforded the uterus when the contractions
are of the regular rhythmical type seen in a perfectly
normal labor. -
Notwithstanding all that has been written and said
against the danger of administering ergot to hasten labor,
there are not a few practitioners who persist in this prac-
tice. To these physicians, as well as to those who are
often sorely tempted to use it in this way, but who have
moral courage enough to refrain, I would recommend a
trial of faradisation. The action of ergot is slow, and un-
certain in degree ; faradisation produces its effect instan-
taneously, and the amount can be accurately gauged.
Ergot exerts its influence for a variable length of time,
which is entirely beyond control; faradisation acts upon
the uterus for just so long a period as the operator de-
sires—it can be instantly checked, and as quickly re-
sumed. Ergot produces a tonic cramp of the uterine
muscle, which unnecessarily exhausts the mother, and
is dangerous both to her and to the child ; faradisation
produces a steady, rhythmical contraction of the uterus,
which allows a proper interval of rest to the uterine
muscle, and closely imitates Nature’s method. In no
class of obstetric cases does electricity possess such sig-
nal advantages over other and better known measures
as in that in which a safe, speedy and certain oxytocic
agent is indicated. I say” “indicated,” because there
THE USE OF ELECTRICITY IN MIDWIFERY. 393
are many cases, besides those due to simple inertia of the
uterus, in which such an agent is desirable. Thus, there
is often a slight narrowing of the pelvis, or the foetal
head is unusually large, or is abnormally Ossified, causing
a tedious labor, and yet, at the commencement, it is im-
possible to say whether or not delivery can be safely
effected without instrumental aid. Under such circum-
stances, it is true conservatism to make an effort to ac-
complish delivery without resorting to instruments or
to an operation, and this is especially so when that
effort does not involve any additional risk. No evidence
has yet been brought forward to show that electricity, as
ordinarily applied, is harmful, either to mother or child,
so that one has nothing to lose and everything to gain
from a trial of its oxytocic properties.
Faradisation is likely to prove very useful in those Oc-
casional cases in which the induction of labor becomes
imperative. On account of the comparative rarity of
this procedure, only one such case has come under my
personal observation in which this agent was so em-
ployed, but, in this instance, its action was so admirable
as to place it far in advance of the methods usually
recommended. In cases of inevitable abortion and mis-
Carriage, it is also an extremely valuable agent; but
this will be again referred to in considering its action in
the third stage of labor. *
III. Its Power to Prevent and to Control Uterine Haem-
orrhage.—Under this head will be considered more par-
ticularly its usefulness in the third stage of labor. As in
all cases where uterine inertia already exists, or is likely
to be present, there is danger of haemorrhage in the third
stage. The indication is to employ such treatment as
Will place the uterus in the best possible condition to
Prevent such a mishap. The usual practice is to do little
*9te in the way of prophylaxis than to guard against
undue exhaustion of the patient, and to avoid emptying
the uterus too rapidly. The best authorities advise
*śainst the use of ergot until it is certain that the second
394 NEW YORK STATE MEDICAL ASSOOIATION.
stage of labor will be completed within a very few
minutes, and many prefer waiting until the child is
delivered before administering this remedy. The writer
prefers the latter plan, and is of the opinion that the
giving of ergot a short time before delivery is often
responsible for difficulty in removing the placenta. This
objection does not apply to the use of electricity, for, as
has been already stated, the contractions of the uterus
which it produces are entirely under the control of
the operator. Among the more common causes pre-
disposing to post-partum haemorrhage may be men-
tioned rapid emptying of the uterus, and the use of
chloroform to the point of producing profound an-
aesthesia. Where there is imperfect contraction of
the uterus after the delivery of the placenta, or where
post-partum haemorrhage is imminent or is actually
present, faradisation is very useful, and when the haem-
orrhage is not excessive may be all that is required.
I do not wish to be understood as advocating its use in
the face of an alarming haemorrhage, to the exclusion
of well recognised methods of treatment, for this might
mean the loss of valuable time, and, perhaps, even of a
life; but, if the electrical apparatus be in readiness
beforehand, as it should be, it will be found a valuable
adjuvant to other methods, just as a hypodermic injec-
tion of ergot may give temporary aid after the obstetri-
cian has removed any portions which may have been
retained in the uterus, and when, perhaps, a few precious
moments would otherwise be lost while hot water for a
douche was being brought to the bedside or its tempera-
ture was being adjusted.
Electricity is also useful in aiding the expulsion of the
placenta. Most obstetricians will be able to recall cases
in which, owing probably to fat abdominal walls, or, still
more commonly, to distension of the bowels with gas, the
placenta has been delivered only after considerable manip-
ulation, which has left the abdomen sore and tender. By
calling electricity to our aid, we shall be able, in most
THE USE OF ELECTRICITY IN MIDWIFERY. 395
cases, to expel the placenta with scarcely any manipula-
tion of the abdomen, and with a trifling loss of blood.
Analogous to the assistance rendered by electricity in
the third stage of labor, is its action in cases of abortion.
Here, it may be resorted to with good effect, saving much
time and annoyance, both to patient and physician, by
doing away with the necessity for prolonged manipula-
tions, and so diminishing both the dangers and the dis-
comforts attendant upon such accidents. For instance,
in those cases of early abortion, occurring in women in
whom the cervix is high and the ostium vaginae quite
small, it need hardly be said that the removal of the
contents of the uterus is often attended with much
difficulty, yet it is just under such conditions that fara-
disation does yeoman service ; for it not only causes the
expulsion of the contents of the uterus, but also guards
against One of the most common complications, i. e.,
haemorrhage.
From what has been already said, one would very nat-
urally and properly infer that electricity would be useful
in cases of sub-involution, and while this is true, the limits
of this paper prevent a consideration of this, and such
kindred subjects, as the use of faradisation to stimulate
the Secretion of milk, or for the relief of the vomiting of
pregnancy.
It has been the object of the writer, thus far, to give a
general idea of what may be expected from faradic elec-
tricity in obstetrical practice. It remains now to con-
sider briefly, a few illustrative cases, and then take up
Some practical points regarding the technique of its ap-
plication.
As some of the following cases were observed in hos-
pital practice, jointly by Dr. Irwin H. Hance and myself,
I am indebted to him for some of the clinical notes:
CASE I.—A good SEDATIVE AND OxYTOCIC ; PROMPT CONTROL OF POST-
PARTUM HAEMORRHAGE AFTER FORCEPS DELIVERY.
Ipara; tWenty-eight years of age. The first stage lasted twenty-one
hours, and the pains were fifteen or twenty minutes apart. At the begin-
396 NEW YORK STATE MEDICAL ASSOCIATION.
ning of the second stage faradisation was begun, and was kept up almost
continuously for forty minutes. The pains were then more vigorous, and
came on about every five minutes, yet the electricity produced a marked
Sedative effect, which was commented upon both by the patient and the
nurse, although I had been careful to refrain from saying anything about.
the severity of the pain. The current was then applied for some little time
longer, but only during the pains, which became somewhat less frequent.
again, but still quite strong. The head was obstructed at the pelvic floor,
and after waiting a considerable time, the forceps were applied under full
chloroform narcosis, and delivery effected in twenty-five minutes. The
tonic contraction of the uterus was not very good after the delivery of the
placenta, and there was a small gush of blood, which was instantly checked
by the application of the electrode.
CASE II.-A GooD SEDATIVE AND oxyTocIC.
II para; twenty-two years of age. The first stage was characterised by
almost constant knagging pains, and after some hours, although the
patient was quite plucky, she became very nervous, and her pulse rose to
120 beats per minute. At the time of beginning the faradisation, the os was
about two and a half inclues in diameter, thick, and unyielding, and the
head of the child was quite high in the pelvis. In from three to five min-
utes it was evident that the patient was suffering much less, although the
uterine contractions were frequent, short, and sharp. In a few minutes
more the os was fully dilated, and the head on the perinaeum, and the
child was delivered in half an hour. The electricity was applied at inter-
vals during this period until just before the delivery of the head. The
patient had become quite calm, her pulse had been reduced to 104, and was
of better quality, and the uterine contractions were much more regular
and effective.
CASE III.-A GooD SEDATIVE AND OXYToCIO ; USEFUL IN THE THIRD
STAGE ; EFFECT OF WARYING THE INTERRUPTIONS IN THE CURRENT,
Ipara; twenty-five years of age ; a large and strongly built woman.
The dilatation of the os was very slow, so that thirty-six hours after the first
pains began, it was only about two inches in diameter. Seven hours later,
notwithstanding the use of several hot vaginal douches, and the evacuation
of considerable liquor amnii, the os was not much larger, and the pains
were irregular, short, and inefficient. The full strength of the current
from a large faradic battery was then applied in the usual way, and after
about fifteen minutes of almost continuous application, the pains had
become more regular and frequent, and had increased in severity, yet the
patient was much quieter, and expressed herself as experiencing much less
pain. The application of the current lasted for half an hour. After this,
the progress was more decided, and the os was fully dilated in a little less
than four hours. There was slight obstruction to the descent of the head
in the pelvis, so the forceps were applied, aud the head soon delivered by
gentle intermittent traction. There was some little difficulty in delivering
the placenta, and its expulsion was followed by more than the usual
THE USE OF ELECTRICITY IN MIDWIFERY. 397
amount of bleeding, and although this was checked by ergot and hot
douches, the uterus remained flabby. The faradic current was again ap-
plied for about five minutes, with the result of causing a firmer contraction
of the uterus, and preventing further haemorrhage.
In this case, it was found that the most work could be
obtained from the current with the least inconvenience
to the patient, by adjusting the contact-breaker So as to
make very fine interruptions during the intervals of the
pains, and changing to coarse interruptions as soon as
the uterus began to Contract.
CASE IV. —PROLONGED FIRST STAGE FROM RIGID OS ; FARADISATION
FAILS BOTH AS AN OXYTOCIC AND A SEDATIVE , CEILOIRAL SUC-
CEEDS.
Ipara; twenty-one years of age. She had pains at short intervals for
four days before any dilatation of the os was evident. When the os had
reached two inches in diameter, there was scarcely any further progress.
The uterine contractions occurred every three minutes, and were very
strong, but with each pain the os would dilate to nearly the full size, and
then contract to its former size when the pain subsided. During the night
the patient received three hot vaginal douches, and thirty grains of chloral,
but with little benefit. A strong faradic current was then applied, almost
continuously for fifteen minutes, and then only during the pains, for fifteen
minutes more. The uterine contractions then became very severe, and re-
Curred every two minutes, but there was no advance and no sedation, and
the faradisation seemed to cause so much discomfort, that it was stopped.
During the next four hours, the patient received three hot vaginal douches,
and thirty grains more of chloral. She then came pretty well under the influ-
ence of the drug, and at the same time, it was noted that the child's head
Was lower, and that the cervix was receding. The progress of the labor
from this point was uninterrupted, and the child was born two hours later.
This case is worthy of special notice, not only because
of the failure of electricity to accomplish good results
under conditions which seemed theoretically to be pecu-
liarly appropriate for its use, but because it also shows
that the writer does not wish to convey the impression
that electricity will accomplish wonders in every case.
Contrast this case with the following:
9ASD V-good oxytocic Action, AND some sedation; chlor:AL FAILs.
ſpara; twenty-eight years of age. The first stage was quite slow, the
9s being only about one inch in diameter at the end of twenty-four hours.
º Cervix was thin for a long time before the os dilated, and the head was
9W down in the pelvis, but the pains were not very strong. Chloral failed
398 NEW YORK STATE MEDICAL ASSOCIATION.
to assist the dilatation. The faradic current was applied continuously for
twenty minutes, and produced some sedation. The second stage began
fifteen minutes later, and was completed in half an hour.
CASE WI.-MARKED SEDATION, ALTHOUGH NO EFFECT UPon THE Os;
PELVIC CONTRACTION ; FORCEPS DELIVERY.
Ipara; twenty-five years of age. After being in the first stage for
twenty-four hours, suffering severely, it was found that the os was only
about two inches in diameter, and its margins quite thick. There were
severe uterine contractions every five minutes, and hot douches and mor-
phine had given no relief. Faradisation was employed continuously for
thirty minutes, with the effect of producing more efficient uterine contrac-
tions at longer intervals, and causing the entire disappearance of the knag-
ging pains in the back and hypogastric region. After the second stage
was reached, it became evident that the mother would require assistance,
so the forceps were applied, and delivery effected.
This case is presented in order to show that even in
the presence of pelvic deformity, relief from pain may
be obtained by the use of electricity, when morphine in
appropriate doses has failed. In view of the fact that,
in such cases, it is probable that an operation under an
anaesthetic will ultimately be required, it is obvious that
it is safer to apply electricity, than to administer chloral
or chloroform. .
CASE VII.— INDUCTION OF LABOR IN FIFTEEN MINUTEs, BY FARA-
DISATION.
This patient, a primapara, thirty-one years of age, with a decidedly
phthisical family history, had suffered for a long time previous to her
pregnancy, from gastritis, and had been further debilitated during preg-
nancy, by persistent nausea and vomiting. After her admission to the
hospital she rejected all stimulants and food, with the exception of a little
milk and carbonic acid water. In view of her wretched and somewhat
precarious condition, it was decided after consultation that, as the Com-
puted time of her confinement had arrived, it was not advisable to wait
any longer, and that labor should be at once induced. On the day she had
expected to be “sick,” there were no uterine contractions, and no indica-
tions of the onset of labor; the os only just admitted the tip of the finger,
the vertex presented in the L. O. A. position, and the foetal heart Was
beating strongly. The patient was very weak, and excessively nervous
and apprehensive. The electrodes were applied in the usual manner OVer
the sacrum and abdomen, and the strength of the faradic current adjusted
so as to be slightly disagreeable, but not painful. While the current W*
being applied, Dr. Hance attempted digital divulsion of the OS. The first
uterine contraction occurred four minutes after applying the current, and
THE USE OF ELECTRICITY IN MIDWIFERY. 399
several others followed in rapid succession. At the end of twelve minutes
from the beginning of the application the OS had dilated sufficiently to ad-
mit two fingers. Faradisation was then stopped for a few minutes. In
twenty-five minutes from the beginning of the seance the os admitted
three fingers and was quite dilatable, and the pains were returning regu-
larly at intervals of three or four minutes. In the next twenty-five
minutes the current was applied only during the uterine contractions. The
pains were now only two minutes apart, the mother was much more com
posed, and her pulse was 68, regular, and fairly good. Labor being now
well established, faradisation was discontinued. The first stage lasted four
hours, and the second only thirty minutes.
CASE WIII.—ExPULSION OF THE PLACENTA BY ELECTRICITY; LESS THAN
THE USUAL BILEEDING.
Ipara; twenty-one years of age. The faradic current was applied only
during the pains near the termination of the second stage, and was then
omitted for about five minutes, until the umbilical cord had been ligated.
On again closing the circuit, the uterus promptly contracted, and in a
moment the placenta was forced into the vagina. Although chloroform
had been administered sparingly during the last few expulsive pains, the
delivery was attended with practically no haemorrhage. About three years
later I attended the same lady in confinement with her second child. The
first and second stages together only occupied a little over two hours,
chloroform was given in the same way during the last fifteen minutes of
the Second stage, and faradisation was not employed at all. There was
considerable more blood lost than at her first confinement, when the elec-
tricity was used, but the amount still did not exceed that found in many
normal deliveries.
CASE IX.-HOUR-GLASS CONTRACTION ; ADHERENT PLACENTA ; FARA-
DISATION FAILS.
Ipara; thirty-three years of age. After applying the current for a
reasonable time, it was found that the expulsion of the placenta was hin-
dered by a contracted ring in the lower segment of the uterus, and also by
the placenta itself being adherent. An examination of the placenta after
delivery showed its cotyledons to be unusually large and soft. No ergot
had been administered.
CASE X.—PLACENTA EXPELLED ; IMMEDIATE ARREST OF A SLIGHT
POST-PARTUM HAEMORRFIAGE. -
iº Ipara; twenty-five years of age. An application of the faradic current
* the usual way caused the prompt expulsion of the placenta from the
uterus into the vagina, and then, very gentle downward pressure with the
electrode resulted in the placenta being immediately forced outside of the
vulva. Just after stopping the current there were a few gushes of blood
from the uterus, but this haemorrhage ceased immediately on closing the
circuit again, and after a few minutes the uterus remained firmly con-
tracted without artificial aid.
400 NEW YORK STATE MEDICAL ASSOOIATION.
The foregoing cases are representative ones, and have
been selected with the object of showing what electricity
can do and what it cannot do in the practice of mid-
wifery. Looking over those cases, of which I have pre-
served careful notes, and in which electricity has been
employed with a specific object in view, I find that in
twelve cases in which faradisation was employed for its
sedative and oacytocic effects, its sedative action was
shown in eight, and its oxytocic action in nine cases. In
twenty out of twenty-seven cases, in which it was em-
ployed in the third stage of labor, it materially aided
the expulsion of the placenta, and in three out of four
cases of moderate bleeding, occurring immediately after
delivery, it promptly checked the flow and produced
firm uterine contraction. .
No doubt by this time some of you have been thinking
that this employment of electricity in midwifery is pretty
in theory, and, perhaps, useful in hospital practice, or
where there are more facilities for using electrical appar-
atus than ordinarily fall to the lot of the general practi-
tioner, but that it is of very doubtful application to the
every-day routine of practice. I hope to show that such
is not the case, and that the effects described in this
paper may be obtained without the use of any elaborate,
expensive, or cumbersome apparatus. I find no objec-
tion to the treatment on the part of the patients or their
friends. On the contrary, they are gratified at the effort
the physician makes to relieve the suffering, and are not
slow to compare this practice with the more common One
of sitting at the bedside and turning a deaf ear to the
patient's pleadings. Do not misunderstand me on this
point. I am no advocate of “meddlesome midwifery,”
but I do believe that the accoucheur should stand ever
ready to assuage the sufferings of childbirth whenever
this can be done with safety to the mother and child;
and while leaving much to Nature, he should be Con-
statly on the alert to see when art can aid her. If in a
Severe and prolonged case of labor we can safely reduce
THE USE OF ELECTRICITY IN MIDWIFERY. 401
the patient's sufferings and conserve her failing strength
by causing the pains to come at longer intervals, and
then to do more efficient work, it is certainly our duty to
do so. Chloral, we know, will accomplish much under
such circumstances; but let us not forget that electricity
may do as much, or more, and with even less risk to our
patients.
The needful appliances are, a portable faradic battery,
two or three electrodes, and the necessary conducting
cords. It is all important that the battery should be so
constructed as to require very little attention while in
operation, and also when not in use. It is desirable that
the contact-breaker should be capable of nice adjustment,
so that the current may be “made ’’ and “broken’’
evenly ; and just here, I would say that it would be a
great advantage to the obstetrician to have the usual
contact-breaker replaced by the new “singing rheotome”
which Dr. Hutchinson has devised for the purpose of
making very rapid vibrations. This instrument, as I
have already said, has only just been brought to the
notice of the medical profession, but I feel quite con-
fident that had I had it at the time I was attending the
cases described in this paper, the sedative effects of the
current would have been still more remarkable. As, in
a general way, it may be said that a current from a coil
of coarse wire is the most appropriate for stimulating
muscular fibre to contraction, and that from a fine wire
coil most suitable for producing sedation, it is desirable
to have the faradic apparatus provided with such coils.
Where, however, one desires to have a very small battery
Which can be carried in the coat-pocket or in the obstet-
ric bag, some of these refinements must be sacrificed to
portability. A very useful machine of this class is the
One known as “the Smith & Shaw Closed Cell Battery.”
It is not nearly so dirty and wasteful as the well-known
Gaiffe pocket-battery, and is in every respect a much
more efficient instrument. The current is sufficient for
most cases, but even the coil with two cells of battery, is,
26
402 NEW YORK STATE MEDICAL ASSOCIATION.
in exceptional cases, hardly strong enough. It can be
carried about charged, so as to be ready for use at a
moment’s notice. Each charge is sufficient to run the
battery for a number of hours, and its renewal is quickly
and easily effected.
The best method of applying the current to the patient
is with the positive pole to the sacro-lumbar region, and
the negative pole to the abdomen. Fairly good work
can be done with two sponge electrodes applied to the
abdomen on either side of the uterus, but this method is
not so convenient or so effective as the One first described.
The only precaution necessary in regard to the position
of the electrodes is to place them so that the current will
not pass through the head of the child. The method
described will avoid such a danger in vertex cases, but
where the breech presents, it is better to apply one pole
to the sacro-lumbar region, and the other to the nape of
the neck.
For the lumbar electrode, I use a small copper plate, to
which is attached the conducting cord from the positive
pole of the faradic machine. The portion of the cord
near the plate should be covered with rubber tubing, so
that it may be easily cleaned. When the electrode is to
be applied, it is laid upon a strip of roller bandage and a
thin sheet of wet absorbent cotton is wrapped around
both the plate and bandage. The bandage is then fas-
tened around the patient like a belt, and serves to retain
the electrode in contact with the skin and in proper posi-
tion, even though she be rolling about the bed. It
matters not if the electrode be soiled with the discharges,
for the rubber-covered cord and the copper plate are
easily cleaned, and fresh absorbent cotton and bandage
are used for each case. Unless very powerful currents
are required, the best abdominal electrode is the Opera-
tor's hand, as he is kept constantly informed concerning
the strength of the current, and more important than all,
he can keep the uterus in his grasp. This will be pal-
ticularly appreciated by any one using faradisation in
THE USE OF ELECTRICITY IN MIDWIFERY. 403
the third stage of labor, for with an ordinary sponge
electrode, it is a very easy matter for the uterus to relax
and escape around one or the other side of the electrode.
Where the hand is used, the Operator takes an Ordinary
sponge electrode in one hand, while the other is applied
to the abdomen, Or, the conducting cord from the nega-
tive pole is connected to a metal band fastened to his
wrist. The objections to this method of application are
the weariness it produces in the Operator's hand and arm,
and the fact that if the current be sufficiently strong to
be effective, it is very disagreeable to some persons who
are especially susceptible to its influence. The best sub-
stitute for the hand is a flat sponge, insulated at the
back with a piece of sheet rubber. In Selecting such an
electrode, it is important to see that the back is very
flexible. Another method is to connect the negative
cord with a small metal ball, which is placed in the
centre of a large Sponge. The Operator can then grasp
the Sponge with the naked hand, or can protect his hand
with a rubber glove.
Before beginning the application one should always be
Careful to see that both electrodes are well wetted with
Warm water, that the strength of the current is reduced
to the minimum, that the contact-breaker is adjusted
to Work smoothly, and that the current is turned off
from the electrodes. Both electrodes are then placed in
Position, the current turned on, and its strength very
gradually increased until it is distinctly perceptible to
the patient, but causes no pain. The circuit should be
kept closed for ten or fifteen minutes, when the sedative
effect should be evident. When this is once obtained it
IS only necessary to keep the circuit closed during the
Pains. When used for its oxytocic effect the current
should be strong enough to be disagreeable without
*ing decidedly painful, and should be applied inter-
*ittently in imitation of the normal rhythmical con-
"actions of the uterus. When it is desired to employ
electricity in the third stage of labor to facilitate the
404 NEW YORK STATE MEDICAL ASSOCIATION.
delivery of the placenta and to encourage firm uterine
contraction, the circuit should be closed as soon as the
child is delivered, and a mild current applied to the
uterus. Unless it is evident that this will cause the
expulsion of the placenta prematurely, the current need
not be broken. If the uterine contraction be sluggish
the strength of the current should be rapidly increased,
when there will usually be a sudden and powerful con-
traction sufficient to expel the placenta. It must be
remembered that adipose tissue is a very poor conductor
of electricity, and that, therefore, in women with fat
abdominal walls, the results are likely to be very dis-
appointing unless powerful currents are employed.
To recapitulate:
(1). The necessary apparatus is neither complicated
nor troublesome.
(2). The application of electricity in cases of midwifery
requires no special technical skill, and is, therefore,
applicable to the needs of the general practitioner.
(3). Electricity exhibits its sedative effect in parturi-
tion sufficiently often to make it worthy of trial where
the physician is reluctant to administer chloral or
chloroform.
(4). Electricity assists labor by increasing the force
and efficiency of the natural uterine contractions. It is
prompt and reliable, and is entirely under the control of
the Operator.
(5). The use of electricity in the third stage of labor
aids the expulsion of the placenta, and diminishes the
risk of haemorrhage. -
In conclusion, the writer ventures to express the belief
that every physician who may be induced to give electric-
ity a fair trial in his obstetric practice will find in it a
valuable ally, but one which no more deserves to be Con-
sidered infallible than do the other remedial agents at
Our command.
THE RóLE OF MICROBES IN DISEASE.
By N. B. SIZER, M.D., of Kings County.
November 17, 1892.
At a former meeting of this body, I had the honor to
discuss the “Ptomaines,” or “Leucomáines.” By your
favor I am again permitted to address you upon the
present state of our knowledge of microbes as causes
and accompaniments of disease. -
The word “microbe” means any minute living thing ;
while the words “bacterium,” “bacillus” and “coccus”
refer to the shape of the organism as being like a rod or
staff, or berry-shaped.
There is a general misapprehension, even in our pro-
fession, regarding the nature of bacteria. Bacteria and
their congeners are not animals, although they may be
close to the border-line of the two kingdoms; they are
undoubtedly vegetables, although mobility is one of their
characteristics.
As we study our subject we shall see that microbes do
harm, not so much by the local irritation due to their
presence in the tissues, as by excreting, during their life,
poisons called “leucomáines.” Some of these substances
are, Weight for weight, twenty to thirty times as poison-
OuS as Strychnia or aconitia.
These virulent bodies are called “leucomáines” when
formed in living bodies; when set free after death by the
microbes of putrefaction they are “ptomâines” (Greek—
Pºoma, a corpse). A general name applied to them all is
“toxine,” or “animal alkaloid.” It is to their absorption
that the symptoms of most bacillary diseases are due.
Anthrax (“wool-sorter's disease,” “charbon,” “milz-
brand”) is common in herbivora, and is transmitted by
406 WEW YORK STATE MEDICAL ASSOCIATION.
them in various ways. When infection occurs through
a scratch or bite, an early resort to excision or the cautery
may destroy the germs before systemic infection has
occurred. Sometimes dust loaded with spores is inhaled
by those who handle dry hides, hair, and wool from
infected beasts. Here the lungs contain the primary
foci of infection, and very little can be done for the
unfortunate victims.
This disease has been an awful scourge, France at one
time losing millions of sheep and cattle every year, and yet
the most skillful veterinarians were absolutely helpless.
Although, as I have said, the herbivora are very suscep-
tible to this disease, the carnivora generally are immune ;
but if, for example, rats are temporarily fed on a veget-
able diet, they will become as susceptible to anthrax
as rabbits, but will again become proof against this
disease when fed exclusively on flesh. Fowls are almost
entirely immune, probably because their temperature is
naturally high, for if we reduce the bodily temperature
two or three degrees centigrade, for a few hours, by keep-
ing the legs and lower part of the body in ice-water, they
may be successfully inoculated with this disease.
Pollender seems to have first seen the bacilli in 1849,
in the blood of cattle. One year later Davaine redis-
covered them and was first to demonstrate their meaning,
which he did in 1863–4, before the Academie Française,
where he proved that the blood of sick beasts was full
of these germs, and that inoculation of a minute frag-
ment of dried or fresh blood was followed by rapid death,
the blood of the inoculated animal being the habitat of
myriads of the characteristic rods of charbon, which
were plainly visible under the microscope.
Pasteur has made thousands of pure cultures, and
finds progeny as vigorous as the parent stock, even to
the hnndredth successive generation. The microbe is
“aerobic,” or lives on oxygen, like animals, and the
power of infection resides wholly in the rods, as filtered
cultures are harmless.
THE RóLE OF MICROBES IN DISEASE 407
The Sudden deaths in certain microbic diseases are
fully explained by what we know of their wonderful
powers of reproduction ; thus, certain species divide once
every hour. At this rate the total progeny in twenty-four
hours would be 16,777,220, or almost seventeen millions,
and at the end of forty-eight hours, 281,500 millions;
and at the end of a week a row of fifty-one figures would
be needed to express their numbers
An average oacillus is a cylinder one-five hundredth
millimeter long by one one-thousandth millimeter wide,
and one cubic-millimeter (a space only the one-twenty-
fifth part of an inch high, wide and deep) will comforta-
bly contain about 633,000,000 of them. At the end of the
twenty-four hours the progeny of one such microbe will
occupy only one-fortieth part of the cubic-millimeter,
but after forty-eight hours it will need 442,570 such
cubic-millimeters to hold them, or say half a litre. If
Our Oceans cover two-thirds as much space as the land,
and average one mile in depth, the cubic-contents will be
about 928 millions of cubic miles. By a short calcula-
tion it is easy to show that the number of microbes
present at the end of about five days, and expressed by a
row of fifty-one figures, would require so much space that
they would fill all our terrestrial oceans up to the brim—
almost a thousand millions of cubic miles |
We need not wonder, then, that in anthrax, with the
blood full of countless myriads of microbes which feed
On Oxygen, these mischievous parasites consume so much
of the vital gas that it is abstracted from the blood more
rapidly than the lungs can replace it, and that, therefore,
the poor patient has urgent dyspnoea, cyanosis, and a
Subnormal temperature, and dies of asphyxia.
{ { One of Koch’s most useful discoveries was that of the
resting-spores” of anthrax. These are highly refrac-
tory bodies which are developed in the rods and have
ºnormous vitality, even resisting prolonged immersion
* Strong alcohol, long boiling, complete dryness and
Putrefaction, while the rods succumb to them all.
408 NEW YORK STATE MEDICAL ASSOCIATION.
Spores are not found during life, but develop in the
rods during the early stages of putrefaction, and take
their place, so that dried blood containing these spores
may be as virulent as fresh blood containing the rods.
A dead body, full of spores, continues to be a source of
contagion for an unlimited time, owing to the earth-
worms which feed on the remains and leave their “casts”
on the surface of the ground for the wind and rain to
scatter the spores over the herbage, and so communicate
the infection to grazing animals.
Pasteur has succeeded in so attenuating the bacilli by
starvation that gradual inoculation renders animals im-
mune to anthrax. No wonder, then, that France has
showered such wealth and honors upon Pasteur, for,
aside from the human suffering and death thus averted,
this discovery saves six or eight millions of francs to
France every year.
CHOLERA ASIATIC A.
The cholera germ is a “spirillum,” and when broken
up into its component parts, is found to be a thickish,
slightly curved, mobile bacillus ; hence its sobriquet,
“comma bacillus.” Its mobility, when free, is due to
its long flagella, growing from one end only ; by means
of this it sculls its way through liquids. It was first
found by Koch, in India.
The photograph I now present, amplifying the bacillus
about 1,000 diameters, demonstrates the flagellae admir-
ably; you will note that some bacilli have two of them,
while in others they are bifid.
The “rice-water” dejecta contain these microbes in
such immense numbers that they have been called a
“pure-culture” of the B. Cholerae Asiaticae, but in the
later stages the microbes penetrate into the mucous
membrane and tubular glands of the intestines.
It is safe to say that we have cholera only when the
“comma” microbe is present; it is absent in all other
THE RöLE OF MICROBES IN DISEASE. 4.09
conditions, no matter how apparently “choleriform '’
the symptoms. Other curved bacilli are abundant in
the mouth, but cultivation proves at once that they are
not the true cholera bacilli.
The lower animals, so far as we now know, are usually
immune.
In the Hamburg epidemic, last summer, the microbe
was found growing abundantly in the city water, and in
the soil wherever cases of cholera had appeared.
In cultures the bacilli grow in colonies of several hun-
dreds, adhering end to end, and so twisted as to produce
a “spirillum,” that is, a spiral colony, like a cork-screw
in shape, having from ten to fifteen complete spires or
coils. The “comma” shape is caused by each individ-
ual retaining the slight curve which it had while living
in its colony. These “spirilla” are curious sights
indeed, as they slowly propel themselves along by
revolving each upon its axis, just as a cork-screw works
its way through a cork. You see, therefore, that the
cholera spirillum is the original screw-propeller, and
long antedates Ericsson.
It has of late been suggested that the B. Coli Com-
Tnumis may be a sort of quiescent form of the “comma”
microbe.
IERYSIPELAS.
This is a bacillary disease, because certain cocci are
always found in the tissues. They are extremely abun-
dant in the newly-attacked oedematous parts, have been
isolated and cultivated, and when pure cultures have
been inoculated, have successfully reproduced the disease
in both men and animals. After inoculation the classical
Symptoms develop after an incubation period of from
fifteen to sixty hours.
..This germ is a streptococcus (i. e., growing in chains
like a string of beads), which is always present in
*mmense numbers, especially in E. Vagrams. A drop of
Serum from the peripheral oedema is the best place to
410 NEW YORK STATE MEDICAL ASSOCIATION.
look for them, the oedema being due to the fact that
they are so abundant as to literally cause thrombosis of
the lymph spaces.
DIPEITHER.I.A.
Microbes were seen in diphtheritic exudates as long ago
as 1868 by Oertel, Bahl and Hueter, and Ziemssen wrote!
“It is not diphtheria if the microbes be absent l”
Klebs and many others have isolated and grown pure
cultures, and have, by inoculation, caused a rapid growth
of the cocci all over the body. Chickens and cats often
die of a similar disease during epidemics of diphtheria
in human beings.
GON ORR][[OE A.
This is caused by Neisser’s “gonococcus,” described
in 1879. It has been found in pus from the urethra and
vagina, and from ophthalmia neonatorum, but never in
pus from other sources, or in simple leucorrhoea, or ure-
thritis; so that, if present in abundance, the nature of
the case can no longer be doubtful.
In certain German obstetric charities, ophthalmia ne-
onatorum formerly appeared in about eight to twelve per
cent. of all the newly born ; but since the adoption of
systematic ante-partum disinfection of the maternal va-
gina, and the careful cleansing of the conjunctival Sur-
face in the babies as soon as born, with the instillation
of a weak silver-nitrate solution, this disease has been
much less frequent. Thus, in a clinique of eight Or ten
thousand accouchements per annum, where formerly
there were from eighty to one hundred and twenty cases
of ophthalmia neonatorum each year, there has not been
a single case in the last three or four years.
RARIES.
Pasteur's researches in rabies are well known, so that
it is sufficient here to say that careful cultivation has
1 Vol. I., p. 590.
THE Róſ, E OF MICROBES IN DISEASE 411
produced a very concentrated fluid, known as “labora-
tory virus,” which is six or eight times as virulent as
the ordinary virus of “street rabies.” By repeated in-
oculations with this virus, and by drying the spinal
cords of the animals so treated, the virus becomes suffi-
ciently attenuated to use for protective inoculations.
The following statistics show what has been done:
The deaths from rabid dog-bites average 25 to 35 per
cent., but out of 10,992 persons inoculated by Pasteur
during 1886–91, only 62 succumbed, or slightly more
than one-half of one per cent. Of wolf-bites in the head,
always very fatal, 82 per cent. die. Pasteur had under
his care nineteen Russian peasants thus bitten ; of these,
three died before the inoculations were completed; the
other sixteen at last accounts remained well. What can
be nearer a specific than this 2
MALARIA.
This whole class of complaints has been ascribed to the
presence in the body of the B. Malariae, a discovery of
Klebs and Tommasi-Crudeli; though our own Salisbury,
I believe, claims that honor.
Doubtless more than one organism may exist, for it
Seems generally agreed by those who have seen it that
the dreadful “Roman Fever” of the Campagna, which
has made a desert of what was once the most productive
and beautiful region of Italy, differs essentially from
Such cases as we commonly observe in this country.
LIEPROSY.
Leprosy has been admitted definitely into the class of
bacillary affections because the B. Leprae is found con-
Stantly present in the tubercles. This bacillus was dis-
°ºvered by Hansen, in 1879, and many successful cases
of inoculated lepra have been published.
MEASLES.
The bacterium of Cozé and Feltz, so far as we know,
*ms always to be present in this familiar disease. It is
412 NEW YORK STATE MEDICAL ASSOCIATION.
an extremely minute, very mobile microbe, which is
found in immense swarms in the rapidly fatal so-called
“malignant’’ types, and in very small numbers in the
milder cases.
Pure cultures have been made and inoculated, and
although the lower animals do not seem very susceptible,
a few successful cases have been reported.
PLEURO-PINEUMONIA.
This often occurs epidemically among animals, under
the familiar name of the “Epizootic.” As human beings
Often coincidently suffer, I do not hesitate to mention it
here. The parasitic microbe of this disease was seen first
by Williams, about 1852. This was probably the first
bacillary disease in animals to be purposely propagated
for the sake of the acquired immunity, as this was done
in New York and vicinity more than thirty years ago,
in the time of the famous “swill-milk?” panic.
PNIEUMONIA.
This is now admitted to appearin a distinctly infectious
form, and all such cases have been proved to be caused
by the presence of the pneumo-coccus of Friedländer.
This germ is constantly found in the lungs in all cases
of acute croupous pneumonia, and is also believed to be
the cause of various suppurative processes independently
of pneumonia, e.g., primary ulcerative endocarditis,
purulent cerebro-spinal meningitis, and certain severe
cases of purulent otitis. When present in the pus from
Such cases, a cautious prognosis should be given, as
owing to the wandering habits of these cocci, they in-
vade the lymph channels, and infect the mastoid cells,
and even the meninges.
According to Goldenburg, this pneumococcus is to be
found in fifty per cent. of all healthy mouths, and in a!!
mouths for weeks after pneumonia. It is easy to see how
THE RöLE OF MICROBES IN DISEASE 413
they can migrate to the frontal sinuses, by the tuba
Eustachii to the ear, and through the lymphatics to the
brain cavity.
I am often asked, why, then, do we not all get pneu-
monia ; and why does it so often apparently follow a
severe chill after exposure ? I answer, no seed, however
good, grows if the soil be not adapted to it; and exposure
to cold and wet will lower our resistance to the invading
pneumococci in the same way that chilling the legs of a
fowl will render it susceptible to anthrax.
IRELAPSING FFVER.
The spirillum of relapsing fever was discovered by
Obermeier in 1868. It lives in the vascular system, and
during the pyrexia the blood is full of them ; but they
disappear instantly and completely as soon as deferves-
cence occurs. These facts show us that the fever is due to
the presence in the blood of a brood of these spirilla and
to the absorption of the “toxine’’ which they excrete.
When the brood dies the toxine ceases to be formed,
defervescence ensues, and the patient suddenly recovers.
This microbe has been grown, pure cultures produced,
and monkeys inoculated there with, with the result of
reproducing the fever with all its peculiarities.
SC AIRLATIN A.
Definite proof of the bacillary origin of scarlatina is
not yet at hand, but it is all but settled.
RAIBBIT SEPTIC AIEMIA.
I mention this disease, though not a human ailment,
from its curious history and the light thrown by it upon
other pathological conditions.
It was discovered accidentally by Sternberg, in Sep-
tember, 1880, and by Pasteur in December of the same
year. It was found that a few drops of healthy human
Saliva injected into a rabbit would produce a rapidly
414 NEW YORK STATE MEDICAL ASSOCIATION.
fatal form of septicaemia, due to the presence in the
saliva of the “B. Cuniculicidus ; ” and wonderful to
relate, rabbits previously inoculated with any other
microbe, no matter what, were totally proof against the
Saliva bacillus !
Some saliva is very fatal, a couple of drops killing in
forty-eight to sixty hours; usually life is prolonged
for three or four days.
Pure cultures are much more virulent because stronger
in microbes; but if filtered, the filtrate being germ free
is absolutely innocuous, thus proving the microbes to be
the cause of the disease. -
Now for the practical application of this knowledge.
It is well known that the venom of serpents is derived
from a gland, similar in all respects to our salivary glands,
and that, therefore, the venom is saliva, more or less
modified by development.
Do not the results of a snake-bite explain, not only
these cases of Saliva-Septicaemia, but also the frequent
deaths and more frequent amputations following that
most dangerous injury, a “man-bite,” the analogue, as I
take it, of Serpent poisoning .
SYPHILIS.
As a germ disease, syphilis is still doubtful, but the
famous “fuchsine bodies,” once called “artefacts,” are
now supposed to be parasitic. The great obstacle to
success is the difficulty of cultivating any microbes thus
far found, for man alone seems susceptible to inocula-
tion.
TU BERCULOSIS.
We have at last returned to the faith of our fore-
fathers, and to-day consider consumption, in One sense,
an infectious disease.
In 1882, Koch announced his discovery of the tubercle
bacillus, not at all to the surprise of pathologists. Since
then, by sterilising the sputa of phthisical persons,
isolating bad cases, and forbidding these patients to
THE RóLE OF MICROBES IN DISEASE 415
disseminate their sputa broadcast, after the time-honored
fashion, the mortality from this disease in the German
army has been reduced to one-quarter the former rate.
The air of rooms where consumptives live, is full of
microbes, and the dust adhering to the walls has been
found loaded with the B. Tuberculosis, so that a few
particles thereof, injected under the skin, or blown into
the lungs of animals, will soon cause death from that
disease.
Our ideas of “scrofula.” have been greatly modified ;
what were formerly called “strumous joints’’ are found
to be nests of bacilli, and the same is true of many en-
larged glands, all caseous deposits, and lupus nodules.
Diagnosis and prognosis now largely depend upon what
the microscope reveals, and in this connection I may
mention that Ehrlich’s method of starving the tubercle
bacilli is the easiest and most certain. Out of 2,509
cases of Supposed phthisis, observed some years ago, the
tubercle bacillus was found in 2,417.
I need say little of “Tuberculin.” If this “toxine’’
does no more than act as an “indicator” in lupoid dis-
eases, it deserves immortality as being unique in the
history of medicine.
TETANUS.
This awful disease is especially frequent in the tropics,
Where, especially in India, half the babies succumb to
trismus nascentium before the end of their second week
of life.
. It is caused by Nicolaier's bacillus, found everywhere
in cultivated soil, in stables, and on and about horses.
For this reason, the majority of those affected with
tetanus are stablemen or drivers. Horses are very subject
to tetanus, and often contract it from human beings.
It is supposed that the ground is kept infected by
manuring it. Many cases follow a wound where dirt
has been rubbed in, so that it is probably not so much
”/8/y nails as dirty nails which are likely to infect
Wounds, and cause tetanus.
416 IVEW YORK STATE MEDICAL ASSOCIATION.
The same microbe is present in trismus nascentium, as
Beumer has isolated it, and caused tetanus by inocu-
lation.
The microbe resembles that of rabies, the virus residing
mostly in the bulb and cord. It can be similarly atten-
uated, and is also most active after sub-dural inoc-
ulation. -
The rule of contagion is: man to man, very seldom ;
from animals to man, very often ; man to animals, often;
from soil to men and animals, very often.
TYPHOID FEVER.
The stools in typhoid fever abound in Eberth’s B. Ty-
phosus, which thrive in water, and in hundreds of cases
have thus infected the water supplies of cities and towns,
causing the death of thousands. The terrible epidemic
at Plymouth, Pa., is still fresh in our minds, where too
few were left to care for the sick or to bury the dead.
So far as now known, most animals are immune.
The bacillus abounds in Peyer’s patches, the mesenteric
glands, and on the mucous membrane of the small intes-
times, and is always present in this disease. Hence,
intestinal antisepsis is, in my opinion, the best treat-
ment; and phenol, or preferably, salol, should be the
antiseptic agent selected. This treatment, in a series of
seventy-five cases, was followed by prompt deferves-
cence, and a disappearance of all faecal odor from the
stools.
The alkaloid which is produced is “Typhotoxine,”
and this, by its systemic intoxication, causes the fever
and the various typhoid degenerations. A filtered cul-
ture contains no germs, but its repeated injection into a
rabbit produces fever and other symptoms, and after
death the intestinal glands are found to be congested.
If the typhoid bacilli are mixed with a rabbit's food he
sickens, and at last dies, with all the physical and ana-
tomical signs of typhoid fever.
THE RöLE OF MICROBES IN DISEASE 417
VARIOLA AND WACCINIA.
We cannot, as yet, cultivate these germs outside of
the body, but when we do succeed in obtaining pure
cultures, the last support will be taken away from
that criminal folly—anti-vaccination.
WELOOPING COUGH.
Paulet discovered his microbe in 1867, cultivated it,
sprayed the culture into the tracheae of rabbits, and pro-
duced the characteristic spasmodic cough of pertussis.
Tschamer, of Gratz, repeated these tests, inhaled the
spores himself, and in eight days whooped violently, and
his sputum was found to be full of the growing colonies.
Many others have repeated these experiments with the
same results. This explains the good effect of phenol, in
sprays or when administered by mouth, and also the
benefit derived from inhaling the fumes from a gas-
house.
YELLOW FEVER.
Sternberg is somewhat doubtful as to the microbe of
this disease, but Freira and Carmona are more confident,
the latter naming his organism. “Peronospora Lutea,”
and both of them claiming very successful results from
inoculations with attenuated cultures.
MICROBES IN SURGERY.
Pyaemia is a general invasion of the body by the pus
Cocci, while septicaemia is a systemic intoxication pro-
duced by the absorption of the toxines or leucomáines
Set free by the microbes of decomposition. Puerperal
fever is often due to contagion, and always to sepsis
When it arises spontaneously, set up usually by putrid
matter in the uterus and vagina.
“Latent Gonorrhoea,” the specialty of the late Dr.
Noeggerath, though often ridiculed by old fashioned
Practitioners, “who never owned a microscope and
Wouldn’t know a germ if they saw it,” to quote Dr.
Noeggerath’s own words to me, is an excellent example
27
4.18 NEW YORK STATE MEDICAL ASSOCIATION.
Of what damage a few dangerous spores may do in the
life of a previously healthy woman. There can now be
no doubt that this is the cause of a great deal of pelvic
disease.
Osteomyelitis is caused by its special germ, already
cultivated by Pasteur and reproduced in animals, while
malignant Oedema is due to Koch’s “B. Oedematis Mo-
ligmi,” and “Swine-fever’’ to Klein’s “B. Pneumo-em-
teritis,” while the “Madura Foot,” of India, has a well
marked special organism, named from its discoverer,
“Chronypha Carteri.” -
Actinomycocis, the “big head” or “big jaw” of our
cowboys, is due to the growth in the body of the fungus
“actinomyces,” whose spores are found on herbage gen-
erally, but which are harmless until they gain entrance
through a wound. Men have taken it from picking their
teeth with a stem of grass or straw, and thus wounding
the gums.
“Chronic Leucorrhoea,” is always accompanied by
the “micrococcus albicans Amphes” of Bumm, who has
made pure cultures, and by inoculating them in the
vaginae of monkeys has reproduced the disease.
In operative surgery, how important are the microbes |
Pyaemia, hospital gangrene, and half-a-dozen other pests,
Once the surgeon’s perpetual dread and nightmare, are
now seldom seen, and experience has taught that if the
microbes are kept out of wounds they heal without pain,
fever or suppuration, and all sorts of major operations
may be done with the almost certain prospect of speedy
recovery.
Our immense canning and refrigerating industries de-
pend on the discovery that fermentation and decompo-
sition are due to micro-organisms, and that all that is
needed to preserve food indefinitely is to keep out the
germs. Nowadays ships leave New Zealand with thirty
thousand carcasses of sheep aboard; refrigerating ma"
chines, at work day and night, keep the hold at or below
the freezing point, and mutton can in this way be
THE RöLE OF MICROBES IN DISEASE 419
delivered in London Or Liverpool in prime condition,
and sold to consumers at about half the price of English-
grown meat. -
Let us now consider Some of the recent accessions to
our knowledge of microbes, and their relations to disease.
We find that B. Tuberculosis is far from being a
hardy plant; its cultivation is tedious, and it is easily
killed, even by a bright light. This explains why the
best-lighted rooms in barracks and prisons have less
than their proper average of cases of phthisis, and vice
versa. For years the fact that many simple exploratory
laparotomies in cases of tubercular peritonitis have been
followed by recovery, has remained a mystery. But it
is a mystery no longer—the light was too much for the
bacilli, and caused their death. Exploratory incision is
now deliberately done in these cases, an incandescent
lamp being introduced in order to thoroughly expose all
the viscera to the bright light.
In my former paper* I have discussed the question of
poisonous food “toxines”, so fully that I shall only
refer now to “Tyrotoxicon.” This has been proven to
be the cause of cholera infantum, and arises from fer-
mentation of milk in dirty bottles, nipples and tubes.
For years many of the more enthusiastic bacteriologists
in this part of the State have been getting excellent re-
Sults in cholera infantum by the administration of half
a milligramme of the bichloride of mercury every three
hours. At the end of seventy-two hours we expect to
find that 75 to 85 per cent. of our cases have assumed
the character of a simple diarrhoea. The green stools
of nursing children are almost a pure culture of the
microbes of “Tyrotoxicon.”
I must not forget the phagocytes, or wandering cells,
whose duty it is to devour the disease microbes which
invade the body. Thus, in a diphtheritic exudate we
find on its surface almost a pure culture of the Klebs-
Loeffler bacillus; in the deeplayers we find very few, but
* Trans. N. Y. S. Med. Assn., Vol. W., p. 102.
420 JNEW YORK STATE MEDICAL ASSOCIATION.
plenty of phagocytes stuffed full of half-digested bacilli.
The “toxine'' of these microbes is a powerful poison,
and causes the well-known nerve-cell degenerations,
whence arise multiform paralysis and frequent heart
failure. All these have been produced in a rabbit by
the continued injection of the “toxine,” although not
One microbe was present in his body.
The curious fact has been noted that a microbe, harm-
less in itself, may become fatal if injected in company
with another equally harmless microbe. Again, if we
poison an animal by one “toxine,” he is made thereby
Subject to quick death from an inoculation of the same
microbe. This shows why people already ill with typhus
fever, or tuberculosis, are so apt to have multiple ab-
cesses, for they become infected with the common sup-
puration cocci found in the air.
All our mucous cavities swarm with disease germs, but
they are kept off by the intact epithelia and the vigilant
phagocytes. If we weaken these guardians, a local
disease first appears; and if the phagocytes be too few,
or are weakened by previous disease or constitutional
inheritance, systemic infection follows.
The moral is, keep the skin clean and free from cracks,
cuts, and other solutions of continuity; clear out harm-
ful microbes by normal alvine evacuations. Headache
and bad taste in the mouth, so constantly present with
torpid liver and bowels, are due to “toxines” absorbed
from the intestine. You will find that attacks of furun-
culosis can be quickly cured by brisk laxatives and keep-
ing the intestinal tract aseptic for a few days. Ana-
logous to this is Sir Andrew Clark’s discovery that
chlorosis is a “toxine” poisoning—a “stercoraemia,” as
he calls it—due to chronic constipation.
So you see the old saw has yet teeth to it, which bids
us keep our heads cool, our feet warm, and Our bowels
soluble; though we give its ancient wisdom a new namº
and now call it “applied bacteriology l’’
ABDOMINAL HYSTERECTOMY FOR MYOMA.
By FREDERICK A. BALDWIN, M.D., of New York County.
Movember 15, 1892.
In the latter part of June, Dr. Sinnett brought to me
Kate W., born in the United States, single, twenty-five
years of age. Her family history was good.
Five years ago she began to have pain in the right
iliac region, beginning ten days before menstruation,
and ceasing as soon as the flow was established. This
continued every month up to the time of the Operation,
the pain during the past year being more severe, and
the flow of blood more profuse. She was under medical
treatment more or less during this time, but without
relief; she was losing flesh, and complained of being
tired.
Upon examination, we found the uterus enlarged, the
Sound entering the cavity four and one-half inches, and
by palpation a growth could be readily made out. The
diagnosis at this time was a fibro-cystic tumor of the
uterus.
The patient was informed that an operation would
have to be done, and its serious character fully explained
to her. She was put on tonic treatment and sent to the
Country for the summer. She returned on September
5th, looking and feeling much better. On examination
it was found that the tumor had increased about twenty-
five per cent. during the previous nine weeks, so im-
mediate operation was advised. Accordingly she en-
tered St. Elizabeth's Hospital on September 12th. On
the following day she was examined by Dr. S. J. Walsh,
Pr. J. H. Sinnett and myself, when we concluded that a
hysterectomy Would have to be performed. That evening
422 NETW YORK STATE MEDICALL ASSOCIATION.
she was given a purgative, and as this did not act
sufficiently, she was given a laxative pill the next night
and a bath of bichloride of mercury the next morning,
For her breakfast a bowl of bouillon was given at
seven o’clock. All the instruments used during the
operation had been previously boiled for twenty minutes.
At eleven o’clock on the morning of September 14th,
Dr. Sinnett etherised the patient, and the parts were
then shaved, and made thoroughly aseptic. She was
placed in the Trendelenburg posture, and with the assist-
ance of Dr. S. J. Walsh, and Dr. Valentine Mott, the
operation was begun by making the usual median inci-
sion, three inches in length ; the abdominal cavity was
opened, and the fingers passed around the tumor. There
were no adhesions, but it was found necessary to enlarge
the incision to six inches. The tumor was then brought
outside the abdomen, and wrapped in towels wrung out
of a hot Thiersch’s solution ; the intestines were covered
with flat sponges and pads of gauze moistened with the
same solution, and these were frequently changed dur-
ing the operation. s
An elastic ligature was placed around the cervix, and
a transfixion pin passed just above it. The tubes were
ligated and cut, and the uterus removed. There was
quite a free haemorrhage from the broad ligaments,
which was controlled by continuous sutures of catgut.
The patient became so weak at this time that a hypoder-
mic injection of whiskey was given, and this was re-
peated eight or nine times during the operation.
A V-shaped section was taken out of the stump, and
the cervical canal obliterated by the thermocautery; the
sides of the stump were then brought together with
sutures of twisted silk. On removing the elastic ligature
and pin, there was slight bleeding from the stump, which
was controlled by sutures of silk. The pedicle Was
dropped back. As the patient was suffering greatly from
shock, the abdominal cavity was hurriedly, but thor-
oughly, washed out with hot Thiersch's solution, a glass
ABDOMINAT, HYSTEREOTOMY FOR MYOMA. 423
drainage tube introduced, and the cavity filled with the
same hot solution and Sewed up in this condition with
silver wire Sutures.
The condition of the patient was such that I did not feel
warranted in taking the time to bring the peritonaeum
and fascia together with buried sutures. She was
wrapped in hot blankets and placed in bed with bottles
of hot water around her. It was then two hours since
beginning the ether, and the amount of ether used was
five-eighths of a pound. The shock was extreme ; radial
pulse imperceptible, and the patient in a condition
of collapse. She was given one-quarter of a grain of
strychnia, one-hundredth of a grain of atropine, and
one-sixth of a grain of morphine hypodermically, and an
enema of one ounce of whiskey and two ounces of hot
water. For the next three hours free stimulation was
continued, and she improved slightly.
At half-past four o’clock her pulse was 138, respira-
tions 15; and at this time, three ounces of red fluid
were taken from the drainage tube. One hour later
her condition was so much better, that a small quan-
tity of hot water was given by the mouth ; and at
Seven o’clock, whiskey and hot milk were given by
the rectum, but were not retained, and patient had a
Small stool. As she complained of great thirst, hot
Water was given in small quantities by the mouth at
frequent intervals.
At nine o’clock, her temperature was 101.5°, pulse 136,
respirations 20. The urine was drawn by catheter, and
One and a half ounces of red fluid taken from the tube.
At ten o’clock she was bright and cheerful; at eleven
o'clock she voided urine. She was then perspiring; her
temperature was 101.5°, pulse 134, respirations 20. Six
drachms of lighter colored fluid were taken from the
"be. She complained of pain in the wound, and was
8 Wen one-sixth of a grain of morphia hypodermically.
She passed a comfortable night, and at seven o’clock in
*morning had a movement from the bowels. Her tem-
424 JNEW YORK STATE MEDICAL ASSOCIATION.
perature was 100.5°, pulse 128, respirations 17. During
the day, the fluid was removed from the tube every two
hours. She had a full natural movement from the
bowels, and took a little whiskey and milk.
At six o'clock her temperature was 99°, pulse 112,
respirations 15. From this time on, all nourishment
was given by the mouth. For the next twenty-four
hours she had whiskey and milk, then beef tea, and on
the fourth day after the operation, eggs were added to
her diet. In the evening the first dressing and tube
were removed, and the edges of the wound brought
together with plaster and a dressing of iodoform and
moist bichloride gauze applied. She slept over four
hours during the night, and at nine o’clock the next
morning her temperature was 99°, pulse 96, respirations
16. She passed a comfortable day; nourishment was
given every two or three hours, and at ten o’clock the
next evening her temperature was 100.2°, pulse 104 and
respirations 16. For the next eight days, she had an
evening temperature ranging from 99.5 to 100°, but after
the sutures were removed, it did not go above 99°.
She had no distention of the bowels, but as a precau-
tionary measure, she was given one drachm of Sulphate
of magnesia, which produced the first nausea since the
operation. In the morning she was given a Seidlitz
powder, and later one drachm of sulphate of magnesia,
which she vomited in a few minutes. At eleven o’clock
she had three watery movements from the bowels. She
continued to do well, and on the ninth day the sutures
were removed, and the wound was found to be healed.
Another dressing was applied and left on for one week,
when it was changed, and the patient allowed to sit up
in bed. Three weeks from the day of operation she was
allowed to get up and be about the ward, and five weeks
from the day she entered the hospital she returned
home.
On October 26th I examined her, and found the wound
in good condition, and the cervix freely movable. She
DISCUSSION. 4.25
had increased in weight, and was feeling better than at
any time during the past three years.
i)uring the fourth week after the operation she com-
plained of peculiar sensations in her head, and of hot
flashes over her body, sensations she had never expe-
rienced before.
The tumor, after being washed and drained, weighed
four and three-quarter pounds; it was very vascular,
and, I think, contained fully three pounds of blood,
which would make the weight of the growth between
seven and eight pounds.
A section of the tumor was sent to the Carnegie
Laboratory and examined by Dr. Edmund K. Dunham,
who reports as follows:
Microscopical examination of the growth from the
uterus reveals the structure of a myoma. The appear-
ance harmonises with the history of rapid growth, in
that the cells appear young and ill-developed ; but I do
not think the structure warrants the diagnosis of Sar-
coma. There is very little fibrous tissue present, the
great bulk of the growth being apparently composed of
unstriped muscular tissue.
DISCUSSION.
DR. H. D. INGRAHAM, of Erie county, wished to congratulate the
reader of the paper on the successful issue of his case. In fact, so terrible
are these cases of fibroid tumor or myoma that an operation with recovery
should always be considered an abundant cause for congratulation. He had
removed several fibroids by operation, and had treated a good many of them
With electricity, but he had come to the conclusion that aside from stop-
ping the haemorrhage, electricity did very little good, and often caused a
great deal of harm, notably by causing the formation of adhesions. If a
Case of fibroid tumor be amenable to operative treatment, it should be
treated in that Way, and the sooner the better. The difficulties attendant
"pon Such operations can hardly be exaggerated. He had seen Bantock,
of London, work almost three hours over such a case, but he was rewarded
by saving his patient's life.
& The speaker said he had gone to Philadelphia on the way to this meet-
ing, for the express purpose of seeing Dr. Baer, of that city, perform his
original Operation for fibroma. The operation which he saw him do was
the sixteenth according to this method, and he had already reported eleven
426 JWE W YORK STATE MEDICAL ASSOCIATION.
recoveries out of his first twelve operations, the death in the one fatal case
being due to shock. Dr. Baer places the patient in the Trendelenburg
position, and brings the tumor outside of the abdominal cavity, and pass-
ing a curved needle close to the uterus, ligates the broad ligament.
(Method of ligation illustrated.) He then dissects down to the cervix and
amputates it, and after pulling the peritonaeum over it, and perhaps taking
a stitch or two in the peritonaeum, he drops the cervix back into the pel-
vis. In the case referred to, not a teaspoonful of blood was lost from the
neck of the uterus. Seven or eight hours after the operation his patient.
was in excellent condition. The speaker thought this was the best opera-
tion of the kind which had yet been devised.
DR. JoHN CRONYN, of Erie county, said that in connection with the
use of electricity in gynaecology he wished to refer to a case which had
come under his observation, in which electricity had led to a fatal termina-
tion. The patient had a fungous growth involving about two-thirds of the
right side of the uterus, which he advised her not to have removed. She
consulted a gynaecologist who, after puncturing the growth with a trocar
and examining the contents of the tumor, expressed his willingness to
operate if the patient would take the risk. This she declined to do.
Although the speaker had cautioned her against submitting to electrical
treatment, she went to a gentleman in Buffalo who is fond of using elec-
tricity, and allowed him to treat her by electro-puncture, with the result
that the tumor rapidly increased in size until it finally ruptured and caused
her death three hours after the last electrical treatment. The post-mortem
examination showed the abdomen filled with clotted blood, and an enormous.
cauliflower growth protruding from the fundus uteri. Recent literature
seemed to him to clearly establish the fact that although electricity may be
useful in some departments of medicine, it has no place in gynaecology.
DR. F. W. Ross, of Chemung county, said that the case just narrated
was evidently not a proper one for electrical treatment, but that was no
reason for condemning the whole method of treatment. In that case the
electricity was, without doubt, improperly applied. All that Apostoli and
his followers claim to do is to arrest haemorrhage, reduce the size Of the
tumor in many cases, and in general to relieve the symptoms. Personally,
he preferred giving the patient the benefit of a trial of electricity before
attempting the removal of a large tumor by operation.
DR. J. G. TRUAx, of New York county, commended the filling of the
abdominal cavity, after the operation, with warm Thiersch's solution, and
called attention to the fact that it was so quickly absorbed that there W88.
good reason for believing that it lessened shock and favored recovery. He
advised irrigating the abdominal cavity with this solution, or with Warm
sterilised water, in every case of this kind.
ExTRACTION OF STEEL FROM THE INTERIOR
OF THE EYE WITH THE EIECTRO-MAGNET.
By ALVIN A. HUBBELL, M.D., of Erie County.
November 15, 1892.
The use of the magnet in removing steel from the eye
has been suggested and practiced at various times in the
past, but the merit of effectually introducing it and
stimulating the profession to examine into its utility, is
due, first, to Dr. W. A. McKeown, 1 of Belfast, Ireland,
who, in 1874, published his experience with the per-
manent magnet, constructed with a tapering point; and
to Dr. J. Hirschberg,” of Berlin, who, in 1881, published
the results of his experiences with the electro-magnet as
most ingeniously adapted to the eye by himself. Since
then, various forms of both permanent and electro-mag-
nets have been constructed, and every good ophthalmic
Surgeon makes one of these instruments an especial part
of his armamentarium. The permanent magnet, how-
ever, has so little power of attracting iron as compared with
the electro-magnet, that the latter has quite superseded
the former. Hirschberg's electro-magnet is, perhaps,
the form most used at the present time; yet, of all with
Which I am acquainted, this is the most cumbersome and
unwieldy.
It was upon the failure of a Hirschberg magnet in the
hands of a friend to serve the purposes desired, together
with peculiar circumstances pressing upon me, and a de-
* to save a patient’s only eye, that I was led, in 1884,
* devise an instrument that seemed to me to be more in
*ord with the needs of the case then put into my hands.
I submitted the plan for an electro-magnet to a practical
* British Medical Journal, vol. I., 1874.
* Archives of Ophthalmology, vol. X., 1881.
428 NEW YORK STATE MEDICAL ASSOCIATION.
electrician of my city, who made for me the One hereto-
fore published in the Buffalo Medical and Surgical
Journal for July, 1888. George Tiemann & Co., of New
York, have, at my suggestion, recently made Some im-
provements in its construction, preserving at the same
time the essential features which distinguished the
Original.
In its new form the core is solid, soft iron, instead of a
bundle of wires, and the connecting-posts are enclosed
in a hard-rubber mould, which carries a slide by which
the electric circuit may be closed when the magnet is
being used, and opened when it is not in use. The insu-
lated wire surrounds the core in eight layers, and this coil
is encased by a light, hard-rubber jacket.
Some of the extension-points have been Squared or
flattened at their ends, by which more surface of contact
is presented, and their holding power increased. The
accompanying cut gives an excellent representation of
the magnet and extension-points in actual size, as now
manufactured by George Tiemann & Co.
ELECTRO MAGNET, ACTUAL SIZE.
A, A, ends of cords connecting the magnet with a galvanic battery; B, slide.”
opening and closing electric circuit; C, end of core tapped to receive the extenSiOD-
points. The extension-points, a few of which are shown, may be of any desired length,
shape, curve or size.
The instrument is 3% inches in length, including the connecting
posts, the body being 2% inches long. It is a little less than 3% inch in
diameter, and it weighs 3% ounces. In power of attraction it seems equal

EXTRACTION OF STEEL FROM THE EYE. 429
to that of the original one which, when connected with an ordinary, single,
quart-cell battery, was found by careful tests to suspend 31 ounces of iron
with an extension-point % inch long (measuring from the face of the mag-
net) and º, inch in diameter at its end; 28 ounces, with one V4 inch long
and ſº, inch in diameter; 24 ounces, with one the same length and # inch
in diameter; and 18 ounces, with one the same length and ſº, inch in
diameter.
The power of attraction diminishes very rapidly as the size of the point
is lessened, or its length increased. Therefore, in using the magnet, as
short and large an extension-point should be selected as is consistent with
the case in hand. The length need never exceed 34 inch. The points
may be curved or straight and of any shape desired.
The electric circuit should always be opened by pushing the slide
toward the end receiving the connecting-wires, when the magnet is not
being used, as the current heats the wire of the coil if allowed to pass too
long. The magnet can be used with any galvanic battery, by not turning
on too strong a current ; but the manufacturers supply a cell suitable for
the instrument.
The advantages claimed for this magnet are : Its great
power of attraction, its lightness, its small size, and its
shape, most convenient for manipulation. With this
instrument I have extracted steel from the interior of
the eye in the following cases:
CASE I. Michael S., forty-three years of age; boiler-maker, was struck
in his left eye, June 18, 1884. The sight, he says, was destroyed at once,
and an ophthalmic surgeon enucleated the ball.
On the morning of August 27 following, two months after the accident
to the left eye, while striking a “set,” a chip of steel flew into the right
eye. The eye “watered” some afterwards, but there was very little pain,
and the vision was “pretty good.” Attempts were made on the 28th by a
fellow-practitioner, to extract the steel through the wound produced by it
by means of a Hirschberg magnet, but without success. The doctor
declined to make further efforts to get the foreign body, and the patient
Was placed in my hands on the evening of August 30. The eye at this
time was in constant pain with a “pricking” sensation in its upper part.
Vision was reduced to counting fingers. There was considerable lachry-
mation, the lids were somewhat swelled, the eye-ball was very red, and the
Conjunctiva of the lower part was chemotic. There was a wound two to
three millimeters long at the junction of the lower part of the cornea and
selera, This was still open, and a bead of vitreous was pressing through
it. The pupil was irregular in shape, a piece of iris evidently having been
* off in the direction of the wound. The ophthalmoscope showed the
* Cases I. and II. have already been published in the Buffalo Medical
*d Surgical Journal, July, 1888.
430 NEW YORK STATE MEDIOAL ASSOCIATION.
fundus to be greatly obscured by haemorrhage or inflammatory products
in the vitreous, and the steel could not be seen. I was assured, however,
that it had been seen in the vitreous. The lens appeared to be perfectly
transparent, the wound and field of previous operations having been
through the suspensory ligament.
The case did not present a very hopeful prospect, but as this was the
only eye left to him, I was willing to add my efforts to those that had
already been made to extract the steel, and, if possible, save at least a little
vision. The first thing needful, however, was a good electro-magnet, and
this I did not possess, and my only means of obtaining one within a brief
time was to have one made. I at once applied to an electrician of my city
and suggested to him how one, in my opinion, should be made. At 10 o'clock
the next day he had one ready.
At 11 o'clock A.M., August 31, just four days after the injury, I pro-
ceeded with the proposed operation. The patient being anaesthetised, I
dissected back a small triangular flap of conjunctiva from the sclera between
the equator of the ball and the ciliary region, and between the external and
inferior recti muscles. After the haemorrhage was stopped, I made an
antero-posterior incision about three millimeters long, through the sclera
into the vitreous. A few drops of straw-colored fluid escaped. Through
this incision I introduced into the vitreous an extension-point of the electro-
magnet, about one centimeter in length and one millimeter in diameter at
its end. I directed the point at first towards the centre of the ball and pos-
teriorly, but found nothing. I then directed it forwards, when I both felt
and heard a distinct click, which was also heard by the bystanders. On
withdrawing the point the steel came with it, firmly held in its magnetic
grasp. It was a thin scale about three millimeters in length and one and a
half in width. The conjunctival flap was replaced over the incision and
sutured at its apex.
Very little reaction followed the operation, and both the original and
operative wounds healed kindly. After several months the opacities
had cleared up in the vitreous, and the patient was able to read No 2
Jaeger at fourteen inches with the aid of + 1.00 D glass. The visual
field was considerably contracted—most, however, on the inner side. The
ophthalmoscope showed marked choroidal changes, such as are found after
choroiditis, and these were numerous, but most marked in the lower and
outer parts of the fundus. The patient reads a gread deal and is enabled
to earn an independent livelihood.
CASE II. April 5, 1888, I was invited by Dr. Frank W. Abbott, of
Buffalo, to assist him in the following case: On April 3, Miss A., about
twenty years of age, was stitching leather with a sewing machine, when the
needle broke and a piece struck her right eye. She applied to Dr. Abbott
for advice, not, however, suffering much distress or pain. On examination
there was scarcely any evidence of injury, except that the anterior chamber
was obscured with blood. A solution of atropia was instilled, and She W*
asked to return in two days. At this time I was invited to see the C*
ExTRACTION OF STEEL FROM THE EYE. 431
The blood had become absorbed, and the pupil was nearly at its maximum
dilatation, thus permitting an easy examination of the fundus. The Oph-
thalmoscope showed all the media to be transparent. A piece of the
sewing-machine needle could be distinctly seen in the vitreous, projecting
from the anterior and inner part of the cavity directly towards its centre.
A slight mark could be distinguished externally at the inner cornea-scleral
junction, indicating the point of its entrance. It had evidently passed
through the iris, and nearly through the ciliary body by which it was now
firmly held. The eye was slightly red and irritable.
Arrangements were made for an operation on April 6, at which I
assisted with my electro-magnet. The patient being anaesthetised, Dr.
Abbott excised a piece of conjunctiva immediately posterior to the point of
entrance of the needle on the inner side of the ball over the ciliary region
The haemorrhage was stopped, first using pieces of ice, but afterwards
cotton steeped in hot water, which was much more effective. He then
made an antero-posterior incision about three miliimeters long, directly
down to the steel, through the sclera and ciliary body into the vitreous
cavity. The magnet being in readiness, I introduced a small extension
through the incision, and it at once grasped the broken needle, but without
loosening it. I held it steadily with the magnet while the doctor enlarged
the incision anteriorly until it was entirely disentangled, when it was easily
withdrawn, adherent to the magnet.
The conjunctival wound was closed by two sutures passed perpendic
ularly to the sclerotic incision. The patient was kept quietly in bed a few
days with the eye bandaged, and atropia was occasionally instilled.
I examined the eye four weeks after the operation, and it appeared to
have fully recovered, and vision was, the patient said, “as good as ever.”
CASE III. Patrick H. E.,, twenty-eight years of age, boiler-maker,
While caulking a boiler, using a hammer and caulking tool, on August 6,
1888, was struck by a scale of iron on the outer part of the cornea of the
left eye. He visited an oculist of Buffalo, who examined his eye and told
him that there was steel in it. He prescribed for him a two-grain solution
of atropia, to be instilled every two hours, and directed him to call in two
days. The patient then went to his family physician, who advised him not
to Wait so long, and sent him to me. I found a vertical wound in the left
99Thea, One millimeter to the inside of the outer margin and two milimeters
long. The iris beneath also had a vertical wound a little shorter and
slightly gaping. No foreign body could be seen by an external examina-
tion, and with the ophthalmoscope the fundus appeared clear posteriorly;
but to its outer side there was a dark, opaque spot behind the region where
*iris was wounded. The vision was normal. There was no pain in the
*.*, but there was some lachrymation, and the eyeball was reddened. I
diagnosed Steel in the eye and proceeded to find and remove it, if possible,
With the electro-magnet. I used a small extension-point a little less than
* “entimeter in length. After thoroughly cocainising the eye I intro-
duced this through the wound of the cornea and iris produced by the
432 MEW YORK STATE MEDICAL ASSOCIATION.
foreign body, carefully avoiding the crystalline lens. I passed the point
to the depth of about one-half centimeter, when the iron struck it with a
distinct click, which was heard by all present. It was firmly held by the
magnet, and was drawn out through the wound by a little effort and after
enlarging the wound slightly with a knife, the edges of the steel being
ragged and catching On the surrounding tissues. The magnet was aided
by forceps in the extraction, after the steel was brought to the wound.
The steel was a thin scale seven millimeters long and two millimeters
wide at its widest part, and weighed one grain. The crystalline lens did
not seem to have been wounded either by the passing in of the steel or its
removal. The eye was dressed with one to four thousand bichloride solu-
tion, and a four-grain solution of atropia ordered to be used every two
hours. The eye was considerably inflamed for two days after the opera-
tion, but from that time on recovered rapidly, and on September 29 it was
well. There was a slight scar of the cornea, and the iris showed a vertical
slit at the point of injury. The crystalline lens was dotted with opacities.
The vision equaled No. 60 Snellen at four meters, and Jaeger No. 18 slowly
at ten inches. The patient was not seen afterwards. In this case the eye
was saved, but a traumatic cataract followed which, if successfully
removed later, would undoubtedly have given good vision.
CASE IV. George C., twenty-nine years of age, blackSmith, consulted
me on the evening of August 6, 1890, for an injury of his eye. That after-
noon while cutting a bolt with a “cold chisel” a piece of the steel flew off
and struck his left eye. I found a vertical wound about four millimeters
long just outside of the inner cornea-scleral junction, and the iris was pro-
truding through it. The anterior chamber was filled with blood, and the
fundus of the eye could not be seen with the ophthalmoscope. No foreign
body could be seen upon external examination, but I was of the opinion that
a piece of iron had entered the vitreous space. Under cocaine anaesthesia
I cut off the protruding iris, and with the electro-magnet armed with an
extension-point one centimeter in length and one and one-half millimeters in
diameter at its end, I began my search. On introducing the point to a
depth of about one-half centimeter it caught the iron with a pronounced
click, and on being withdrawn brought it to the corneal wound. I found
it to be a large piece of irregular and ragged contour, and it became neces-
sary to enlarge the wound a little and assist with forceps before it could
be drawn out. The conjunctiva was drawn together over the sclerotic
wound by a suture. After instilling a six-grain solution of atropia, the eye
was dressed with 1 to 4,000 bichloride solution, and both eyes Were band-
aged. The piece of steel was one centimeter long, one-half centimeter
wide, and two millimeters in thickness, and weighed seven grains. Some
inflammatory reaction followed the operation, but this soon subsided. The
pupil was kept dilated by atropia, and the suture was removed on the fourth
day. The patient was discharged September 29, with vision equaling No.
24 Snellen at three meters. At this time the media were all clear, but tº
fundus showed several spots of choroidal atrophy at its inner side.
FXTRACTION OF STEEL FROM THE EYE. 433
CASE W. Michael B., thirty-nine years of age, laborer, consulted me
December 13, 1890. Two days previously a piece of steel from a hammer
struck his right eye. The eye pained him for a short time, but had since
been easy, and at this time was only slightly red. Vision equaled No. 60
Snellen at one meter. The anterior chamber was normal ; pupil normal in
size and responded well to light. At the Outer part of the cornea, One
millimeter inside of its margin, there was a vertical cut one millimeter in
length, nearly healed. The iris showed a minute vertical opening at its
outer side, half way between its pupillary margin and periphery, the bot-
tom of which appeared whitish. The pupil dilated readily under cocaine,
and the ophthalmoscope showed the lens to be slightly hazy at its posterior
part, and at its outer and anterior portion was a milky-looking reflection
one millimeter wide, starting from the iris-wound and running backwards
about four millimeters. Instillations of atropia and boracic acid Solution
were used every four hours.
December 14, 9 A. M., consultation was held with Dr. Abbott, who
agreed with me that there was steel in the eye. Under cocaine I made a
vertical incision of the cornea near its outer margin and Over the iris-wound,
and introduced through this and the opening in the iris, electro-magnet
points of different sizes and lengths, but could not find the steel, although
they were passed as deeply into the vitreous as seemed prudent. The eye
was then dressed, and atropia and boracic acid solution ordered as before.
December 16, the eye was painful and much inflamed. Gave the
patient chloroform and made another attempt to find the steel with the
magnet, and succeeded, introducing the point through the same wound as
before. The steel was very minute in size, being a thin scale, two milli-
meters in length and half a millimeter in width. Inflammation, which had
already begun, continued, and resulted in panopthalmitis, necessitating
enucleation of the ball at the end of four weeks.
CASE WI. Fred T., thirty nine years of age, laborer, visited me De-
Cember 5, 1891. He stated that the day before, while cutting off a rivet
from a salt evaporating-pan with a chisel, he was struck in the right
eye by a piece of iron. Upon examination of the eye I found it in-
flamed, with a wound in the ciliary region near the outer border of the
Cornea, extending obliquely downwards and inwards, and about six milli-
meters in length. The iris was protruding between the lips of the wound,
and both the aqueous and vitreous chambers were filled with blood. Vision
°qualed no perception of light. Under cocaine the iris-protrusion was
* off. An exploration was then made with the electro-magnet, using an
extension-point one centimeter long and two millimeters in diameters at its
end. On passing the magnet about three millimeters into the vitreous and
directing it backwards, some stagnant blood flowed out and the iron was
ºracted to the magnet with a pronounced click, as is usual in such cases.
The piece of iron seemed to lie across the wound, and it was worked down
and back With a silver probe, and after a little came out end-wise without
*ging the wound. I instilled a four-grain solution of atropia, and
dressed the eye With 1 to 4,000 bichloride solution.
28
434 NEW YORK STATE MEDICAL ASSOCIATION.
The iron was a thick scale twelve millimeters long by four wide, and
weighed three grains. Considerable inflammation followed, the conjunc-
tiva becoming chemotic and the eyelids swelled. This subsided, however,
in a few days, when he returned to his home fifty miles distant, after
which I lost sight of him.
CASE WII. William M., twenty-two years of age, boiler-maker, called
at my office November 30, 1891, and stated that he had been struck in the
left eye about an hour previously with something while caulking a boiler
with a hammer and caulking tool. I found some blood in the lower part
of the anterior chamber, and there was a cut through the sclera just below
and to the inner side of the cornea, extending horizontally inwards and
about three millimeters in length. No foreign body could be seen by
external examination. The pupil was dilated under atropia, but the
ophthalmoscope showed the fundus to be clouded with blood. The patient
bad no pain. Vision equaled No. 5 Snellen at two meters.
My diagnosis was steel in the vitreous humor. Under cocaine I intro-
duced a point of the electro-magnet through the wound, and at a depth
40f not more than three millimeters caught a piece of iron and drew it out
by a little coaxing, without the aid of any other instrument. The con-
junctiva was drawn together over the sclerotic wound, a solution of atropia
was instilled into the eye, and a bichloride dressing applied.
The steel was a thin scale about seven millimeters long, one and one-
half wide, and weighed one-half grain. The eye recovered without any
inflammatory reaction, and at a subsequent examination the vision was
found to be No. 5 Snellen at five meters.
CASE VIII. Arthur S., twenty-four years of age, machinist, on Janu-
ary 14, 1892, while holding a mandrel for another man to strike with a
sledge-hammer, a piece of something flew and struck his right eye. He
consulted me about four hours after the injury, and I found a clean-cut,
vertical wound at the outer margin of the cornea in the Sclera. It was
about three millimeters long, and the periphery of the iris was drawn into
it, giving the pupil an irregular shape and a displaced position. With a
probe, gently used, the iris and pupil were restored to their proper
position, when an opening was detected through the iris and suspensory
ligament of the lens. The eyeball was red, but the patient complained of
very little pain. I could not see the bottom of the fundus with the oplithal-
moscope on account of the blood in the vitreous. Vision equaled No. 9
Snellen at one meter.
My diagnosis was a piece of iron in the vitreous humor, but on several
careful trials with various sized points of the electro-magnet introduced
through the wound, I could not find any. Failing in these efforts, I in-
stilled a six-grain solution of atropia and applied bandages, with directions
to call again the next day. e
January 15, 10 A.M.–The eye had been comfortable since last visit,
Vision equaled No. 9 Snellen at one and one-half meters. The pupil was
dilated, and with the ophthalmoscope I could see at the upper and back
I, XTRACTION OF STEED FROM THE EYE. 435
part of the fundus to the right side a black opacity appearing to be about
six millimeters in diameter, making positive the diagnosis of steel in the
vitreous chamber. The corneal wound had closed and the aqueous humor
had re-formed. Atropia was again instilled and the eye bandaged.
January 16, the eye was more inflamed. Vision equaled No. 24 Snellen
at one meter. Dr. Abbott was called in consultation and agreed with me
as to the diagnosis and that another attempt at extraction should be made.
After cocainising the eye thoroughly a small conjunctival flap was raised
from the sclera on the Outer side of the ball, between the external and in-
ferior recti muscles. After the haemorrhage was stopped, a borizontal
incision about four millimeters long was made through the Sclera into the
vitreous. Through this I introduced a somewhat curved extension-point
of the electro magnet, having a length of about one centimeter, and a
diameter at its end of one and one-half millimeters. At a depth of about
five millimeters the magnet caught the piece of iron, and it was easily
brought out. It was a thin scale two millimeters long and one and one-
half wide, and weighed about one-fourth of a grain. The conjunctival
flap was replaced with a suture at its apex, atropia was instilled, and the
eye bandaged.
January 17, 11 A. M. He had very little pain during the past twenty-
four hours. Pupil was well dilated and vision equaled No. 9 Snellen at
two meters. The eye afterwards healed well, but on March 22, vision was
lowered to a few of No. 12 Snellen at two meters. The media were trans-
parent.
CASE IX. John S., twenty years of age, a boiler-maker, consulted me
February 21, 1892, with a history that two hours before, while driving a
Steel plug into a boiler, a piece of iron struck the left eye. There was a
Small wound through the lower lid below the central part of its margin,
and one through the sclera a little to the left of the lower margin of the
Cornea. Beneath this a small, shiny spot could be seen in the iris. A fine
probe showed that the wound extended into the vitreous at this point.
Vision equaled No. 36 Snellen at one meter. Under cocaine the electro-
magnet was applied, introducing a small point one centimeter long through
the original wound, which had been slightly enlarged with a knife. At the
depth of about three millimeters the magnet caught the piece of steel, and
*fter several attempts it was drawn out. Atropia was instilled and the eye
Was dressed antiseptically.
The steel was a thin scale about one and one-half millimeters Square.
The eye made a rapid recovery, and on May 29, with —3.00 D, vision
*qualed No. 18 Snellen at five meters, and the media were transparent.
CASE X. William T. G., thirty years of age, a machinist, was brought
to me by Dr. A. G. Bennett for consultation August 8, 1892. Sia weeks
before he was struck in the left eye with a piece of steel. Vision was
*Paired at once. The patient had a druggist look at his eye, but no foreign
. °ould be seen. He gave him some “eye water,” which he used and
**W* Šave no pain or trouble; but, as the vision did not improve, he ap-
Plied to Dr. Bennett a few days ago, who examined him and made a diag-
436 NEW YORK STATE MEDICAL ASSOCIATION.
nosis which I consider most commendatory to his judgment and skill as a
young practitioner. My own examination simply confirmed his diagnosis.
IExternally, the eye appeared perfectly normal, except that a minute hole
could be seen in the iris at its inner part near its periphery. The pupil
being dilated with a mydriatic, the ophthalmoscope showed a few minute
opaque dots in the lens as if ‘‘peppered ” in half a dozen places, but other-
wise the media were transparent. Every part of the fundus was normal,
except at the macular region. Here, extending from the macula lutea
directly upwards was a black line, in length a little less than the diameter
of the optic disc, and in width a little more than the diameter of the largest
retinal vein. It showed a slight lustre and on each side was seen a white
line, evidently the sclera, exposed through the split choroid. Around this
was a line of pigment. Peripheral vision was apparently normal, but
central vision and that part of the field a little below the centre was lost.
At a distance of five meters the central scotoma was about the size of a
man's head. I did not take a perimetric chart of the field. By looking a
little eccentrally, vision equaled No. 60 Snellen at five meters. There was
no doubt in my mind as to the correctness of Dr. Bennett's diagnosis of
steel in the retina at the upper part of the macula lutea.
What should be done 7 It was agreed that the eye would be better off
with the steel out, that very little danger would attend a careful attempt
at extraction, and that if the effort was unsuccessful, the eye would not
suffer more in the end.
The eye, therefore, was thoroughly anaesthetised with cocaine and the
proposed operation begun. A triangular conjunctival flap having been
raised from the sclera in front of the equator, and between the external
and inferior recti muscles, haemorrhage stopped, and a horizontal incision
five millimeters long carried by Dr. Bennett through the bared sclera into
the vitreous, I placed the patient in a convenient position in which I could
use both the ophthalmoscope and the electro-magnet. I used an extension-
point one and one-half centimeters long, with end one millimeter in diam-
eter, and curved so as to be directed easily towards the macula. With my
right hand I introduced this point through the sclerotic incision, and under
the clear observation of the fundus with the ophthalmoscope held in my
left hand, cautiously passed it through the vitreous to the macular region,
lightly touched the black object, and then withdrew the magnet with the
offending body on its point. The single attempt secured the coveted
trophy.
The conjunctival flap was replaced and held by a suture at its apex,
atropia instilled, and the eye bandaged. No reaction followed the Opera-
tion, and the eye rapidly recovered. The steel extracted was a minute scale,
one and one-half millimeters long and three-fourths of a millimeter wide.
October 23, 1892.—Eleven weeks after the operation the eye appeared to
be normal on external examination, and with the ophthalmOSCOP9, the
pupil being dilated with a mydriatic, the lens presented the same appear-
ance as before the operation, the vitreous was transparent, and at the
macular region at the point from which the steel had been extracted, there
EXTRACTION OF STEEL FROM THE EYE. 437
was an area of about the same extent (although a little wider) as seen at
the first examination, resembling in disturbance of pigment and color a
patch of choroidal atrophy. Vision was the same as before the Operation,
but the eye was more sensitive to light.
This case, to me, is a most interesting one, and is one among a very few
on record in which steel has been successfully extracted from the retina.
The injury which the steel inflicted was peculiar in view of its location, and
although the vision was permanently impaired by it, the operation of ex-
traction did not further lessen it.
REMARKS.
In this group of ten cases, all that I have seen, it will
be noted that in every case the steel was found in Some
part of the vitreous space. In every case it had entered
near the cornea-scleral junction and passed through the
iris and suspensory ligament or ciliary body. In One
case it passed through the lower lid first, and then
through the cornea and iris into the vitreous. In eight
cases it seemed to be resting in the vitreous. In One it
was lodged in and held at its outer extremity by the
ciliary body, and in one it was imbedded in the retina.
The size of the steel varied from a minute scale to a large
piece weighing seven grains. In every case but one the
accident occurred while striking steel with a hammer,
and the steel was propelled with great momentum. One
eye was lost by infection, although antiseptic precautions
Were taken in this, as in all the other cases. In three cases
the first attempt at extraction failed. In one of these a
Second attempt through the original wound, and in two
through a sclerotic incision, was successful. In the first
of these the eye became infected and was afterwards
enucleated. The other two recovered with useful vision.
In seven cases the steel was extracted through the original
Wound on the first attempt. In one the first attempt was
by an incision through the sclera and was successful.
These Cases only add further and impressive illustra-
tions to those furnished by other ophthalmic practitioners
of the benefits of the electro-magnet in the class of in-
Jºries under consideration. The lesson is that with it in a
8*at majority of the cases in which iron has been driven
438 WETW YORK STATE MEDICAL ASSOCIATION.
into the cavities of the eye, this can be saved with more
or less vision ; while without it almost every one would
be totally lost, and perhaps cause, also, the loss of its
fellow eye. In some cases the injury to an eye is so
great that no attempt should be made to save it by
removing the steel, but it should be enucleated or
eviscerated at Once. -
In considering the propriety or need of using the
electro-magnet, a correct diagnosis is always desirable,
but this is often not easily arrived at.
The history of the case that in hammering or working
iron a splinter has struck the eye, that it has made
a wound through its coats, and that the piece was not
afterwards found by the patient, makes the presumption
very strong that it has entered the eye. As a rule, a
minute object striking the eye with sufficient force to
cut through its coats is carried on into the non-resisting
fluids within by its own momentum. The examination of
the eye by oblique illumination and the ophthalmoscope,
the pupil being dilated, if possible, sometimes gives
negative and sometimes positive information.
Steel may be lodged at any point in the cornea, Sclera,
iris, or lens, or in the vitreous or inner coats of the eye.
Blood and inflammatory exudates and opacities of the
cornea or lens obscure the view. But when there is
no obscuration, steel is easily recognised by its black
appearance, or by its shining lustre from the reflection of
the light from the ophthalmoscope or focal illumination.
This lustrous reflection often replaces the dark appear-
ance of the iron. If the iron is in the vitreous cavity, it
will appear, when seen with the ophthalmoscope, Very
much magnified in size.
The sensations of the patient or the state of vision are
of very little value in making out a diagnosis. The
diagnosis is positive when the foreign body can be seen ;
when it cannot be seen it is probable in different degrees
of certainty according to the history of the injury and
the character of the wound inflicted.
EXTRACTION OF STEEL FROM THE EYE. 439
In using the electro-magnet in a case in which steel
has either probably or positively entered the eyeball, it
should be made to pass as directly as possible to the
supposed or known location of it in lines of least resist-
ance, and through an area of least functional value.
Sometimes the accident-wound meets these requirements,
but oftentimes it does not. If steel has penetrated into
the vitreous through the cornea near its margin, and
through the iris and suspensory ligament of the lens,
there is always great danger of adding further trauma-
tism to the parts, and especially to the lens. That part
of the ball through which the magnet can be introduced
with least danger to important structures and to sight,
and at the same time most accessible to every point
within the vitreous chamber, is the sclera just in front of
the equator of the ball, and preferably in most cases on
the outer side between the external and inferior recti
muscles. It is better to make the sclerotic incision after
dissecting up at the place chosen a small triangular flap
of conjunctiva, or excising a piece and stopping the
haemorrhage.
Had I selected this position for operative procedure in
Case W., instead of endeavoring to follow the track of the
steel, I have no doubt that I would have found and
removed it on the first attempt, and saved the eye.
In Cases I. and VIII. the effort to extract the steel
through the cornea and iris-wound failed after several
trials. But on opening the sclera, as described above, the
first introduction of the magnet secured and brought it out.
Case X. shows, also, how the magnet-points may be
passed directly to the macular region (and, indeed, to
any other) with the minimum of operative traumatism to
the eye. It is also a forcible illustration of the greater
ease and Safety with which a piece of steel imbedded in
the coats of the eye posteriorly can be reached, than by
*9te extended operative procedures.
The early use of the electro-magnet is preferable to
Wºlting till pathological processes follow the introduc-
440 NEW YORK STATE MEDICAL ASSOCIATION.
tion of the steel. Sometimes, it is true, the eye will
tolerate steel for an indefinite period of time, perhaps for
years, but this is the exception rather than the rule. By
waiting, the steel becomes imbedded in exudates, when
the magnet cannot attract it at all, and if the eye does
become inflamed, enucleation is then the only safe treat-
ment. The proper use of the magnet is usually so suc-
cessful when applied early, that it seems to me there is
no alternative between immediate operation and delay.
The form of electro-magnet, especially of the extension
points, is a matter of no little importance. The magnet
itself shonld be as light as possible consistent with
sufficient attracting power, and of a shape convenieut
for handling. The extension points should be as near
as practicable to the coil around the core, and no
longer than is necessary to reach the supposed location
of the steel, and certainly never more than two centi-
metres (three-quarters of an inch), and at the ends from
one-half to one and one-half millimeters in diameter.
The power of attraction diminishes very rapidly as the
end is lessened in size or carried further from the coil
around the core. Again, the points should not be
rounded, but flat at the ends, and also on the sides from
the ends backwards for a short distance, as by this a
larger surface of contact is presented and the holding
power increased. The magnet which has served me so
well is constructed upon these principles.
In conclusion, I submit this report to emphasise anew
the utility and benefits of the electro-magnet in ophthal-
mic surgery; to recommend its early employment ; to
call attention to a special form of instrument which, I
believe, better than some others, fulfills the require-
ments needed; and, in addition, to advocate a more
general adoption of the sclerotic incision as the safest
method of reaching steel when it lies at any point, Sup-
posed or known, in the vitreous humor, or the inner
coats of the eye, even to the disregard of the original
wound in many cases.
THE MENTAL SYMPTOMS OF FATIGUE.
By EDWARD CowLEs, M.D., of Somerville, Mass.
November 16, 1892.
The subject of mental symptoms carries with it the
suggestion of something vague and difficult of appre-
hension. The study of mental disorders is forbidding to
the general physician who feels that he has neither time
nor patience for it. The present purpose is to contribute
something to a better understanding and an easier ap-
preciation of the mental symptoms of fatigue, which will
be considered under the following heads: (1) the nature
of mental symptoms; (2) the physical conditions of
fatigue; (3) Some elementary facts of the nervous and
mental mechanism ; and (4) the alterations of mental
functions that are significant as symptoms.
1. THE NATURE OF MENTAL SYMPTOMS.
It has been the fashion to regard this branch of neu-
rology as being slow in its progress, having no coherent
principles, resting upon an indeterminate basis, and as
being unscientific in its classification and therapeutics.
Krafft-Ebing admits that the anatomy of the nervous
System has so far been incomplete and unsatisfactory in
not enabling us to reason from structure to function, as
has been done in the relatively simple structure of the
vegetative Organs; and that pathology has been disap-
Pointing in failing to explain the most marked disturb-
*nces of function. But he points to the fact that
Psychiatry is one of the youngest of our special sci-
*S. He says it seems almost exclusively dependent
442 NEW YORK STATE MEDICAL ASSOCIATION.
on itself, and is limited to the direct observation of mor
bid mental phenomena; also that it is from the empirical
valuation of these phenomena that we are obliged to
draw conclusions as to the kind and degree of the func-
tional disturbance in the organ of mind. His conclusion
is that great progress has been made in the raising of
psychiatry to the rank of a natural science with methods.
of empirical research. Its direct advancement can be
accomplished only by tireless observation and report of
clinical phenomena, and thus fixing the facts of the
mental life. While mental disease is always brain dis-
ease, the course of the processes in mental disorders is
discovered through observation, as in any other disease.
The hope of gaining a clearer appreciation of mental
symptoms lies in the fact that we may observe so much
more directly the manifestations of mind, and conse-
quently of nervous function, than we can those of any
other function of the nervous system. We may study,
by the aid of anatomy, physiology, pathology, and
physics, an involuntary mechanism like the heart ; or
the action of the muscular system as a voluntary mech-
anism. In the action of the peripheral apparatus we
note the expression of the setting free of central nervous
energy, and can trace the conducting path of the motive
energy back to motor centres. But we can get no further
than to speak of “innervation ” and “inhibition ” with
entire ignorance of the way in which nervous substance
is stimulated, and augments or controls that which
stimulates it into activity. We are conscious that the
mode of expression of the active mind through the peri-
pheral instruments is indirect.
All this is true also of the complex organ of speech,
when examined as an organ, and as one of the minor
mechanisms of whose anatomy and pathology we may
make the most scientific study, as we need to do for a
correct interpretation of any change from normal action.
But through this organ we hear in the articulate sounds
with varied tone, pitch, and inflection, and in the words
THE MENTAL SYMPTOMS OF FA TIG UE. 443
which this instrument produces, the direct expression of
a function by which brain cells are able to convey to our
understanding the largeness and fineness of meaning
that is comprehended in the “infinite variety” of the
buman mind. This takes us into a field of phenomena
that our kindred sciences fail to reach. Instead of
lamenting that they do not aid us, it is perhaps more
true to say that we do not need their aid in the interpre-
tation of these manifestations, which, by a superior mode
of expression, convey finer variations of meaning, and
make revelations of earlier and slighter departures from
normal action than we can get from any other function
of the human organism. Moreover, it is given us to
make these discriminations, by the natural law of mind,
without any need of laborious study and interpretation
of the working of an intervening instrument. We hear
the expression of thought and feeling in sounds that we
come to know, and we need not stop to note the mech-
anism of their utterance. From the moment when we
are thrust into this noisy world, the articulate sounds of
the human voice begin to be familiar to us. Every man
makes his way in the world largely by his success in
measuring the minds of his fellow-men. We have, by
nature, a most intimate common knowledge of variations
in mental function; of no science have we a more prac-
tical every-day knowledge than of psychology. It is
true that we have to discover a way to reduce the data
of this knowledge to orderly form, and to recognise the
import of commonly observed mental manifestations by
observing their correspondence with recognised bodily
°onditions. This must constitute a true science of the
health and disease of a function which has its own
Peculiar character and physiological laws.
The nature of mental symptoms, or manifestations of
*partures from normal functions, being thus under.
stood, we should approach their study with minds free
from prejudice, prepared to observe and fix the facts of
*h kind of manifestation and array them in the order
444 NETW YORK STATE MEDICAL ASSOCIATION.
of their occurrence and relations with each other. The
question now comes, can we set up a plain and intelli-
gible conception of the normal mental mechanism that
will serve as our standard in which to note and localise,
as it were, the departures from normal action ? We
must begin in an elementary way, and deal first with
the slighter variations from conditions of health in the
mechanism, and its fullness of power to do what it can
do. In the brief time allotted here, the attempt will be
made to do little more than to point out a method of
observation and study on the basis of some of the prim-
ary facts of the mental and nervous mechanism.
2. THE PHYSICAL CONDITIONS OF FATIGUE.
The proposition may be laid down to start with, as a
working formula, that the organ of the mind is an appar-
atus for the storage and discharge of nervous energy,
and that all mental symptoms indicate a failure of the
mental elements to functionate with normal co-ordi-
nation, because of modification of the power to set free
nervous energy, due to lack of the discharging force, or
the obstruction of it, or to lessened power of control; or
as due to excess of stimulation and discharge, which
means also relative weakness of inhibitory control. All
of these conditions of nervous action may exist together,
or side by side, and often do, not only in the most mani-
fest of mental diseases, but in the lesser degree of ner-
vous fatigue. In fact the key to the understanding of
these graver conditions seems to be in the appreciation of
the slighter degree of nervous exhaustion always to be
observed in normal fatigue. The condition of the Cen-
tral organ may be directly observed through the mental
symptoms which quickly reflect the variations in nervous
force and activity. The correct understanding of these
symptoms is essential to the best treatment of nervous
exhaustion in all its forms. And this is the soil in which
the more serious nervous diseases take root and grow.
THE MENTAL SYMPTOMS OF HATIG UE. 445,
The bodily conditions of fatigue should first be con-
sidered as far as we can know them, and may be studied
in their two forms of degrees: (1) normal fatigue, or the
condition of wholesome tire from daily physiological
use ; and (2) pathological fatigue, or the condition of
persistent “impoverishment of nervous tissue in excess
of repair,” according to Beard, which constitutes nervous
exhaustion or neurasthenia. The mental symptoms are
to be studied to their close and direct correspondence
with these conditions of fatigue.
The effects of fatigue are produced by sufficiently con-
tinued exercise in the physiological use of any func-
tion, muscular or nervous. The sense of fatigue is com-
plex, and may have a central or peripheral source, or
both together. In muscular tissue the condition of
fatigue depends upon the physiological fact that muscu-
lar contraction is in some way or other the result of a
chemical change, whereby the latent energy is set free
and expended in the mechanical work, with also the
setting free of heat. The resultant chemical products
are toxic, and obstructive of muscular function unless.
they are duly washed away in the blood current ; and
time must be given in rest and sleep for this process, as
Well as for nutrition and repair. These toxic products.
being variously irritant or benumbing, doubtless thus.
affect the sensory apparatus through which fatigue is
felt. It is evident from this that the condition of mus-
cular fatigue has always a dual character—there is direct
expenditure of energy, requiring repair, and a toxic
element that may be obstructive of function, both that of
discharging energy and of taking up nutrition.
In nervous substance, the nature of nerve force being
unknown, the effects of the passage of a nervous impulse
along nerve-fibres are not demonstrable as attended by
chemical changes, or loss of normal irritability as a
*anifestation of fatigue. But in the central nervous.
*8ans it is found that their function is dependent on an
* Bowdich, Journ. of Phys., Wol. 6, p. 133,
446 NEW YORK STATE MEDICAL ASSOCIATION.
adequate supply of Oxygen, and this implies that “in
nervous, as in muscular substance, a metabolism, mainly
of an oxidative character, is the real cause of the develop-
ment of energy.” In fact we do not doubt that toxic
waste products attend upon central nervous activity, and
this accords with the biological theory that all function
is due to chemical changes taking place within the
organism, and that the functional activity of a specialised
tissue depends primarily upon the changes in its individ-
dual cells. The dual character of all conditions of pri-
mary fatigue is evident, as is also the importance of
recognising the effects of the self-produced poisonous
substances that regularly result from the chemical
changes in tissue metabolism within the body, as we are
taught by the brilliant revelations of modern chemical
physiology and pathology.
Normal fatigue from the discharge of tissue energy
is therefore shown to be inseparably accompanied by
toxic products that contribute to the effects of fatigue.
Pathological fatigue represents a further development
and persistence of this condition in the organism. Stimu-
lation too soon repeated, without giving time for rest and
repair, finds nerve-cells in fatigued areas having less
power to act because of inanition from deficient rest and
nourishment; they are also hindered in action by the
incomplete removal of the toxic products of previous
action. Then assimilation is further hindered, first, by
the lessened nutritive quality of the blood from the
presence of non-eliminated toxic materials; and Sec-
ondly, by the probable toxic weakening of the cells' power
to assimilate the nutrition that is furnished to them.
The development of a manifestly morbid condition may
be very slow and insidious, or more rapid, according as
the balance of the processes of constructive and regreS-
sive metabolism are more or less on the side of impover-
ishment, exhaustion, and weakness. From the gradually
failing elimination, the local inanition may become more
1 Foster, Physiology, 5th Eng. Ed., 1890, pp. 914–918.
§
THE MENTAL SYMPTOMS OF FA TIG UE. 447
general, and the first results are an increased excitability
from weakened resistance and inhibition, with a quick
exhaustion of the nervous system under exercise. These
are the constant characteristics of neurasthenia. Thus,
as Kowalewsky “says, “a locally limited over-strain of
a certain part of the nervous system may lead to general
exhaustion and neurasthenia.” Hence neurasthenia has
been defined by Ziemssen “as “a functional weakness of
the nervous system, varying from the slightest degrees in
simple localities to entire loss of strength in the whole
nervous system.” Arndt * states the characteristics of
neurasthenia to be “increased excitability with a ten-
dency to rapid fatigue, especially of the muscular sys-
tem.” He notes particularly, also, the cerebral irrita-
bility, and hyperaesthesia of the cranial nerves, especially
those of special senses.
The remarkable experiments of Hodge' are most sug
gestive as demonstrating the physiological shrinkage and
recovery of cell contents in spinal ganglion cells; it is
shown that upon stimulation and upon normal exercise,
the histological changes of breaking down and building
up of cell contents are accompaniments of the physio-
logical discharge and re-storage of energy, and as being
normally attendant upon fatigue followed by rest.
The conditions of the organism in normal and patho-
logical fatigue being thus understood, we have a basis
for the study of the relation thereto of the mental symp-
toms of fatigue. It is agreed by all observers that the
Symptoms of nervous exhaustion are mainly suggestive.
The objective symptoms need not be dwelt upon here; the
°ommonly noted manifestations of increased excitability,
irritability and restlessness are readily recognised as
*ēpresenting the internal hyperaesthesia so significant of
the “irritable weakness” of nervous exhaustion. The
* Centralblatt, f. Nervenheilkunde, October, 1890.
Neurºshenia, Wood's Monographs, Vol. 1, 1889, p. 534.
4 * Neurasthenia, Tuke's Dict. Psych., Med., 1892, Vol.2, p. 848.
4mer. Jour. of Psychol., May, 1888; May, 1889; and February, 1891.
448 NEW YORK STATE MEDICAL ASSOCIATION.
purpose now is to show the significance of a few easily,
and in fact commonly, recognised subjective or mental
symptoms, which stand as distinctive signs of fatigue.
They furnish a ready index of the fatigue and auto-
intoxication of nerve and muscle tissues as a guide for
diagnosis, prophylaxis and treatment ; and the general
symptoms of nervous exhaustion can be understood
better and earlier by the proper interpretation of the
mental symptoms.
3. SOME ELEMENTARY FACTS OF THE NERVOUS AND
MIENTAL MECHANISM.
In order to make clear the changes, that we call symp-
toms, in the mental manifestations, it is necessary to
note some elementary facts in the relations between the
functions of the mind and body. While they are very
complex in their detail, there are still certain broad gen-
eralisations that we could readily grasp but for the
difficulty of keeping a number of the elements alike
prominent in our minds at the same time, while studying
their inter-play. This may be aided, with some exercise
of the imagination, by the tabulated diagram here pre-
sented. It is designed to represent the nervous and
onental mechanism, and to show some of the relations of
the inner activities that we call mental, to the body in
general, and to the environment.
Let us suppose that we can lookinto the region of Con-
scious mind as into an enclosed place, and a section being
made of it we can see noted thereon, as in the “field of
consciousness,” the modes of mental action as they are
designated by common agreement. At the other end of
the diagram are noted the organs of special sense through
which stimuli from the environment start impulses that
are conducted along sensory tracts, and produce physical
sensations in the sensory centres in the entrance to the
“field of consciousness.” When these sensations alº
intense enough to pass over “the threshold of the field of
§

|NERVOUS AND MENTAL MECHANISM
:
| PH Y s ] C A L F E E 1 | N G - Co N scſo Us A N p SU B-C O N scſo Us |
L-J SEnsory L-J
SENSORY CENTRES <- 4— SENSORY ORGANS
| | NERVES
| – ; H l—tt—l l— , -1
| | | 1 t | 1
1. SEWSE PERCEPTION. ! !! | | | H
' (IDEAs) 5 | *; | | | - 2
2 ' Memony tal : ; ; r --- " ---n Lº-
| (IMAGINATION ) : | | : ! GENERAL ! SPECIAL g
3. cdºcriving JUDGING º | ! ; : | “..."
º ;Reasoning. -> | 1 , ! --~~~~ | || Evg
* | 1 * STOMACH, Y
| § |
% ; +; ! HEART EAR
4. FEELINGS, EMOTions, | 1 t { 4-
tº p # I | Lungs ! Nose O
tº- |
*—, 5 MORAL SENSE. d ; : uscles Mourº
| INSTINCTS * | ! : EYC ETC Skirt ſ:
t
R | | | : t ETC | Erc. º
| !!! *-- ºr-- P
| 6. WiLLING - ; : ; : :
| , anº # ; ; ; : 2
t
| | ACTING. > | ! | ! g
|
W :*: | | | -
º |
|-} *
L-TVEToº Tl-
MOTOR CENTRES –). N — MOTOR ORGANS ->
_r-l ERVEs T-I T-
3.
450 NEW YORK STATE MEDICAL ASSOCIATION.
consciousness,” there is a conscious mental perception of
Such sensations, as of sight, hearing, and the like. This
is the initial event of the process by which we mentally
see, perceive, and know, something in the environment;
there is, through Sensory action, the presentation in our
field of consciousness, and the perception, of what we call
the image or idea of the external thing. But we may
immediately remember that we have seen the same object
before, and we become conscious of an action of memory,
by which we retain impressions previously received, and
can recall them by the law of association of ideas. We
image them again, or imagine them. Thus a complex
mode of mental action arises; there is consciousness,
then conscious perception of a sensation, as from the
Sense of sight, and memory, acting all together. Hard
upon this comes the higher process of ideation or intel-
lection, the comparing process, by which we conceive
abstract notions of things, judge them by comparison,
and reason about them. All these may be included also
in the mode of consciousness along with perception and
memory, and form parts of a complex process of knowing,
or intellection, although we name them as separate
actions. Whenever we talk with a man, we gauge and
test minutely all these operations of his mind with great
practical accuracy. We estimate his mental quality and
power; we judge the man by what his mind can do.
One of the points of present interest is now before us;
as the antecedent fact in the mental process just described,
we must premise the state or existence of conscious-
ness, without which there can be no mental action. We
may say that there is latent consciousness in an unborn
infant, that soon after enters upon conscious life ; then
consciousness springs into action, and the first percep-
tion is likely to be of sensations from the sense of touch.
But active consciousness is always attending to Some
presentation in its field, to the more or less complete
exclusion of other presentations. While the multitude
of sensations are thronging into the sensorium through
THE MENTAL SYMPTOMS OF FATIG UE. 451
all the organs of special sense, the attention, being fixed
upon some intensified perception, excludes all but this
intensified one. The same is true of a presentation of
memory, or of a process of reasoning; or all these may
be involved in a complex object of attention. When-
ever, by the action of what we call the attention, we hold
in mind a perception, a memory, or the data of a process
of reasoning, we are exercising the memory also in the
very act of retaining all these elements of the mental
process. On the other hand we know that by the atten-
tion we can control the memory, by controlling and
changing the flow of ideas it recalls; and all this
goes to show the inseparable working together of these
processes.
The attention is a mental element of the greatest
interest, and is commonly regarded as meaning a “con-
centration of consciousness.” According to Sully it may
be defined as the active intensification of consciousness
in particular directions. Whatever, at any time,
“Occupies the mind,” is for the moment the supreme
object of attention. The attention is one with active
Consciousness, and is often described as accompanying
eVery other mental action.
It is a common experience, in revery and in dreams,
that a spontaneous flow of ideas is continually passing
through the mind; one item follows another in the
train of associated ideas through the working of memory
and imagination by the laws of habit and association,
Without direction or control. The attention is then said
to be acting in one of its two forms, and this form is
*Pºntaneous attention. It is also called reflea attention,
*s it acts by being attracted to the idea or object in the
*ind that most interests it, or keeps it on the alert, or
Stimulates it. The idea may be intensified in interest
by pleasurable or painful feeling, by a desire or a fear.
The act itself of attention to such an object of thought,
*ses the intensification of it, and tends to keep
* Art, Attention. Tuke's Dict. Psych, Med., Wol. 1, p. 106.
452 NEW YORK STATE MEDICAL ASSOCIATION.
ideas of kindred nature in the mind ; the mind dwells
upon them, is absorbed in them.
Voluntary attention is the other form of this mental
function ; and this is at the very centre of interest in
this inquiry. It is spontaneous attention with the added
power of direction and control ; the attention is thus in-
separably associated with the will, volition, or control-
Ting power. The essential fact is that in voluntary atten-
tion lies the mental activity of inhibition ; it is inhibition
working through attention. According to Foster, just
as physiological inhibition plays its part in the lower
mechanisms of the body, so is it important in the whole
work of the central nervous system. Also, just as all
voluntary muscular actions are under the control of an
attending will, so is the directing and concentrating of
the attention upon a chosen thought an act of volition.
A man controls his own mind by willing his attention,
as it were, to be fixed upon some one item or object, in
the train of presented ideas, to the exclusion of others.
He thinks about what he chooses to think about, and
inhibits mind wandering. He may make the most
worthy object interesting; this is intensified by holding
in mental view its worthiness, and thus the attractions
of less worthy interests and emotions are resisted.
Sully says it is pre-eminently by acts of attention that
all the elaborate work of thought is effected, and that the
attention is the great conditioning factor in our intelled-
tual life; all great intellectual achievement involves
energy of will acting as voluntary attention. The student
attains to this power by training and education of his
higher mental control; the man who chooses the path of
wisdom and rectitude exercises and strengthens his
power of voluntary attention by the practice of self-con,
trol in inhibiting the impulses of his passions. Thus it.
is that voluntary attention is in close relation with tº
highest as well as the latest developed acquirements of
the mind, in its power to use the force of nervous ener8X
to the best effect. It is well known that the late"
THE MENTAL SYMPTOMS OF FATIGUE. 453
acquirements are soonest impaired with the abatement
of normal energy. w
Every exercise of the will in attention is accompanied
by the expenditure of energy, and by the “sense of
effort” that occurs, particularly when the attention works
against Some resisting motive, interest or feeling. This
directing and inhibitory control is at its best in the equi-
librium of health of mind and body, and therefore it is a
most important means of estimating mental health and
vigor; mental disorder is commonly attended with dis-
turbances of the normal process of attention, as will
directly appear in the discussion of mental symptoms.
This constitutes one of the points of great diagnostic
value. -
We have, so far, concerned ourselves in this discussion
quite exclusively with the processes of knowing or intel-
lection. But we are always conscious of another order of
mental phenomena, the feelings, and they are of pleas-
ure or of pain, or they may be in varying degrees agree-
able or disagreeable. From the lower forms of bodily
pleasure and pain, upward in the scale to those aroused
by the perceptions of color and music, the feelings are
said to be “corporeal.” But the purely mental feeling
that always attends upon pleasurable or painful ideas, is
inseparable from them. Without ideas there can be no
such feeling; and according to its intensity, a feeling of
pleasure or pain intensifies the idea it accompanies, and
makes it prominent in consciousness, tending to attract
*ore strongly, and to hold, the attention. Thus, as has
already been shown, there may be an antagonism between
Worthy and unworthy ideas and feelings, or in the moral
*nse of right and wrong, with need of the inhibitory
P9Wer of voluntary attention to choose, control, and
guide conduct. This brings out the opposing factors in
* Of will, attention, ideas, and feelings. The
be i § excited by ideas prompt to action, which may
ºubled or augmented by an opposing or consenting
454 NEW YORK STATE MEDICAL ASSOCIATION.
Referring now to the diagrams, the relations of these
activities are seen to be noted in their natural order.
Feeling follows upon intellection, and all the included
mental activities are operating in the field of conscious-
ness. The outcome of this interplay is in the union of
willing with acting at the point where the resultant of
the mental forces appears to act upon the motor centres,
or stimulate in them the impulses that end in the setting
free of muscular motion. Thus the picture of the “nerv-
ous circle” is now complete, and shows the working of
the nervous and mental mechanism under the stimula-
tion of sensations through the special senses. Then con-
sciousness, through the attention (these two being gen-
eral states, or modes of mental action), knows, or “sees”
in the very mind’s eye, the special modes of action which
we call sense-perception, memory, reasoning, feeling, and
the willing of motor impulses which end in muscular
motion. This completes the “circle.”
The sensations from the special senses are those of
which we are most conscious; they are of high intensity,
but we little realise that they are small in volume com-
pared with the great inflow of organic sensations of
which, in normal conditions, we are not conscious.
These organic sensations, that, according to Ribot, give
us the sense of body, or of personality, are of low inten-
sity but vast in volume; proceeding from every minute
part of the tissues and organs of the body, their inflow,
along sensory tracts, enters the sensorium beneath the
“threshold of consciousness” into the region of sub-
consciousness. Their origin is shown in the Sources
noted in the fainter letters in the diagram, and their
course by the dotted lines. The muscular sense, which
is complex in its origin, includes feelings that afford an
example of the more pronounced of these organic Sensa-
tions. Thus, we get the sense of weight and posture.
Again there are those not felt in normal conditions,
but, like hunger and thirst, which are general in their
origin, may become intensified so that at times there 18
THE MENTAL SYMPTOM'S OF HATIG UE. 455
consciousness of them. There are still others, as in the
morbid conditions of hyperaesthesia, and paraesthesia,
that appear as pain or a general feeling of misery ; they
are vague in character, and their sources often can not
be determined.
These organic Sensations, and their alterations, are of
such a nature that they afford another point in the nerv-
ous and mental mechanism of great diagnostic value. In
normal states, when all is well with the organism in the
equilibrium of health, they constitute the sense of well-
being. Here again we have an important means of meas-
uring any falling off of nervous vigor; from the slighter
alterations of bodily feelings in fatigue to those that
Create a persistent sense of ill-being, these changes cause
Variations in the emotional tone that are the most sensi-
tive indices of the degree of fatigue and exhaustion, both
normal and pathological. The emotional tone is thus
Seen to be affected in two ways. There may be, in
health, all degrees of pleasurable or painful mental feel-
ing, between the extremes of exaltation and depression,
according to what one has to think about ; in this case a
lowered emotional tone from grief or care may be a pass-
ing event, or if prolonged, may have a directly debilitat-
ing effect upon the organism through the motor tract
of the nervous system. The stimulant and depressant
effects of the natural emotions upon the circulatory sys-
tem and upon bodily health in general, are well enough
known. On the other hand, a persistent state of morbid
depression of feeling may be no more than the mental
ConComitant of bodily ill-being, however it may have
been induced. There may be three events in the train:
First, undue care, real trouble, and anxiety or grief may
initiate a general condition of ill-being, which, in turn,
*y be the cause of morbid depression as the third
*Vent. The first in this order may be entirely wanting,
but the condition of precedent impairment of health and
*Wous Vigor must exist from some cause, before the
Strictly morbid mental Symptoms can appear.
456 NEW YORK STATE MEDICAL ASSOOIATION.
4. THE ALTERATIONS OF MENTAL FUNCTIONS THAT ARE
SIGNIFICANT AS SYMPTOMS.
It now remains to describe the special alterations in
some of these prominent factors of the mental mechan-
ism, and their significance in conditions of normal and
pathological fatigue. In normal fatigue it is to be
kept in mind, that the dual physical condition is one
of the expenditure of nervous energy in work to the
immediate fatigue of nerve cells, and the accumulation,
locally and in the circulatory system, of toxic waste
products; and that the processes of nutrition and elim-
ination require time and rest. The mental concomitants
of this condition are : A diminished Sense of well-
being, or a feeling of fatigue, sometimes amounting to
a sense of ill-being, which includes in its complex causa-
tion the influence of the toxic elements. The emotional
tone is lowered, and there is less vivacity of feeling. There
is also lessened mental activity in general. Voluntary
attention is fatigued; that is, the mental inhibition is
lessened, with diminished control over the attention, and
one is conscious of an extra sense of effort in mental
work. There is “mind wandering.” The logical pro-
cesses work more slowly and with less effect in making
comparisons and judgments, and in reasoning to conclu-
sions; the tired attention holds on with effort to One
member of a proposition, while another slips away.
There is a consciousness of mental inadequacy and diffi-
culty in keeping awake. This is the common experience
of evening tire. Testoration follows upon a due amount
of rest, sleep and nutrition, and the somnolence disap-
pears when the acid waste products, etc., in the circula-
tion are removed.
The condition of pathological fatigue is induced
when the process of restoration is continuously incom-
plete. Then we have to conceive of deficient nutrition
and an irritating intoxication as both contributing to the
“irritable weakness,” which is a manifestation of the
characteristic hyperaesthesia. We may now note the
THE MENTAL SYMPTOMS OF FATIGUE. 457
significant alterations of the feelings, the irritability of
temper, the weakening of the power of voluntary atten-
tion, and the effects of these alterations. The patient
may complain of painful or miserable bodily sensations
–hyperaesthesia and restlessness—and often of paraes-
thesia in various forms. The symptoms may be ana-
lysed and classified according to the order of their
appearance, and the functions affected.
The first order of mental symptoms of pathological
fatigue, in the importance and earliness of their appear-
ance, may now be noted. These most obvious mental
signs are the characteristic depression of feeling, a low-
ering of the emotional tone, and a sense of ill-being.
The symptoms quickly reflect debilitated bodily con-
ditions that are the sources of the “miserable feelings.”
These subjective indications are often the only ones of
the existing exhaustion in its complex character. Again,
they are corroborative of a suspicion of general neuras-
thenia when complaint is made of some local functional
disorder; in other words, local disorder is often shown to
be simply an expression of general neurasthenia, of which
the only diagnostic evidence is in the mental symptoms.
The second order of mental symptoms, in time of
appearance, is usually the persistent decrease of the
power of voluntary attention (reflea attention), and
80metimes of memory; there is also the sense of in-
adequacy of effort.
These symptoms refer to the attention, which acts in a
Thore Spontaneous and reflex manner as its control is
Weakened; the memory is weakened in its power of
retaining and recalling ideas. This lessening of inhibi-
tory power, and mental activity in general, shows the
abatement of cerebral energy. It does not always appear
to the observer, for the reason that the patient may draw
"Pon the reserved nervous energy, and put forth more
effort in the act of controlling his attention, and succeed
IIl doing it. But he is both expending energy more
*Pidly in so doing, and is conscious of the need of
458 WEW YORK STATE MEDICAL ASSOCIATION.
increased effort ; he will usually readily confess it on
being questioned. This consciousness finally amounts
to the very characteristic sense of inadequacy. This
symptom of weakened voluntary attention is also an
early one, and is very diagnostic. The patient will often
complain that he cannot keep his thoughts on his work
or business, or has to read over again what he reads, and
can not remember it. One patient said “I can not sense
it;” and another, “I can not centre my mind on what I
try to do.”
A third order of symptoms may now arise, and it is an
interesting fact that they grow out of the other two
orders, and are their logical consequence; these are
ſmorbid introspection, retrospection, and apprehension
(worry and hypochondria).
These symptoms, when manifestly developed, mark a
graver degree of fatigue. The emotional tone being low-
ered, the patient in a state of depression of feeling is
prone to “look upon the dark side of things.” Ideas
are intensified that are accompanied by painful feelings,
which are thus in harmony with the prevailing emotional
tone. There being also a lessening of nervous energy in
voluntary attention, it cannot inhibit the intensified
painful ideas and feelings, and there is consequently
worry about the present, past, and future. The Vague
fear arises of being unable to meet the requirements of
the future. The increasing sense of present inability
gives intensification to the characteristic sense of inade-
quacy noted by Beard as being so prominent.
There is one other set of symptoms to be mentioned as
constituting a fourth order. While those previously
noted are purely mental, these are partly so, but relate
chiefly to alterations that cause peculiar bodily effects,
and are often manifest to the observer. These symptoms
are: changed organic sensations, physical and mental
£rritability, and restlessness ; diminished sens?!?0°
quess, dullness and languor.
There is apparent irregularity in these changes of
THE MEWTAI, SYMPTOMS OF FATIG UE. 459
bodily feelings and their manifestations—the intensify-
ing of some and the lessening of others. Arndt says:
“It is clear that the increased hyperaesthesia, which a
degenerating nerve at first presents, can not last long,
and that soon decreased excitability, bluntness, paresis,
or whatever we call fatigue or exhaustion, must take its
place.” -
There is not alone hyperaesthesia, with the external
signs of irritability and restlessness, but there is much
diminished sensitiveness. Some cases are altogether of
the latter character, and many present both conditions
at the same time, in Some particulars. It may be a ques-
tion of the different effects of variations in the toxic
waste products. While chemical physiology and pathol-
Ogy do not yet enable us to ascribe sensory and motor
disorders definitely to the influence of poisons produced
Within the organism by its own activity, it cannot be
doubted that both the conditions of nervous irritability
and those of dullness, languor, and stupor, may be so
Caused. It is certain that such external manifestations
may be caused as the direct expression of defective
functional activity in cerebral centres that are the source
of the nervous energy which innervates and controls
both the somatic and mental mechanisms. The study
of physical expression which Darwin raised to the dig-
nity of a new science, shows that while there is certain
Voluntary control over it, still the manifestations in the
muscular movements of expression, whether occurring
in the face or the extremities, have a direct automatic
dependence upon interior states of the central nervous
System, which are thus externally reflected. The inflow
of 9 ganic sensations to the senorium has its complement
* the constant, regular and subconscious transmission
* nerve force from central cells to the muscular peri-
P*Y. This accords with Gowers' statement that every
*ture of the brain concerned with sensation proper is
*cted directly or indirectly with a part concerned
* Loc. cit,
460 NEW YORK STATE MEDIOAL ASSOCIATION.
with motion ; and, in regard to the unstable condition of
brain cells in disease, when the equilibrium between the
discharge of energy and the inhibition of it is disordered,
“the discharge may depend on the production of force
within being increased in excess of the resistance, or on
the resistance being duly lessened.”
In the common forms of insanity are seen the most
pronounced expressions of excessive or diminished cen-
tral activity, and this applies alike to innervation and
inhibition, whether mental or somatic. In the belief of
the writer' it is possible to detect important variations in
the several elements of mental activity in normal fatigue
and nervous exhaustion. For example : the letting down
of mental power in voluntary control, with the conse-
Quent lessened inhibition of verbal expression of grief
and worry, or excitability and aggressiveness. Bancroft”
has made an instructive application of the physiological
principles of expression, to the study of facial expression
of the emotions in insanity and of expression in posture,
etc., as the results of habit in automatic muscular action.
His work gives definite value to the clinical use of photog-
raphy in the physical expression of mental changes.
All such clinical studies of mental symptoms demon-
strate the value of precise appreciation of the changes
in the elementary mental activities. It is common to
observe, in mania, either excessive, uninhibited, mental
and motor activity, or the quite normal control of the
latter, along with the gravest deficiency of mental inhi-
bition. Again, there is excessive nerve-muscular activity,
or tension in fixed attitudes, in the mental and motor
expression of painful emotion in melancholia, and in
consequence of lessened inhibitory will power; and still
again, all expression may be abolished in the real mental
stupor of melancholia and mania. This abolition may
*Pathological Fatigue or Neurasthenia (the Shattuck lecture, 1891, Mass.
Med. Soc.) Amer. Jour. Insanity, July and Oct., 1891.
*Automatic muscular movements among the insane, Amor, Jour. */
Psych., Feb., 1891,
THE MENTAL SYMPTOMS OF FATIG UE. 461
also be due alone to the fact that, while perception and
ideation are quite normal, the power to give expression
to them is diminished or lost, either in the failure of the
mental function of willing, or of excitability in the
motor centres. A man at the McLean Asylum, who was
apparently in profound stupor, afterwards said: “I
wanted to answer you, but couldn’t make my jaws go.”
A woman who would stand in a fixed position for hours
with almost entire loss of muscular movement and ex-
pressionless face, could respond to kind words only by
directing her eyes, and they would fill with tears. When
she was well, the next year, she gratefully told what
had been said and done to her. The apparent stupor is
often mistaken for the real condition.
These discriminations of the mental processes being
once established, they have the highest therapeutic value
in their preventive application. Hence the thesis of
this paper: the importance of an early appreciation of
the mental symptoms of normal fatigue that tends to
nervous exhaustion, for they are prodromic of its graver
forms. Moreover, the recognition of the significance of
changes in the motor and sensory manifestations, in the
direction of languor as well as irritability—anaesthesia
as well as hyperaesthesia—is of the first importance in
the difficult task of managing convalescence from true
neurasthenia. The “irritable weakness,” includes the
liability to quick exhaustion of the small increments of
hervous energy that have been slowly gained, and there-
With the speedy reduction of sensory, as well as motor
power, to the degree of “bluntness,” as Arndt has stated
it. Pathological fatigue, or nervous exhaustion, being
shown to be a condition in which there is direct and
°onstant relation between physical disorder and mental
Symptoms, these should be noted, together with both the
*rease and the blunting of sensitiveness, in any compre-
hensive definition of the disease. It may therefore be
*fined as follows: Neurasthenia is a morbid condition
of the nervous System, and its underlying characteris-
462 NEW YORK STATE MEDICAL ASSOCIATION,
tics are ea cessive weakness, and irritability or languor,
with mental depression and weakened attention.
This method of analysis into four orders of symptoms
is applicable to all cases of neurasthenic disorder of the
physiological activities involved, from the passing over
of normal into pathological fatigue, in the simplest
forms, to the gravest manifestations of emotional dis-
turbances, disordered attention, and sensory and motor
irritability and languor. The symptoms included in the
first three orders are regarded as purely mental ; those
characterised in the fourth order, while referring to the
well-marked development of changes in sensitiveness
and activity of bodily functions, imply the necessary
association with them of the mental symptoms before
noted. These changes of bodily sense and activity may
be detected, in the slighter degrees, in the earlier stages
of neurasthenia. The value of the practical application
of these discriminations in diagnosis may now be illus-
trated by describing some of the special ways in which
certain symptoms must be interpreted. By this method
of analysis we may readily estimate the significance of
the symptoms of depression of feeling, of weakening of
voluntary attention, and of worry. But there are certain
more subtle effects of the mixed condition, usually found,
of hyperaesthesia and anaesthesia.
One of the most striking special symptoms which the
foregoing considerations point out and may serve to ex-
plain, is a paradoxical one, but one most commonly pre-
sented for clinical observation. The sensory function by
which the complex normal feelings of fatigue are
appreciated, may itself be over-exercised to exhaustion.
There is tire of the power to feel the tire. This condi-
tion may be called fatigue-anaesthesia, and, beginning
with the early stages of pathological fatigue, there is
usually some degree of it. Every physician has ex-
perienced this when, after a night of anxious profes-
sional work, , with loss of sleep, he has a day of excit.
able alertness of mind and body, and there is a Sense of
THE MENTAL SYMPTOMS OF FATIGUE. 463
nervous strain, with, perhaps, undue mental facility and
physical irritability. Many hours sleep may be gained
in the following night, but instead of feeling refreshed
he has a sense of malaise, languor and fatigue. The
real fatigue was greater the day before, but he could not
feel it as such. It is not until the Second day after the
excessive effort that he has recovered his exhausted
power to feel the fatigue. In a lesser degree this fatigue-
anaesthesia becomes a constant accompaniment of the
neurasthenic condition. Over-worked women, profes-
sional and business men “work on their nerves,” and
say they “don’t feel tired, and nothing is the matter.”
They “feel better” when actively exercised in their
customary labors. This condition comes on insidiously,
and is a most dangerous One. The patient is neuras-
thenic before anybody suspects it. With the impair-
ment of the natural fatigue-sense the mental effect is that
he will not believe even his physician’s diagnosis of
“fatigue.” He is, therefore, prone to look for some
other reason for his sense of ill-being and inefficiency ;
and finds, in retrospection, cause for Self-reproach and
helplessness in the future.
Fatigue-anaesthesia manifests itself in connection
With another special symptom peculiar to conditions of
“fatigue,” that of “morning tire,” sometimes called
“morning misery.” Extreme examples of this are seen
in the victims of dissipation. In ordinary cases of
pathological fatigue it is a persistent symptom; the
patient is likely to awake in the early morning unre-
freshed by a fair amount of sleep, and often in the depths
of depression. The physical signs of exhaustion are then
more manifest. These symptoms represent the truth as
to his neurasthenic condition. After breakfast he feels
better, and by the middle of the day the stimulation of
the daily interests and press of business has apparently
restored his good feeling. At the close of the day he is
comfortable and cheerful, laughs at his morning fears,
* is prone to over-do himself in recreation or evening
464 NEW YORK STATE MEDICAL ASSOCIATION.
work. That day’s experience is regularly repeated.
Each night he rests enough to recover Some of the feel-
ings that attend upon “fatigue,” but he often does not
recognise it in the absence of the true fatigue-sense. A
still further blunting of this sense is caused by the ill-
timed stimulation of unwisely continued effort. Along
with the restlessness of his “irritable weakness,” there
is a fictitious sense of well-being because of the tempor-
ary abolition of the sense of ill-being, as in mild intoxi-
cation by alcohol.
In the management of convalescence from neurasthenia,
or of cases that would get well if they could be man-
aged, there is nothing more discouraging than the succes-
sion of relapses that they undergo. Such patients, having
been subjected to rest treatment, may be fat enough and
maintain a fair degree of comfort when effort is kept
within the limits of pathological fatigue. They complain
of tire and various discomforts upon a little effort, which
must be made in order to gain by physiological use the
strength to make it. It seems a never-ending process;
Some patients cannot abide its slowness, and make effort
too soon ; others resist great persuasion to make enough.
But some event may occur that excites desire or a sense
of duty. The undue quickness of response to the stimu-
lation of interest and attention is to be recognised as an
evidence of irritable weakness. The apparent ease and
unwonted Zest of the effort is not a manifestation of real
power; it means that there is a speedy blunting of the
sense of fatigue. The reaction of exhaustion and mental
misery that follows shows the real weakness and the need
of unfailing patience and discretion. Most patients of
this class have to be taught how to recognise the mental
and physical signs of fatigue peculiar to themselves,
other than the normal feeling of it. They must also be
taught that some degree of fatigue thus manifested must
be regularly incurred as wholesome tire. But both
patient and physician must be guided alone by indi:
vidual experience and judgment as to the amount of
THE MENTAL SYMPTOMS OF FATIG UE. 465
effort. Feeling is often a misleading guide for doing or
not doing.
Many neurasthenic people are plied with recreation
to “distract the attention,” and go on journeys in
search of health, when it is not stimulation, mental or
physical, that is needed, but rest. The physician may
save many a patient from such a final strain, that would
precipitate a break-down, by recognising the fact that
his apparent ability to do things without fatigue, when
the mental signs of it are present, is the strongest indi-
cation that he has reached a dangerous degree of nervous
exhaustion, marked so plainly by loss of the fatigue-Sense.
In such cases, after a course of rest treatment, which
must often be more or less modified, exercise becomes
most important, in the form of gentle bodily effort and
mental stimulation by recreation in gradually increased
amount. The guide to the limitation of exercise is to be
found in its effects, such as the slight return of restless-
ness and insomnia at night, and the mental and bodily
discomfort liable to appear on the following morning.
Exercise may be pressed to the extent of not causing
these effects; it promotes nutrition, and excretion of
Waste products, the free action of the skin, etc.
The physician will look to the therapeutics of tonics
and nutrition, with careful attention to all the forms of
elimination. But while he is doing this, the successful
treatment of neurasthenia means the careful recognition
of all its signs. The earliest indications for diagnosis,
and the clearest for treatment—and often the only ones
are the mental symptoms. It is the conditions of
fatigue that are to be treated, and the study of the
Wºrking of the fatigue-sense affords the safest and surest
guide, although its Signs are so often negative. A cor-
Tect, and fine appreciation of what the mind can do
°nters into our commonest knowledge and experience,
* We use the most familiar words to describe its Oper-
ations. This paper has been written with the hope that
it may be a help to the Systematic observation of some of
80
466 JNE W YORK STATE MEDICAL ASSOCIATION.
the commonest and most valuable of clinical indications,
both for prevention and cure.
DISCUSSION.
DR. GEORGE M. GoulD, of Philadelphia, was invited to open the dis-
cussion. He thanked the Association for so courteously and unexpectedly
calling upon him to participate in the discussion. As he listened to the
paper, he could not but think that the author had been stealing the
results of all his own cases for the past few years, and had epitomised the
generalisation of what had been the outcome of his own observation.
Physicians are prone to look upon organic factors as being the cause of
disease, but, to him, the cause of disease is simply abnormal physiology.
If we can get at the morbid physiology, so to speak, of the disease, we
shall very often reach the root of the trouble. Turning to his own-special
department of medicine for illustrations, he said that he had had bundreds
of cases of disease of the eye which exemplified fatigue, hyperaesthesia,
and abnormal actions of the mind itself, due to what is called “eye-strain.”
The subject of eye-strain had received more than its share of attention, yet
neurologists still fail to grasp the true significance of incipient mental
disease, from the simple fact that they fail to perceive the morbid action of
the physiology of the peripheral organs. Mind is only formulated vision,
and all thinking is only an act done in pictures. If vision is abnormal in
its action, it certainly must throw an irritational strain upon the mind, and
an excessive stimulus goes into the cerebral centres which control vision and
thinking, and sets up there an abnormal cerebral action. Every act of our
mind and brain tries to translate it into cerebral products of vision. This
results in a strain, which is more than the subject can stand. This is a
general statement. The speaker assented cordially to the scheme presented
by the reader of the paper. He had met with many illustrations where
this everlasting eye-strain, especially in young women, results in nervous-
ness and irritability of the mind, and in morbid products of intellec-
tion, which finally result in hysteria. He believed that it even went
further, and resulted in gastric disorder and in anaemia. Strange as
this may seem, he thought observations directed to this point would
sustain his statement. A case in point was that of a gentleman Who
for twelve years had been tormented by various symptoms of mental
trouble; his mind seemed to be giving way, and for several years he had
to fight against suicide, but being a strong-willed man, he controlled this
feeling. The gastric symptoms and various troubles of intellection and
memory supervened, and he felt, as he expressed it, that if he “could
only get behind his eyes” he might in some way do himself good. An
examination of his eyes showed such a frightful, unsymmetrical astig”.
tism, as to render his vision as much a source of irritation as if he had
tried to lift a hundred-pound weight with a crippled arm. His Vision W&S
a constant source of worry to the brain, and the brain in trying to interpret
DISCUSSION. 467
these symbols of sensation was required to constantly act abnormally. It
was not equal to this task, yet was compelled to do it, and so the man went
on from bad to worse. This case was only a recent one, but he had had
many similar ones, and they served to illustrate the philosophy of the mind
which had been so beautifully set forth in the paper.
DR. JAMES W. PUTNAM, of Erie county, said that he had been much
interested in the paper, and in the discussion. He emphasised the im-
portance of not forgetting that the impressions we receive come from very
many different sources, as many sources as we have organs and special
senses. To find the cause of the mental fatigue, we must seek in every
avenue through which the mind receives impressions, and must make it a
routine practice to examine a patient from his head to his feet, before
making up our minds as to the location of the cause. Of course Dr.
Gould, being an ophthalmologist, sees many cases of eye-disease, but the
dermatologist sees many chronic cutaneous affections which are sending
more or less annoying impressions to the brain, and in a large proportion
of these cases, neurasthenia is the result of this irritation. Again, a man
with stone in the bladder will suffer considerable nervous exhaustion, and
so will a man suffering from haemorrhoids, and a child with a congested
and inflamed prepuce. We must remember, also, that there are certain
conditions of the blood which bring about nervous exhaustion. Habits of
life may also have a similar result, as, for instance, in the various func-
tional neuroses from occupation, such as writer's cramp, and telegrapher's
Cramp. Many patients, after consulting an oculist and receiving full and
Satisfactory correction for their errors of refraction, recover from their
nervous exhaustion, and remain so for a certain length of time; but hav-
ing once been victims of nerve exhaustion, there seems to be a certain
instability of the cerebral health, and they are, therefore, apt to relapse,
and to suffer from analogous symptoms, due probably to overwork. He
had frequently seen patients with defective vision, and with no lithic acid
in the blood, and no sugar in the urine, nevertheless become exhausted
because they were not receiving a sufficient variety of impressions, their
Work being, so to speak, too “humdrum,” so that it produced what
might be called a “local neurasthenia.”
DR. H. S. WILLIAMs, of New York county, said that not many years
*89, a Very different view was taken of the mind from that now held. He
W* taught, for example, that one department of the mind could operate
independently of the other, and that, consequently, a person who had tired
out one portion by studying mathematics constantly, could rest himself
*Y studying another subject, as, for instance, geography. Now, this is
to a certain extent true, but the general exhaustion of the mind includes
the general functions of the mind ; and this extends, also, as the reader of
the paper has shown, to the body. It was also taught formerly that a
Person occupied with physical labor, when fatigued in body, could rest
himself by 9°Cupying his mind; but those who have tried this, know it is
not a Satisfactory way of Securing rest. The best way to develop the
468 NEW YORK STATE MEDIOAL ASSOOIATION.
mind is not by developing physical fatigue, but by keeping the body in a
healthy condition. It must not be forgotten that some individuals have
such an inherent capacity for work, that an amount of physical exercise
which would completely exhaust another one's mind, is only a stimulus to
them. The mind, of course, cannot operate unless the body be in health;
but if the body be fatigued, this fatigue will extend to the mind and
render intellectual effort impossible.
DR. E. M. MooRE, of Monroe county, had listened to the paper with
great interest; but it was so distinctly metaphysical, that he had found
some difficulty in following the author's line of thought. He only wished
the author had gone one step further, and told us what the mind is.
DR. E. D. FERGUSON, of Rensselaer county, remarked that probably the
old definition here still held : “What is meant by the mind 7” “No
matter.” “What is matter 7” “Never mind.”
A REVIEW OF SOME INJURIES OF THE UPPER
EXTREMITY.
By E. M. MooRE, M.D., of Monroe County.
November 16, 1892.
When asked by your committee to prepare an address
on surgery, I assented upon condition that I might re-
capitulate my work on the upper extremity, which, in
my opinion, represented certain corrections and additions
to our antecedent knowledge. The dictum of Solomon
that “there is nothing new under the sun,” receives
frequent confirmation in the prosecution of our re-
searches. An observation is made and recorded, and
not attracting attention at the time, is forgotten until it
is again observed by some One possessing no knowledge
of the earlier observations. I do not know that I have
been especially unfortunate in this respect. Whatever
further reading may show in relation to the conditions I
am about to describe, it has thus far been remarkably
free from the annoyance of the discovery of correspond-
ing antecedent observations.
But this is not a matter of much moment. The real
interest lies in the relation of the condition expressed,
and the current belief and practice of the profession.
The views I shall offer you are original with me, and I
have had to sustain a polemic on behalf of most of them.
An extensive experience has confirmed me in my belief
of their correctness.
I will at first call your attention to fractures of the
clayicle. Whatever peculiarity there may be in my
rationale of the causes of the displacement and difficult
*ctification of this fracture by the methods usually em-
ployed, I may say that the conclusions arrived at were
Purely the result of ratiocination. These were confirmed
by subsequent experience, and have not undergone any
*ification since their first announcement.
470 NEW YORK STATE MEDIOAL ASSOCIATION.
First, then, as to the methods usually employed for the
purpose of rectifying the displacement incident to these
fractures. As every surgeon knows, these consist in the
use of a fulcrum in the axilla over which the humerus
is moved as a lever, so as to throw out the shoulder and
draw the fractured ends into apposition. There are various
methods of handling the arm. We have the quilted
bandages of Boyer, the shawl of Liston, the sling of
Fox, as well as many other forms, but the rationale is
the same in all of them. The other general plan consists
in the use of some form of the figure-of-eight bandage.
Dr. Sayre has proposed, as you all know, an adhesive
plaster dressing. The arm is held to the side ; then a
Strip of plaster is carried around the arm near the axilla,
and the other end drawn around the body to pull the
shoulder backward. I regard this as a great advance
over the methods by the axillary pads and the figure-of-
eight bandage. But it fails of a better result by not
making the clavicular fibres tense, which can only be
accomplished by carrying the elbow backward. Neither
does it move the scapula around the thorax toward the
spine, as surely and as far as by the action of the
shoulder bandage, combined with the backward position
of the elbow.
After the publication of my paper, I learned that a
fractured clavicle had been treated by carrying the
forearm behind the back. It had occurred to me that
this would fulfill the indication, but it was rejected
because of its painful character.
The symptoms of fractured clavicle are very constant.
The shoulder goes downward, inward and forward, in
obedience to the action of gravity, the shape of the
thorax and the tonic power of the pectoral muscles; and
as a sequence of this altered position, the inner frag-
ment almost surely rides the outer one. It is of this
common condition only that I speak. º
It is well known that the treatment of this fracture 18
conducted generally upon two plans, with a great variety
IWJURIES OF THE UPPER EXTREMITY. 471
of modifications of detail. One is by the use of the
axillary pad, which is the fulcrum for the humeral
lever; the other is by the figure-of-eight bandage, which
draws the shoulders backward by a band passing around
the axilla. There are other plans, but these prevail.
The tension of the clavicular fibres is the chief indi-
cation for rectifying the déformity. There are other
considerations, however, among the principal of which
is the position of the scapula. When we place a patient
in a chair, and, standing behind him, seize the upper
part of the arms near the shoulder and draw them back-
ward, the replacement of the fractured ends becomes
perfect, almost with certainty. But when, with more
force, we use the axillary pad or figure-of-eight bandage,
the restoration is so rare that many surgeons assert its
impossibility. I criticise the axillary pad, because it en-
sures the relaxation of the clavicular fibres of the great
pectoral. If this results from its action, we lose the
antagonism of the sterno-cleido-mastoid, and therefore
no matter how high we elevate the shoulder, the end of
the inner fragment will be the bigher. But if the shoul-
der is carried backward, and the clavicular fibres of the
pectoral muscle are rendered tense, the riding, inner
fragment will be brought down, thus securing perfect
apposition. This results from the well known treatment
by recumbent posture, and from the attitude in the chair,
as above described.
* The attachment of the great pectoral to the humerus,
it will be remembered, is quite peculiar. The muscle
makes a half turn upon itself and is inserted for a full
inch-and-a-half along the bicipital groove, the thoracic
fibres running to its upper, and the clavicular to its lower
Pºrt. It must be obvious that the tension of the fibres in
the same muscle will vary according to the position of
the humerus. If the arm is carried backward, it moves
from the shoulder joint as the fulcrum, the lower por.
tion of the muscular insertion describing the larger
Circle, thus involving a greater tension of the clavicular
472 NEW YORK STATE MEDICAL ASSOCIATION.
fibres. By this tension we antagonise the sterno-cleido-
mastoid muscle, and if the shoulder be carried back far
enough, the apposition will be perfect, provided no
inequality of the fractured surfaces prevents, which will
often happen in oblique fractures even when the length
is fully obtained.
Before presenting a plan of treatment, I will criticise,
in the first place, the axillary pad. As the large end
of this pad is placed upward, it operates of course upon
the humerus just at the border of the axilla. Its ration-
ale is that of a fulcrum for the humerus as a lever. The
motion on the fulcrum, if a mathematical line, is nil.
The pad is opposite the attachment of the clavicular
fibres of the pectoral muscle. At the point of their
insertion there is no motion, no matter how much force
we may use. The shoulder is thrown out as far as the
thoracic fibres of the pectoral muscle will allow. The
upper end of the bicipital groove is the point of insertion
for these fibres, which are put upon the stretch, because
it is removed from the fulcrum. The clavicular fibres of
the pectoral are relaxed, and kept so, and the Sterno-
cleido-mastoid draws up the inner fragment.
I also criticise the figure-of-eight bandage for produc-
ing a similar relaxation of the clavicular fibres of the
pectoral muscle. This bandage acts upon the lower
border of the muscle, which is composed entirely of
thoracic fibres, and the more tightly it is drawn, the
more will it curve its axillary border, and incidentally
shorten it. The fibres of the clavicular portion are not
bent, and of course not shortened. Thus they are
inevitably relaxed by the drawing in of the humerus. It
will therefore be seen that, in the effort to carry the
shoulder out by the axillary pad, or backward by the
figure-of-eight bandage, the condition of tension of the
thoracic, and relaxation of the clavicular fibres of the
pectoral muscle results. The indication, therefore, to be
fulfilled, is to reverse the action, and by carrying the
humerus backward, make tense the clavicular and
IWJURIES OF THE UPPER EXTREMITY. 473
relax the thoracic fibres of the pectoralis major muscle.
This motion is at the shoulder-joint as a pivot. The ten-
sion of the pectoral fibres is now reversed—the lower
portion of the bicipital groove is moved through a
greater circle than the upper, and the clavicular fibres
are rendered tense in proportion to the distance the
humerus is carried back.
No plan that leaves the humerus perpendicular can
make the clavicular fibres tense.
The scapula must also be moved as near the spine as
can be borne, for the obvious reason that the thorax is
the most salient at this part, and a sliding of the Scapula
thus produces a movement of the shoulder backward and
outward. As it goes back it rises. I also make criticism
upon the effect of the shawl, Fox's or Dessault's band-
age, in their operation on the scapula. If the hand be
placed upon the inferior angle of the scapula and the
shoulder raised, keeping the humerus perpendicular, it
will be seen that the scapula moves forward upon the
thorax at its lower border. This criticism, however, does
not obtain with reference to the figure-of-eight bandage.
This is in the wrong direction, and although it is the
lower angle, it nevertheless allows the whole scapula to
Come forward, and thus shorten the broken clavicle.
The obvious indications in the treatment of this frac-
ture, therefore, consist in the use of any bandage or
posture that will carry the humerus backward and hold
it toward the side. The effect of carrying the arm back-
Ward is to move the scapula toward the spine, thus ful-
filling the first important indication. But besides this,
as Stated above, the clavicular fibres are rendered tense
by this attitude, and thus the only remaining indication
ls fulfilled. Some aid may perhaps be obtained by lift-
ºng the shoulder from the elbow, but this is subordinate.
In order to obtain the results stated I have resorted to
Various devices; but to treat fractures well we must be
* to find our appliances in every house, and after
Imuch experimenting I use a shawl or piece of cotton
474 NETW YORK STATE MEDICAL ASSOCIATION.
cloth, which, when folded like a cravat, eight inches in
breadth at the centre, should be about two yards long.
Placing this at the centre across the palm of the surgeon,
he seizes with his hand the elbow of the patient, which
corresponds with the broken clavicle. The two ends of
the bandage hang to the floor. The one falling inward
toward the patient is carried upward, in front of the
shoulder and over the back, making a spiral movement
in front of the shoulder. This is intrusted to an assist-
ant. The outer end is then carried across the forearm,
behind the back, over the opposite shoulder and around
the axilla. This meets the other end, which may be
carried under the axilla and over the shoulder of the
opposite side, thus making the figure-of-eight turn
around the sound shoulder. This twist, it will be seen,
makes also the figure-of-eight turn around the elbow of
the affected side. I therefore style the bandage :
“THE ELBOW FIGURE-OF-EIGHT.”
The forearm should be sustained by a sling which
raises it to an acute angle, in order that gravity may
assist in moving the whole arm backward. This is best
done by a simple strip three or four inches wide, which
may be pinned to the shoulder. Any tendency on the
part of the shawl to slide from the shoulder may be
arrested by a pin thrust in at the crossing. The bandage
at the elbow is kept in place by folding the upper part
that fits the arm and securing it by a pin. This makes
a sort of cup for the elbow.
The bandage is worn with ease, except on the sound
shoulder, which is vexed by the pressure of the Ordinary
figure-of-eight.
It will be observed that the shawl, as it passes in front
of the arm, does not press on the axillary border of the
pectoral muscle, and therefore avoids the objection of
the ordinary figure-of-eight. At it passes over the fore-
arm, and over the opposite shoulder, it lifts up the arm
like the ordinary shawl bandage.
INJURIES OF THE UPPER EXTREMITY. 475

476 NEW YORK STATE MEDICAL ASSOCIATION.
Additional evidence of the correctness of the views
herein stated, is to be found in the fact that dislocations
of the clavicle are almost surely retained by it while the
patient keeps the erect posture. This, I think, cannot
be said of any other plan. Nothing but absolutely full
extension can retain the luxated surfaces at either end
Of the clavicle.
The word perfect is one of doubtful application to any
repair of fracture. But we use the term, and I think it
may be correctly applied to all fractures that are
brought to a correct line and unembarrassed by redun-
dant Ossific deposits, as in the Osteophytes so common in
fractures of the neck of the thigh bone, or the union
that takes place with a parallel bone, as sometimes occurs
in the forearm. By the figure-of-eight from the elbow
the whole length of the bone is attained, and the frag-
ments brought into line. Most of the cases, if carefully
watched, show a perfect result when measured by the
standard above delineated. I find it necessary to see the
patient for a period of one or two weeks, tightening the
bandage daily. At the end of this time, the adjust-
ment is apt to be complete, or nearly so. The fractured
ends do not inosculate, but nature remedies this defect.
Closely associated with these considerations as a
whole, we may speak of the luxations of the clavicle.
These are not common; many surgeons have spent a life-
time without meeting a single one. The authors dis-
pose of their management very summarily. They simply
recommend the use of a clavicle bandage. The diagnosis
is easy. Whether at the sternal or the acromial end,
they are readily reduced by seizing the arm below the
shoulder and drawing it backward. The moment this
traction is relaxed, the tension of the muscles, added to
the weight of the limb, produces consecutive luxation.
It is perfectly palpable that the least shortening of the
clavicle will throw the bone out of place in either of the
dislocations mentioned. I have not been able to learn
from any surgeon of a complete and satisfactory result
INJ URIES OF THE UPPER ExTREMITY. 477
in his treatment, except in two cases, one treated by Dr.
McGraw, of Detroit, and another by Dr. Pancoast, of
Philadelphia. But both were placed in the recumbent
posture and strictly confined to bed. One had a thick
band carried under the axilla and tied to the bed-post.
As you all are aware, the recumbent posture has long
been considered the only sure mode of rectifying frac-
tures of the clavicle. But only young females who
dread the deformity will submit to this treatment.
I have now collected eighteen cases, treated with the
patient in the erect posture, by men widely separated
from each other, and with absolutely perfect results in
most of the cases. This would be impossible but for
the fact that the rotation of the Scapula On the thorax
throws out the acromion, and secures the full length of
the clavicle.
The position attained by the use of the bandage, is
also favorable to the rectification of most, and perhaps all
of the fractures of the scapula. These injuries are not
frequent. The most common among them are those
where the lines run across the body. I have met with
but two of these, one was in a gentleman who was thrown
from his berth by the lurch of the ship on his voyage
from Europe to New York. He fell under the care of
the late Prof. Carnochan, who treated him with Boyer's
apparatus for fracture of the clavicle. His suffering
Was intense. After remaining in the city for a fortnight,
he reached his home, and I changed the bandages for
Fox's pad and sling, but without any marked relief.
His recovery was very slow. The next case occurred
after the bandage had been used by another physician,
from Whom I first received the intimation of its bene-
ficial application. The fracture was in a German
laborer, and he had passed a week of pain before coming
under treatment. The relief from the bandage was im-
"ediate and marked, but not so great as I think it
Would have been if employed at the beginning. The
first recipient of benefit from this bandage was a railroad
478 JNETW YORK STATE MEDICAL ASSOCIATION.
laborer living in a hut near the border of the track.
While walking alongside the road he was struck on the
scapula by the projecting frame of a passing locomotive,
and sent headlong into a ditch. Another laborer living
close by, moved him into his cabin, and placed him
upon a lounge, from which he could not be induced to
stir for any purpose, the posture and absolute quiet
being his only relief. A young physician from a neigh-
boring town was summoned, and after getting the man
into a sitting posture with much trouble, he dressed the
fracture. In reporting the case to me a few days later
he compendiously stated it thus : “I found the fracture
of the body of the scapula very readily, its line running
across it below the spine ; but I did not know what to
do, so I applied your bandage for fractured clavicle.
The relief was immediate, so much so that he stood up
and walked to his own home, which was about half a mile
distant.” This surprising statement of my young friend
induced me to use it as stated above.
I think a little reflection will convince any one of the
correct rationale of such relief. The movement of the
scapula toward the spine will bring it into closer apposi-
tion with the thorax, which thus becomes the natural
splint. But besides this, every muscle attached to the
exterior of the Scapula, is relaxed except the Supra-
spinatus, which being above the spine, can have no effect
upon the fracture. The infra-spinatus, teres major and
minor, as well as the sub-scapularis, are relaxed by Carry-
ing the elbow backward. Of the muscles attached to
the scapula and the thorax, it is evident that the rhom-
boideus is relaxed, and the elevation of the bone, as the
result of the bandage, also relaxes the levator anguli
scapulae. The serratus magnus is placed upon the
stretch, and being attached to the whole base of the
scapula holds it steady as it is carried backward between
the two forces.
Of fractures of the neck of the scapula I am not sure
that I know anything. Theoretically, I suspect the plan
INJURIES OF THE UPPER EXTREMITY. 479
of carrying the elbow backward would bring the sepa-
rated fragments together. One day while in Jackson,
Michigan, I was walking in company with a physician,
who suddenly stopped on meeting a man, and Com-
menced questioning him with reference to the condition
of his shoulder. The patient pronounced it very satis-
sactory. Turning to me the doctor remarked, “I made
a diagnosis in this case of fracture at the neck of the
scapula, and I treated it with your bandage, making no
change as the relief was so good.” -
I have, as you perceive, shifted the responsibility of
suggesting a sort of panacea for the ills of the broken
scapula, but I am not quite done with its uses. I had a
friend who always insisted that the position secured by
it, was the most comfortable one for retaining the head
of the humerus in its socket after the reduction of a dis-
location at the shoulder joint. But I never employed it
for this purpose in my own practice, preferring to stuff
the axilla with a compress, and throw a bandage around
the humerus. But about two years since a man was
brought to me who had been successively in the hands
of two surgeons. The first one had undoubtedly re-
duced the bone to its place in the glenoid cavity, and
had attempted to keep it from the consecutive luxation
Which every surgeon knows is so easy after the reduc-
tion has been made at this joint. But the patient was so
uncomfortable the next day that he applied to another
Surgeon, who did nothing. The patient then came into
my hands. I recognised the injury as one well known
but very rare, a luxation of the head of the humerus on
the dorsum scapulae. Manipulation easily replaced the
bone, and I proceeded at once to retain it in place by
filling the axilla with cotton and throwing a bandage
*Qund the thorax and arm. But during the handling,
a little shock was felt, and the head of the humerus had
Pºssed out on to the dorsum scapulae. My interest was
*Oused, and I again reduced the bone, and found that
if the humerus were brought in a line with the thorax
480 NEW YORK STATE MEDICAL ASSOCIATION.
perpendicularly, it slipped out. This Irepeated, and thus
the failure of the surgeon who first reduced it was ex-
plained. Here was a dilemma. The experience of my
friend, above alluded to, came to my mind. The elbow
was carried backward, the clavical bandage applied, and
all trouble was at an end.
Of the fractures of the superior end of the humerus, I
speak only of those that follow the line of the epiphyseal
junction.
About twenty years since I had an experience that led
to a new exposition of the pathology, and a simple and
quite perfect method of treatment. Permit me to read
Some of my paper :
Great confusion has existed, and still exists, as regards
the exact nature of fracture of the humerus through the
line of its superior epiphysis. After the very clear state-
ment of symptoms that has been given by Sir A. Cooper,
Prof. R. W. Smith, and Prof. Frank Hamilton, one
would hardly suppose that error of diagnosis would oc-
cur; but it does occur and constantly. I think this
results from the fact that a clear conception of the
change of position has not been put forth, and more
than this, and growing out of it, no method that secures
reduction of the fracture has thus far, according to my
knowledge, been proposed. If there had been a good
method, especially if it were connected with its ration-
ale, the eaſperimentum crucis would have been present
to clear up doubt of diagnosis as well as rectify deform-
ity. We must, therefore, look to the configuration of
the epiphyseal junction, to explain the position of the
bones, after the separation. Taking the head of a bone
from a subject ten years of age parted by maceration, We
find the angle made by the junction of the plane, pro-
jected through the anatomical neck (and which makes
about two-fifths of the whole surface) with the plane,
passing below the tuberosities, measures about one hun-
dred degrees. gº
“The development of the humerus,” says Gray, “is
INJURIES OF THE UPPER EXTREMITY. 481
EXPLANATION OF PLATE.
Fig. 1 represents the head and part of
the shaft of the humerus, from a boy
ten years of age, and is photographed
life-size. These have been separated by
maceration, and replaced.
Fig. 1 gives a profile of the bone re-
garded from its external aspect.
The dotted line, A, indicates the ana-
tomical neck.
The epiphyseal line, B, is seen to cor-
respond with the anatomical neck along
nearly one-half of its length, and diverges
nearly at a right angle below the tuberosi-
ties.
º; 3 represents the same bone in the
position it retains after fracture along the
epiphyseal line. The smaller facette of
the superior diaphyseal surface is locked
with the larger facette of the correspond-
ing surface of the head.
Fig. 3.



















482 JWEW YORK STATE MEDICAL ASSOOIATION.
by One Ossific point for the shaft, one for the head, and
One for the greater tuberosity. At birth the shaft is
Ossified nearly in its whole length, the extremities re-
maining cartilaginous. Between the first and second
years, the centre for the tuberosities makes its appear-
ance, usually by a single Ossific point, sometimes another
for the lesser tuberosity, which does not appear until
after the fourth year. By the fifth year, the centres for
the head and tuberosities have enlarged and become
joined, so as to form a single large epiphysis.”
The constancy of the symptoms makes this fracture
differ from most that occur. The projection of the angle
of the diaphysis, making the singular appearance about
One or two inches below the acromion, according to the
age of the patient, and the shortening of the humerus
from half to three-fourths of an inch, will render the
diagnosis so plain that the difficulty should not be mis-
taken for any other injury. But it is constantly mis-
taken, and the mistake is acted on, severe and protracted
extensions being made to reduce relaxation.
A little irregularity is found on the surface, but the
plane is pretty accurate. On the surface of the head is
found a depression into which, if the shaft is moved in-
ward about one-fourth of its breadth, there is a coapta-
tion, which arrests the movement of the bones, and which
also fixes the shaft at the point which Smith and other
observers have described. The change of coaptation in
the facettes explains the constancy of the symptoms SO
regularly noticed, by which the projection forward of the
diaphysis replaces the rotundity of the head. This
change has a little analogy to dislocation of the knee
laterally, by which the external condyle of the femur is
jumped, as it were, into the cup on the internal condyle
of the tibia, and retained by the tension of muscles.
The posterior facette of the diaphysis, by the force of
the blow and action of the muscles, becomes fitted to the
anterior facette of the head. Of course, in such injuriº
as fractures, the muscles are apt to acquire their greatest
INJURIES OF THE UPPER EXTREMITY. 483
tension at the moment of separation. Those that act in
the direction of the shaft press upward. The head is set
upon the shaft at an angle, and if there were no other
cause, they would have a tendency to roll the now mova-
ble head upon the glenoid surface. But besides the
muscles, parallel with the shaft, there are those attached
to the tubercles, whose traction would now roll the head
so as to produce dislocation of the facettes. This posi-
tion throws the superior edge of the diaphysis forward,
and then retains it there. It is the observation of all,
that traction will cause the deformity to disappear. That
traction does not produce reduction, is also equally evi-
dent, for the reason that it does not remain in place after
it appears to be reduced. I think, however, that the re-
lief of the deformity by traction is not as great as ob-
servers have thought. When extension is made, the
head will undoubtedly work on the projecting angle of
the diaphysis, and the tense deltoid, pressing the shaft
back, will restore the rotundity of the shoulder. But
the reduction of the luxated surface does not take place,
and the cessation of the extension finds the capsular
muscles ready to roll the head over and project the
diaphysis forward. In consequence of the very common
error of diagnosis, and the belief that a luxation is
present, the attempt at reduction is made by exten-
sion. The evidence of the mistake in supposing that
restoration had occurred after extension, is quite com-
plete, for no one claims that the appearance of reduction
is permanent, the symptoms recurring as soon as the
extension ceases.
In view of such a displacement, the natural mode of
reduction would seem to be one that would carry the
Giaphysis backward, and thus restore the corresponding
facettes to their normal positions. This I succeeded in
doing, not by extension, but by carrying the humerus
Jºrd and upward. The head will roll upon the
glenoid surface in any motion of the arm until restrained
by its Capsule. While the humerus is still back of the
484 JNETW YORK STATE MEDICAL ASSOCIATION.
central line of the body, the head is rolled upward, and
long before the humerus is brought up perpendicularly,
the capsule at the lower border of the head has become
tense, thus holding it firm ; while the humerus being
drawn up and restrained by its muscles, slides the diaph-
ysis backward, producing a coaptation of the corre-
sponding facettes. If these facettes have changed their
position, or rather if one is entirely thrown forward, and
the internal facette of the diaphysis is brought and re-
tained in contact with the external One of the head, it
must be obvious that when the shaft is hanging perpen-
dicularly, the head must be rolled in such a position that
the arm, if there were no fracture, would be nearly at
right angles with the body. Of course the head will roll
around in any direction, in consequence of the lock of
the surfaces, unrestrained by any influence except the
capsule. By a firm grasp of the thumb on one side, and
the fingers on the other, the head may be so far restrained
as to enable one to elicit crepitus. This hold is not secure
enough to answer the necessities of reduction ; but when
the head is rolled over until the capsule becomes tense,
the restraint will become perfect, if the force be applied
in a direct line.
A very slight extension of the humerus will now pre-
serve the relation of the two surfaces. While this mod-
erate extension is maintained, the arm can be brought
down to the side, all deformity having disappeared; in
short, a reduction of the fracture has been accom-
plished.
From these statements, it becomes apparent, that this
fracture possesses many of the characters of a luxation.
The bones after separation are moved into and retained
in a definite place in obedience to definite forces.
A fracture in other than an epiphyseal line is, as a
matter of course, irregular at its surfaces; and while We
may find that a general law may govern fractures at Cer-
tain points, we also find frequent variations incidental to
the form of the surfaces. No better illustration of this
INJURIES OF THE UPPER EXTREMITY. 485
truth can be found than in the fractures immediately
below, that is to say, at the surgical neck, for in these it
is well known that the usual displacement is that of the
shaft inward, in obedience to the pectoralis major and
latissimus dorsi. But even in this fracture, there are
numerous cases where the obliquity of the surfaces has
caused a reversal of the usual relation.
The admission is made by all that no plan of treatment
is likely to succeed, and that the characteristic deformity
appears upon the removal of dressings; but I have found
no difficulty whatever in the use of Swinburne’s exten-
sion plan. The axillary border has been sufficiently firm
to bear the extension necessary, and the axillary band
by passing over the head of the humerus assists in exten-
sion. I find the pressure is not sufficiently great to dis-
turb the axillary nerves; indeed, the method leaves
nothing to be desired, and the facility with which it may
be applied and worn renders it quite perfect. In every
Case it has entirely succeeded; but I think it can do this
Only when reduction has occurred.
It has been my fortune to see but a single case at its
Commencement, and that after severe and unsuccessful
attempts at reduction. Two others having been un-
Successfully treated, or not treated at all, were restored
by me at periods of time varying from two to three weeks
after the accident. It is well known that fractures
Separated after adhesions have formed, are not quite as
easily retained as those which are recent. The swelling
and the accommodation to new positions are circum-
stances that aggravate the difficulties. Yet in each of
the three cases just mentioned there has been a perfect
*sult. The restoration to full use was accomplished in
less than thirty days; for the adhesive process is rapid,
and, where we do not delay for Osseous deposit, the use
of the arm is soon possible.
"he following cases confirm the correctness of the
º as Well as illustrate the rationale of displace-
Iſlent.
486 METW YORK STATE MEDICAL ASSOCIATION.
John Duff, fourteen years of age ; September, 1868. Fell from a loaded
wagon, striking on the right shoulder. He was seen two hours after the
accident by a well-instructed physician, who committed the error of diag-
nosis formerly alluded to, in regarding the case as one of dislocation.
Violent traction must have been made, for two men pulled at the arm
but when the extension ceased the deformity reappeared, although the
supposed luxation was believed to have been reduced. This having failed,
it was renewed the next morning, in consultation with another physician.
The patient was then sent to me the same day. The characteristic
symptoms were present as already detailed. It is also to be noted that on
rotating the arm before reduction there was no crepitus until the head was
grasped firmly. The bandage and splint were worn during the period of
four weeks. The restoration was absolutely perfect, and so remains, as
proved by a recent examination.
Nelly Coates, sixteen years of age. Fell from a height of about six
feet, striking on the shoulder in front. The patient was seen immediately
by the family physician, but he did not recognise any displacement. Four-
teen days later she was seen by another physician of great experience,
but, on examination, he also thought there was no displacement. The
patient still suffering, a third physician was called, who thought there was
luxation. I saw the case seventeen days after the accident. The symp-
toms, as detailed in the résumé, were all present. It was treated by first.
reducing the displacement, and the application of Swinburne's dressing,
which was worn about two weeks. A year afterwards the arm was
examined, and the result was so perfect that no difference in form or
motion could be discovered.
Charles Bunnel, six years of age ; on March 15, 1873, fell, as it was
thought, on his shoulder. He was seen by Dr. C. Hammond, of Monroe
county, on the day following, who diagnosticated luxation, but, On
making further examination while the patient was under the influence of
ether, he “found the movements of the shoulder perfect ;” and getting no
crepitus supposed the deformity resulted from ecchymosis. At the end of
two weeks the swelling had subsided, and the prominence Was more
marked. At this time (March 18, 1873) I saw the patient for the first time.
The boy was the unfortunate subject of infantile paralysis, which had
occurred between the first and second year, and affected the arm which
was broken. My views had been pretty well settled before, but now I
had a case, which, though not quite, was almost as capable of demonstrat-
ing the facts, as an autopsy. I need not remind the profession of tº
shrunk muscles and lax skin that invest the bone in such cases. As *
usual, there was some muscular power ; but while in the strong and
healthy there is much diminution of utility in the arm, in this patient the
little he possessed was gone, and hence its restoration became a matter of
unusual interest. The adhesion of the bones was readily broken up by
carrying the arm upward. The muffled crepitus was obvious, and the
restoration perfect. Three months afterwards, Dr. Hammond in a note tº
me remarks, that the “restoration is complete in every respect.”
INJURIES OF THE UPPER EXTREMITY. 487
Aesoſºme.—1st. The symptoms of this fracture are
striking and uniform. The shaft of the humerus is so
inclined as to carry the elbow a little backward and Out-
ward, while the superior end of the shaft is brought
forward, so as to make a prominence less rounded than
the head, and lower down. This is usually found about
an inch and a half below the acromion (the distance
varying a little with the size of the youth) and near the
coracoid process. The curved line from the acromion
down to this projection has a long sweep, instead of the
small sphere of the natural head. This appearance is
pathognomonic, and may be safely trusted in diagnosis,
without insisting upon crepitus, which, as in other epi-
physeal fractures, is not clear and sharp, as when the
fracture is of bone, but is muffled. When the arm is
moved gently, and without grasping the head, the pecu-
liar lock of the surfaces is sufficient to cause the head to
rotate, and thus the timid practitioner fails in getting
his pathognomonic sign; but if the head be firmly
grasped, it can not only be felt in the glenoid cavity, but
can be held sufficiently firm to get this muffled crepitus
by rotating the humerus, or by carrying the elbow in-
Ward and thus rubbing the two surfaces on each other.
In addition to these striking symptoms we may add the
fact of a shortening of half an inch or a little more in
the length of the humerus. When the two shoulders
are inspected from behind, the impression produced on
the mind of the surgeon is that described as sub-luxation,
for there is a slight flattening of the shoulder. The
breadth of the shoulder is also increased when seen in
profile. The motions of the arm are somewhat circum-
scribed. The ability to carry it upward and forward, as
Well as upward and outward, is impossible much be-
yond a right angle with the body.
. 2d. The reduction of the fracture is effected by carry-
i. the arm forward and upward to the perpendicular
Ile.
* The retention is effected by moderate extension
488 NEW YORK STATE MEDICAL ASSOCIATION.
while bringing the arm down to the side, maintaining
this slight extension until dressings for the purpose of
continuing it are applied. Swinburne's method fulfills
the indication easily and perfectly.
4th. Even if not restored, the arm soon becomes useful,
and nature gradually rounds off the prominence of the
diaphysis, and elongates the capsule at the lower
border, allowing the upward motions to improve.
Professor Robert Smith acknowledges the difficulty
of rectifying the fracture, and quotes Mr. Tyrell as suc-
ceeding by dressing the fracture with the arm extended
from the body. But this, in his experience, was an
exceptional case. The extraordinary projection which
Professor Smith figures in his book is so remarkable that
once seen it can never be forgotten or mistaken. This
is the only form he speaks of, and it is very rare. I
think it accounts readily for the general ignorance of
surgeons on this topic. I have photographs of two such
cases, and they confirm the correctness of Smith’s
engraving, which I had formerly thought to be an artist’s
exaggeration. The deltoid in these cases is split, and the
end of the diaphysis comes forward under the skin. (See
portrait.) The finger can be put into it as in a cup. But
in by far the larger number of cases the diaphysis remains
covered by the deltoid, and thus the sharp edge is thickly
covered and the shoulder presents the appearance of
moderate flattening. Every case of this kind that has
been sent to me was regarded by the attending Surgeons
as a sub-luxation, and unsuccessful attempts at reduction
had been made. -
As regards the management of fractures and disloca-
tions of the elbow, I may say that I have found the
diagnosis of the lines of fractures often very difficult,
owing to a moderate ecchymosis. As a teacher, I looked
around for some method which would be entirely safe
pending the clearing up of the diagnosis, and also for One
that could carry the cure to a successful conclusion. Some
teach that the extended position is the proper One, on
INJURIES OF THE UPPER EXTREMITY.
Photograph of a young man sixteen years of age, the end of the
diaphysis having penetrated the deltoid muscle.
489

49() NEW YORK STATE MEDICAL ASSOCIAT ION,
the ground that it enables the patient to maintain a good
carrying power ; but I have found that by this treatment
the use of this marvelous member is reduced to the mean
position of a mere hook for burdens. The old rule in
the after-treatment of luxation of the elbow, of placing
the forearm at right angles to the arm, is one that we
cannot abandon on any terms. I have seen several
cases where there was an epiphyseal fracture of the
lower end of the humerus, which was mistaken for a dis-
location—an error that even a good surgeon may make,
because the forces inducing displacement are precisely
the same in both injuries. The tissue does not produce
the sharp grating of an ordinary fracture, and even with
a dislocation there is some crepitus as the bones go into
place. In dislocation, the reduction soon after the acci-
dent is very easy, and therefore does not differ percepti-
bly from the muffled crepitus of an epiphyseal fracture.
All authorities agree that, after a reduction of the luxa-
tion of both bones of the elbow backward, the forearm
should be kept at right angles to the arm ; but this is
necessary only for a short time, just long enough to
allow of the repair of the capsule. In a case of fracture,
if the arm be liberated from the sling at the end of this
short period of time, it gradually drops down to the
angle of 135°, which is the compromise between the
flexor and extensor muscles. It then becomes firmly
united in this false position. The case is aggravated
where the extension is made by splints. The numerous
modes of fracture of the lower end of the humerus, the
epiphyseal, that of the external and internal condyle, as
well as that of the neck of the radius, are more or less
obscure of diagnosis.
The fractures of the olecranon are so easily diagnos-
ticated that no error can be made in them. That they
should be treated in the extended position requires nº
assertion. For fractures of the internal condyle, it seems
to me that the rectangular position, and even one of "
acute angle looking upward, is the proper method,
INJURIES OF THE UPPER EXTREMITY. 491
because it relaxes the muscles which originate from the
broken fragments. Now, as I regard the knife-and-fork
function as much more important than the carrying One,
my effort in elbow injury is to see that the hand can be
carried up to the neck on the side opposite to the broken
arm, knowing that gravity is pretty sure to bring the
forearm down.
I have found the same position efficient in the treat-
ment of fractures of the external condyle. In them the
muscles of origination are tense if the forearm be placed
at right angles to the arm. Such a contradiction in
theory with correspondence in results should be ex-
plained. For this purpose I experimented upon an arm of
a boy ten years of age, which had been amputated at the
shoulder-joint. I cut down through the tissues in a line
with the fracture of the external condyle, merely split-
ting the muscles so as to allow the introduction of the
points of a pair of bone-cutters, with which I made a
fracture. On moving the forearm up and down, it was
found that the fragment was drawn close up to the shaft
When the forearm was carried up, in consequence of a well-
known anatomical condition. You will remember that
the fascia over the external condyle is very dense, like
a broad tendon, and is inserted along the external line
of the humerus. This, when tense, makes the most
perfect of splints.
Fracture of the neck of the radius is one of the rarest.
It is obvious that it is our first duty to relax the biceps
muscle by bringing the forearm to the rectangular posi-
tion, or even to an acute angle.
Let me Say here a few words with reference to the
dislocations of both bones of the radius and ulna back-
ward. Every surgeon knows with what ease the reduc-
tion is made when the luxation is recent, and what
difficulty attends it when a few weeks have elapsed
before it is undertaken. It is also easy to recognise the
reduction when made, for the anatomical points are very
marked. In the county of Livingston, some years since,
492 NEW YORK STATE MEDICAL ASSOOIATION.
four law suits were brought because of an alleged non-
reduction of such a luxation. It was bitterly contested
by the surgeon in attendance, who was perfectly sure of
the reduction, and of this fact I was quite as certain as
the surgeon himself. But at the end of two months it
was also manifest to every one that the luxation was
complete. Only one inference was possible—consecutive
luxation had occurred. Consultation of the authorities
furnished no information. It is not necessary to say
anything of these trials, but it is significant that, even in
the limited area of western New York, two other cases
should appear to show how easily consecutive luxation
of these bones may occur. In one of these cases the
Surgeon placed the arm on a pillow, with the forearm at
right-angles to the arm, and the swelling and pain were
So great for several days that no manipulation was
undertaken. The swelling also served to obscure the
consecutive luxation, and the surgeon was blinded to the
fact that there was any re-luxation in consequence of his
firm conviction that he had reduced the bones to their
proper place. Even if the forearm had been placed at
right-angles to the arm and laid on a pillow, the muscles
would slowly but surely bring it down to the angle of
135°. The question to be solved was the angle at which
the luxation would be reproduced, but no light whatever
was thrown upon the subject by surgical writers. An-
other case was brought forward where the arm was
placed on a pillow for the night, and at the morning visit
a re-luxation was discovered. It was again reduced, and
the forearm being retained by a splint at right-angles to
the arm, no further trouble was experienced.
After appearing as a witness on the first trial, I reduced
a similar luxation in a young woman. The bones went
into place easily. I then carried the forearm out to an
estimated angle of 135°. The luxation occurred at Once:
This patient was nineteen years of age. At a later period
I reduced a similar luxation occurring in a man about
forty years old, but the re-luxation did not appear when
INJURIES OF THE UPPER EXTREMITY. 493.
the forearm was carried out to the angle above described.
In neither case was there any evidence of a fracture of
the coronoid process. These observations prove that
consecutive luxation will sometimes follow when the
natural relation of the muscles is allowed full play.
I have alluded above to my desire as a teacher to de-
vise some correct method for the early stages of fractures
of the elbow, and thus give the time necessary for correct
diagnosis and subsequent treatment. With reference to
the luxation of both bones backward at the elbow joint,
the necessity of following the common advice of authors
to place the forearm at right-angles to the arm, is obvi-
ously correct. It is my judgment that in all fractures
except those of the olecranon, or of the ulna just below
the articulation, the same position should be taken. But
if the fractures are treated in any fixed position there is
apt to be more or less interference with the motion of the
forearm. The least tilting of the fragments may inter-
fere with full extension or flexion. Every surgeon prac-
tices passive motion, more or less. But my method,
which I believe to be original, and which I have practiced
So long, Secures all the advantages of passive motion and
Something more. At the end of about ten days I change
the angle a little by the application of side splints of
trunk boards, or their equivalent. At the end of two
days another set is fitted at a more acute angle, and
again another set at the end of two more days. The
patient should now be able to carry the hand up to the
neck on the side opposite the injured elbow. Two days
later the reverse movement is made, and continued down
nearly, but not quite to, the position of extreme exten-
Sion. The arm is carried upward and backward as
before. The change of position is so little at a time
that it does not interfere with the union, and the frag-
ºnents are moulded into place or out of the way.
tº of the fracture of the radius at its lower end near the
19nt which receives so much elucidation from the obser-
Vations of Professor Colles, I may say, that I have
494 NEW YORK STATE MEDICAL ASSOCIATION.
departed widely from the views heretofore entertained
by the profession and still mostly held by it. Professor
Colles found surgeons constantly blundering in supposing
that when this fracture was present they were either
dealing with a sprain complicated with blood clots, or
with a dislocation of the wrist. This latter error is not
now often made, but was formerly quite frequent.
At the last meeting of the Surgical Association, Dr.
Roberts, of Philadelphia, wrote an elaborate paper on
this subject. He sent to the Fellows a series of ques-
tions especially referring to the treatment of the fracture.
He also solicited the general experience as regards the
results, especially with reference to the pain and stiff-
ness that so often occur. I must confess that their state-
ments make rather dismal reading. A great variety
of splints had been used, but the results were very
nearly similar. Dr. Roberts seems to draw the same
conclusions that I do, viz.: that splints and confinement
are worse than useless. He places a band of adhesive
plaster around the wrist, but unless this is drawn too
tightly for the comfort of the hand, I cannot see in it
anything but a placebo. But his method is an advance,
for he first very carefully rectifies the deformity, which
is usually neglected, and abandons the use of Splints.
When he shall have gone a little further, and held the
ulna up by the weight of the limb pressing it into its
place, the method will be complete. I propose no general
criticism of Dr. Roberts’ paper; the oft-quoted Saw
about the play of Hamlet, with the Prince of Denmark
left out, is strictly applicable to it.
My first paper on this topic was a description of a
single case, that of Mary Tumey, which drew my atten-
tion to the subject in a new light. This paper was pub-
lished in 1870, and read before the New York State
Society. In it I made the statement that the displaced
ulna, which had been observed in most cases by every
surgeon, was really the displacement of luxation. Pº.
Hamilton regarded this as merely producing a stra”
INJURIES OF THE UPPER EXTREMITY. 495
upon the ligaments. Benjamin Bell said there was a
dislocation, but founded his opinion upon the obvious
displacement which every one recognises. Sir Astley
Cooper, however, found the luxation by autopsy, and
gave a plate of it, but his description is very meagre.
My work is of a kind that I think has not been trav-
ersed. My paper is upon “a luxation of the ulna not
heretofore described.” Notwithstanding Cooper’s state-
ment, I still think the claim is correct. Malgaigne also
recognises a dislocation of the ulna in connection with
Colles' fracture. He quotes Bouchat, who, in studying
the luxation of the ulna upon the cadaver, found, as I
have done, that the radius will usually break before the
styloid process of the ulna gives way.
My second paper was written in 1880, and read before
the New York State Medical Society. In this paper Isay:
It is now just ten years since I read a paper before this
society upon “a luxation of the ulna not heretofore
described.” The claim of originality in a matter of
this kind, at this late day, was too great to be readily
admitted, and it is a mild statement to say that it was
received with incredulity. It will be recollected that
my observation was founded on one case only, that of
Mary Tumey, who sprang from a third-story window in a
paroxySm of mania, and was instantly killed, making
a few respirations for about twenty minutes. Both
Wrists were broken, and the spine opposite the second
and third dorsal vertebrae was crushed. The examina-
tion of one wrist revealed, to my astonishment, the
peculiar break and entanglement which I have described.
Amazed at the result, which was not comprehended in
its fullness at first, I proceeded to the dissection of the
other wrist, and found precisely the same condition, with
the exception of the line of fracture of the radius; one
being nearly transverse, and the other quite oblique.
The luxation of the ulna presented the same form of
*Pure of the lateral ligament, from the styloid process,
With the same entanglement of the annular ligament.
496 IVEW YORK STATE MEDICALL ASSOCIATION.
To my report it has been replied that there have always
existed irregular luxations that were not to be regarded
as capable of classification. A regular luxation, so
called, is one where the joint surface that is separated
from its proper connections, is held in its abnormal but
definite position, in obedience to definite forces. People.
do not often spring from third-story windows, and this
case, like the cause, is abnormal.
This cavil, more specious than just, served to satisfy
the conservative, and check further inquiry. The fract-
ure of the radius close by the joint is one of the most
common, and usually occurs from a fall upon the level
ground, or from a step. This presents often very great,
and heretofore insurmountable difficulties of restoration.
Since the observation of the case of Mary Tumey, I have
had far greater success in the management of these fract-
ures, for I have relied upon the relation of the two con-
ditions that I found in the autopsy of Mary Tumey, and
that resulting from a fall on the level surface, as being
similar, in consequence of the similarity of the appear-
ance of the wrist. I, nevertheless, quite agree that We
must not insist upon appearance, and diagnosis founded
upon it, without proof from dissection. Now, patients
do not die from the circumstance of falling over on the
hand. The combination of circumstances that would
destroy life, and leave us with a definite force of this
kind, must recur at very remote intervals of time. Great
violence must occur in the cases where we can get
autopsies, although the force at the wrist might not be
more than common in Colles’ fracture.
The doctrine I have taught my classes for the last ten
years may be succinctly stated. The fall comes upon the
palm of the hand, and the radius which sustains the full
force of the strain gives way at a point near the Wrist.
The line of fracture is usually an oblique one, starting
from a point on the anterior aspect of the radius, n°
the articulation, and running backward and upward,
making the posterior surface of the lower fragment
INJURIES OF THE UPPER EXTREMITY. 497
longer than the anterior. It is seldom more than an inch
from the joint, rarely so far. But the line of fracture is
very various, sometimes simple and nearly transverse,
but often comminuted to the last degree. The luxation
of the ulna exists in more than half of the cases. I now
feel quite sure, though I cannot demonstrate it by dis-
section, that a proper observation of the relation of the
head of the ulna to the carpus will make a just diagnosis
of its luxation or non-luxation. The force of the fall
may be just balanced by the strength of the radius, but
in the nature of such accidents this would not often be
the case. In most, there would be some force still to be
borne. Upon what structures does this fall ? The radius
instantly, on fracture, ceases to afford resistance, the
hand is carried still further back, and then comes the
strain on the attachments at the end of the ulna. It will
be remembered that the ulna does not articulate with the
wrist, but there is a distinct synovial cavity between its
head and a strong membrane called the triangular fibro-
cartilage. The membrane takes an origin from the rim
and side of the radius, and covering the head of the ulna,
is inserted in the pit at the root of the styloid process.
As the hand, with its broken fragment of the radius, is
forced backward, the strain is often sufficient to rupture
the connection between the two bones or to break the
ulna near the head. I have seen this double fracture
twice only. The rupture takes place at the weakest
point, which is its insertion in the pit at the root of the
Styloid process. But this is not the Only resistance. The
Styloid is held to the carpus by the internal lateral liga-
ment, which takes a very firm hold upon the end and
radial surface of the styloid. This also gives way, and
usually does so in a peculiar manner—viz., by pulling off
the surface of the bone, which proves to be weaker than
the ligament. Thus the remaining styloid is brought to
an edge like a gouge-chisel, and is shortened about one-
half. When these resisting forces are disposed of, the
end of the ulna, now laid bare, is pressed against the
32
498 NETW YORK STATE MEDICAL ASSOOIATION.
posterior annular ligament, and is apt to become engaged
upon it either by a fold, or, what is more likely, by
splitting its fibres and hooking upon it. If very great
violence has been used in the production of these lesions,
the head of the ulna will be driven forward through the
annular ligament and skin, thus producing a compound
luxation. These opinions were urged by me upon the
profession, chiefly in consequence of the autopsy of Mary
Tumey, but also from the very greatly improved results
of treatment founded on those views.
But Iwaited for further proof with no little impatience.
The next case that goes to confirm the views I have
brought forward, was one that proved the luxation by
thrusting the head of the ulna through the skin. I
report the case: -
John O’Hara, forty years of age, a laborer in a lumber
yard, fell from a lumber pile eleven feet high, striking
with his outstretched hand on a plank roadway. The
force was so great as to break the radius just above the
wrist, also at its middle, and to dislocate it forward at
the elbow. As might be supposed, the radius was much
shortened. The ulna was freed from its attachments, as
has been described, and pushed through the skin. In
this condition the case was presented to me. I removed
the end of the ulna with a saw, dressed the fracture, and
reduced the luxation at the elbow. The patient made a
slow recovery, but finally obtained very good use of the
arm. This bone I now present.
Fig. 1.
FIG. 1–1, Styloid shortened by fracture; 2, tags of triangular *.
cartilage at the root of the styloid; 3, smooth articulating surface at the
end of the ulna.

INJURIES OF THE UPPER EXTREMITY. 499
It is absolutely as first found. This adds another, now
the third case, where the triangular fibro-cartilage and
lateral ligament were torn off in precisely the same man-
ner; the two in Mary Tumey being only engaged in a
rupture of the posterior annular ligament and skin.
But it will be remembered that the two in Tumey’s case
were only accompanied with the ordinary fracture of the
radius at the lower end, and Only one fracture in each
arm. Where the luxation of the ulna was compound,
the radius was enormously shortened by two fractures
and luxation at the elbow.
A case like O’Hara's has the full value of an autopsy,
for the end of the ulna is in our hands, and the fracture
can be diagnosticated without failure. I think, in view
of the fact that the fractures in the case of Tumey were
only of the ordinary character of those styled Colles',
with a good deal of the peculiar deformity, that the
mode of luxation found here may be fairly concluded to
occur from apparently slighter forces, but which are suf-
ficient to break the bone.
But I now present you a specimen which, in a singular
Way, leaves no chance for argument or cavil with refer-
ence to the ability of the apparently moderate force to
produce the luxation I describe. I am indebted for this
to my friend, Dr. Thos. Collins, of Rochester, who was
called to see a farmer, who, attempting to get out of his
Wagon, Slipped from the hub, falling upon his hand.
pon examination, the radius was found to be broken,
and the ulna was protruded through the skin. An
attempt Was made to reduce the luxation, but to his sur-
prise and that of his counsel, Dr. J. F. Whitbeck, it was
found impossible to reduce it. Therefore it was sawed
of and the fracture dressed. (I might add at this point
that he made a good recovery, acquiring as good use of
the arm as before the latter accident.)
I now present this specimen. Upon inspection, it will
be seen that it presents a very extraordinary appearance.
The shaft of the ulna is apparent, but the side and part
500 NEW YORK STATE MEDICAL ASSOCIATION.
of the end is covered with as fine a specimen of eburna-
tion as it is possible to produce. The extremity of the
ulna exhibits, instead of a smooth articulating surface, a
rough one, made up of ruptured tags of cicatricial tissue.
FIG. 2.-1, End of ulna, sawed surface : 2, crust of eburnated bone.
FIG. 3.−1, Styloid short and smooth, rounded by time ; 2, tags of mem-
brane attached to and obliterating articular surface; 3, crust of eburnated
bone.
Inquiry revealed the fact of an antecedent fracture of the
radius sixteen years before. The case, as rendered by
Dr. Collins, is as follows: Jacob Winslow, seventy-five
years of age, received the injury as above described,
October 25, 1873. In the year 1857, while walking in a
saw-mill yard, he stepped on a slab and fell over on his
hand, producing Colles' fracture. The mode of treat-
ment at this time is unknown.
There can be but one inference from this case. We
have, by the complete disappearance of the articulating
surface, unmistakable proof of antecedent luxation.
The eburnation also shows the effect of long and severe
friction upon the side, the result of the severe and pro-
tracted labor of a farmer's life. The return of the luxa-
tion was attempted, but in vain, in consequence of the
extreme projection of the ulna, due to the antecedent
accident.
Several years elapsed without further proof derived
from autopsy. But another case, resembling Mary
Tumey's, occurred on the 11th of October, 1879.
Morris Huntington, fifty-six years of age, a painter,
fell from the roof of a three-story house, through a tree,
to the side-walk. He was at once taken to the City

IWJURIES OF THE UPPER EXTREMITY. 501
Hospital, but only lived a few hours. A fracture of the
wrist was observed, but he was so nearly moribund that
it was not interfered with. I was invited, by the kind-
ness of the staff, to make the autopsy. This was done
by simply removing the skin from the posterior surface
of the wrist, extending to the sides, thus coming at Once
upon the annular ligament. The end of the styloid
chisel protruded through a rent in the ligament. This
was carefully touched by Drs. Whitbeck, Montgomery,
Little, Langworthy, Ely, Mallory and others. It was
precisely, in all its details, as before observed, and as I
described it ten years since.
The next move in the dissection was the removal of
the skin on the anterior aspect of the arm, and the di-
vision of the muscles and tendons down to the bones.
These were then lifted up just far enough to see the end
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—Posterior aspect of wrist.—1, wrist-joint; 2, comminuted frag-
*ents of the end of the radius ; 3, shaft of the radius; 4, styloid process
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Fig. 5.—Anterior aspect of w
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502 NEW YORK STATE MEDICAL ASSOCIATION.
of the ulna. The triangular fibro-cartilage was torn out
at the pit of the styloid, and the internal lateral liga-
ment torn off with the end of the styloid, as in the other
cases. I now present you this specimen in its wet state.
The rent and luxation can be seen, and the styloid chisel
is almost precisely the same in shape as that of O'Hara's.
This case confirms all previous observations. It would
not unlikely have been a compound luxation, but for the
fact that the ulna was broken about three inches from
the wrist, for the radius presents a condition of extraor-
dinary comminution.
Luxations of the ulna have been noted heretofore, but
they have been regarded as irregular, and as having no
definite character. In the discussion upon this topic at
the meeting of the American Medical Association, held
at Buffalo, I took the ground that for every compound
luxation of any joint we will have a large number of
simple ones. In the absence of statistics, which are not
possible, I asseverated the round number of fifty. I
repeat it on the ground that it could not be an exception
to all our observations of other joints. A distinguished
author replies that this could not be said of dislocation
of the astragalus. But I rejoin that there is no analogy.
The only analogue of the tarsus is the carpus. The
ulna is a long bone, and must find its analogue among
the long bones. It requires very great violence to pro-
duce a compound luxation at any place. Less force
produces the simple luxation, and this we have Very
often with Colles’ fracture.
Thus far my paper has referred only to the evidence
bearing on the question of the existence of luxation of
the ulna at the lower end—evidence that is purely
demonstrative and beyond the reach of argument. But
I feel justified in adding some inferences of observation
on the living subject. In my previous paper I called
attention to the position of the tendon of the extenso"
carpi ulnaris. It runs alongside of the head of the ulna
and behind the styloid. When the luxation does not
IWJURIES OF THE UPPER EXTREMITY. 503
exist and the fracture does, the head of the bone main-
tains its relation with the tendon but little disturbed.
When, however, the luxation does occur, the tendon will
appear to lie over the head. I feel quite sure that this
does not result from any twist of the hand carrying the
fragment of the radius. The dead tissue presents the
tendon curved out of its place. In the living, under
muscular contraction, this would be a straight line and
lie over the head of the ulna. I find also, in what I
deem cases of luxation, a mobility of the end of the ulna
incompatible with the integrity of the ligamentous appa-
ratus. Every observer has recognised a difference of the
form of the wrist in different cases. Some are curved
backward—the genuine silver-fork shape; others have
the hand carried more laterally. My convictions are
that those that present the wrist well curved back are
more apt to be those of luxation of the ulna with fract-
ure, but the lateral bend implies generally shortening of
the radius from fracture without luxation of the ulna.
In my previous paper I proposed a form of traction
and circumduction which is intended to disentangle the
ulna and carry it up in its place between the tendons of
the extensor carpi ulnaris and extensor minimi digiti.
I by no means wish to say that this is always necessary,
for the great point should be not to relax any effort until
Complete restoration has taken place. The gentle hand-
ling that is ordinarily employed in the management of
the fracture is out of place here. Great force is often
necessary to restore the symmetry of the parts. We
must keep in mind that a luxation is to be reduced, and
should not cease our traction until the end is attained.
Besides, the muscles will produce consecutive luxation
instantly if the parts are not held firmly until the dress-
ing is complete.
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Fis
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2. , Wºlf h" ſº liff ſh
ºſmºs
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FIG. 6.—Position of roller compress.

504 NEW YORK STATE MEDICAL ASSOCIATION.
I find, as a rule, that a strong pull, with the head of
the ulna resting against my knee, and the hand of the
patient curved downward is sufficient to bring the bones
into their proper place. But it requires great force in
some cases. Effort at the rectification of the luxation
and fracture should not be abandoned until the end is
attained. If the fracture is simple and transverse, it is
usually retained in its place with ease, but if it be com-
minuted or even oblique, displacement is apt to occur at
once. Therefore the dressing should be completed
before any relaxation of the retentive apparatus is
allowed. -
With the thumb of the surgeon under the ulna, the
hand beneath, and the fingers upon the back of the wrist
holding with great firmness, I apply my dressing. This,
it will be remembered, consists of a simple roller from
half to three-quarters of an inch in diameter and two
inches long. This is to be carefully placed under the
ulna, abutting against the pisiform bone and slowly dis-
placing the thumb. Then a strip of adhesive plaster of
FIG. 7.-Roller, with adhesive strap applied.
the same width is drawn, with as much force as it will
bear, around the wrist and pinned to prevent relaxation.
The band of plastered cloth is carefully adjusted so that
the distal edge is brought around on a line with the end
of the radius. It is manifest that this bandage will
grasp the broken fragment, and hold it to the end of the
ulna. The rule, of loose dressing at first, is distinctly
violated for a purpose. I repeat that I draw it as firmly
as I can, often breaking the plaster cloth. The dressing
is entirely completed by the use of a sling which must
not be more than three inches wide. This must be
placed over the roller, and is made of this width to Cause

INJURIES OF THE UPPER EXTREMITY. 505.
the whole bearing to come on the roller, which is both
compress and splint. The hand is brought down and
allowed to hang naturally. Thus its weight and that of
the forearm is used to press the ulna upward into its
proper place.
If all this is successfully accomplished, the broken
fragments of the radius are easily kept in place.
The full length of the arm is maintained if the ulna
does not fall down, and the tendons that run over the
back of the wrist are so closely parallel as to make the
best possible splint. I do not continue so gross a viola-
tion of the primary rule in dressing fractures, as to
retain the bandage in its tight condition ; but, after six
hours, cut it by thrusting one blade of a pair of scissors
FIG. 8.-Colles' fracture; dressing complete.
inder it on the back of the wrist, dividing it completely.
* few hours of such retention seem to be sufficient.
The meagreness of the appliance has startled some
Who have attempted its use. But any addition that I
*Wºmade has injured it. I find there is a strong dis-
Pºsition on the part of the patient to lift up the hand

606 NEW YORK STATE MEDICAL ASSOOIATION.
with the sound one. With unintelligent patients this is
often troublesome, and a splint of thin iron, such as
hoop iron, bent so as to come over the back of the wrist
and hand, and bound upon the forearm but not upon the
hand, will guard against this error. I am careful not to
bind the hand to it, for I desire the constant action of
gravity. The position can be maintained, even in the
recumbent posture. The slight motion in the joint which
will necessarily be produced by allowing it to hang
freely, prevents the stiffness that is so often a very seri-
ous inconvenience after the treatment of this fracture.
There is another question to be answered: How good
are the results & My experience has been considerable,
as my professional brethren have shown me their cases
when treated after my method. When there is much
comminution there will be some absorption of the bone.
This will produce a slight deflection. But if the fracture
is transverse, deformity can hardly be said to exist. As
in other luxations, the union of the ligaments is apt to
result in their elongation, making, when the cure is per-
fected, a certain laxity and mobility of the head of the
ulna after the fracture is perfectly firm. When the
fracture is transverse, I have removed the bandage at
the end of two weeks, but in other cases the treatment
has been extended to four weeks.
I would remark that the reputation of the pistol-shaped
splint, Bond's, Levis’s, and most others, can be explained.
If great pains is taken to restore the parts, the flexed posi-
tion of the hand will have a tendency to keep the restored
ulna in place, especially if suitable compresses are used.
These can be well adjusted in Bond's and Levis’s splints.
Moreover, in those cases in which there is no luxation,
the results are apt to be good in the fixed position, for
the full length is obtained because the ulna is not dis-
turbed. Where luxation occurs, the muscles have a Con-
stant tendency to displace the ulnar head, which, when
slipped downward in the least, is apt to remain. I there.
fore prefer gravity to any fixed splint ; for the Comº
INJURIES OF THE UPPER EXTREMITY. 507
presses, even if applied tightly, will yield, and any relax-
ation of the retentive force is apt to be accompanied with
displacement. Moreover, by my simple dressing, the
parts are under view without its derangement.
I would urge the profession to banish the fear of its
use as leading to disaster, with the full conviction,
founded on the experience of my friends, that once
understood and practiced, no other would be thought of.
Since this paper was written, my observation has been
extended. I have refractured many forearms brought to
me by medical men. I never hesitate in this matter, and
do not recollect a single case in which there was any
cause for regret. Those that have remained displaced
are usually such as have been retained in their mal-
position by the splints. Great stiffness and pain are the
common results, with the fingers so fixed as to give the
hand the appearance of a claw. When the luxation and
fracture have been reduced immediately after the accident,
the pain rapidly disappears as a result of the rectification.
The suffering so often witnessed in those who have this
fracture, is due to displacement; indeed I have never
Seen it occur in cases that were properly rectified. But
When after a continuance of the erroneous position for a
few months the refracture is made, it does not relieve
the pain at once; on the contrary, it is aggravated for a
time in consequence of the new traumatism.
After reduction of the fracture and the accompanying
luxation in recent cases, I trust to the weight of the
hand, which naturally hangs down, to retain the frag-
ºnents of bone in their place. For this purpose no splint
“an be devised so well fitted as the tendons which run
9Wer the back of the wrist. But when the hand has
been thrown back for a period of weeks or months, its
*ght is not sufficient to cause it to hang down. This
Position of the hand is necessary to assure the carrying
Of the head of the ulna up into its place. I therefore
strap into the palm of the hand a pound of shot, having,
While the patient is under ether, bent the hand well
508 NEW YORK STATE MEDICAL ASSOCIATION.
down. At the end of two days there will be no tendency
on the part of the hand to rise, and the weight may be
removed. The question has been asked if stiffness of
the fingers and wrist occur, with this method of treat-
ment. The answer is definite—it does not. When they
are not confined by splints, they will be moved, and in
consequence of these movements the wrist and fingers
will have a gentle, passive motion. The time necessary
for treatment is only about half of that which is usually
employed—two or three weeks in recent cases, and four
or five in refractures. If the bone be comminuted, I
advise a longer period of treatment. I have again broken
the lower end of the radius more than six months after
the original fracture ; indeed I have treated one in this
manner that was fractured three years before, and with
much benefit. But the absorption of bone so shortens
the radius that the deformity is not relieved. I there-
fore make it a rule not to operate in this manner more
than six months after the injury. •
A great many cases can be improved by another Opera-
tion. On measurement it will be found that most of
them present half an inch shortening of the radius.
This is easily made out by using an ordinary carpenter's
square, placing the arm and forearm upon it so that the
elbow is in its angle. The styloid processes of the ulna
and the radius should be opposite each other, and the
difference when there is a fracture can be easily read by
this method. - -
There is also another kind of deformity at the point of
injury. The breadth of the forearm is increased by one-
fourth or one-third of an inch. In consequence of the
shortening of the radius the ulna is pressed forward and
downward against the side of the wrist when it is lux-
ated. This usually gives rise to great pain. It is also
asserted that a nerve filament is rendered tense. By re-
secting the end of the ulna and removing half an inch
the bone is made of the same length as the radius. !
know of but two cases that have been thus treated, and
INJURIES OF THE UPPER EXTREMITY. 509
both with charming results. One was by my own hands
and the other by another surgeon by my advice. The
operation should have a wide application until better
methods of primary treatment are more general.
It will be recollected that I have stated that the inju-
ries known as Colles’ fracture may be, as Professor
Colles states, confined to a break of the radius; but my
belief is that the connections of the ulna are usually rup-
tured as above described, so that its head and styloid
process press against the posterior annular ligament. If
the unexpended force be a little greater than in such a
case, the ligament becomes ruptured by the point of the
styloid, or has even the whole head thrust through it.
If the radius be broken in another place at the same
time, or if it be dislocated at the elbow, it may be so
shortened as to allow the head of the ulna to go through
the skin. These opinions are the result of a careful study
of cases by autopsy. I have expected when making such
examinations to find some of them presenting a simple
fracture, but this has never been my lot. Professor
McGraw cites an autopsy of this kind. But in several
cases Ihave found the triangular fibro-cartilage ruptured,
and in six of the cases the internal lateral ligament was
torn off. After reduction the treatment that holds the
head of the ulna up in its place is applicable to all these
forms of injury, for it places an unbroken parallel bone
in its proper relation to the wrist. I find the attachments
to the ulna are less likely to be ruptured in hard-working
men than in persons who do not labor. I refractured a
radius that had been broken at this place in a laborer
While the ulna was still in its normal position. He was
disabled by the pain from displacement, but the opera-
tion gave complete relief.
I cannot close my paper without speaking of my
method of dressing the phalanges when they are broken.
Most authors seem to consider these fractures insignifi-
*t, but this is not my opinion. The great value of the
fingers to Workingmen, and perforce to all men, should
510 NEW YORK STATE MEDICAL ASSOCIATION.
make us careful to Secure exact apposition, and to use
the neatest Surgical appliances. The usual custom is to
dress these fractures with straight splints of wood, thus
carrying the fingers out in a straight line. This puts the
flexor tendons on the stretch, which will of itself cause
the passing of fragments and interfere with proper mo-
tions of the joints. I have for a long time dressed all
these injuries in the semi-flexed position, which relaxes
the strong flexors.
The retentive apparatus should also bear a proper rela-
tion to the size of the member to be treated. For this
purpose I employ upon the broken phalanges a strip of
tin half an inch wide, bent to correspond to the joint
so as to make a close fit and give perfect support. In
bandaging, a broad strip of either cloth or adhesive
plaster is inappropriate. Adhesive plaster should be
cut into strips less than a quarter of an inch in width,
and these should be wound straight around the finger
and splint, lapping over each other for one-half of their
width. This plan provides for smoothness without re-
verse turns. The end of the finger should be held by an
assistant and drawn upon so as to get its full length.
The bandaging should vary from the surgical rule and
should be applied firmly for a few hours, or even for the
first day, after which it may be split down by inserting
the blade of a pair of scissors under it and cutting
through its whole length. The adhesion of the plaster
is sufficient to retain it, and any swelling is relieved by
its sliding over the surface.
It is particularly in compound fractures that We See
remarkable results from antiseptic surgery. Ithink one
of its most striking and generally useful applications is
in the repair of a hand torn in pieces by machinery.
Formerly the mode of dressing I have described Was
applicable to cases where the hand was so injured. The
parts would be brought together and poultices applied,
if the bandage of adhesive plaster was not cut ; but
sloughing and necrosis were common, and often after
INJURIES OF THE UPPER EXTREMITY. 511
much delay amputation became necessary. Now, with
clean hands we devote half an hour or more to Searching
out with the nail brush and Soap and water the minutest
speck in the creases of the begrimed skin and wounded
tissue, after which we apply our antiseptic, and at last
stitch the torn tendons and nerves. The theoa is sutured
over the tendons, and the skin over all. A proper dress-
ing is now applied, and usually no splinting is required,
the united tendons causing the fingers to take the Semi-
flexed position. But it may be necessary to add splint-
ing. The plan I have proposed may be rendered as anti-
septic as any of the other dressings. The tin may be.
most thoroughly purified by passing it through the flame
of an alcohol lamp, and the strips of adhesive plaster
can also be rendered aseptic by the same method, and
still not destroyed.
FRACTURE OF THE PATELLA TREATED BY
CONTINUOUS EXTENSION: PATIENTS NOT
CONFINED TO BED.
By Jose,PH. D. BRYANT, M. D., of New York County.
JNovember 16, 1892.
Two varieties of treatment of fractured patella are
generally recognised, the mechanical and the operative.
It is not my intention to allude to the latter method,
except in a general way; nor, in fact, to the devices of
the former plan except as they may be employed to
illustrate the method of treatment that I present. The
indications to be met in the treatment of this fracture
are the stereotyped ones that are applicable to all fract-
ures, namely, the reduction of the fragments and the
holding of them in place until a proper degree of union
ensues to permit of the removal of the retaining forces.
In fracture of the patella the uppermost fragment is
drawn upward by the influence of the quadriceps extensor
muscle, while the lower is somewhat displaced downward
by means of the non-muscular tissues attached to it.
Ordinarily, crepitus can be easily elicited between the
fragments, provided the attempt be made before the for-
mation of the firm blood-clots that become closely con-
nected with the broken surface of the bone within a few
hours after fracture. The failure of the medical attend-
ant to obtain crepitus at this time should be attributed
to the presence of these clots rather than to the influence
of the stretched aponeurotic tissues connected with the
upper surface of the patella. The presence of these
clots and their influence in separating the fragments are
frequently and easily demonstrated during the operative
technique of wiring the patella for fracture.
FRACTURE OF THE PATELLA. 513
The steps necessary for the reduction are, first, the
extension of the leg and the elevation of the limb to
secure complete relaxation of the quadriceps extensor
muscle ; second, the drawing together and retention of
the fragments in position until some form of union
insures sufficient strength to properly maintain them in
place. It is hardly necessary for me to describe the
various instrumental means heretofore employed to
effect the reduction and retention of the fragments in
this fracture. It is sufficient to say, however, that their
basis-action consists in extension applied directly or
indirectly to the upper fragment, and the holding of the
lower fragment upward in position. The extension is
represented in these cases as applied to the upper frag-
ment and to the thigh, and also to both of these parts
simultaneously. It is manifest to one familiar with the
relationship of the tissues composing the thigh, that
extension applied to the thigh alone can exercise but
little other restraining influence on muscular contraction
than that dependent on coaptation pressure, because the
dense fascia lata intervenes between the muscles of the
thigh and the integument to which the extension is ap-
plied. However, when extension-apparatus is applied to
the upper fragment of the patella with sufficient firmness
to meet the indication, then, indeed, some command of
the quadriceps muscle is secured. But even in this
instance the inequality, severity, and direction of the
pressure necessarily brought against this fragment,
together with the absorption of the surrounding soft
parts incident to the pressure, quickly render its influence
insecure and migratory, unless constant and tedious, not
to Say painful attention be given to the case.
In my judgment, the feature most commendable in the
Wiring method is this: It permits patients to move
around on crutches within a few days, thereby relieving
them of the tedium and depression of long confinement.
Of the mechanical appliances permitting patients to be
at Once about on crutches, plaster-of-Paris, applied in
33
514 NEW YORK STATE MEDICAL ASSOCIATION.
the form of a thigh or hip spica, extending down to
cover the foot, with an oblique patella-traction arrange-
ment of the bandage at the knee, is most often selected.
With this method, even in a very few days, the limited
direct-extension influence that the splint exercises on
the upper fragment disappears, owing to the shrinkage
of the limb, and in part to the pressure of the splint
itself. The coaptation-influence on the tissues of the
thigh, exercised by the splint at the time of its applica-
tion, is soon much lessened on account of the same
shrinkage. I have quite often witnessed the treatment
of this fracture with the plaster-of-Paris splint when
little attention was paid to the tissue-changes following
its application, even up to final recovery ; and candor
compels me to state that in these cases the results were
quite as satisfactory in all respects as in cases treated
more actively and with seemingly better philosophy. I
have often remarked that the results of the treatment of
fracture of the patella with a plaster-of-Paris spica were
much more convincing of the fact of how little treatment
the fracture required than of the efficiency of this par-
ticular method. However this may be, it is surely a
great desideratum to employ a means that, while it holds
the fragments as well as possible by mechanical meas-
ures, still subjects the patient to as little confinement as
if wiring of the patella had been done. The plan that I
have employed with some interruptions, for a number of
years past, can be divided for the sake of simple elucida-
tion into five separate steps.
A'irst step. The first step consists in the application
to the leg of a plaster-of-Paris splint, extending from
the base of the toes up to and partly around the lower
fragment. The splint is firmly applied to the limb a
sufficient time in advance of the succeeding steps to
permit of its becoming thoroughly hardened. It is care-
fully rounded at the lower extremity, so as to press into
position and hold there the lower fragment. Its func-
tions can be said to be threefold: 1st. It serves to protect
FRAOTURE OF THE PATELLA. 515
the foot of the patient from the pressure of the rubber
extension, which acts from this part of the limb. 2d. It
confines in place the lower fragment, and the pressure
upward of the splint due to the elastic force of the
extension transmitted through it to the foot, retains the
upper border of the splint in proper relationship to the
lower fragment. At all events, any diminution of pres-
sure on the part of the splint in this situation can be
readily supplemented by the introduction of suitable
pads between it and the lower fragment of the patella.
3d. It affords attachment to the lower end of the sup-
porting rod or brace, intended to maintain complete
extension of the limb while acting as a posterior support.
Second step. The features of the second step are quite
as strongly expressed by the illustration representing it
as words can define them." This step consists in the
application to the thigh of an extension-apparatus fash-
ioned after the manner of the well-known Buck’s exten-
sion, which reaches from the perinaeum to the upper
border of the upper fragment.
It is confined in position by the ordinary muslin roller.
The adhesive element of this appliance terminates a little
below the knee in a loop at either side, through which
may be passed the rubber extending cord, or to which
may be connected hooks for the convenient attachment
of the rubber cords or bands that are to pass around the
bottom of the splint, and by means of which the extension
is made and maintained. The broad, triangular adhesive
Strips to which the extension loops are sewed are con-
fined in position at the sides of the thigh by means of
simple roller bandages. Moderate extension is then
made on the loops by means of the rubber cords, in order
to draw as far as possible downward the soft tissues of
the thigh and the upper fragment of the patella. While
the extension is thus being made, the roller bandage
intended to hold the adhesive plaster strips in place is
CoVered by plaster-of-Paris rollers from the upper to the
* Illustrations not reproduced.—ED.
516 NEW YORK STATE MEDICAL ASSOOIATION.
lower limits of the adhesive plaster extension, and so
fashioned as to control the upper fragment in the most
serviceable manner while extension is in action. The
object of this plaster-of-Paris addendum is, first, to aid
in holding the primary dressing of the thigh in a firm
position ; Second, and principally, to afford an upper
Support for the extending rod or splint to be placed
behind the limb, and to aid, also, in confining the upper
fragment of the bone in proper relationship to its fellow,
as will appear in the succeeding step.
The second step meets the following indications: First,
it coaptates the tissues of the thigh, thereby exercising a
controlling influence over muscular contraction, and is
the agent causing extension of the integument and the
subcutaneous tissue. Second, it makes direct extension
of the quadriceps through its firm application to the
upper fragment of the fractured bone and the tissues
immediately above and around it.
Third step. This step consists in strapping the frag-
ments of the patella in such a manner as to draw them
well together and properly maintain them in position.
These strips of plaster are fastened in position behind
to a wooden support or brace, about two inches in width,
one inch in thickness, and extending from near the
upper border of the thigh portion of the splint to the
lower part of the splint surrounding the leg. These
adhesive strips should be applied cautiously, so as not to
irritate the integument, and also to prevent either of
them from being drawn downward between the fragments
of the broken bone. If this accident happens, greater
separation of the fragments ensues, and union of a Ser-
viceable kind is much delayed, and may be defeated.
These strips can be applied with greater care, Conven-
ience, and effectiveness, if traction be made away from
the median line of the thigh. -
Fourth step. This consists in fastening the posterior
support or brace in proper position, and fixing it there
by means of plaster-of-Paris rollers carried around it and
FRACTURE OF THE PATELLA. 517
the upper and lower segments of the splint where they
lie in contact with each other. These bandages harden
quickly, and thus incorporate the posterior support firm-
ly with their structure, forming an interrupted plaster-
of-Paris splint, with a posterior connecting brace.
Fifth step. The posterior support in the illustration'
is unusually thick, being composed of wood. A Small
iron rod on each side of the posterior surface of the limb
will answer much better for many reasons, and is less
cumbersome. The posterior support should be placed
against the posterior surfaces of the plaster splints pre-
viously described, and confined there by fresh plaster
rollers while the extension force is in action. These band-
ages are represented as carried around the limb from the
extremities of the support to the contiguous borders
of the underlying plaster splints. As already mentioned,
the hardening of these newly applied bandages incor-
porates the posterior support with the plaster-of-Paris
Structure so firmly that an unyielding common apparatus
is formed. The object of this support is obvious to any
One. It serves to keep the limb extended, thus prevent-
ing undue traction on the fragment of the quadriceps
muscle, and it affords attachment to the adhesive
plasters that confine the fragments of the patella in
proper position. Leather collars, properly fashioned and
padded, passing around the limb above and below the
patella, and drawn firmly toward each other by means
of leather straps, as figured in the text-books, may be
employed instead of this method of strapping. In either
instance the hamstring tendons should be carefully pro-
tected from undue pressure by the interposition of some
soft suitable material. After the apparatus is completely
and suitably applied, the patient may be permitted to
Walk around, but the limb during this time should be
flexed somewhat on the trunk by means of a long sling
extending from the foot, which it supports, and carried
9Ver the neck of the patient. The employment of this
* Not reproduced.
518 NEW YORK STATE MEDICAL ASSOCIATION.
expedient will flex the entire limb considerably on
the trunk, and thereby cause greater relaxation of the
Quadriceps extensor muscle, and also obviate the in-
fluence on the upper fragment of the involuntary con-
traction of the muscles that are associated in the effort
of locomotion.
TIII. ADVANTAGES OF THIS APPLIANO.E.
The following advantages appear to me to be quite
clearly defined : .
1. It apposes the fragments of the patella from the
first as well as any other non-operative appliance can
accomplish this purpose.
2. It maintains them in position better than any
mechanical means yet employed, unless the patient be
confined in bed and a constant and tedious scrutiny be
exercised by the physician in charge.
3. It permits the patient to be up and around sooner
and more comfortably than any non-operative method of
treatment yet employed.
I have thus far treated nine cases by this method, with
results equal to those of any other non-operative method,
and with much more comfort to the patients. Like all
methods, this one, too, has its fallacies. It is important
to regulate the degree of elastic extension in accordance
with the requirements of each particular case. If greater
extension be employed than is essential, the straps by
means of which the extension is secured may be torn Or
drawn away from their fastenings. At all events, great
discomfort will be caused. It is proper to say, however,
that a degree of extension may be employed which will
be readily withstood by the straps at the earlier period
of their application, which is out of all proportion to
the requirements of the case, and at a later period would
promptly cause slipping of the adhesive straps. In One
instance, as a matter of experiment alone, I applied a
degree of elastic traction to a case equivalent to forty
FRACTURE OF THE PATELLA. 519
pounds. It may be thought, perhaps, that the applica-
tion around the thigh of the plaster-of-Paris casing, and
introduction of the posterior support connecting the two
portions of the splint, will interfere with the extension
influence applied to the thigh itself. This, however,
is not the case, as the extension acts independently of
the incasing plaster, while at the same time the incasing
plaster serves to confine the adhesive strips properly
in position. If the interval between the plaster splints
corresponding to the knee and popliteal space be not
thoroughly and carefully covered, either with straps,
cotton, or bandages, pain and Oedema will, for obvious
reasons, take place there.
After the adhesive strips are properly applied to the
patella, the intervals between the splints, behind and in
front, should be filled in with layers of absorbent or
other kind of cotton, and bandaged closely in place. At
the time the posterior support is placed in position, cot-
ton or other suitable material for exercising moderate
pressure should be interposed between it and the pos-
terior surface of the knee, before the patella-retaining
straps are applied, as then this material can be drawn
firmly into place. As before remarked, the fragments
should be carefully and properly strapped, and great
Care exercised in the application of the straps, else one
of them may be drawn between the fragments, and
before its discovery may cause greater separation and
interfere with the union. *
Finally, it is necessary that the plaster splints should
be kept firmly apposed to the underlying surfaces,
Which, of course necessitates their being cut up quite
Soon after their application. The cutting up can be easily
done by means of an ordinary knife after the manner
usually employed in other forms of splints of a similar
nature. If a proper portion of the splint be removed in
the line of incision, the splint can then be firmly drawn
in place around the limb by means of an ordinary mus-
lin roller.
520 NEW YORK STATE MEDICAL ASSOCIATION.
In presenting to your consideration this method of
treatment of fractures of the patella, I do not claim any
originality as to the application of extending force in
this manner to the thigh, as I recall distinctly having
seen, while an interne in Bellevue Hospital in 1870, a
similar extension applied to the thigh for fracture of the
patella by Dr. Stephen Smith. However, in that in-
stance the patient was kept in bed, and no effort was
made to control the lower fragment by means of a plaster
splint or by the influence of the extension employed
in making traction upon the upper fragment. I have
not, however, as yet seen or learned of the treatment
of fracture of the patella by a method in any way con-
templating the use of extending influence associated only
with the limb itself, the introduction of a posterior
stiffening Support, and non-confinement of the patient
in bed.
WINTER CHOLERA IN POUGHKEEPSIE.
By JAMEs G. PortEous, M. D., of Dutchess County.
(Read by title November 17, 1892.)
For twelve years, and an uncertain period before that
time, there has been in Poughkeepsie, an epidemic of
diarrhoea, which both the medical profession and laity
are accustomed to call Winter Cholera. It usually begins
in December and lasts into March with varying intensity,
and is much more severe in cold weather ; but even in a
warm open winter like that of 1889–90, it prevailed to a
moderate extent. Last winter it appeared to be more
Severe and widespread than formerly.
An attack of winter cholera usually begins with slight
nausea, at times accompanied by chilly sensations, more
or less pain in head, back, and extremities, thin grayish
discharges from the bowels, occurring, in severe cases,
as often as every half hour. If unchecked it soon
takes on a flaky appearance, is not unfrequently tinged
With blood, and is attended with considerable pain in
the bowels, just before and during an evacuation. There
is often slight general tenderness over the abdomen, and
Sometimes moderate tympanites. The temperature does
not often rise above 101° or 102° F. ; the tongue is
Coated with a white or yellowish fur; the pulse is rather
Small and rapid, and there is an almost entire loss of ap-
petite. When uncomplicated, recovery ensues, but it is
often tedious, and the disease is prone to recur.
The pathological condition is as yet unknown.
Non-residents, as a rule, are much more susceptible to
the disease than residents of the city. A few years ago,
during a Convention, numbering about two hundred, I
should judge that over one-half of the delegates were
affected by the disease.
622 NEW YORK STATE MEDICAL ASSOCIATION.
Winter cholera, as a rule, is readily checked by small
doses of mercurial chalk, and some opiate, as Tully pow-
der, but is very likely to return ; astringents do not con-
trol it very well.
The principal point of interest in a disease like this,
which causes a great deal of suffering and loss of time, is
its cause. My own opinion is, that the cause lies en-
tirely in the city water. Many of the physicians in
Poughkeepsie deny this, though I have never known
them to assign any other cause.
The water supplied to Poughkeepsie is taken from the
Hudson River, 28,000 feet above the outlet of the city
sewers, and 18,000 feet below the outlet of the sewer
from the Hudson River State Hospital for the Insane.
The city has about twenty-three thousand inhabitants,
and a number of factories, and the insane asylum has
over five hundred inmates. The pumping station for the
water works is on the same side of the river as the city
and asylum, and being between their sewers, whichever
way the tide is running, sewage is likely to be carried
to the intake pipe, which takes the water from under,
and about four feet inside the face of the dock used to
land coal. From here it is pumped into the filter-beds,
where it is passed through two feet of sand, eighteen
inches of gravel, and two feet six inches of broken
Stones. -
Notwithstanding the enormous growth of algae in the
filter-beds in the summer, this filtering, aided by the
vegetable growths in the river, and the action of the Sun
and air, appears to purify the water sufficiently to pre-
vent disease; but as soon as the ice forms in the river
and filter-beds, winter cholera invariably begins.
The proof that it is the river water rests almost entirely
on clinical facts; bacteriological and chemical examina-
tions do not positively account for it. In reply to an
inquiry addressed to H. Lyle Smith, Health Officer of
Hudson, he says of that city: “Winter cholera prevails
regularly, beginning in January and continuing until
WINTER CHOLERA IN POUGHREEPSIE. 523
spring. There is no doubt in my mind that the cause
lies in the river supply, as it was an unknown factor in
our disease list before the river water was introduced.”
Dr. Joseph D. Craig, of Albany, in an address read
before the Medical Society of the County of Albany,
speaking of the use of river water contaminated by
sewage, SayS:
“The Schenectady type of diarrhoea began about the
first of December, and continued till about the middle of
March. Furthermore, rivers contaminated with sewage
and covered with ice, are more dangerous as sources of
water supply, through insufficient ačration of the con-
tained water, than when open.
“Among men engaged as boatmen during the Summer,
and as ice-cutters during the winter, and drinking river
water at all seasons, it was distinctly observed that such
men were free from diarrhoeal disease in the summer,
but were largely affected in the winter.”
The winter cholera or diarrhoea of Poughkeepsie is
Of the same severe type described by Dr. Craig, as caused
by the use of river water at Schenectady, Cohoes, Albany,
and West Troy.
During the winter of 1890, a young lady from one of
the towns of Dutchess County came to Poughkeepsie for
the winter. In a short time she was attacked by winter
Cholera, and for four days was treated by the usual
remedies, but grew constantly worse, until the evacua-
tions reached an average of two each hour during twenty-
four hours. These discharges were thin, offensive, and
tinged with blood. During these four days she was
allowed to drink city water; then I sent water from a
cistern at my house, and this was used for her drink and
In preparing her food. During the first twenty-four
hours the diarrhoea was very much diminished, during
the second twenty-four hours medicine for the diarrhoea
Was Omitted, but cistern water continued, and at the end
of that time the diarrhoea had ceased. During the entire
Winter two days' use of the city water would bring a
524 NEW YORK STATE MEDICAL ASSOCIATION.
return of diarrhoea, which would as promptly cease on
leaving it off.
A gentleman and his wife came to Poughkeepsie for
the holidays, taking their daughter from Wassar College
to a hotel in town. The second day all three were down
with violent diarrhoea, but a change of water promptly
relieved them. The daughter had not suffered from
diarrhoea at the college before, the water there being
taken from a Spring.
During about four years that I was consulting physi-
cian at Vassar College, I never knew of a case of winter
cholera which could not be traced to the use of city
water, although the college is less than two miles from
the city.
One morning last winter, a whole family, mother, two
daughters, nurse, and servants, were taken ill the same
morning. They stated that they did not use city water
for drinking or cooking, but on inquiry, it was learned
that for two days the cistern pump had been frozen, and
they had used the city water. A return to the cistern
water relieved them promptly.
A strong, active mason called me for a severe attack
of winter cholera. I gave him three or four Tully's
powders to relieve pain, and told him to change from
city to cistern water. Three days after I was recalled,
and was surprised to find him still in bed with diarrhoea.
as bad as ever, notwithstanding he said he had used no
city water. Investigation showed that he had changed
to soda water manufactured from the city water. Thirty-
six hours' use of cistern water enabled him to return to
his business.
In my own family, where we use cistern water en-
tirely for drinking and cooking, none of the family or
servants ever has winter Cholera.
Amusing cases sometime occur. A family who be:
lieved the city water perfectly good, but who never used
it, called me to see a friend from out of town who Was
visiting them, and was taken quite violently with diar-
WINTER CEIOLERA IN POUGHKEEPSIE. 525
rhoea. The lady of the house said: “Now, my friend's
illness cannot be caused by the city water, as we never
use it.” “Why,” said her friend, “it can, for I have
drank two glasses from the faucet every night on retir-
ing.”
Such cases can be furnished every winter, well marked,
easily traced, and as easily cured by change of water,
but it would be useless to multiply them here.
Now, what is it in the water which causes such a diar-
rhoea. ? Evidently the sewage, or some product of it.
Frankland says, “That chemical analysis cannot dis-
cover the noxious ingredient or ingredients in water pol-
luted by infected sewage or animal excreta, and as it
cannot thus distinguish between infected and non-infect-
ed sewage, the only perfectly safe course is to avoid
altogether the use for domestic purposes of water which
has been polluted with excrementitious matter.
“This is more to be desired because there is no practi-
cable process known whereby water once contaminated
by infected sewage can be so purified as to render its
domestic use entirely free from risk.”
The following is a chemical analysis made last Feb-
ruary for the Superintendent of the Water Works, by
T. M. Brown, Ph.D. The nitrates appear to have been
very little, if at all diminished by filtering, while the
nitrites were diminished one-half.
On the 10th of February last, while the river was cov-
ered with ice, three samples of water were collected at
the pumping station and forwarded to Thomas M.
Brown, Ph.D., of the Massachusetts Institute of Tech-
nology, for chemical analysis. Sample No. 1 was taken
from the inlet basin of the filter-beds; Sample No. 2 was
taken from the outlet of the west filter-bed, which had
been cleaned a day or two previous; Sample No. 3 was
taken from the outlet of the east filter-bed, which had
not been cleaned in six or seven weeks.
For results of these analyses see page 526.
§
SAMPLES COLLECTED AND FORWARDED FEBRUARY 10, 1891, EXAMINED FEBRUARY 11, 1891.
(Parts in 100,000.)
APPEARANCE. ODOR. RESIDUE ON EWAPORATION. AMMONIA.
* . I ºf * &
Turbid-| Sedi- || 8 3 |}: #| 3 | Change on 5 §
No. * * - Cold. | Hot. || 3 | # 5, 6 $3 tº a º Free O
ity. ment. 3 ë 34: É Ignition. ââ
Darkens with .0020; .0126
peaty and
Dis- | Very somewhat dis-
1 Distinct Consid- tinctly faint or agreeable
clayey. erable. .25 || musty. none. 7.10 | 1.15 5.95 odor. *.0086
2 | Slight | Very Darkens with .0070
clayey. slight. .20 | None. None. 7.10| 0.80 (6.30 peaty odor. .0000|*.0060.
Very
3 | Slight | Very faint or Darkens with . 0074
clayey. slight. .25 | None. none. 7.15 0.90 6.25 peaty odor. }:0000%.0066
The residue on evaporation was obtained from the water after filtration through paper in the laboratory.
The Second determination of albuminoid ammonia, in each sample marked with star, is obtained from water which
has been filtered through paper in the laboratory.
---i
.08
. 12
§ 3; #|g #4. #5, a
§ 2; § 2; ã, tº # ă ă ă 80 ºr q>
5 *#|É *ālā ā;|5 ##|-3 =
Ž Z|z 2 & #|& "3|8 É
.0420 .0002. 3.80 0.20 .45
.0400 .0001| 3.70 || 0.30 .37
.04001 .0001 3.80 i0.20 | .39


TWINTER CHOLERA IN POUGEIKEEPSIE. 527
On the 17th of February five samples were collected
and forwarded to the same person for similar analysis.
Sample No. 4 was taken from the Hudson River at a
point one hundred feet out from the space of the pump-
ing station dock, thirty-four feet below the surface of
the water, and twelve feet above the bottom of the river.
Sample No. 5 was taken from the Hudson River at the
face of the pumping station dock, nine feet below the
surface of the water, and about nine feet above the bot-
tom of the river, being at or near the end of the inlet to
the pumping well. Both these samples were taken just
after high water. The river was covered with ice. Sample
No. 6 was taken from the intermediate or outlet chamber
of the filter-beds after the water had passed through the
beds. Sample No. 7 was taken from the reservoir on
College Hill. Sample No. 8 was taken from the drink-
ing fountain at the Soldiers’ Fountain.
For results of these analyses see page 528.
The superintendent, in commenting on this, says:
“A comparison of these analyses with those made on
May 1st of last year, shows, in the recent samples, a
very slight increase in the chlorine, and a considerable
increase in the nitrates. The nitrites of the river water
are the same, but are present in very small quantity in
the filtered water.
“The free albuminoid ammonia and organic matter
represented by loss on ignition are all less.”
The conclusion reached by Superintendent Fowler is
“that no harmful or important change is indicated by
the chemical analysis.” How he reached that conclusion
I do not know.
Frankland says: “River water should be considered
dangerous water if, on inspection, any part of the pre-
Vious contamination be traced to the direct admission of
SeWage Or excrementitious matters.” Here there can be
no question of the admission of sewage; the real ques-
tion is, does the filtration render it safe?
Frankland says: “Other epidemics, such as dysentery
§
SAMPLES COLLECTED AND FORWARDED FEBRUARY 17, 1891, EXAMINED FEBRUARY 18, 1891.
(Parts in 100,000.)
APPEARANCE. ODOH. RESIDUE ON EYAPORATION. AMMONIA. | 3 |# g;| = g|... g;|, g;| = ,
• * – 13. , is 3 |#|ä, älä, älä, äläisälä, ä
No.] Tºrbid-| Sedi: | 3 || Cold. | Hot. 3 zāā § | Change on Free, £3 || 3 |É ##|É ## äää ### §5 #
ity. ment. 3 É 3 *f; | * Ignition. 3.5 |F : ; ; ;|É Ālā. #3 ° à
H Prº 3 || O Z, Z |z| Z E : ~!
4 |Distinct.|Consid— Very Distinct- 0.136
erable faintly ly 9.00) 1.25 |7.75|Darkens with .18 .0400 .0002. 3.80 0.70 | .46
earthy. .20 musty. mouldy. peaty and dis-
agreeable *.0086
Dis- odor. .0042
Consid- tinctly
5 |Distinct.] erable Faintly vege- -
earthy. .25 earthy. table. 9.25| 1.40 |7.85|Darkens with .0114.14 .0480 .0002 4.00 || 0.80 .50
peaty odor. .0026
6 | Very | Very Very | None. 7.60) 1.25 |6.35|Darkens with *.0068.13 .0680 .0001| 4.00 0.80 .31
slightly slight. faintly peaty odor. .0000
clayey. .10 earthy.
7 | Very Very Very
slightly slight, .20 | None. faintly
clayey. - vege- w .0080
table. 6.70] 0.95 |5.75|Darkens with *.0062]. 12 .0480 .0001 || 3.80 0.80 .34
peaty odor. .0000 .0078
8 || Very | None. .20 | Very | None. 6.90 0.95 |5.95|Darkens with *.0062]. 12 .0480 .0001| 3.80 || 0.70 | .35
slightly faint or peaty odor. .0000 .0042
clayey. In One. * .0028
The second determination of albuminoid ammonia, in each sample marked with star, is obtained from water which
has been filtered through paper in the laboratory.
WINTER OHOLERA IN POUGHKEEPSIE. 529
and diarrhoea, are also probably propagated by drinking
water, but the evidence is here neither so abundant nor
conclusive as it is in the case of cholera and typhoid
fever,” and although the improvement of excrementally
polluted water by filtration may reasonably be consid-
ered, on theoretical grounds, to afford some feeble pro-
tection against the propagation of epidemic diseases by
water, no trustworthy evidence can be adduced in sup-
port of such a view.
On the 13th of October, 1892, I had a bacteriological
examination made of two samples of water, No. 1 taken
from the river alongside the dock at the pumping-station,
and No. 2 taken from a tap in my office. The examina-
tion was made by Dr. Edward K. Dunham at the Carne-
gie Laboratory, and is as follows:
Sample No. 1 was examined in duplicate for the number of viable
bacteria contained in one cubic centimetre. The figures were 39,809 and
40,608, respectively, or an average of 40,209. This is, of course, an enor-
mous number. But when we consider the length of time which elapsed
between the collection and examination, it is altogether likely that there
Was a multiplication of the species originally present. There were a
number of various species of bacteria present, but I could find none of the
usual forms found in putrefying substances, or any of the species common
in faecal matter or sewage. I, therefore, attach little sanitary importance
to the mere number of bacteria present, and am inclined to think favora-
bly of the water for household use. -
Sample No. 2 contained, in two portions of 1 c.c. each, 15,096 and
15,092 respectively, an average of 15,094. The number of species was
less than in Sample No. 1, the vast majority being of but a single variety
not uncommon in water, and not injurious. This water strikes me as
being preferable to the other, but I see no reason to question the safety of
either. Yours very truly,
EDWARD R. DUNHAM.
The report on sample No. 1 was rather a surprise to
me, even at this season, when there must be sewage in
the river; and this report is given to show that, at this
Season, the examiner did not detect much trouble with
the unfiltered water. From the clinical facts and the
*Crease of nitrates and nitrites, in the winter over that
in May, I am still unable to come to any other conclusion
34
530 NETW YORK STATE MEDICAL ASSOOIATION.
than that the river water is the whole cause of winter
cholera ; that the danger must increase with the increase
of Sewage incident to a larger population, and that event-
ually Hudson River towns will be obliged to find some
other supply than the river water.
SUGGESTIONS RELATING TO IMPROVEMENT
OF QUARANTINE.
By STEPHEN SMITH, M. D., of New York County.
(Read by title November 17, 1892.)
The continued presence of cholera in Western Europe
and the recent arrival in New York harbor of several
steamships on which the disease appeared during the
voyage has awakened a new interest in the quarantine
defences of this country. And this interest has been
greatly intensified by the occurrences on the arrival of
these vessels at the port of New York. They demon-
strated the total incapacity of the most important
guarantine in the United States to meet the emergencies
that may arise at any time when travel and commerce
are unimpeded. The apprehension which now prevails
that there will be a recurrence of the epidemic in the
Seaport towns of Europe next season, and that the
quarantine at this port will prove ineffectual, both in its
appointments and management, to prevent the introduc-
tion of the pestilence into this country, will doubtless
lead to efforts to secure State and national legislation,
designed to remedy existing defects and evils. Whatever
efforts are made should be based on principles established
by Sanitary science and recognised by the medical pro-
fession. It seems eminently proper, therefore, that this
Association, representing the profession of the State in
Which the chief quarantine is located, and by which it
Was established, is maintained, and managed, should at
this time consider this great public health question, and
express an opinion which will tend to guide legislative
action. In this view the following paper has been pre-
pared.
532 NEW YORK STATE MEDICAL ASSOCIATION.
The question of improving the quarantine of New
York may be considered, first, in respect to the enlarge-
ment and perfection of the present establishment; and,
secondly, with reference to supplementing or supersed-
ing it by a national quarantine.
The propriety of endeavoring to place our present
quarantine in condition to meet the demands that may be
made upon it early in the next season may be seen when
we consider its construction and surroundings. The
establishment is located on two artificial islands in the
harbor. They were constructed at great expense by the
State, owing to the intense opposition of the people to
the former location on Staten Island. This opposition
was so violent that the former buildings were burned,
and the Legislature passed an act forbidding the location
of quarantine on Staten Island and on Long Island.
There was, therefore, no other alternative left to the State
but to construct these islands. Like all work of this
kind the construction proceeded slowly, and the expense
was very great. When finally completed, the quarantine
consisted of two islands of limited capacity, one for the
care and observation of well persons removed from in-
fected ships, and the other for the care and treatment of
the sick. Provision was made for but a single conta-
gious disease. The capacity of these islands was for the
proper care of a single infected steamship, with not to
exceed one thousand passengers—of whom two hundred
and fifty might be “suspects,” and seven hundred and
fifty well, but who had been residents of this so-called
infected ship. The arrival of two or more such ships in
quick succession would, as was proved in September last,
create such a congestion as would render it impossible to
remove the well from the ships. The travelling public
must not only be subjected to great hardships under such
circumstances, but they would be exposed to the danger
of contracting the disease prevailing on shipboard while
at quarantine.
The only method of rendering our quarantine adequate
SUGGESTIONS RELATING TO QUARANTINE. 533
to meet the demands of the increasing travel and com-
merce at this port is to enlarge its area. There should
be ample surface area to extend its accommodations to
a limit equal to the largest demand that can be made
upon the establishment. But how is this enlargement to
be effected ? It is impossible to occupy any part of the
shores of the bay belonging to the State, or any part of
Long Island, for the purposes of a quarantine. Not only
does the law forbid such occupation, but public opinion
is so firmly fixed and determined that it will be im-
possible to secure necessary legislation to that end. The
only method of enlargement is, therefore, by increasing
the capacity of the present islands, or by the creation of
new islands. It is only necessary to state these facts to
prove that there is no possibility of relief from the pres-
ent situation by attempting to improve adequately the
present quarantine. The State will never be induced to
incur the expense necessary to such an undertaking.
Nor, indeed, should it be required to create and main-
tain a quarantine of the dimensions and cost which will
meet the present and future wants of the country. This
is an obligation which now devolves upon the national
Government, and it should be required to assume that
Obligation at once.
Fortunately, all of the conditions are favorable for the
immediate organisation and equipment of a national
quarantine at this port. Sandy Hook, which belongs to
the general Government, is, according to recent advices
and events, immediately available for such purposes.
There are ample unoccupied lands which afford the
necessary area for such an establishment, whether to
meet present or any future requirements. The location
can be thoroughly adapted to the wants of commerce,
the anchorage is good, and the surface area and soil are
all that could be desired for the arrangement and con-
struction of the necessary buildings. Here can be created
* Station for infected ships which will admit of the
*mmediate removal of the sick and well from on ship-
534 MEW YORK STATE MEDICAL ASSOCIATION.
board, whatever their numbers may be. The sick can be
taken to hospitals adapted for a variety of contagious
diseases, and the well or “suspects' can be separated
into any required number of isolated groups in pavilions,
where they may have every convenience necessary to
their comfort and health. Here also can be warehouses
for the reception, cleansing, disinfection and ventila-
tion of every form of baggage and every variety of cargo.
And, finally, here can be maintained, in a state of con-
stant efficiency, every agency essential to the rapid
cleansing of an infected ship. With such a station in
this harbor there would be no need of any proclamation
of a twenty days’ quarantine for the purpose of restrict-
ing immigration. Nor would there be prolonged deten-
tion of passengers for observation, nor the withdrawal of
ships from commerce for long periods for proper disin-
fection.
Two questions will naturally arise in the minds of those
who may not be familiar with recent national legislation
in relation to the quarantine system of the United States:
1, Is it practicable to secure the location of a national
quarantine in this harbor ? and, 2, if such a quarantine is
established will it not conflict with the State establish-
ment 7
The first question seems to be already answered in the
affirmative. The Government has taken the initiative,
and laid the foundations of a station that can rapidly be
enlarged and adapted to supply every want and condition
of the most perfect modern quarantine establishment,
and in time to meet any emergency during the next
Se2SOJOl.
It may be objected that the camp created on Sandy
Hook by the Government is a temporary expedient to
meet an emergency, and that a permanent quarantine
cannot be secured without legislation by Congress that
would involve contention and delay. Happily, this is not
true; but, on the contrary, the creation of a quarantine
in New York Harbor and its complete equipment by the
SUGGESTIONS RELATING TO QUARANTINE. 535
general Government would be simply an extension of the
policy which it has pursued for the last decade. A brief
review of the course which the Government has followed
during that period in regard to the protection of the
United States against the introduction of contagious
and infectious diseases, will show not only that the
establishment of a national quarantine at New York
would be in accordance with its present policy, but will
prove that the Government is under obligation to create
such a station for the benefit of the commerce of the
North Atlantic coast.
In 1880 the National Board of Health, after the sup-
pression of the great epidemic of yellow fever of 1878–79,
in the Mississippi Valley, began to inaugurate methods
of preventing in the future the introduction of conta-
gious and infectious diseases into this country. A care-
ful inspection was first made of the quarantines of the
United States, which, at that time, were all State and
municipal Organisations. It appeared from this inspec-
tion that our seaboard and Gulf quarantines were, with
One or two exceptions, utterly worthless. As a rule they
Were maintained as a part of the local or State political
machinery, with no pretense even of performing any
useful public service. The best establishments were
deficient in area, in buildings, and in appliances for the
proper treatment of infected ships.
The plan adopted by the National Board to meet the
exigencies found existing was to supplement these local
Quarantines by a series of national quarantines, called
Refuge Stations. These stations were to be, and have
been, located at such points along the coast as would be
nost convenient for infected vessels bound to ports in
the vicinity. In pursuance of this policy stations have
been created for the Gulf ports, One at Chandeleur
Islands, and another at Key West ; for the South At-
lantic ports one is located at Blackbeard Island, Sapolo
Sound, off Savannah; for the Middle Atlantic ports, one
* at Cape Charles and another at the Delaware Break-
536 NETW YORK STATE MEDICAL ASSOCIATION.
water. In the same manner for the Pacific ports, there
is one at San Diego, another at San Francisco, and a
third at Port Townsend, Puget Sound. The only part of
Our Seaboard that has not been supplied with these
stations is the North Atlantic. .
These Refuge Stations form a series of exterior quaran-
times, which are at all times to be maintained in a state
of the greatest efficiency. They occupy isolated posi-
tions, generally insular, and have ample areas admitting
of any necessary isolation of passengers and their segre-
gation into groups. They are to be fully equipped with
every appliance required for the quick restoration of an
infected ship to its service.
In practice, any infected or suspected vessel bound for
a port in the district in which a national quarantine is
located, would first proceed to this station and perform
quarantine before it attempts to enter the port of destina-
tion. No local quarantine officer should allow such a
vessel to enter the port which does not bring a certificate
of having performed quarantine and been satisfactorily
cleansed and disinfected at the national station.
This quarantine system finds its best illustration in
England. The coast of that country is divided into
quarantine districts, and for each district there is a
single well-equipped Government quarantine. To this
station every infected vessel must proceed and perform
quarantine before it attempts to enter any port of the
district. The great value of this system is seen in the
thorough protection which it affords a country against
the introduction of a foreign pestilence. It creates two
lines of defences, an exterior, where the infected vessel
and passengers receive prompt and efficient care and
treatment, and an interior, at which every vessel, whether
infected or suspected, is intercepted and turned back to
the Government quarantine.
Again, it insures at proper places along the entire
coast thoroughly efficient quarantines, always ready for,
and capable of meeting any emergency. The importance
SUGGESTIONS RELATING TO QUARANTINE. 53?
of this fact will be recognised when we examine local
quarantines in the absence of any alarm in regard to an
epidemic. With rare exceptions they are allowed to go
to decay, owing to the great cost of maintaining them in
a state of efficiency. Perhaps the quarantine at this
port has been more liberally sustained by the State than
any similar establishment in the United States, and yet
when a cholera-infected ship suddenly entered the har-
bor in 1887 it was wholly unprepared for the occasion.
Though the next legislature granted a large appropria-
tion, and very extensive additions and improvements
were made, yet on the arrival of the recent cholera ships
much of its equipment was found too defective to be of
any service.
In regard to the relation of the local to the national
guarantines it is apparent that they should act in har-
mony. There should be no friction. The local quaran-
times should continue to immediately guard their respec-
tive ports against the introduction of any infections or
contagious disease, and two or three might perhaps be
relied upon to quarantine vessels having the milder.
forms of these affections on board, but they should de-
pend upon the national establishment to care for vessels
bringing cholera or yellow fever, or to meet any emer-
gency.
If any legislation by Congress were necessary to place
the national quarantine stations in their proper posi-
tions, it would only be necessary to pass a law dividing
the seaports into quarantine districts, and require every
infected or suspected vessel, bound to any port, to per-
form Quarantine at the national station for the district
in Which the destined port is located. The same pur-
Pose Would be accomplished if Congress would pass the
following section of a bill reported by the Committee of
Commerce and Manufacture to the House of Represent-
atives, as early as May 7, 1796:
“Be it enacted, etc. The President of the United
States be, and is hereby authorised to direct at what
538 NEW YORK STATE MEDICAL ASSOCIATION.
place or station in the vicinity of the respective ports of
entry within the United States, and for what duration
and particular periods of time, vessels arriving from
foreign ports and places, may be directed to perform
quarantine.” +
The quarantine at the port of New York, in the event
of the creation of a national station at Sandy Hook (or,
indeed, in any event), ought to be placed under the juris-
diction of the Health Department of the city of New
York, which should be made responsible for its proper
management. Its officers and employees should be ap-
pointed by that department, and the chief officer should
be the Sanitary Inspector of the Port. The laws relating
to the government of quarantine should be repealed, and
1 One of the most vigorous supporters of this bill was Mr. Smith, of
South Carolina. He said: “If this question be a mere question of acqui-
escence in the State laws there might be a propriety in the Federal Gov-
ernment overlooking those laws; but it was essentially connected with
the powers of Congress on an important subject. He had been surprised
to hear gentlemen assert that this subject was not of a commercial nature.
The gentleman from Virginia had said diseases were not articles of im-
portation, or, if they were, they were contraband, but gentlemen must
know that importations of all kinds were under the regulation of Congress,
and contrabands as much as any other. Consider how epidemics, im-
ported, affect the United States at large. They do not merely affect the
city where first imported, but they obstruct the commerce of all others;
they not only embarrassed the commerce, but injured the revenues of the
United States. Another point of view in which it had an effect : the laws
regulating the collection of imports were counteracted and obstructed by
the laws regulating quarantine, and would any gentleman say that a State
legislature had the power to contravene the act of the Federal Govern-
ment, to obstruct all of the laws by which it collects its revenues. It had
been said that this subject could be better considered in each individual
State than we could possibly settle it. Who are we? Are we a foreign
government 7 Gentlemen had already forgotten their arguments on former
occasions when speaking of the power of the House; they could then do
anything and everything, and the people looked up to them alone for Prº-
tection. If the subject was vested in the General Government it Was their
business to protect the health of their fellow-citizens as much as their
property; because if the performance of quarantine was neglected, such
neglect naturally tended to affect the lives as well as the revenue and Coº
merce of the citizens throughout the United States. He, therefore, thought
it a subject perfectly within the Federal jurisdiction.”
SUGGESTIONS RELATING TO QUARAWTINE. 539
the Health Department should be authorised to make
such rules and regulations relating to the inspection of
vessels, their proper care, and the details of administra-
tion of this sanitary Service of the port, as it may from
time to time deem necessary. Such a change in Our
quarantine establishment would of itself be an immense
improvement, for it would be brought under the imme-
diate supervision of a department which has a vital in-
terest in its efficient and Successful management.
THE LIMIT OF RESPONSIBILITY IN THE
INSANE.
By JoHN SHRADY, M. D., of New York County.
Movember 17, 1892.
In consideration of the present topic, reference is to
be had not so much to the psychological as to the legal
aspects. In its discussion, the subject is to be applied
to the view in the gross—just as it should be when the
decision is to be made to the jury, who, after all, put
the final construction upon the value of the facts. As
a lawyer once remarked to me, the “law might not be
synonymous with justice, but it is the nearest approach
to it.” The individual involved in the consideration
must needs be taken as the exemplar of what was likely
to be done under similar circumstances, yourself being
the subject.
Now, for the purpose of more fully stating the argu-
ment, let the suspect be studied as regards motive with
the concomitant sequences of acts, where the personality
of the culprit has been made exchangeable with One's
own self.
The limit of responsibility is quite difficult to fix,
since many circumstances, with their value as affecting
individual results, must be studied. What would be
regarded as harmless or inconsequential in one individ-
ual, may not be otherwise than direful or significant in
another. Clews, upon which detectives lay so much
stress, come in for their proper value; mental behavior
and general habits much more. There may be in the
minds of the jury all kinds of explanations, ranging from
eccentricity to madness. There may be present SuS-
picions of malingering, outbursts of temper, or a down-
right set purpose of revenge; there may be discussions
upon the presence or absence of remorse, congenital
mental defects, temporary delusions that life Was tº
jeopardy; there may be much criticism of facts, much
RESPOWSIBILITY IN THE INSANE. 541
averaging of expert Opinions, and much confusion in
the matter of technical interpretations.
Let it be borne in mind that no attempt is made in this
thesis to call up for deliberation the question of testa-
mentary capacity, for the reason that too wide a scope
must needs be given, and too many judicial charges cited.
As in criminal cases, decisions in those having reference
to bequests involving undue friendship at the expense
of unimpeachable heirship, must be arrived at upon the
merits of individual cases. As interesting as this field
is, it is, as has been suggested, too wide for present pur-
poses. Decisions, though erroneous in point of doctrine
and opinion, Subserve the One purpose of settling ques-
tions for the benefit of that community, which, after all,
does not much care to occupy itself with the grievances
of others. If precedents are many, and cases have been
numerous or of startling magnitude, the court-room may
be crowded, but the whispering mob seeks after the sen-
sation merely.
Much stress has been very justly laid upon the irresist-
ibility of the will-power, or rather that the individual
has become inexplicably the subject of circumstances
OVer which he has no control. In fact, to make the
Statement adjustable to the ordinary intellect, it were
Well to take into account the ready belief of by-gone
Centuries or epochs, that the subject was possessed of a
daemon, which stalked the earth, alert for an entrance
through a point of least resistance, the conception being
that an accident confronted the community of which the
maniac was only a part, and contributed to the catas-
trophe in a manner which could not by any known pre-
“aution be provided against. The irresponsible agent
Was prominent, and the act became merely a part of the
*tastrophe. The penalty required discussion, but the
Culprit escaped through the convenient loophole of a
doubt for his eSpecial benefit.
But has the Community no rights or immunities that its
P* must be continually threatened A Certainly not,
542 NEW YORK STATE MEDICAL ASSOCIATION.
exclaims a vigilante, for these lapses, of necessity, must
call for constant adjustment, and we are compelled to
interrupt the usual business of Society for the mere sen-
timent of perhaps saving a worthless life—for the as-
sumption of a burthen which, at the last, does not pay
even the cost of transportation. Society, too, in its
pitiless way, allows but few obstacles to its progress as
well as very little embarrassment of its machinery. The
individual in its way may go down with a shriek, but
the mangled corpse is soon removed because of its in-
utility and unsightliness. Great indeed, however, must
be the crime, and indisputable the evidence before the
juryman convicts. He dreads the possibility of a mis-
take, the fallibility of testimony, and the coloring of
prejudice. He may question the ability of the judge, the
propriety of his charge, and the purity of his motives.
“The consciousness or knowledge of right and wrong”
has long been held to be the legal test of responsibility,
to which the higher law of humanity has added the
more sweeping qualification of the loss or absence of self-
control. Out of these definitions, for they have the force
of such, is to be eliminated the trick of the mind of
reasoning from false premises. The deduction, so ram-
pant in mediaeval times, which phrased itself in the
royal morals in the expression that “the king can do no
wrong,” evidently can have no place in the logic of the
situation. With the conceded obliquity there need be
no conclusion that there were delusions of grandeur.
At the bottom of the paternal form of government is a
kind of hero-worship, contrived more for the convenience
of the ruler than for the practice of justice among the
people. It was the temper of the times, which enforced
the submission, while of the popular mass, Some Welº
sincere believers, others secret doubters. The king
merely drew around his person the circle of a mysti"
wand, at first to awe into obedience, but later to apºlº
gise for his vices. Now, above the king is the limitatio"
of constitutional law, extending from dethronement to
RESPOWSIBILITY IN THE INSANE. 543 ,
decapitation. History has furnished many examples of
both methods of disposal—methods which have been
stamped by Succeeding generations as being both un-
merciful and undeserved. They were, however, only
the lessons of a moving drama, now toned down, and
serving, like the red-shawled figure in the sombre land-
scape, to guide toward still deeper gloom.
Law at the present time takes more cognisance of in-
dividual rights, and in juxtaposition of the rights of the
state is more careful in the adjustment of the rights of
both. The nature of an uncontrollable impulse has
been happily expressed by a very emotional lunatic, who
rounded up her career by suicide. “My intellect is all
right—it's Only my feelings that are at fault.” Uncon-
trollable impulse, then, is entitled to consideration by the
jury in the case of the murderer, but deliberative plan-
ning, never, unless it be that overmastering delusions
were present and the victim in propria persona with
Opportunities to beckon on to the crime, suggested the
ease with which the deed might be done. But even here,
qualifications come in to balk a summary verdict, the
prisoner getting the benefit of the doubt. Thus the
Community is more likely to suffer than the individual—
the asylum, rather than the prison, or very distant chair,
gallows, or guillotine, being the portion of the culprit.
But, should an outraged community, driven at last to
balance its books and summarise its assets, drum-head
Court-martial the suspect, and hurry him to execution,
the criminal community must content itself with a dying
Speech or maudlin confession. Thus both are avenged.
Besides the powerlessness of the will, absence of mem-
9*y is to be regarded as a feature of the non compos
*** condition, for here comes the instant conclusion
that facts have made no impression and the faculty of
*lºgical reasoning is gone. Without these mental
attributes there looms up the assumption that an appre-
*tion of the corelative adjustment is gone, that the
mind cannot keep books even by single entry. Drunk-
544 JNEW YORK STATE MEDICAL ASSOCIATION.
enness, notwithstanding the legal theory that the indi-
vidual takes a voluntary risk, is an instance of a mania,
transitoria in its acute form ; punishment is apt to fol.
low Swiftly and surely with all due form of law, while
the influential criminal, after having been discharged
cured from an asylum, resumes his position in society
with the added flavor of the romance. Society is tolerant
as long as the antics of the lunatic are harmless, amus-
ing, and on the safe side of eccentricity. But let the
patient—and this is the most convenient designation—
give the freest play to his moods of violence, straightway
it becomes alarmed, and puts itself upon the defensive.
Then laws are enacted to preserve its autonomy, and in
its comprehensive attempts to cripple its forceful mem-
bers, tyrannises over the few.
Again, if the suspect be really overcome by some in-
scrutable power, hypnotic in action, and demoniac in
expression, does society gain in an economic sense ; has
it added to its ranks even a reformed straggler ? Let it
not be understood that in the argument cruelty is in-
tended; merely that just a moiety of political economy
is taken into account. Popular clamor may condemn,
but it does not always convict ; it may be provost mar-
shal rather than judge ; the reversal of judgment may be
read to the deaf ears of the corpse, and the attainder
upon the property remains only to be removed, and that
only for the convenience of passing title. The alleged
culprit is dead, and society views the remains with Com-
mendable indifference.
Emotional supremacy out of the question, that inde-
scribable mental element, denominated intuition, with
its impossibility of being imparted or delegated, not Con-
sidered, the powerlessness of the will, with all its subter-
fuges against self-betrayal accorded its true weight, and
the mere opinions of experts upon hypothetical cases
are eliminated, after summing up the value of the proº
and cons, why should the key of memory be thrown OVer
the fence before it was inserted into the lock'
SOME PERSONAL OBSERVATIONS AND REFLEC-
TIONS UPON ALCOHOLISM, THE EFFECTS
OF ALCOHOLIC ABUSE UPON POSTER—
ITY, AND THE TREATMENT OF
ALCOHOLISM.
By H. ERNST SCHMID, M. D., of Westchester County.
November 17, 1892.
I do not know of any topic which is of greater im-
portance than this to the individual, the family, and
even to the nation at large. Alcoholism far exceeds in
interest, magnitude, and wide-reaching consequences,
morphinism or any allied vices. He who lives under the
Constant influence of an opiate, will become conspicu-
Ously obnoxious to those surrounding him only when
deprived of the enslaving drug. In the majority of in-
stances, he will commit acts of selfishness and cruelty
Only when impelled by the bitterest misery to secure, at
any hazard, the means of purchasing more opium or
Cocaine, or whatever special form of anodyne or opiate
to which he may be particularly attached.
According to my, not small experience, when sup-
plied sufficiently with all he craves, beyond being a
social nuisance, he is comparatively harmless. But how
different With the man who drinks to excess In many
instances he becomes a brute, and acts brutally toward
Strangers, friends, and relatives.
In order to criticise, or select intelligently, a plan of
treatment adequate to the greatness of the subject, it is
but proper to Contemplate first the way in which alcohol
damages the System. Of course, I speak of the damage
Wrought by its abuse.
35
546 JNETW YORK STATE MEDICAL ASSOCIATION.
The effectively-intoxicating part of all alcoholic bever-
ages is called ethyl-alcohol, and by pharmacologists is
properly ranked with the poisons; but, in common with
other drugs of the same class, it is, in Suitable cases, pre-
scribed by physicians, for, when a physician orders
brandy in the form of cognac, his patient thus takes
about 55 per cent. of ethyl-alcohol. When he orders
Malaga wine (a favorite prescription for children in cer.
tain countries), the little one gets from 17 to 28 per cent.
of the same alcohol, and in lager beer, from 3 per cent.
to 5 per cent.
It has often amused and astonished me at the same
time, when I have heard it said that lager beer is a non-
intoxicating drink; for, the man who imbibes ten glasses
of it, often but an ordinary feat, drinks about half a
glass of pure ethyl-alcohol. This substance is carried
into the blood, chiefly through the intestinal veins, and
to some extent through the chyle-vessels. It speedily
passes through the walls of the vessels, and the richer an
organ is in blood, the more of the alcohol it imbibes.
The rapidity with which the entrance of alcohol into the
system is effected, is truly astonishing, for, in only a few
minutes after it is swallowed, it can be found in the
venous and arterial blood and in the main trunk of the
lymph-vessel system. Again, the brain is the first Organ
to absorb this poison from the blood, and, hence, also
the first in showing its effects. It is thought that the
action upon the nerve-centres is atomic or molecular in
character. If the excess in drinking be slight, and of
short duration, this atomic union will occur in a Very
loose manner, so that the alcohol must soon let go itS
hold again, so to speak; but where severe and protracted
indulgences are practiced, the chemical affinities of the
nerve elements are paralysed, and their life finally alto-
gether destroyed. Next in order comes the heart, whose
action is quickened, while the tension of the arterial
walls and the blood pressure is lessened. The blood it
self is not changed by the alcohol.
OBSERVATIONS ON ALCOHOLISM. 547 *
Upon the digestive function alcohol exerts a peculiar
influence. Small doses, diluted, stimulate and increase
the secretion of the gastric juice; whereas, large amounts
interrupt, delay, or entirely suspend it. Competent
observers maintain that any quantity at all, if taken
during the process of digestion, produces the latter effect.
According to almost all observers, tissue-change is
decreased by the use of alcohol. The breathing, at first
accelerated, gradually grows slow, and the excretion of
carbonic acid is lessened. The temperature of the body
is affected only by large doses, which lower it. A great
expenditure of warmth is caused by the dilatation of the
vessels of the skin, by paralysis of the muscles, and by
a reduction of the oxidising processes in the tissues.
A study of the intoxicating and, hence, destructive
effects of alcohol upon the child, furnishes a guide to the
proper treatment of alcoholism in the adult. The child
shows far more clearly its powerful effect on the nervous
system. The first stage is almost always one of excita-
tion, though this is occasionally absent in the child, as
Well as in the adult, either on account of a large dose
being taken, or because of individual susceptibility.
This stage of excitation is marked by a great sensitive-
neSS to external excitants, and by most active muscular
unrest, often progressing to light muscular spasms of a
clonic or general tetanic character. In the next stage,
the child becomes deeply depressed; there is a relaxation
of nerves and muscles, resembling paralysis. In this
Coma-like condition, it may lie from twelve to thirty-six
hours, being roused with difficulty, and only for a few
iminutes at a time. Occasionally, I have said, there is
an absence of the first period of excitement, and then
the rapidity of the absorption of alcohol is exemplified
by its almost lightning-like action upon the central ner-
VOuS system.
once saw a man drink a full goblet of whiskey, and
* less than five minutes, a second. A third was
*ttempted, when all at once the glass fell from his hands,
548 NEW YORK STATE MEDICALL ASSOCIATION.
and he lay senseless upon the floor. He was ill for
weeks at the doctor's house. During the first week of
September I was called to see two cases of alcoholism
which were to be treated at the Keeley Institute. Both,
however, arrived in so terrible a condition, that I was
sent for to see if they could be roused from the almost
coma-like state in which the last drink had placed them.
It was impossible. One expired within fifteen minutes
of the time I first saw him, and the other within two
hours. The latter presented a very interesting point.
He was pulseless, unconscious, insensitive to any touch;
his feet and hands were cold. I gave him hypodermatic
injections of brandy, and he reacted. In an hour he was
perfectly conscious, answering all questions, but he lived
only about two hours from the time I made my first
visit. I mention these cases on account of the interest-
ing deductions to be drawn from them.
We should always bear in mind when prescribing
alcohol for a child, that it not infrequently produces
convulsions in the infant; and furthermore, that even
very small doses of it act only transiently, as a vivifier
and apparent strengthener of the nervous system ; even
then, such effects are soon followed by relaxation. In
reality, alcohol only transiently benumbs the feelings of
weariness ; and finally, in larger doses, produces a
momentary, but never an enduring strength. It is,
therefore, indicated medicinally only in that pathological
condition which approaches collapse, and in which there
is a frequent and small pulse. In such cases, alcohol
may serve to “tide over,” by causing temporarily a
slower, fuller, and stronger pulse. We should also
never forget, that in tea and coffee, more particularly the
former, we have the agents, par eacellence, which raise
and sustain strength in muscular and mental labor. The
wife of Lieutenant Peary, lately returned from a most
successful North-Pole expedition, informed me that tea
almost always, coffee rarely, was their beverage. Alcº:
hol some time ago was excluded from the quartermaster's
OBSERVATIONS ON ALCOHOLISM. 549
department of Northern expeditions. It is a mistake .
on the part of any practitioner to direct even the smallest
doses, long continued, of alcohol in water or milk, to be
given with a view to imparting strength. This it will
not do, but will disturb the natural course of digestion
by inducing chronic irritation of the mucous membrane
of the stomach. Chronic and intractable gastric catarrh,
enlargement of the intestinal lymphatics, rapid loss of
weight and strength, and in a few instances, cirrhosis of
the liver, are some of the pathological changes following
long-continued use of even small doses of alcohol.
But what are these effects compared with those wrought
upon the central nervous system of the child? They are
not surprising, when we recall to mind the grave and
constant anatomical lesions which develop in the cere-
bro-spinal system of the adult alcoholist. The very
delicate nerve-elements of the child are still in a very
active state of development—i. e., more full of blood
than later in life—the meninges are therefore very prone
to congestions, to dangerous serous effusions, and to in-
flammations. For these reasons, alcohol must affect the
child a great deal more injuriously in this, the most im-
portant organ. From its baneful influence often arise
epilepsy and chorea. That, in many cases, this is the
Cause, is recorded by thoughtful and investigating
physicians, and has been proved by the happy cure of
these dreadful nervous disorders as soon as its use was
discontinued.
. I cannot resist alluding with a deep-felt word of warn-
Ing, to the pernicious practice of allowing and even
prescribing for nursing-women the systematic use of
alcoholic drinks, with a view to producing a greater flow
of milk for the baby; it is often advised by the family
Physician, and the hired wet-nurse stipulates as her
*ight, a certain daily allowance of beer or whiskey in the
shape of milk punch. Can a sadder mistake be made
"hese same men who allow or advise the practice, are
doubtless Opposed to the use of so-called swill-milk,
550 IVEW YORK STATE MEDICAL ASSOCIATION.
which means milk from cows fed on distillery grain, by
the eating of which they are kept in a chronic state of
mild intoxication. But opposed as they are to the em-
ployment of swill-milk for adult or child, they help to
produce in the human female a similar Swill-milk for the
poor infant. Competent and close observers have dis-
covered a connection between this habit of the mother
and the development in the children afterwards of true
imbecility, and even idiocy.
Of all the effects upon the nervous system of the child,
however, the most distressing and far-reaching is that
upon the moral power, upon the morality of the being.
Alcohol paralyses this. The youth, who, so to speak,
was alcoholised as a child, gives free rein to his pas-
sions; his will-power stands at Zero ; neither dissipa-
tions nor crimes have any terror for him at the very
first meeting ; and he not infrequently ends his career
as a suicide.
Neurasthenia is a growing evil, even amongst the school
children. Think how one admires, almost as a curiosity,
a really fresh, sound, healthy child. As head of Our
local Board of Education for many years, I have given
more than usual attention to the young in my district,
and I have been astonished to find how many pupils
at the age of twelve to fifteen, complain of headache,
palpitation of the heart, insomnia, and bad feelings
generally—or perhaps they are dull and indifferent to
everything, and evidence great weakness of memory,
unnatural sleepiness, and easily induced exhaustion.
Parents of such unfortunate and uninteresting and
non-progressive children are very apt to lay all the
short-comings of their poor children to the fault of the
much-suffering teacher.
What must be the effect of all such lesions if allowed,
unchecked or unremedied, to go on into adolescence and
manhood? I think far beyond the wretchedness with
which it burdens the entire life of such an adult, is to be
considered the inheritance it bequeaths to the children.
OBSERVATIONS ON ALCOHOLISM. 551
Heredity is an unquestioned fact at this age. We
know that qualities of the parents reappear in the child.
A child whose father died before it could recognise or
remember him, will often exhibit the same peculiar gait
in walking. If, occasionally, the child will escape such
inheritance, the grandchild may have it. Some families,
from generation to generation, inherit mathematic or
artistic capacity. If virtues and great traits are inher-
ited, why should not defects, dispositions to diseases of
body or mind, or of both be also inherited . There is
no question that the drunkenness of parents can and
does entail the love for drink upon the offspring, or it
may at least very decidedly imperil life and health.
When we reflect on the fact, that inheritance makes the
good or bad quality or defect of the parent stronger in
the Offspring, this matter assumes a far graver aspect.
The craze for drink, the so-called acute alcoholism,
alcoholic mania, dipsomania, delirium tremens, chronic
alcoholism, specific alcoholic psychoses—all are classed
with mental disorders. As such they can descend to the
children. Dipsomania can be transmitted from father
to child, or else the effect of such defect in the father
may produce an otherwise injured mentality in the off-
Spring. It is astonishing how early this was recognised,
for Plutarch uttered this startling sentence: “Ebrii
9?gnſunt ebrios”—Drunkards beget drunkards.
The following facts have been collected, all pointing
in this same direction:
1. A man became a drunkard after middle life; chil-
dren born to him before his degradation remained free
from the vice of drunkenness, while those born after-
Ward, became drunkards.
2. Erasmus Darwin states that diseases inherited from
drunkards descend to the third and fourth generation,
until, finally, the family dies out. -
8. Another observer Says that of ninety-seven children
Of drunkards, Only fourteen remained free from some
defect.
552 NEW YORK STATE MEDICAL ASSOCIATION.
4. Still another maintains, that fifty per cent. of the
idiots and imbeciles of great cities are the children of
drunkards.
5. The children of drinkers inherit the same or a larger
predisposition to nervous disorders than those of nervous
or really insane parents. They suffer most frequently in
infancy from convulsions and epileptiform diseases.
6. Districts known as “drinkers' districts” in Europe
furnish far fewer good recruits for military service.
7. A law was made in Sweden against drunkenness,
7. e., making it a punishable offence, and since then the
number of persons unfit for military service on account of
undersize and general weakness has grown much smaller.
8. A distinguished specialist on children’s diseases
observed ten families of drinkers, and ten of temperate
parents for a period of twelve years. The ten drinker-
families produced in those twelve years fifty-seven chil-
dren. Of these, twenty-five died in the first weeks of
life, of weakness, of convulsive attacks, or of oedema of
the brain and membranes; six of them were idiots; five
were stunted in size, and were of real dwarfish growth :
five, when older, became epileptics; one, a boy, had
grave chorea, ending in idiocy; five had inherited dis-
eases and deformities, such as chronic hydrocephalus,
hare-lip, and club-foot; two of the epileptics mentioned
became, by inheritance, drinkers. Only ten, therefore,
of all these fifty-seven, or 17.5 per cent., showed, during
youth, normal disposition and development of body and
mind. The ten temperate families produced in the
twelve years sixty-one children. Of these, five died in
the first weeks, of weakness; four, in the later years of
childhood, had curable nervous affections; two only
showed inherited nervous defects. The remaining fifty,
or fully 81.9 per cent., were normal in every way, devel-
oping well in body and mind.
My friend, Dr. Wandenburg, has kindly furnished me
with a list of forty-four patients treated by him for alco:
holism. On examining the notes carefully, I find that
OBSERVATIONS ON ALCOHOLISM. 553
twenty-five of them had ancestors, or, any rate, relatives,
who drank. Of ten of them, there was no previous his-
tory obtainable. These, very likely, ought to be added
to the twenty-five, as it appeared from certain signs that
they merely did not wish to expose their family his-
tories.
It is a curious but very general fact, that there exists
a sort of instinctive tendency in the members of a family
to hide from others, as well as from themselves, anything
which would tell of a defect by a faulty nervous inherit-
ance — I mean an inheritance of defects in the central
nervous system. Men do not like to acknowledge the
controlling effect of such a fate, and they often instinct-
ively take pains to refer diseases which are unmistakably
inherited, to very ordinary, accidental, and always differ-
ent causes. To try to obtain information in such matters
from family members is too frequently a fruitless under-
taking. They will often throw impediments in one’s
way, even leading one into wrong paths. And yet to
make a proper diagnosis and prognosis in nervous dis-
eases, one must try to learn not only the history of his
patient, but also the diseases which are prominent in his
family.
But to return to my Wandenburg statistics: Four
mothers and sisters are consumptives; one has a father
Who is very nervous and smokes incessantly; one has an
asthmatic grandfather. Only three have a family record
Which seems free from all defects. Eleven of them
showed consumption or some lung difficulty in their
families; one had insanity on the mother's side, and of
9ne, the father's sister was insane; of one, the uncle and
aunt on the father's side were insane, and one had in-
Sanity in two aunts on the father's side. There was
insanity in the father of one, induced by drink, and in
* instance the paternal grandfather drank heavily and
* father moderately. In one case the paternal grand-
*ther drank hard and died of apoplexy ; the great-
§randmother was Consumptive, and the mother paralytic.
554 NEW YORK STATE MEDICAL ASSOCIATION.
In four instances the grandfathers drank heavily, though
the fathers were free from the vice.
All these researches only point the more strongly to
the importance of ascertaining the best methods, if there
exist any, to stop the disease and its ravages.
The establishment of a so-called Keeley Institute at
the village where I reside, has brought to my mind with
more than common emphasis the subject of the treatment
of alcoholism, craze for drink, or dipsomania.
It is to be deplored that the State has not created
special laws for the legal commitment of drunkards, and
erected suitable institutions in which these unfortunates
could be confined, treated, and kept until not only well
of a debauch, but until their will-power had been re-
established. The only institution near New York for the
treatment of drunkards is not calculated to do all this.
There, they are simply helped over a spree, and set afloat
again as soon as sobered and restored to sleep and appe-
tite. Nothing is done to help them improve or recreate
their moral strength, which, after all, is the great point
to be attained. I have sent alcoholic habitués to the
insane asylum. This, also, is not a proper place for
them, and besides, one has often to strain points to bring
such cases before the Commissioners in Lunacy in Such a
way that they will allow them to be received in an asy-
lum for the insane.
The Keeley system, which I have had much oppor-
tunity to observe, has something in it which none of the
formerly established institutes have ever shown. It tries
to reach the mind, and hence to establish on a new basis
the dethroned will-power. This is done, first of all, by
an appeal to the patient's honor. And the great Success
which in the beginning seemed to follow this method of
cure was unquestionably due to the fact that the ma"
jority of the earliest patients were of the very best class,
men of intelligence, who were willing and anxious to be
cured. These patients helped themselves by their desire
to be helped. Then, there existed a sort of brotherhood
OBSERVATIONS ON ALCOHOLISM. 555
among them — a feeling of kindliest interest in each
other’s improvement. A later arrival on expressing him-
self still miserable, after a few days’ treatment, was
strengthened by older patients saying, “It was so with
me too, but a few more days will help you.” Then, sure
enough, in a few days the later arrival would all at Once
say to himself: “Well, Isee these others gave up alcohol ;
I can do so, too,” and he would do it, and then every
day carried him farther away from the beverage, and left
him feeling better and better. Then, although his mind
cured him, being impressed with the idea that Some
secret, subtle means had been used to produce this bene-
ficial work, he cherished a growing belief in the marvel-
ous effects of this treatment.
It goes without saying, that I by no means advocate
the secret manner in which the Keeley system is prac-
ticed. It is wonderful, nevertheless, to note the many
Successful cures made by it. What helps to increase in
the eyes of the public this success, is the ingenious way
in which Dr. Keeley himself dismisses his cured patients,
or “graduates,” as he strangely misnames them. Every
evening—such is the practice at Dwight—the graduates
of that day are requested to step into Dr. Keeley’s pri-
Vate office before departing, to receive his final lecture.
There he tells them : “Now, gentlemen, remember, I
have filled your bodies with a poison inimical to alcohol.
If in the next four weeks you return to your old prac-
tice of drinking it, this poison which I have introduced
into your bodies will kill you, by meeting alcohol within
You. If you abstain for four weeks, but begin to digress
from your present abstemious life, after the fourth week
the same poison will make you seriously ill.” This is
* ingenious plan to make his cases tell on the com-
*nity, for the patients, after their return to their res-
Pºtive homes, will be closely watched at first by the
Pºple around them. But four weeks' escape, and no
*pse into dissolute habits takes place. Interest begins
t * e gº
° "ag; a four-weeks' wonder becomes tiresome, and
556 NEW YORK STATE MEDICAL ASSOCIATION.
after another four weeks of continued steadfastness it
ceases to attract attention. The best impression is thus
left on the minds of the people as regards the Keeley
treatment, and Dr. Keeley’s clever parting lecture has
brought forth the desired fruit.
The great object of my address to you is to rouse this
Association into action, to urge it to petition the Legis-
lature to pass the laws I have alluded to, and to vote
money for the erection of a building dedicated solely to
the restoration of drunkards. There is no need of bring-
ing forward plans for effecting this restoration until a
movement in the direction indicated has been crowned
with success. I feel very strongly on the subject. The
deep sympathy which a drunkard’s condition calls forth
should impel us all to forward the good work. The
establishment of institutions of this kind will be, in the
end, of immense benefit to the public treasury. Only
reflect on the labor power thus saved to the Common-
wealth ! The skillful mechanic (and how often are the
best given over to drink 1) will be restored to his family,
perfectly confident again, and willing to be the bread-
winner as of yore. The unfortunate who, during a crazy
spree, has threatened perhaps the lives of people, will no
longer go to jail to expiate a sentence in complete idleness,
but will speedily be cured of his debauch, and at Once
carry on remunerative labor in one of these institutions.
It is sad to watch our present system. I will give you
just one experience of mine.
A few months ago a prisoner was brought into our jail
in a most terrible condition—crazed by drink, with his
face beaten into a pulp during self-provoked rows, and
unwilling to be controlled in any way. The attending
physician found him chained close to the floor of the cell,
as dangerous and violent as a wild beast. A hypoder-
matic injection of morphine restored him to his former
quiet, and he was soon brought before the court and sº
tenced to a certain term of imprisonment in the county
jail. When the time of his release drew near, the judº
OBSERVATIONS ON ALCOHOLISM 557
who had sentenced him requested me to examine him as
to his mental condition, for the behavior of the man dur-
ing his trial had led the judge to fear he was insane. I
visited him at once, and found him a most intelligent,
wide-awake man, who only a year ago had given himself
up to drink, and had ever since lived in constant alco-
holic excitement. Deprived of drink, he had perfectly
recovered, and felt ashamed of his condition. The jail
was not only not the place for him, but it was most
detrimental to his moral condition. Thrown into close
contact there with criminals of all shades, while his mind
was still weakened from the long-continued and exces-
sive use of alcohol, the former drunkard was in immi-
ment danger of becoming a future criminal.
There are people who have no patience with drunkards,
just as there are those great masterpieces of virtue who can-
not understand how one can ever be led by passion’s wild
demands from the straight and practical road, whose
every step is well calculated beforehand, and arranged
in an undeviating routine system. But such people are
possessed of natures which cannot be tempted—cold and
Self-contained individuals, their virtues are to my mind
no virtues at all, for they have never to sustain an on-
slaught of the evil one. To them I do not turn for co-
Operative sympathy, but to those scarred in many a bat-
tle, won or lost. And it is scarcely necessary that I
should portray for such, the many ways in which excel-
lent men or women may become almost unconsciously
enslaved by alcohol.
Look around you, and see how many homes have been
destroyed; how much happiness undermined ; how
*uch of grief planted in the hearts of men and women
by the unfortunate victims of alcoholic excess ; and then
yOu will join in doing this great work in which my whole
heart's energies are enlisted.
After reading the paper, Dr. Schmid moved that a
°9mmittee be appointed with power to endeavor to secure
558 NEW YORK STATE MEDICAL ASSOCIATION.
the passage of a bill through the legislature, which would
make legal the commitment of drunkards and morphin-
ists to suitable institutions, and to petition the legisla-
ture to make a sufficient appropriation for the erection
of asylums devoted exclusively to the treatment of alco-
holists and morphinists.
Dr. H. D. Didama, of Onondaga county, suggested as
an amendment, that a committee be appointed to take
into consideration this question of the legal commitment
of inebriates, and report on it at the next meeting.
As thus amended, the motion was then put to vote, and
carried. -
The president appointed on this committee the follow-
ing: Dr. H. Ernst Schmid, of White Plains, N. Y., and
Drs. E. F. Brush and William D. Granger, of Mount
Vernon, N. Y.
DISCUSSION.
DR. NELSON. L. NoFTH, of Kings county, considered the subject im-
portant, and an appropriate one for action by this Association. We all
know the way in which drunken people are thrust into jail and other
places, and it certainly behooves medical men to think of these matters
soberly and earnestly. These unfortunates are to be found everywhere, and
they should be cared for in just such a place as suggested by the author.
THE PRESIDENT thought we should consider well the difficulties in the
way of legalising the commitment of these people. To what institution
shall they be committed ? Neither the lunatic asylums nor the jails Want
them, but he knew of no other places to which they could be committed
except to private institutions; and in this connection he would remind the
Association that Binghamton was formerly an institution of that kind,
and proved to be such a complete failure that the State took it, and Con-
verted it into an institution for the treatment of the chronic insane.
DR. GEORGE Douglas, of Chenango county, said that he had been 9”
of those who had contributed money to that institution for the sake of hav-
ing the experiment tried, and as the President had said, it proved an utter
failure; and others who had had a similar experience would probably *
him out in the statement that such institutions were failures because theº"
no manhood in these poor inebriates. He did not wish to discourage efforts
at reclaiming these unfortunates, but only to point out the obstacles which
had already been encountered; for, although his hairs were 8*Y with
seventy years, he could not forget that from his earliest childhood his
father had brought him up to abominate drinking habits.
CLIMATOLOGY IN ITS RELATION TO DISEASE.
By S. J. MURRAY, M. D., of New York County.
JNovember 17, 1892.
Being obliged a few years since to seek a more con-
genial climate on account of my own health, I was led to
a more thorough consideration of the subject of climate
in its relation to disease. Climate we know is a fixture;
the weather may change, climate does not. The people
of the world are to-day beginning to learn that the great-
est destroyer of human life has its remedy in climate.
There never was a time in the world’s history when the
advice of a physician was more eagerly sought for by
the better classes, than at the present time, not alone on
those subjects which pertain strictly to medicine, but on
everything pertaining to their general welfare. On this
account, our responsibilities, as physicians, are very
great, and hence the necessity of our being qualified to
meet the demand. The time is not far distant when the
duty of the physician will be rather to instruct the peo-
ple how to live so as to avoid disease, than to treat dis-
ease; and the great object of this paper is to emphasise
the importance of giving intelligent advice sufficiently
early to save the life of the patient.
Our first duty, then, consists in the proper education
of the human race with a view to avoiding disease. To
what extent are we as physicians responsible for so much
*ase? It has been fashionable of late to attribute disease
largely to the poor little microbes, which have been at-
tacked in all conceivable ways; but still they move and
have a being, and existin as great a variety and number as
*Ver. While I believe them responsible for many dis-
* I do not attribute as much to their agency as has
560 NEW YORK STATE MEDICAL ASSOCIATION.
been claimed by some. We are greatly indebted to the
bacteriologists of the present day for their many valuable
discoveries, but the question here arises, how much bet-
ter are we prepared to treat the diseases caused by germs,
from Our having made the discovery of their existence #
Professor Koch made a wonderful discovery when he
found the tubercle bacilli; but with all his knowledge
he has failed to discover an agent which will destroy
these bacilli without killing the person whom they
attack. We do not know of anything by which the
farmer can kill the weeds, but not the potatoes in his
field; and in like manner, we can hardly expect to find
an agent capable of killing the tubercle bacilli without
injuring the human body.
So we are obliged to seek a remedy for many diseases
in a change of climate, and therefore every practicing
physician should possess some knowledge of climatology.
I have frequently met patients with advanced phthisis,
away from all the comforts of home and its surround-
ings, dying in a strange land, sustained only by hope,
and the fact that they were carrying out the advice of
their physician, who had not taken the trouble to look
sufficiently into the matter to qualify himself to decide
the important question, as to which particular climate or
locality was most suited to his patient’s case.
I wish I could adequately picture to you in words the
many sad scenes I have witnessed. It is indeed a Very
easy thing for the doctor, who probably knows that all
hope is ended, and a fatal termination not very far dis-
tant, to say to his patient, “Go to Europe, Australia or
Southern California.” The poor unfortunate patient is
at once inspired with hope, his weakened frame is sus-
tained by will-power, and yet he scarcely reaches his
destination before nature gives way. A long journey.”
a surprising tax on the strength of even a healthy
person.
I am strongly opposed to the method adopted by ma").
of recommending places in a general Way, regardless of
CLIMATOLOGY IN ITS RELATION TO DISEASE. 561
their individual characteristics. The benefits and dan-
gers of the climate of a heaſth resort cannot be arbitra-
rily stated, for the climatic conditions which constitute
life to one invalid or class of invalids may be inimical to
the well-being of another. There are, it is true, certain
conditions equally desirable for all classes of cases, such
as purity of the atmosphere and of the water, hygienic
surroundings, and other circumstances, and these should
be carefully considered in all cases.
Residence in a suitable climate is an almost indispen-
sable factor in the treatment, prevention, and cure of
many forms of disease. Thus we constantly see invalids
about us whose condition is critical, until they remove to
a suitable climate, when their malady is cured, or, at
least, so alleviated that life is prolonged for years, and
they again become active, useful members of society.
But some of these cases only continue to improve as long
as they reside amid these congenial surroundings.
The prescriber of climate must learn to individualise
his prescriptions, not alone in regard to the disease, but
more particularly in regard to the temperament of the
patient and the nature and stage of his malady. When
Contemplating a change of residence for an invalid, we
are of course to keep in mind other equally important
Conditions, such as rest, clothing, cuisine, nursing, con-
genial company, avoidance of the excitement of fashion-
able resorts, sanitary surroundings, etc. The latter, from
my OWn Observation, receive about the least attention of
them all. In many of our so-called health resorts, they
have not the least conception of what constitute good
Sanitary conditions; the water-closets are located very
*the house, and the slops from the kitchen are thrown
out of the door or window, upon the ground, without any
*image but that which nature provides. This state of
things exists, year after year, until the whole soil about
the premises becomes thoroughly saturated. The place in
other respects may be healthy enough, but if the house in
Which the patient stops has improper drainage, little will
36 -
562 INEW YORK STATE MEDICAL ASSOCIATION.
be gained by change of climate. It must also be remem-
bered that a person with quiet tastes will not enjoy a gay
place, and vice versa. Again, if one with moderate means
visits an expensive place, the worry about pecuniary
affairs will probably neutralise the good effect of climate.
It is a matter of great importance for the invalid to
seek the benefits of a change of climate at a sufficiently
early stage of his malady to be really helpful. Nothing
is more pitiful than to see a dying patient, or one who
cannot be relieved or improved, expend his Small store of
strength in a fruitless journey, and exchange his many
home comforts for the discomforts which have to be
endured by the sick when traveling. There are, however,
many persons affected with chronic and incurable dis-
eases, whose sufferings may be alleviated, and whose life
may be prolonged by a residence in a suitable climate,
and such should be encouraged to make a change.
I shall make no attempt to describe transatlantic
resorts, for our own country affords a sufficient variety
and range of climatic conditions to meet the wants of any
case where change of climate is desired. It seems wholly
unnecessary for Americans to seek relief at the various
resorts abroad, when in our own land they may enjoy an
equally good, or even a Superior climate at the health
resorts of the Adirondack Mountains, Southern Cali-
fornia, Colorado, Asheville, N. C., the Cumberland range
of mountains in Tennessee and Kentucky. While it is
true that the Alps and the Pyrenees afford many attrac-
tions, the resorts of Colorado and the Rocky Mountains
compare very favorably with them in every respect.
Many of the famous European Spas are but prototypes of
more or less noted mineral springs in this country, which
are numbered by hundreds. If our American people
would more generally seek health in our own sanitaria,
the value of these places would soon be appreciated, and
their fame become widespread. For the American, the
health stations of his own land are preferable, in that
while he is seeking benefit from the change of climate, he
CLIMATOLOGY IN ITS RELATION TO DISEASE. 563
is among his own countrymen, with familiar customs,
language and diet, a truly important factor in the treat-
ment of many diseases.
In speaking of resorts, you may notice that I mention
the Adirondacks first. I do this because of my personal
knowledge of this region, and because I believe it more
nearly, than any other section of our country, combines
all that is desirable in a health resort to make it the most
famous in the world. Another important advantage is
its accessibility. In Southern California may be found
many delightful seaside resorts. The most Southern of
these resting-places is San Diego, situated only about
fifteen miles from the Mexican border. It is a beautiful,
flourishing city, and has the finest harbor on the Pacific
coast, south of San Francisco. The climate is wonder-
fully bracing and equable, the mean temperature being
62°, seldom rising to 80°, or sinking below the freezing
point. The air is particularly dry, and free from the
fogs found further north along the coast. The aver-
age annual rainfall is about ten inches. The dry,
spring-like climate all the year round has induced many
invalids to locate here with their families, and, in time,
they have been restored to health, and have become per-
manent residents. Near here, across the harbor, is
situated, on a peninsula, a new resort known as Coronado
Beach. It has a fine sandy beach, and good surf bathing
the entire year. This place is destined to rival other re-
Sorts along the coast.
For those who require a greater altitude, there is prob-
ably no better place than the range of Rocky Mountains
which passes through Colorado, for here is where they
attain their greatest altitude, many peaks reaching a
height of 13,000 or 14,000 feet above the sea-level. The
mountain region of North Carolina, and the adjoining
parts of South Carolina, Tennessee and Georgia, have
many desirable resorts. The country has a delightfully
Salubrious climate, in many respects similar to that of
the White Mountains. It has an average elevation of
564 JNETW YORK STATE MEDICAL ASSOCIATION.
2,000 feet above the sea-level, and some of the peaks at-
tain a height of 6,000 feet. Asheville, N. C., is in the
centre of this region, and here the hotels are desirable
and the scenery beautiful. It has a cool, dry climate,
and is a favorite all-the-year-round resort.
I wish now to call your attention to the Cumber-
land range of mountains in Tennessee. I spent nearly
two years in this region, and from personal observation
can assure you it is well worthy of your consideration.
I have witnessed here some wonderful recoveries. The
late Dr. E. M. Wight has left a valuable contribution
on this subject in an article startlingly entitled “A
People Without Consumption,” in which he refers to the
inhabitants of the table-land of Tennessee, on the Cum-
berland plateau. He says: “During the ten years I
had practiced medicine in the neighborhood of the Cum-
berland table-lands, I often heard it said that the people
of the mountains never had consumption. Such infor-
mation came to me in such a variety of ways that I deter-
mined I would investigate the matter. The observations
extended over a period of four years, and were made
with great care and with as much accuracy as possible,
and to my own astonishment and delight I have become
convinced that pulmonary consumption does not exist
among the people, natives and residents, of the table-
lands of the Cumberland Mountains.” In the perform-
ance of the work which enabled Dr. Wight to arrive at
this conclusion, he had the assistance of more than twenty
physicians who had practiced for many years on the
mountains. The facts seem all the more startling when
one considers the diet of the native residents of the
mountains. They live almost wholly on corn-bread,
bacon, and coffee; all food is eaten hot, and coffee
usually accompanies all three meals, and is drank with-
out sugar or cream. A large majority of the adult
population use tobacco in some form, the men in chew-
ing and smoking, the women in smoking and dipping
snuff. They very seldom have dyspepsia, and they never
O'LIMATOLOGY IN ITS RELATION TO DISEASE. 565
grow fleshy after childhood, though nearly all the chil-
dren are ruddy in appearance.
Now, what classes of cases are mostly benefited by
change of climate 7 I would answer, pulmonary phthisis,
catarrhal affections of the respiratory organs, asthma,
hay-fever, neurasthenia, debility, rheumatism, Bright's
disease, hepatic disorders, scrofulous affections, and ma-
larial troubles. In my experience, a pure, clear, dry,
cool, rarefied atmosphere, with good electrical conditions,
and plenty of sunshine, is desirable for most phthisical
cases. Such a climate may be found in the Adirondacks.
A mild and moderately dry climate is well adapted for
some phthisical cases, and such a climate may be found
in Southern California amid the most delightful sur-
roundings. Of all the charming resorts in this region,
San Diego and Coronado Beach deserve to be mentioned
first, but Santa Barbara and Los Angeles are not far
behind.
Catarrhal affections of the respiratory organs are very
favorably influenced by a change of climate, some cases
being benefited by the dry, rarefied atmosphere of high
altitudes, which stimulate the absorption of inflamma-
tory products, while other cases are relieved by a resort
to the Sulphur and Salme Mineral Springs. Sea air is
especially applicable in some cases, and pine forests are
also very helpful in certain cases.
Few conditions are more favorably influenced by cli-
mate than asthma, but it is a malady presenting so many
forms that it is difficult to lay down any definite rules as
to climate. Hay-fever is markedly relieved, if not com-
pletely cured, by a residence in Southern California. The
White and Rocky Mountains are also suitable places.
Those suffering from nervous diseases more often re-
quire change of scene, with congenial surroundings, than
change of climate. Debility, though not in itself a dis-
tinct disease, is a definite condition. These cases require
the tonic, invigorating air of the mountains and sea.
Rheumatism needs a climate free from sudden changes
566 NEW YORK STATE MEDICAL ASSOCIATION.
of temperature, one with an abundance of sunshine,
Sandy soil, and a high altitude; in short, perpetual
spring. The nearest approach to this exists in Southern
California.
Sufferers from Bright's disease, hepatic, scrofulous
and malarial affections all require about the same cli-
matic conditions, namely: the bracing air of the sea and
the mountains, with the use of alkaline and Salme min-
eral waters. In a word, the paramount considerations
for the promotion of health are abundance of pure air,
sunshine, and outdoor exercise. Without these, no
climate will restore the sufferer to health, but with them,
wonderful results may be obtained.
PEL WIC VERSION.
By T. J. McGILLICUDDY, M. D., of New York County.
Movember 15, 1892.
The subject of version might, with advantage, be en-
tirely re-written, for the text-books in use to-day give
but a portion of the important facts connected with it,
and it would well repay our writers on obstetrics to again
carefully study and review this whole subject.
I would divide version into three classes, which may
be named in the order of their desirability and impor-
tance as follows: (1) cephalic, (2) pelvic, (3) podalic.
This is the ideal classification, and there can be but little
doubt that it is the correct one. Pelvic, or breech ver-
sion, is mentioned by some writers on obstetrics, but it is
generally considered as synonymous with podalic ver-
Sion, and the indications for its employment are not by
any means well understood. Cameron, in the American,
System of Obstetrics, says: “As the foetal ovoid has but
two poles, the cephalic and the pelvic, the foetus must
be turned to one or the other of them. When it is
turned to the head the operation is called cephalic ver-
Sion; when turned to the breech, pelvic version. Podalic
Version, or turning to the feet, is a variety of pelvic ver-
Sion, and should be classed as such.”
The Operation of pelvic version has not yet been prop-
erly described, and its advantages are known only to a
Very few ; hence it has seldom been performed manually.
Obstetric works rarely even refer to it, and if they do,
half a dozen lines are considered sufficient space to
devote to a description of it. This systematic neglect of
Such an important operation seems to me a most unfor-
tunate error, and one which should have been corrected
long ago by practical obstetricians.
568 NEW YORK STATE MEDICAL ASSOCIATION.
Spontaneous pelvic evolution (Figs. 1, 2, 3) is said to
be of quite common occurrence, and I think it would be
much more frequently observed if special attention were
directed to it, and if obstetricians were not so prone to
interfere with Nature’s methods. It is more easily ac-
complished when pregnancy has only advanced to the
seventh or eighth month, and it is possibly more common
at this time than later on in pregnancy, when the child
is larger. Welpeau cites one hundred and thirty-seven
Fig. 1. Fig. 2. Fig. 3.
cases of spontaneous evolution. Where the child is
dead, and the shoulder low down in the pelvis, the uterine
contractions, aided by the anatomical conditions present,
readily cause the spine to become doubled on itself an-
teriorly, for, the abdomen having no bony structure, and
the spinal column no spinous processes in front, anterior
flexion is easily effected. Spontaneous pelvic evolution
is a more common occurrence than spontaneous cephalic
evolution. The latter is quite rare, and is due to the
same factors operating in the opposite direction.
In spontaneous pelvic version the breech presents,
while the head and trunk pass toward the fundus. This
is of much more frequent occurrence than the preceding,
but it cannot take place when the uterus is retracted
and moulded to the foetus. The natural mechanism of

PEI, VIO VERSION. 569
spontaneous pelvic evolution can be readily imitated by
art, because artificial efforts tend to supplement and
assist the natural ones; indeed, they follow in the line
of Nature's method of delivery. Pelvic version in these
cases is simply the imitation artificially of spontane-
ous pelvic evolution, and is especially indicated in
transverse presentations. This method of delivery, how-
ever, has seldom been attempted by artificial means.
According to Kleinwachter, it is indicated in cases where
the pelvis lies nearer the inlet than the head does, and
where cephalic version would be difficult, or impossible.
It may be performed by external manipulation alone, but
is more easily accomplished by the combined method.
When this method is chosen, the fingers of the obstetri-
cian should be inserted in the child’s groin, or over the
crest of the ilium (Fig. 4), and the breech drawn down
ºsts
sºs NSR,
Sº
St. S. S. -
N. §
Fig. 4.
into the pelvic basin. The operation of extraction can
then be easily performed if the child be small; or, if
large, and it has been decided not to wait for the natural
delivery, the forceps may be applied to the breech.
Spontaneous expulsion, as a result of the uterine con-
tractions, may take place in transverse presentations
Where the shoulder presents, and the body is fairly

570 JNETW YORK STATE MEDICAL ASSOCIATION.
engaged in the pelvis. Denman cites several cases in
which this has occurred, but we should not think of
depending upon nature to effect delivery in this way.
Where artificial delivery has been resorted to under
these circumstances, it has been the custom heretofore
to perform podalic version, but instead of this, I would
recommend the performance of pelvic version. Its ad-
vantages over podalic version in cases of transverse pres-
entation may be summed up as follows:
(1) It is a much simpler operation, as it simply con-
verts the case into an ordinary breech presentation.
4.
Fig. 5.—Pelvic Version.
(2) It necessitates the introduction into the uterus of
the fingers only, whereas podalic version requires the
introduction of the whole hand and arm.
(3) It is only necessary to move the child sufficiently
to draw down the breech, while in most cases of podalio


PEI, VIO VERSION. 571
version the body of the child must be made to rotate
around the whole cavity of the uterus. (See Figs. 5, 6.)
(4) There is much less risk of rupture of the uterus.
(5) The operation is attended with much less shock.
(6) For the foregoing reasons, the mortality for both
mother and child is much less than in podalic version.
:
sº
.
:
!
Fig. 6.—Podalic Version.
Now, in podalic version (Fig. 6) the body and head
must ascend to the fundus before delivery begins, thus
making the circuit of the interior of the uterus. This
does not occur in pelvic version, for the breech is drawn
down at once, and in doing this it does not traverse, at
the most, Imore than one-fourth of the circuit of the
literine cavity. If the uterus be strongly retracted over
the body of the child, podalic version is extremely




572 NEW YORK STATE MEDICAL ASSOCIATION.
hazardous, both on account of the profound shock which
it produces, and the great liability to uterine rupture.
Podalic version is often of doubtful utility, and the
writer firmly believes it has been elevated to a position
which it does not merit. It is often employed for con-
ditions in which the forceps or pelvic version is indicated,
and its performance in cases where there is thinning of
the lower segment of the uterus has been responsible for
many deaths from shock, or from uterine rupture.
In cases of transverse presentation, where the child is
alive and movable, and no great force is requisite, ce-
phalic version (Fig. 7) should be attempted in the inter-
\
Fig. 7.-Cephalic Version.
vals of the pains, while the uterus is thoroughly relaxed
by means of morphia or chloroform. If this fails, it
Will usually be found that pelvic version is practicable.
If an examination during the last month of pregnancy
shows that the presentation is not cephalic, it should be
made so, and if during labor the presentation is found
to be neither cephalic nor pelvic, the child should be
immediately turned so as to make the case one of
cephalic or pelvic presentation, and then this position

PEI, VIO VERSION. 573
carefully maintained. In turning the child, the pressure
should be made in such a way as to shorten the long axis
of the foetal ovoid, and to place it in proper relation to
the pelvis. Pressure should be made, therefore, exter-
nally upon the head and breech, thus producing flexion,
and approximating the two poles of the foetus. If this
external manipulation be not successful, the external
hand should be made to press the head and shoulder
of the foetus upward, not too strongly, while the inter-
nal hand draws down the breech. If much force be
required, the breech may be drawn down by the thumb
and two fingers of the Operator grasping the foetal
pelvis, with their extremities on the iliac crests, or in the
groins (see Fig. 4). After the completion of version,
if immediate extraction be indicated, it may be accom-
plished by continuing to make traction with the hand,
or by using for this purpose the forceps, fillet, blunt
hook, or, in some cases, my compression forceps. All
this may seem very radical, but it is in the line of prog-
ress. It is important not to confound version and ex-
traction, for they are two distinct operations, and each
has its own special indications.
Pelvic version is especially useful in those unfavorable
cases in which the arm presents, with the shoulder
pressed well down into the pelvis, where the liquor amnii
has been discharged, and the uterus is retracted on the
child’s body. Here podalic version is usually out of
the question. Podalic eatraction certainly has advan-
tages which should be borne in mind, but it must not be
Confounded with podalic version, which has been recom-
mended for so many different conditions. The recent
additions to our knowledge, derived from abdominal
palpation, and the other improvements in obstetrical
Science, lead me to believe that it is far from being a
panacea for all obstetrical ills; indeed, I think that it is
rarely necessary. In a pelvis of fair dimensions and with
a child of moderate size, pelvic version is not a difficult
Operation, and when carefully performed, there will
574 NEW YORK STATE MEDICAL ASSOCIATION.
rarely, if ever, be any need for decapitation or eviscer-
ation.
The following case, which is illustrative of a large class,
will, I think, serve to show the indications for pelvic
version :
Mrs. W., twenty-five years of age ; the wife of a physician. Her first
pregnancy was normal, and nothing unusual occurred during the second
pregnancy until the ninth month was reached, when an accidental blow
on the abdomen caused slight uterine haemorrhage, which lasted for a few
days, and was followed by labor, pains. On examination, her husband
found a dorso-anterior transverse presentation, which he attempted to rec-
tify under chloroform by performing podalic version. Owing to the de-
velopment of some alarming symptoms, he desisted, and gave her some
Magendie's solution, to quiet the pains, pending my arrival. I found the
patient well narcotised, and the uterus completely retracted on the body
of the child. The patient had had more or less pain for two days. The
left arm of the child and about two feet of the umbilical cord protruded
from the vulva. The hand and arm were bluish and swollen, and the cord
was cold and pulseless. Owing to the retraction of the uterus, and the
moulding of it to the body of the child, ordinary podalic or cephalic ver-
sion was, of course, inadmissible. As the head of the child lay toward
the right, I introduced my right hand, slipped my fingers into the child’s
groin, and brought down the breech, following Nature's method. I was
in this way able to quickly and easily effect delivery. (Fig. 5.)
DISCUSSION.
DR. OGDEN C. LUDLow, of New York county, said he had had no per-
sonal experience with pelvic version, and had hitherto held the opinion
that its sphere of usefulness was quite limited, being confined to those cases
in which the pelvis was relatively large; but, taking into consideration the
great flexibility of the vertebral column in the foetus, together with the as-
surance of the author, that this method of delivery is quite easy, it seemed
worthy of more extended trial. He had been particularly impressed by
the author's statement as to the limited arc the foetus describes ºn uté?'0
during the performance of pelvic version, as compared with that described
in podalic version, and this alone would be a decided point in favor of
pelvic version, as it greatly diminishes the tendency to shock and to rupture
of the uterus. -
DR. M. C. O’BRIEN, of New York county, said that apropos of What
the author had said about prompt delivery, he would like to relate a Case
in which, for the time being, he was puzzled to know just what to do. A
young woman, twenty-eight years of age, was leaning out of the window,
when the amniotic fluid suddenly escaped, and strong uterine contractions
DISCUSSION. 575
set in within an hour. Examination per vaginam showed the foetus to be
lying in an abdomino-anterior position, so that the hand, cord and foot all
presented at once. During this examination there was a sudden snap, and
a gush of blood, showing that the umbilical cord had ruptured. The end
of the cord was grasped by the finger and thumb, and an effort made to
perform bimanual version, as the child's life was in great danger, and
speedy delivery was demanded. With some difficulty, owing to the violent
contractions of the uterus, one foot was made to slip down alongside of the
right wrist. This was grasped, and slight traction made until the umbili-
cal cord could be reached with the left hand. Then, after changing hands,
as the external One was cramped, the Stump of the umbilical cord was
grasped in the left hand, and with the right hand gently pressed into the
groin of the child, he was able to deliver the child without bringing down
the other foot. On delivery, the child cried lustily. The stump of the
cord was transfixed with a needle, and tied. The delivery of the placenta
was followed by the discharge of many large clots of blood, showing that
the placenta had been partially separated at the time of the rupture of the
cord. She would have delivered herself, in all probability, as sixteen
months before he had arrived at her bedside just in time to see the breech
of the child come into the world ; but in this case a moment's hesitation
would have sacrificed the child’s life. The child was certainly delivered
by pelvic version.
SHOULD WE TREAT FEVER, 7
By S. T. ARMSTRONG, M.D., of New York County.
(Read by title November 17, 1892.)
It is almost unnecessary to offer any excuse for pre-
Senting for your consideration so familiar a topic as is
fever, because, as frequently as it is encountered in the
routine of our daily work, it is nevertheless surrounded
by some of the most abstruse problems in medicine, when
we consider its etiology and treatment. More than six
hundred different names are given under the caption
“Fever,” in Foster’s Encyclopaedic Medical Diction-
argy; and although many of these may be appellations for
the same disease, still their number affords an idea of
the multifarious phases in which fever is encountered.
Pathologists and clinicians have not yet agreed regard-
ing the cause of the manifestation of fever in the animal
organism. The late Austin Flint, in an address delivered
before the Ninth International Medical Congress," said
that “an essential fever is an excessive production of
heat in the body, induced by a special morbific agent Or
agents, and due to excessive oxidation, with destruction
of the tissues of the body, and either a suppression or a
considerable diminution in the production of water.”
He intentionally ignored the causative influence of the
nervous system. W. H. Welch showed in his Cartwright
Lectures” that the most frequent cause of fever was some
substance that exerted a pyrogenic effect when intro-
duced into the circulation, so that it could act in Some
way upon the nervous system. Welch considered that if
1 The Medical News, September 10, 1887.
* The Medical News, April 7, et seq., 1888.
SHOULD WE TREAT FETVER 9 57.7
it was assured that these substances incited directly in
the blood and tissues chemical changes that led to an
increased production of heat, it was even then necessary
to have recourse to some action that was exercised upon
the nervous system, in order to satisfactorily explain the
phenomena of fever. Samuel' defines fever as an eleva-
tion of temperature that is evoked in consequence of a
lesion of the heat-centres. Donald Macalister, in his
work on the nature of fever, expressed the Opinion that
physiological and pathological experiments had showed
that pyrexia depended upon an impairment of the inhibi-
tory force, by which the heat-producing process is kept
within normal physiological grounds, that is, impaired
thermotaxis; upon an increased activity of the process
by which the heat is naturally formed, that is, exalted
thermogenesis; and upon a more or less complete failure
of the process by which heat is discharged, that is, a
failure of thermolysis. If we accept this latter explana-
tion and each year’s discoveries add force to the reasons
now existing for such acceptance, the infection of the
blood by any organic product is simply the means of
reaching the nervous centres, thereby producing the
phenomena of fever. It must be stated that this theory
is not universally accepted, Professor Årnaldo Cantani
believing” that fever is an acute alteration of organic
metabolism, with increase of tissue combustion, thus
agreeing with Flint, though overlooking Welch’s warn-
ing that even with this theory, it was necessary, in the
last analysis, to have recourse to the action of the heat-
Centres.
Most clinicians accept fever as the principal index of
the course of an infective process in the animal organism;
and the question must be decided, in each case of fever,
Whether the infection is autogenetic or heterogenetic.
we know that certain poisons, such as strychnine, vera-
trine, nicotine, and picrotoxine, will produce fever when
* Real Encyclopädie der gesammten Heilkunde, article “Fieber.”
"Transactions of the Tenth International Medical Congress, Vol. i., p. 152.
37
578 NEW YORK STATE MEDICAL ASSOCIATION.
given in certain doses. In certain digestive disturbances
the peptones formed during digestion may gain access to
the general circulation, and produce an autogenetic in-
fection fever, analogous to the ferment fever Hildebrandt
has produced in dogs by the subcutaneous injection of
pepsin. Vaughan and Novy have called attention" to
this intra-organic formation of poisons, and they em-
phasise the importance of the subject by saying that “a
man may drink only chemically pure water, eat only
that food which is free from all adulterations, and
breathe nothing but the purest air, free from all organic
matter, both living and dead, and yet that man’s ex-
cretions would contain poisons.” They consider that
it is unimportant whether the proteid molecule is broken
up by organised ferments (bacteria), by unorganised fer-
ments (the digestive juices), or by those unknown agen-
cies that induce metabolic changes in the tissues, for, in
all cases poisons, differing in quality and quantity ac-
cording to the proteid that is acted upon, will be formed.
These poisons produce the autogenous fevers known as
fatigue, exhaustion, thermic, non-eliminative, nervous,
and hysterical fever.
Whatever cause may produce the fever, there is always
an increased temperature that physiologists have shown
is due not merely to a diminution of the loss of heat, but
chiefly to an increased production of heat, as calorimet-
ric observations have proved. Increased heat production
alone would be insufficient to raise the temperature of
the body if there were a compensating increase of loss of
heat; but this compensation is wanting in fever, and it
has been designated the most characteristic feature of the
febrile condition. Besides the ataxia of the thermal
centres, there are increased metabolism, as is evidenced
by the augmented excretion of carbon dioxide, of urea,
and the other urinary products; great frequency in the
number of the heart-beats, and in the respiration; dimi-
nution of the digestive activity and intestinal move-
* Ptomaînes and Leukomaînes, Philadelphia, 1891.
SEHOULD WE TREAT FE VER 2 579
ments; and general disturbances of the organic func-
tions. *
From this resumé of the febrile phenomena, it may be
deduced that pyrexia, as seen by the physician, is the
expression of certain pathological processes that inter-
fere with the physical and mental welfare of the person
affected, and that consequently demands treatment.
When those interested in the history of medicine read
the works that served to illuminate and instruct our pre-
decessors of the first half of this century, and learn there-
from the then prevalent practice of starving the fever
patient, they will entertain a high regard for Dr. Graves,
whose teaching assisted in securing the abandonment of
this practice, and who said the only epitaph he desired
was: “He fed fevers.” And while there may be una-
nimity of opinion regarding this point, the physician is
confronted in this fin de siècle by another problem that
Cannot but be an absorbing one, for there are those who
urge, though they may not seek epitaphic renown, that
there should be no treatment for fever per se. Are we
to throw, so to speak, our antipyretics to the dogs' Is
fever a beneficial organic reaction to the metabolic and
haemic changes produced by the causative agent of the
disease? Osler, in his recent work on the Practice of
Medicine, says: “Fever alone is not hurtful, but it is
difficult to differentiate the effects of fever and of the
poisons circulating in the blood. It is not impossible, as
Some Suppose, that the fever may be directly beneficial;
still, high and prolonged pyrexia is undoubtedly dan-
gerous, and should be combated.” And Lyman in his
more recent work on the Practice of Medicine, says:
“The elevation of temperature that marks the course of
fever is not an unmixed evil, yet it is customary to
attempt its reduction.” Each of these authors seems to
have accepted the fever process as explicable by the
seemingly fantastic German theory of the day, that fever
* in the nature of a reparative process. In just what
Way it is reparative we are not informed; and it is as
580 NEW YORK STATE MEDICAL ASSOCIATION.
impossible to say with our present knowledge, in exactly
what way fever accomplishes any useful purpose, as it
was when Welch published his classic study on the sub-
ject of fever.
The conclusion formulated by Austin Flint in the
address heretofore referred to, that “the abstraction of
heat by external cold, and the reduction of temperature
by antipyretics administered internally, without affect-
ing the special cause of the fever, improve the symptoms
which are secondary to the pyrexia,” expresses the
practice and belief of most physicians.
Reference has been made to the influence of certain
alkaloidal poisons in increasing the temperature, pre-
sumably in consequence of their effect upon the heat-
centres. But recently Dr. E. Maurel has published" a
series of experimental researches on the action of these
alkaloids on leucocytes, and he finds that the toxic action
of the alkaloids on the animal economy is in the ratio of
its destructive action on the leucocytes. For example,
five centigrammes of Strychnine will immediately kill all
the leucocytes in one hundred grammes of human blood,
while two centigrammes of that drug will effect the same
result in the same quantity of blood in several hours.
Five centigrammes of atropine would also instantly kill
the leucocytes in one hundred grammes of human blood;
although in the blood of the hare, an animal that eats
belladonna with impunity, the alkaloid was almost with-
out effect upon the leucocytes in the strength of tWO
grammes of atropine to one hundred grammes of blood.
Pilocarpine kills the leucocytes in human blood in a dose
of ten centigrammes to one hundred grammes of blood.
These experiments forcibly demonstrate the important
relation existing between the leucocytes and the func-
tions of the organism, and give force to Metschnikoff's
theory of the relation between phagocytosis and im-
munity from disease. If these drugs that may produce
fever are toxic to the leucocyte, should our treatment of
1 Bulletin de Thérapeutique, 1892, czzii., p. 259.
SHOULD WE TREAT FETVER 2 581
fever have in view the preservation of the leucocyte
under the best conditions, because in fever we have
poisoning by animal rather than vegetable alkaloids?
The experiments that were made with the product of
the tubercle bacillas are not so old that we have forgot-
ten the fever that soon followed the hypodermatic injec-
tion of a small quantity of tuberculin. The injection of
the product of the cholera spirillum is also followed by
fever, a result that is subsequent to the hypodermatic
injection to the products of several of the infectious
microörganisms. Such a fever, though usually enduring
only a few hours, may be sustained by repeated injections
of the toxine product employed. It is therefore apparent
that the microörganism causes fever by the production of
its leucomaine or toxine, rather than by the presence of
the organism itself in the body. It is possible to adduce
further evidence of the influence of the increased toxicity
of the blood in producing disturbances of the thermal
centres, just as an analogous autogenetic increase of the
toxicity of the blood-serum causes disturbances of the
convulsive centres. The recently published experiments
of Bouchard have shown, that during puerperal convul-
Sions the urine is diminished in quantity, and that it
is less toxic than usual, so that no effete products that
should be excreted, are retained in the animal organism.
Dr. Chambrelent has proved" the latter statement to be a
fact, by supplementing Bouchard’s experiments with the
urine, by those he made with blood-serum that he also
Obtained from women suffering with puerperal eclampsia.
Chambrelent's results showed that the poisonous prop-
erties of the serum were constantly related to the gravity
of the case, so that increased autogenetic infection aug-
mented the severity of the convulsions.
. The high temperature of fever cannot exercise a fatal
influence on the specific microörganisms with which we
are acquainted, because they develop most favorably at
a temperature of from 35° to 40° C., so that the usual
* Lancet, September 24, 1892.
582 JWEW YORK STATE MEDICAL ASSOCIATION.
febrile temperatures are best suited to their growth.
This would seem as if fever were more useful to the micro-
than to the animal organisms. Robert Koch regards
temperature as the most important factor in the process
of attenuation of the microörganisms, the temperature
effect being aided perhaps by certain products of tissue-
change in the bacilli. That these latter products are the
more important in producing this attenuation, is shown
by the existence of the cholera spirillum, the typhoid
bacillus, and other specific microörganisms in the tissues
of persons affected by those infectious diseases, after all
febrile phenomena have ceased.
The brothers Klemperer have shown that in animals
inoculated with the pneumococcus, temperatures varying
from 40° to 41° C. were reduced to normal in twenty-
four hours after the injection of serum from another
animal that possessed immunity from pneumonia. They
believed that the pneumococcus generated in the animal
organism a product that they called pneumotoxine, that
produced elevation of temperature; the pneumotoxine
in its conflict with the leucocytes generated an anti-
pneumotoxine that neutralised both the pneumotoxine
and the pneumococcus. They injected the blood-serum
of persons convalescent from pneumonia into six pneu-
monic patients, and in from six to twelve hours subse-
quently, there was a decided fall of temperature that
remained normal in two of these patients. -
Metschnikoff, Golgi," Gamaleia,” and Laveran” agree
that fever acts like artificial heat in increasing the activ-
ity of the leucocytes, so that the parasitic elements be:
come more easily their prey than they do in an individual
in whom the temperature is normal. Metschnikoff' states.
that in relapsing fever the febrile access lasts during
the free life of the spirilli in the blood, and ceases
when these parasites become the prey of the leucocytes.
1 Phagocytisme dans le Paludisme.
* Annal. de l’Instit. Pasteur, 1888, p. 229.
* Traité des Fièvres palustres.
4 Annal. de l’Instit. Pasteur, 1887, p. 329.
SHOULD WE TREAT FE VER 3 583
Here again we see the disposition to make the fever a
reparative process; and yet clinical and experimental
facts do not wholly warrant the deduction. In the ex-
periments of the Klemperers, above cited, the fever was
insufficient to increase the leucocytic activity to a degree
that disposed of the pneumococcus and prevented the
formation of more pneumotoxine. It had been proved
that the latter by itself caused fever; therefore, it is a
justifiable inference that the persistence of fever for
from six to twelve hours after the injection of the serum
from the pneumonic convalescents, was due to the pneu-
motoxine present in the blood at the time the injection
was made ; and the subsequent decrease in temperature
was caused by the destruction of the pneumococci by the
serum, and consequent cessation in the formation of
pneumotoxine.
In paludal poisoning the fever persists or recurs as
long as Laveran’s haematozoa are in the blood. Quinine
has no special influence in inciting leucocytic activity, at
least as a principle applicable to all diseases. Yet the
administration of quinine, by destroying the specific Or-
ganism of paludal disease, ends the fever that never plays
the rôle of a reparative process therein.
Opposed to this deduction are the experiments of
Alexander" that showed that the number of spirilli in re-
lapsing fever increased when the temperature of the
affected person was lowered by antipyrin. Wagner”
showed, as Pasteur had shown before him, that fowls
exposed to cold became capable of acquiring charbon ;
he considered that this occurred in them because the
leucocytes lost a portion of their activity, and he was
able to produce the same effect by lowering the tem-
perature of the fowls by antipyrin.
Professor A. Rovighi, in the reports of the results of
his experiments made to determine the influence of
* Bresl. firzt. Zeitschr., 1884, Nov. 11.
* Ann. de l’Instit. Pasteur, 1890, p. 571.
* Le Mercredi médical, August 3, 1892.
584. NEW YORK STATE MEDICAL ASSOCIATION.
artificial elevation and depression of temperature upon
the course of infective processes, stated that he inocu-
lated rabbits with human saliva that was poisonous for
these animals; he placed some of them, together with
uninoculated rabbits, in a thermostat in which the tem-
perature oscillated between 36° and 40° C. Other inocu-
lated rabbits were kept in ordinary cages, while still
others were placed in cold chambers and in cold baths,
in which their temperature did not exceed 40° C. Death
occurred earlier in the latter animals than in those in the
thermostat; in fact, these latter died more slowly than
those in the ordinary cages. But if the temperature of
the rabbits in the thermostat exceeded 43° C., death
occurred quickly. Elevation of temperature occurred
much more rapidly in the infected than in the uninfect-
ed animals in the thermostat. The loss of weight was
much greater in the animals kept in a lower than in those
in a higher temperature. At the point of inoculation in
the latter, there was an abundant fibrinous exudate COn-
taining a large number of leucocytes, while in the re-
frigerated animals the exudate was sero-purulent and
less rich in leucocytes. The blood of the animals in the
thermostat was much more toxic than that of those re-
frigerated, evidencing an increased formation of toxines
in the former ; though cultivations succeeded better if
made from the blood of the refrigerated animals, because
it more frequently contained the living microörganism.
Rovighi also inoculated rabbits with mouse septicaemia;
and those to which he subsequently gave acetanilid
rapidly succumbed to a considerable decrease of tem-
perature, while those placed in a thermostat and in-
fected in the same way, presented no other morbid
phenomenon than an induration at the point of inocu-
lation. He also found that rabbits and guinea-pigs
inoculated with charbon, survived longer if kept at a
high than at a low temperature, the charbon bacillus
appearing later in the blood of the former than in that
Of the latter.
SHOULD WE TREAT FE VER 2 585
Walter published" the results of experiments on the
effects of artificial elevation of the temperature of the
body on the course of infection with the pneumococcus,
in which he found that high temperature prevented its
passage into the blood.
While it appears to follow from these experiments,
that an elevation of temperature to a certain degree exer-
cises a favorable influence upon the infected animal, and
that a lowering of temperature increases the intensity of
the infective processes, it must be remembered that these
are extraneous influences, while fever is an intrinsic
influence. The observations of Röhrig and Kuntz, Colo-
Santi and Kukler, Theodor, and others, have shown that
gaseous exchange, and particularly tissue-oxidation in
febrile animals, are much more intense in those exposed
to cold than in those kept in thermostats. Yet these
results are at variance with clinical facts, for, it cannot
be denied that the best results in treating typhoid fever
have been obtained by the use of cold baths that keep
the temperature below 40° C.; and if these increase the
intensity of the febrile process and of tissue-oxidation,
We are led to believe that the patients of those who use
them, recover in spite of, rather than on account of, the
treatment that is only useful in increasing the elimination
of toxic products.
The researches at Penro have shown that karyokinesis
and the regeneration of tissue are affected much more
rapidly at a temperature of from 34° to 38° C. than at a
temperature of from 7° to 12° C. But it has not been
shown that karyokinesis and tissue-regeneration are af.
fected at a temperature of from 38° to 40° C., as well as
at the lower temperatures that antipyretic treatment en-
deavors to Secure, and never does that treatment seek to
reduce the temperature below 37.2° C., at which, experi-
ºnent has shown, these processes are most effectively per-
formed.
If the statements that “fever alone is not hurtful,” or
*Archiv für Hygiene, 1891, Bd. xii., p. 329.
586 NEW YORK STATE MEDICAL ASSOCIATION.
that “fever is not an unmixed evil,” are based on the
production of artificial fever in animals by inoculation, it
is necessary to remember that in the latter, such a fever
only reaches a temperature of from 18 to 4°F. above the
normal temperature of the animal. And if based on the
fever produced by prolonged confinement in thermostats
kept at high temperatures, the animal’s temperature in
such instances was only 4° to 5° F. above the normal.
Such rises of temperature are not regarded with any
alarm when they occur in man ; but while we may not
look upon them as intrinsically hurtful or evil, they cer-
tainly cannot be regarded as beneficial or good. A fair
analogy to the treatment of moderate rises of tempera-
ture is that of the treatment of pain. Each condition is
indicative of irritation of certain portions of the nervous
system ; and though it has been maintained that pain is
beneficial, it is the popular plan to relieve it at Once
whenever it appears, subsequently attending to the dis-
turbing factor, of which the pain was the index. So, I
believe, we should deal with fever; relieve it by suitable
antipyretics whenever it appears, and then give those
remedies that will eliminate the exciting cause.
In this review of the question, whether it is desirable
to relieve pyrexia by the administration of antipyretics,
the following points have been held in view :
1. That fever is the expression of some disturbance of
the thermal centres.
2. That while this disturbance may be traumatic, it is
usually the result of the existence in the organism of
certain autogenetic or heterogenetic (infectious) prod-
ucts, that have the same affinity for the thermal Centres
that certain vegetable alkaloids have for certain cerebral
Centres. gº
3. That fever does not exercise any beneficial effect in
limiting an infectious process; this is a fact that has
been known clinically for years, by the occurrence Of
cases of infectious diseases that pursued their usual
course without any rise of temperature.
SHOULD WE TREAT FETWER 9 587
4. That it is the general experience of clinicians that
the relief of fever exercises a beneficial influence on the
general condition of the patient, though the apyrexia
does not indicate that the cause of the pyrexia has been
removed.
5. That in many febrile conditions the causative prin-
ciple has produced a thermotoxic paresis that is at once
relieved by some suitable antipyretic.
6. That in continuing the employment of antipyretics
we are not losing sight of the possibility of obtaining,
either synthetically or derivatively, compounds, that
will, when administered in the specific diseases, have the
same inhibiting influence on the further development of
the microörganisms of those diseases, that certain alex-
ins, toxalbumins, or toxines possess. The action of such
compounds should be as specific in each infectious dis-
ease, as is the action of quinine in paludal fevers.
BRIEF COMMENTS ON THE MATERIA MEDICA,
PHARMACY, AND THERAPEUTICS OF THE
YEAR ENDING NOVEMBER 1, 1892.
ALPHABETICALLY ARRANGED.
By E. H. SQUIBB, M.D., of Kings County.
(Read by title November 17, 1892.)
No other preface is needed than to repeat the introduc-
tion of last year, that the aim of this brief commentary
is to give a short, compact digest of the prominent cur-
rent literature of the professions of pharmacy and med-
icine. There has been no attempt made to treat the Sub-
ject exhaustively by noticing every article written upon,
but an effort has been made to give only such informa-
tion as will be of some interest to readers, both in the
way of furnishing a ready index of passing articles in
Materia Medica and Pharmacy, and also as an abstract
of what has been accomplished in Therapeutics during
the year past. +
The alphabetical arrangement is intended, of course, to
aid in easy reference to any individual article.
Acacia, or true gum Arabic, is now obtainable again
by reason of the somewhat more settled condition of
Egyptian affairs and the reopening of the Soudan—the
chief source of our supply. It is just a little over ten
years since the true gum ceased to find its way freely to
our market. The cessation of this supply called forth an
abundance of very fair gums from many quarters, in-
cluding some localities from which it had never been even
suspected good gum could be furnished. Still they were
all inferior to the true gum Arabic. Many gum substi-
tutes were manufactured and processes devised for
rendering the gums soluble, which were obtained from
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 589
localities where plenty could be procured, but if taken as
found, were useless because insoluble. None of these,
however, could take the place of the true gum for many
pharmaceutical and mercantile uses.
We should now be able to have in future not only
more satisfactory “gum drops,” but more elegant,
useful, and cheaper preparations into which the true
gum enters.
Acetanilid (Antifebrin), prepared by the action of
strong acetic acid upon aniline, still retains its position
as an effective and reasonably reliable hypnotic and
analgesic. Its antipyretic action continues, as last year,
to be less reliable, and at times has produced a sub-
'normal temperature. Dr. H. E. Garrison, of Dixon,
Ill., reports satisfactory results in the treatment of all
cases of scarlet fever for more than two years past."
Its use still furnishes many toxic symptoms. It is
reported that during the last epidemic of influenza in
Sweden, there were a great many poisoning cases—all
recovering, however. This was largely due to the pro-
miscuous and extravagant abuse of the drug.
It fortunately continues to act well, almost univer-
Sally, when given to children, but in all cases overdosing
must not be practiced.
Acid Agaricic (Laricic Acid) is gradually growing in
usefulness, particularly among continental and English
|practitioners, although still little is published concerning
it in our own country. Its effect appears to be very
Pronounced in checking most forms of sweating. The
night-sweats of pulmonary tuberculosis continue to be
effectually abated by it, and its use has been extended
to cases of sweating in other affections. -
As reported from some quarters, it appears to be
necessary to obtain the acid from the true white agaric
from the Polyporus officinalis (Agaricus albus), and
not from the “fly agaric” or Muscarine (Agaricus Mus-
Caria), as Dr. C. Basil Richards, of Tottenham, England,
* N. Y. Med. Record, Wol. 42, p. 481.
590 NEW YORK STATE MEDICAL ASSOCIATION.
believes what has been noted by others, that the action
from the latter is exactly opposite. Dr. Richards has
found the true acid very valuable in checking persistent
Sweating from any cause, and in mentioning its marked
effects in the sweating after influenza, he takes occasion
to state that he has had only one case in which it failed
throughout an experience of over two years. He men-
tions the article he used as agaricin, but this is a term
formerly applied to the agaricic acid which Martindale
found to contain about three per cent. of the physiolog-
ically inert Agaricol. The term agaricin, although less
exact, is still retained by some.
Acid Camphoric is deservedly gaining in popularity
with the medical profession, both here and abroad. It
has not only been in increasing use in the affections
before alluded to, but has been used largely just as aga-
ricic acid, the article last spoken of, in the treatment of
sweating from various causes. The fact of its being very
quickly and abundantly eliminated by the urine has been
emphasised by nearly every writer, and attention is called
to the necessity of giving it not more than two hours
before the expected sweating is to occur, in order to Ob-
tain effective results; and then relief, either partial or
complete, may be looked for almost universally. Dr.
James Wood, of Brooklyn, has had a number of very
successful results in cases of tuberculosis where the
sweating was profuse. He recommends giving it dry On
the tongue as the best method. His article deserves
reading."
Good results continue to multiply from its use as an
intestinal disinfectant.
Acid Carbolic (Phenol) still holds prominence over
its many and increasing rivals. The reddening of the acid
still occurs, is still unaccounted for satisfactorily, and
still continues to show no deleterious effects from this
small amount of color. None of the synthetical methods
which gave alleged promise of remedying this defect,
1 The Medical News, Wol. 60, p. 293.
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 591
have accomplished the desired result, nor can they Com-
pete at the present time in economical manufacture with
the extraction from the coal-tar products. During the
past year a new series of derivatives of this acid has been
produced from essential oils, and patented in Germany;
they are claimed to be odorless, tasteless, neutral in
reaction, and to cause no irritation. These derivatives
when obtainable will have to be closely studied thera-
peutically, and we may then hear of them under some
new trade name which has not been applied as yet.
Increasing beneficial results have been obtained from
carbolic acid when used as a local anaesthetic in den-
tistry, subcutaneously in some severe cases of tetanus,
and in the form of subcutaneous injections of a strong
solution into the region of a joint—close to the Synovial
membrane—in cases of articular rheumatism.
Acid Cresotic (Paracresotic Acid) has increased in
medicinal value in the past year, as is evident from the
accumulating favorable results from continental observ-
ers. Practically nothing has been published as yet in
this country. Abundant evidence now goes to prove what
was pretty well established a year ago, that it is abso-
lutely necessary that the paracresotic acid only be used.
In the form of the sodium paracresotate, it has proved
itself a safe and reliable article to use, especially with
children. Professor Demme has employed this salt in
the Jenner Hospital in Berne, and his records show good
results in acute articular rheumatism, catarrhal pneu-
monia, gastro-intestinal catarrh, and typhoid fever. As
an antipyretic, it was found to be inferior to salicylic
acid, but it was better tolerated by the digestive organs,
and did not produce the congestion salicylic acid some-
times causes. In the typhoid fever cases it checked the
diarrhoea very markedly. Young adults may be safely
given as much as 4 grammes (60 grains) daily.
Acid Hydrocyanic Diluted (Prussic Acid) has still
failed to be permanently preserved from decomposition,
either by the use of various solvents, other than distilled
592 JNETW YORK STATE MEDICAL ASSOCIATION.
water, or by the addition of preservatives. Scrupulous
cleanliness in the mode of preparation and in the con-
taining packages, alone gives fairly satisfactory results
for at least a year.
Acid Pyroligneous (Crude Acetic Acid), sometimes
called Wood Winegar, is the crude product obtained
from the destructive distillation of wood. It is a dark-
brown liquid, almost black, the color depending largely
upon the amount of tar contained in it, with a charac-
teristic, not unpleasant, smoky odor. The tar would, of
course, be practically insoluble in water simply, but the
acetic acid present renders it perfectly soluble, and the
whole product will permit of very considerable dilution
with water before the tar is precipitated. This solution
of the tar, no doubt, lends additional efficiency to the
product. -
Some attention has been paid during the past few
months to this acid, with the idea of increasing its use
as a disinfectant. From the acetic acid and other anti-
Septic hydro-carbons which it contains, it should prove
Of positive value, whilst from its great abundance, as a
by-product, wherever wood is burned for the charcoal
and wood spirit, it is everywhere accessible at very low
cost. The fact that it can be used with perfect safety,
and that it is always at hand when needed, will make it
the more acceptable should its efficiency be proven.
Acid Salicylic is still under critical investigation,
particularly by the pharmaceutical chemist. A year ago
the impurities were alluded to, and the marked differ-
ence in therapeutic effects between the “natural” and
the “artificial” acid. It was argued by some that there
was so great a difference between the two that the
“artificial” should be interdicted, as there was little
chance of being able to bring the latter to the purity of
the “natural.” It has now been proven by two English
chemists, after careful experiments on the melting points
of the two acids and their fractionation from the stable
silver salt, that cresotic and other allied acids can be
MATERIA MEDICA, PHARMACY, THERAPEUTICS. 593
completely separated from the “artificial” acid. It is
then shown to have identical properties with the “natu-
ral.” It now only remains for the objectors to the
“artificial” acid to prove that the adverse therapeutic
effects claimed are caused by these allied acids occurring
in the “artificial” product, to give satisfactory and
sufficient cause for insisting on the use of the far more
expensive “natural” product. Although at times there
have been many almost decisive reasons, given by ap-
parently convincing therapeutic results, for taking this
step, still the fact has not become sufficiently well estab-
lished yet to offer for sale only the much more costly
article, as the above proof has not yet been substantiated
by close clinical observations.
Acid Tartaric has recently been studied by M. Gen-
resse, a French chemist, in the direction of discovering,
if possible, the exact method of its formation in Nature.
The London Lancet" gives a condensed abstract of his
observations, showing the simple way in which it may be
Synthesised, and it may be of passing interest to repeat
the substance of the abstract here. He starts with gly-
Oxalic acid—an acid found in gooseberries, grapes and
other fruits—and acting upon it with nascent hydrogen
liberated from a mixture of zinc dust and acetic acid,
Obtains eventually tartaric acid, or rather the optically
inactive form of it known as recemic acid, equal mole-
cules of the dextro and laevo varieties being apparently
produced. Upon examination of the formulae of gly-
Oxalic and tartaric acids, it will be readily seen that
the latter simply contains two molecules of the former
joined together by two atoms of hydrogen, so that it is
merely a question of bringing the two molecules together
by hydrogen to produce the latter. It is well known
that oxalic acid is formed most readily in vegetable tis-
Sues, and is closely related to glyoxalic acid. Having
regard, therefore, to the reducing tendencies which are
known to characterise chlorophyll, it is not improbable
* Vol. I. for 1892, page 764.
38
594 NEW YORK STATE MEDIOAL ASSOCIATION.
that the natural building up of tartaric acid may be thus
explained.
Agathin (Salicyl-Aldehyde-o-Methyl-Phenyl-Hydra-
zone) is a new synthetic compound discovered by Dr.
Israel Ross, of Frankfort-on-Main, Germany, and found
applicable in neuralgia and rheumatic conditions. It is
prepared by the condensation of Salicyl aldehyde with
a-methyl phenyl hydrazin. It occurs in Small, faintly
green, plate-like crystals, without Smell or taste, and
insoluble in water. It is recommended in doses of 325
to 650 milligrammes (5 to 10 grains) two or three times a
day. It is necessary to wait a few days after continuous
administration for beneficial action to manifest itself.
Dr. E. Rosenbaum has had very favorable results in an
obstinate case of sciatica. Other observers also report
favorably in articular rheumatism. The maximum dose
apparently produces headache for a limited period.
The reports all come from Germany exclusively, as
none of this compound has yet appeared in this country
Or elsewhere.
Amido-Eugenol Acetate is about the newest anaes-
thetic introduced—originating from a German chemical
firm, who have, of course, patented the process of manu-
facture. Apparently this firm has deviated in this case
from the usual practice of giving a short name to their
compound for every-day use. It comes in the form of a
fine powder prepared by the action of a solution of
ammonia in alcohol upon eugenol-aceto-ethylic ether.
It appears to be a local anaesthetic to mucous membrane.
It is simply a novelty at this time, awaiting its fate.
Amylene Hydrate (tertiary Amyl Alcohol) has not
received altogether as favorable reports as a year ago.
The Journal of Mental Science gives the results of four-
teen cases of chronic epilepsy treated with this drug by
Dr. Dunn. Although at first beneficial effects appeared
to follow its use, it really seemed to have no advantage
whatever over the bromides, which were used in parallel
cases; and, again, the bromides were much cheaper.
MATERIA MEDICA, PEIARMACY. THERAPEUTICS. 595
Analgen (Ortho-Oxy-Ethyl-Ana-Mono-Acetyl-Am-
ido Quinoline) is one of the most recent analgesics. The
chemical name is here purposely extended to an extreme
by hyphens to assist in deciphering the component parts
as well as to aid in the effort of pronunciation. It orig-
inated from the almost universal source of such organic
compounds—from Germany. Its synthetic composition
was thought out before actual production of the Com-
pound was attempted, and knowing the activity of the
combining agents, the aim was to produce a substance of
high physiological power by introducing a definite group
of molecules having known pyretic action. The process
of its production is too technical to be of interest here.
It is a white crystalline powder in the form of delicate
needles, only slightly soluble in water. It has been tried
in 1 gramme (15 grains) doses in various rheumatic affec-
tions with gratifying results, but it will have to make a
history for itself.
Antikol is a very new proprietary antipyretic mixture,
which consists of 75 per cent. of acetanilid, 17.5 per cent.
of Sodium bicarbonate, and 7.5 per cent. of tartaric acid.
The proprietors charge from five to six times the price
of the separate ingredients, and trade on the newness of
the name and the prevailing gullibility of the public to
further the sale of their mixture.
Antinervin—the mixture of 50 per cent. of acetanilid,
25 per cent. of salicylic acid, and 25 per cent. of ammo-
nium bromide—is now reported to have a much wider
field of usefulness than a year ago. Observers give good
reports from England, Germany and Italy. In Glasgow,
Scotland, it attracted much attention in the recent epi-
demic of influenza. It nearly always relieved the pains
in the back and head, and rapidly reduced the fever. It
Produced copious perspiration and no unfavorable effects.
Pr. G. Laurenti, of Italy, now summarises his own
Personal experience: 1. It can be used with advantage
ºn all forms of abnormal excitement of the nervous Sys-
tem, whether to subdue neuralgia or as a general nerve
596 JNEW YORK STATE MEDIOAL ASSOCIATION.
Sedative ; 2. in rheumatism it may be used, and seems
undoubtedly indicated as a drug comprising in itself
antirheumatic, antipyretic, and analgesic properties; 3.
Its low price and feeble toxicity, together with the evi-
dence already given, render it a useful addition to our
list of remedies.
Practically nothing has been written upon it in this
Country during the past year, and it may be hoped that
a good reason may be furnished to account for this
inattention in that we obtain fully as Satisfactory results
by administering the ingredients in proper proportions
made up into an extemporaneous prescription, or other-
Wise dispensed separately.
Antipyrin (Analgesin) has considerably decreased in
demand during the past year by reason of its own deriv-
atives possessing some properties superior to it. But
aside from this, its too popular use has continued to
show so much abuse of it in the way of producing toxic
Symptoms, that physicians and the public both show
very properly a tendency to avoid its use. Unfortu-
nately, toxic cases have been numerous during the year
past, and apparently are somewhat on the increase, or
rather the proportion of them may be greater.
As it is now some eight years since this then new Syn-
thetic compound with such a trivial name was patented
and introduced by a German manufacturer, it may be of
Some interest to recall its composition. Dr. Knorr was
the first to give us some particulars on the subject, and
although the question is replete with technicalities, the
brief outline attempted here many will be willing to
follow. Dr. Knorr found that antipyrin was one of a
series of derivatives from a hypothetical base called
chimizin. These derivatives are products of the action
of di-acetic ether upon one of the hydrazines. If then
one molecule of phenyl-hydrazin be taken and acted
upon in the cold by one molecule of di-acetic ether, the
elements of water are eliminated and the residue COm-
bines to form phenyl-hydrazin-di-acetic ether, which
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 597
upon heating to 100° C., parts with the elements of
ethylic alcohol and is converted into methyl-oxy-chini-
zin. This latter possesses the properties both of base
and acid, but still contains an atom of hydrogen easily
replaceable by an alcohol group, and the compound then
loses its acid character and is converted into the base
di-methyl-oxy-chinizin or antipyrin.
Some writers still have extravagant ideas of its being
a cure-all, but they are greatly in the minority. Again,
it is still a mooted question whether small or large doses
give the best results, but as it does not appear to bear
any relation whatever to the ailment treated, but rather
to each individual observer's habitual practice, the ques-
tion is far from being settled.
Several series of cases of pertussis during the year
have yielded well to its administration in the hands of
such men as Drs. E. Feer and Amos Sawyer, of our own
country, but the experience of Dr. W. A. DeWolf Smith,
of New Westminster, B. C., is rather against its use."
Dr. E. B. Gleason, of Philadelphia, has made quite a
good record with it for the past three years “As a
Local Application in Inflammation of the Mucous Mem-
brane of the Upper Respiratory Tract.”
Experiments continue to be repeated and extended to
Confirm its destructive action upon the bacillus of diph-
theria. Outside of the body the conclusion seems pretty
clearly drawn that it does destroy the bacillus in about
forty-eight hours.
Dr. Charles Leroux adds his favorable results to those
already on record from its uses in cases of chorea. He
has succeeded in forty-one out of sixty cases. Antipyrin
Will finally settle down to a moderate and selective use
from which we may look forward to and confidently ex-
pect to have very definite and beneficial results.
e Antise ptin is an article which was introduced some
time ago as a definite chemical compound called iodo-
* The Medical News, Vol. 60, p. 48.
* N. Y. Med. Jour., Wol. 56, p. 482.
698 JNEW YORK STATE MEDICAL ASSOCIATION.
boro-thymolate of zinc, but it has now been pretty
clearly demonstrated to be simply a mixture of
Zinc Sulphate e º e e e & tº 85 parts,
Boric Acid . ſº e e e º e 10 “
Zinc Iodide * * e g º ę * 2} “
Thymol . . . . . . . 2; “
Apparently little interest is manifested in the article.
Antiseptol (Cinchonine-Iodo Sulphate) has been only
Occasionally heard from the past year, but undoubtedly
many practitioners have made good use of it without
thinking it worth while to make any definite statement.
We have had one personal report from this country—
that of Dr. Hugh Hamilton, of Harrisburg, Penn., who
has had very gratifying results (as an iodoform substi-
tute) for more than sixteen months. It is to be hoped
that Dr. Hamilton will publish his results.
Apiol, the green oleoresin obtained from the fruit of
Our common parsley (Apium Petroselinum), has of late
Varied much in its physical properties—particularly in its
color, density, and action to various solvents—and rarely
have the samples been equivalent to the article as origi-
nally proposed by Joret and Homolle many years ago. To
this fact may be due some of the disappointing results
now noticed when using it in the treatment of amenor-
rhoea and dysmenorrhoea. The cause of the variation
is not yet explained.
Aristol, (Annidalin)—the iodoform substitute—is not
so much in demand, principally on account of the increased
call for its rivals, dermatol, europhen, sozoiodol and the
like. Probably at the present time its largest consump-
tion is by the rhinologists in affections about the nose and
pharynx.
In limited applications the dermatologists still cling to
its use. It has the advantage over dermatol in being
soluble in oil and ether. In the treatment of chancroids
the profession still seems to be somewhat divided as to
its efficacy. Dr. T. Edmund Günts now reports from his
two years' use that, in the treatment of venereal ulcers it
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 599
should not be employed in the form of ointment, or
otherwise than dusted directly upon the ulcer, followed
by a drop of olive oil, which obviates that thick, brown
condition formed when mixed with the oil before appli-
cation. As fast as the solution of the aristol occurs,
absorption goes On, and effectual results are obtained.
The solution in oil of sweet almonds, hypodermically
injected in the treatment of pulmonary tuberculosis, gives
some satisfaction, no doubt, but sufficient time has not
yet elapsed, and the cases are far too few to enable a just
conclusion to be drawn at present. It apparently gives
its best results in the primary and secondary stages, and
the injections cause no pain and no inflammation, eschar
or induration.
Arsenite of Copper (Scheele's Green) has been in
increasing use for the year past in treating diarrhoea,
dysentery, cholera infantum and all gastro-intestinal
irritations. Very various results are reported — many
quite conflicting. In general it may be concluded so far,
that the claimed success may be largely attributed on the
One hand to the older and well-tried remedies which have
been so frequently used in conjunction with it, and on
the other to the hygienic and dietetic treatment which is
SO rationally found to be the necessary accompaniment.
Self-limitation as well, of course, must receive much
Credit for many of the so-called cures.
Asaprol (6-Naphthol-a-Mono-Sulphonate of Calcium)
is probably one of the very newest antiseptics. It is a
White scaly powder, readily soluble in water and obtained
by the action of heated sulphuric acid on pure g-naph-
thol, and then a calcium salt made with the resulting
acid. It has been pretty much confined to the locality of
its origin–Paris. Its introducers, Drs. Stackler and
Dulief, together with Dujardin-Beaumetz, are about the
only ones who have experimented with it in much detail,
and practically nothing is actually known about it in this
°ountry as yet. They advocate its use internally in the
treatment of gout and rheumatism of all degrees—partic-
600 NEW YORK STATE MEDICAL ASSOCIATION.
ularly acute articular rheumatism; in typhoid fever and
influenza.
The growth of the bacilli of Asiatic cholera, herpes
tonsurans, typhoid fever and anthrax has been retarded,
if not wholly arrested by this agent.
We probably will hear further from this article later.
Aseptol (Ortho-Phenyl-Sulphonic Acid) is the name
given by Hueppe to a sulphonic derivative of carbolic
acid and obtained by mixing in the cold equivalent parts
of carbolic and sulphuric acids. It is a thick, reddish
liquid, quite volatile and readily soluble in water.
Although its odor is like that of carbolic acid, it is less
caustic and more antiseptic, and from its less irritating
property it has been given internally in large doses. It
has not supplanted carbolic acid so far, however, although
it has now had several years to fulfill the original expec-
tations.
Assafoetida has been recently recommended in cases
of habitual abortion. The London, Laºcet' states as fol-
lows: “Dr. Turazzo gives it in pills containing a grain
and a half as soon as it becomes clear that a new preg-
nancy has commenced. At first only two pills are pre-
Scribed, but later on the number is gradually increased to
ten daily. The treatment is continued until the labor is
over, and then the daily dose is gradually diminished.
By this method cases, where as many as five successive
abortions had occurred, have been successfully treated,
and where in one instance a miscarriage appeared to be
imminent during the seventh month, it was averted, and
the patient was delivered at full term.”
Atropine continues to find successful use in cases of
lead poisoning. Previous good reports are on record,
and now F. Rowland Humphreys, L. R. C. P., of Queens-
Crescent, Haverstock Hill, London, adds five to his pre-
vious successful result. He uses about 4 milligramme
(1+r grain) of sulphate of atropine and 324 milligrammes
(5 grains) of iodide of potassium. It appears from his
1 Vol. II. for 1892, p. 320.
MATERIA MEDICA, PHARMACY, THERAPEUTICS. 601
experience that atropine in full doses relieves the colic
and the pain in the head in the most rapid manner,
keeps the bowels open freely, assists in the return of the
bodily powers, and aids, directly or indirectly, in the
removal of the lead by the iodide of potassium.
On the Continent, during the year past, atropine has
had an increasing use as a haemostatic. It has been
used with good effect hypodermically in from # to 1
milligramme (+++ to ºr grain) doses in profuse metror-
rhagia after abortion, or of obscure origin, and in phthi-
sical haemoptysis. It may require as many as four
injections, but rarely more, to produce a cessation of the
flow. It appeared to act well in some of the cases where
ergot and plugging had been tried in vain. Only trifling
dilatation of the pupils was noticed.
Benzanilid (Phenyl-Benzanide) is an antipyretic
closely allied chemically and therapeutically to acetan-
ilid, and suggested by Dr. Kähn Some five years ago as
especially adapted to the treatment of children. Experi-
ments were made at that time with a series of anilids,
but Only benzanilid, acetanilid, and salicylanilid were
found effective, the benzanilid presenting an advantage
over acetanilid in the absence of objectionable auxiliary
action following its administration.
It is produced by boiling together equivalent quanti-
ties of benzoic acid and aniline, and occurs as a white
Crystalline, odorless powder with a slightly caustic taste,
and practically insoluble in water. It is given to chil-
dren in initial doses of 100 to 600 milligrammes (14 to 9
grains). It is comparatively little heard of now, but
Occasionally some observer has a sufficiently successful
Series of cases to warrant making a report. This is the
Case With Dr. Luigi Cantu, who gave it in 5 cases of
typhoid fever, 12 of rheumatism, 4 of pneumonia, 3 of
neuralgia, 3 of Sciatica, 2 of malaria, 1 of chorea and 1 of
tetanus—pushing the dose to 1 and 2 grammes (15 and
*0 grains) and even in some cases to 4 and 6 grammes (60
and 90 grains). He regards it as a simple antipyretic,
602 NEW YORK STATE MEDICAL ASSOCIATION.
and to have little other influence on the course of a dis-
€3.Sé.
Benzol (Benzene of the English)—obtained by the dis-
tillation of coal-tar—has been making a very favorable
record for itself for the past year in the treatment of
pertussis and of influenza, and two interesting papers'
occurring together, giving the results in the treatment of
influenza by benzol and carbolic acid, are of note in this
connection. They are both by English observers who
have treated many cases. One of them, Dr. William
Robertson, of Newcastle-on-Tyne Throat and Eye Hos-
pital, while speaking especially of his very favorable
results in influenza, mentions incidentally that he has
employed benzol in the treatment of pertussis “with
unvarying success for years,” and observers from all
Quarters pronounce it a reliable pulmonary antiseptic.
It has been found effectual in destroying pediculi
capitãs or pubis, and, if fire be carefully avoided, is
most convenient and cleanly. A single application is,
as a rule, sufficient.
From Germany we hear that Dr. Putter, Jr., has met
with success in treating simultaneously twenty-seven
cases of supposed trichinosis with benzene (benzol), fol-
lowing it with a brisk laxative. His deductions are not
altogether convincing, however, for he is not positive
that the portion of the pork eaten by each was impreg-
nated, although that tested afterwards proved to be full
of trichinae, and supposing the patients did swallow Some
of the trichinae it does not follow that they necessarily
lodged in the alimentary tract. Nevertheless, Dr. Putter
is so convinced that his treatment was effectual, that he
Strongly recommends it in all such cases.
Benzonaphthol (6-Napthol Benzoate) is one of the
new antiseptics introduced by MM. Yvon and Berlioz, of
Paris, as a substitute for Betol, as the salicylic acid pres-
ent when the latter compound splits up in the intes-
tines, affected the kidneys harmfully. To avoid the use
* Brit. Med. Journal, Vol. 1 for 1892, p. 171.
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 603
of salicylic acid entirely, benzoic acid was chosen to
combine with the ſº-naphthol to form this new com-
pound. It occurs in small, dull, white, odorless and
tasteless crystals, practically insoluble in water at
ordinary temperatures.
Dr. Gilbert’s trials with it in the Paris hospitals
showed it to have very decided diuretic power in addi-
tion to its antiseptic properties in the intestines. Mr.
Dominici carried on a series of experiments, under Dr.
Gilbert, on guinea-pigs, thereby establishing the follow-
ing conclusions, which need further experience to sub-
stantiate them: -
It is very slightly toxic ;
Its antiseptic power is comparable with that of the
other substances employed in promoting intestinal anti-
Sepsis ;
It promotes diuresis and diminishes the toxicity of the
urine ;
The portion of it which is absorbed is easily and
rapidly eliminated by the kidneys;
A dose of about 250 to 500 milligrammes (4 to 8 grains)
Suspended in syrup and water suffices in the majority of
CàSéS.
Benzosol (Benzoyl Guaiacol) occurs in small color-
less, odorless, and almost tasteless (slightly aromatic)
Crystals, practically insoluble in water.
The increasing use of guaiacol in the treatment of pul-
monary tuberculosis has caused further attention to be
8TVen to the preparation of the wood-tar products
obtained by fractional distillation, and a short time ago
this benzosol was brought forward as a powerful anti-
septic and antipyretic. It is prepared either by convert-
*8 guaiacol into a potassium compound, purifying and
heating With a definite quantity of benzoyl chloride, or
*8ain by heating guaiacol with benzoic anhydride (ben-
zoic acid).
In administration, the gastric juice splits up this com-
Pºnd into its constituents, and liberates the effective
604 JNE W YORK STATE MEDICAL ASSOOIATION.
guaiacol under conditions that avoid the unpleasant taste
of the latter, and that reduce the local irritation which
otherwise results. It has been used repeatedly in in-
cipient pulmonary tuberculosis, but owing to the pleth-
ora of remedies recommended for this affection during
the last year or two, it has not received the prominence
it may now assume. It has also been used successfully
wherever creasote is applicable.
Bromamide, the new antipyretic bromine compound
of the anilid group, containing 75 per cent. of bromine,
has received some careful attention from Dr. Augustus
Caillé, of New York City, who carried on a series of
experiments with it in the German Hospital for five con-
secutive months.
It is a very stable compound, occurring in neutral,
colorless, nearly odorless, tasteless, needle-like crystals,
insoluble in water.
Dr. Caillé administered it in doses of 650 milligrammes
to 1 gramme (10 to 15.5 grains), to healthy adults, pro-
ducing a slowing of the pulse without Sweating, and in
doses of 65 to 200 milligrammes (1 to 3 grains), to chil-
dren from one to three years of age without untoward
symptoms, in cases of “typhoid fever, acute articular
rheumatism, chronic rheumatic arthritis, chronic nephri-
tis, acute fibrinous pneumonia, rheumatic fever with
acute endocarditis, general and localised dropsy due to
hepatic, renal, or cardiac disease, and diverse forms of
neuralgia; and special attention was given to a possible
antipyretic, diuretic, diaphoretic, anti-neuralgic, and
sedative action of the drug.” He now makes his Pre-
liminary Report,” giving a compact detail of his nine
cases. It appears to have “the power of reducing the
temperature in most cases of febrile disease from 1" to
2.5° F., without the excessive sweating as produced with
other antipyretic drugs.” He very rightly feels encour-
aged from his trials, and thinks they “warrant further
experiments, especially in other forms of disease.”
1 N. Y. Med. Journal, Vol. 55, p. 208.
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 605
Bromides, and particularly the most largely used
potassium bromide, still have their drawbacks in use.
Bromism, and the ill-effect of the alkaline base, are often
too soon established, and administration has to be dis-
continued. Expedients have repeatedly been tried to
avoid these disadvantages, and it is now recommended
from France to use the strontium salt as an alternate.
M. Germain Sée records some successful results with
strontium bromide in the treatment of thirty-two cases
of gastric catarrh. In all, obvious improvement was
noted. In epilepsy, also, this salt gave good results.
M. Féré confirms the above, and especially in epilepsy,
where he used both the strontium and calcium salts.
Again, with all the bromides, the effect is by no means
universally beneficial, and some observers place the cause
to neglect of early attention. Better results are obtained
by Poulet if the bromide be combined with either cala-
bar bean, belladonna or digitalis. The treatment must
be continued for several months to a year.
M. Féré maintains that after repeated large doses of
the bromides the alimentary tract is in a condition of
Sepsis, which prevents the assimilation of the salt, and
therefore he would recommend the use of some intestinal
antiseptics, as ſº-naphthol and sodium salicylate, com-
bined with the bromide to thus remove the intolerance so
frequently noticed. His prescription is:
Potassium Bromide, & g . 6 grammes (90 grains.)
/3-Naphthol, . * * gº . 4 “ (60 “ )
Sodium Salicylate, . . . 2 “ (30 “ )
ſº Mix and divide into three doses, giving one dose three
times daily. Féré claims this not only to be preventive
but curative treatment.
Bromoform is now well prepared by the action of
sodium hypobromite on acetone (made by the dry distil-
lation of acetate of lime). Caution must again be em-
Phasised in the selection of this article, as it should
* * clear, colorless liquid, with an agreeable odor and
SWeetish taste. If the liquid has color it should be
606 NEW YORK STATE MEDICAL ASSOCIATION.
rejected, as it denotes decomposition, and therefore is
treacherous. -
It still has an increasing use in the treatment of per-
tussis, with comparatively few failures. It apparently
simply aborts the paroxysms, and probably reduces their
number somewhat, but has little other effect on the
regular course and duration of the affection. Increasing
doses must not be pushed too far, especially in children,
as toxic symptoms have manifested themselves in more
than one case. The late Prof. P. W. Bedford, of New
York City, recommended the use of glycerin as a perfect
Solvent, which water is not, and suggested the following
prescription, which has been a serviceable one :
Bromoform, º -> º © 1.0 cc. (16 minims.)
Alcohol, . o º º - 7.5 cc. ( 2 fluidrachms.)
Glycerin, . º e & . 45.0 cc. (12 & 4 )
Tinct. Cardamon. Comp., . º 7.5 cc. ( 2 ( & )
Inhalations of bromoform have been used with Some
success both here and in England in the treatment of
diphtheria—particularly in recent epidemics.
The topical application recommended some two years
ago by Dr. S. Solis-Cohen, of Philadelphia, continues to
meet with some favor in cases of ozaena, and tuberculous
and other ulcers of the larynx. It acts as a deodoriser,
disinfectant and analgesic.
Calcium Chloride added to a fibrin-ferment Solu-
tion forms a combination which is suggested as a new
styptic. It has been tried successfully upon animals by
Dr. A. E. Wright, of Dublin, to possibly increase the
coagulability of the blood in the vessels in cases of
haematophilia, aneurism and internal haemorrhage. He
has not pushed his trials in man and unfortunately does
not intimate that he intends to do so, but the whole sub:
ject is interestingly treated, and deserves more extended
attention."
Camphoid is the name suggested by Mr. William
Martindale, of 10 New Cavendish street, London, W.,
1 Brit. Med. Journal, Vol. II. for 1891, p. 1806.
MATERIA MEDICA, PEIARMACY, THERAPEUTICS. 607
England, for a new substitute for Collodion, recently
recommended by him, consisting of One part of pyroxy-
lin (soluble gun cotton), 20 parts of camphor and 20
parts of dilute alcohol. He publishes the following
note: 1. “It is known that iodoform is soluble (1 in 10)
in Rubini’s solution of camphor, composed of equal parts
by weight of camphor and dilute alcohol. This requires
fixing on the part to which it is applied. I therefore
added 1 part of pyroxylin to 40 of the Solution, and
found it dissolved readily. Applied to the skin this
preparation dries in a few minutes and forms an elastic
opaque film, which does not wash off. The excess of
camphor seems to volatilise, and as it disguises the odor
of the iodoform its solution forms a useful vehicle for
applying this drug. Pyroxylin dissolves readily in the
simple solution of camphor, and this forms a cleanly
basis for the application of many medicaments to the
skin, such as carbolic acid, salicylic acid, resorcin, iodine,
Chrysarobin and ichthyol. . . . . .”
Cantharidin treatment of tuberculosis has appar-
ently not met with much substantial success on the
Whole during the past year. The conservative opinion
of foreign practitioners may be pretty fairly summed up
in the conclusions arrived at by F. Coccia in his careful
trial of Liebreich's treatment by the use of potassium
Cantharidinate :
1. The injections are very painful, and the method is
therefore difficult of application in the case of patients
Who have to continue at their work ;
* Doses of ſº, of a milligramme (ºr of a grain) are not
dangerous in any class of cases ;
8. Doses of + of a milligramme ( s#W of a grain) are
ºfficiently dangerous to be contra-indicated in cases of
*Vanced pulmonary tuberculosis;
* The injections, when frequently repeated during a
long period of time, cause physical prostration and
*ious mental depression;
1
The Pharm. J Ourn, and Trans., 3d series, Vol. XXII, for 1891–92, p. 831.
608 NEW YORK STATE MEDICAL ASSOCIATION.
5. In the last stage of the disease the treatment is
absolutely inadmissible ;
6. In incipient cases the injections may be used with
the view of modifying the bronchial mucous membrane
and the expectoration, and relieving cough ;
7. The night sweating and the general condition may
be favorably influenced by the treatment in the early
Stage ;
8. The injections have no effect on the fever, and hae-
moptysis seems to be made more frequent by them ;
9. Neither the pulmonary lesions nor the bacilli are in
any way modified by the treatment, and
10. Tuberculous ulcers in the larynx are not affected,
except that in the very early stage they show a slight
tendency to become cleaner.
Prof. Liebreich attempts to answer his critics and to
learn from their criticisms, and thus pushes on his
investigations with characteristic persistency, evidently
intending to leave no stone unturned to accomplish his
life object. We trust, for the welfare of humanity, that
his pertinacity may eventually succeed. He is now
trying the sodium salt, with which he obtains satisfac-
tion so far, especially in cases of lupus.
Castoria, which has been so profusely advertised on
almost every available square inch of house and fence
surface unprotected by the warning “Post no Bills.
under Penalty of the Law,” has been counterfeited ()
by some obtrusive intermeddler with lucrative Com-
mercial interests, by producing like results with a
mixture of Fl. Ext. Alexandria Senna, Fl. Ext. Levant
Wormseed, Fl. Ext. Peppermint, Fl. Ext. Anise Seed,
Wintergreen Oil, Rochelle Salt, Sodium Bicarbonate,
White Sugar, Molasses, Alcohol and Water—the alcohol
being very nearly one-third, the Senna about One-
sixth, the molasses about one-twelfth each by mºº
ure, and the “sugar two ounces by weight.” "
originator of Castoria may claim that this concoction
is not at all the true article, but nevertheless “ children
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 609
cry for it” as loudly as for his, and what more can one
ask
Chloralamid (Chloral Formamide) continues to be
used in about the same line of affections as a year ago,
but its employment has become more general. Its purely
hypnotic effects are still pronounced and well recognised
in the same class of cases as before noted. Its more
extended use shows that it has a much larger range of
usefulness than its rivals chloral, paraldehyde or Sul-
phonal. Its marked characteristics, which are being
recognised and taken advantage of every day, first of
not requiring an increased dose after continued use, and
second of definitely establishing the habit of sleeping by
its systematic use so that the habit is well kept up after
administration has been discontinued, are inestimable
qualifications.
During the past year it has been found especially
valuable in cardiac asthma, and renewed claims for its
Superiority in sea-sickness have been prominent, although
not by any means conclusive.
It is true that there have been some disappointing
results reported this year, as well as last, but they are
Comparatively few, and we may very safely say in
general, that in chloralamid we continue to have a safe
and reasonably reliable hypnotic.
Chlormethyl (Mono-Chlor-Methane) is a remedy to
be used in the treatment of neuralgias of all kinds, and
it is rather surprising we have heard so little of it during
the past year—at least from the Continent—after such a
favorable report made by Steiner a short time ago. It is
Put up in copper siphon bottles in a fluid condition
Produced by pressure, and in using it a jet of the fluid is
P*mitted to strike the painful region. It not only pro-
duces a local decrease of temperature of the part, but it
relieves the pain by diminishing the excitability of the
*Sory nerves. Steiner used it successfully in extreme
* of ischiatic neuralgia, and strongly advocated its
ºnore general trial.
39
610 MEW YORK STATE MEDICAL ASSOCIATION.
Chloroform in particular, and anaesthetics in gen-
eral, are still paramount questions under discussion in
the old country, generally, but especially in England, as
the Germans have “trod on their toes” a little by pre-
senting to the professions of medicine and pharmacy a
brand of chloroform which is claimed to be so much
purer than any other known, that it is the only article to
be used in order to avoid the unfortunate results which
have followed the administration of chloroform of late.
This is hard for the Englishman to bear, and immediately
the two professions there are put on the defensive to
explain away the shortcomings, either of their article or
of their mode of administration. Dr. Raoul Pictet, a
Swiss chemist, formerly of Geneva, but now of Berlin,
Secured a patent in Germany, and sent out from his firm
of Raoul Pictet & Co. samples of chemically pure chloro-
form obtained by refrigeration in his special apparatus,
constructed to produce a temperature from — 20° C. down
to —200° C., and applicable not only for chloroform, but
for all purposes requiring these low temperatures. The
specification of this patent is as follows": “It states that
the purification is effected in a copper cylinder, Sur-
rounded by a jacket hermetically sealed at top and bot-
tom and provided with an inlet and outlet pipe. The
process is carried out in three stages. First, the chloro-
form in the cylinder is cooled down to 80°C. by allow-
ing ethyl chloride, ethylene, protoxide of nitrogen, or
“Pictet's liquid,’ to evaporate in the jacketed Space Out-
side the cylinder, and filtering the cold liquid mass.
Foreign bodies crystallising above this temperature are
thus removed, and the chloroform is filtered off. The
second stage is to solidify the chloroform thus obtained
by reducing the temperature of the cylinder to -89° 0.
when about two-thirds of it freezes against the sides of
the reservoir. The remaining liquid is drained off, and
the solid chloroform melted and then run out of.”
cylinder for the second time. The product thus obtained
*The Chemist and Druggist (London), Vol. 40 for 1892, p. 40%
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 611
is finally subjected to distillation at a very low tempera-
ture under reduced pressure, the cylinder used in the
previous stages of the purification now serving as the
receiver. The first and last portions of the distillate are
rejected, whilst the intermediate product, amounting to
about 80 per cent. of the total, is obtained as ‘chemically
pure chloroform.’”
Dr. Pictet and nearly all his followers have claimed
from the first that his chloroform would not decompose
on exposure to light, and that a practically unchangeable
liquid is produced by the patented process. Unfortun-
ately for his cause, however, one of his own experiment-
ers apparently inadvertently explained that it would
decompose if the alcohol which was added to preserve it
be removed. This was afterwards fully verified by
actually producing decomposition in about ten days
when freed from the one per cent. of alcohol it contains ;
and furthermore additional investigations in Berlin
proved that there was no sensible difference between his
and any other well purified brand.
At a certain spasmodic stage of the discussion great
Stress was laid upon the impurities which could be
Separated from all brands, and for a time it was thought
that a solution of the difficulty found with the anaes-
thetic was discovered in this defect; but it has since been
clearly shown that this very small quantity of residue
Would not only have no effect therapeutically, but any
possible effect from such a cause would not produce the
pronounced symptoms complained of.
Throughout this whole agitation, a marked example is
furnished of the perfect indifference foreigners, and par-
ticularly the English, show to anything accomplished in
the United States. They apparently pay little attention
to any Scientific work which has been done here. This
* Very noticeable in some of the investigations which
have been attempted on this subject in question, for
* of that very work has been on record here for forty
* back, and it is amusing to notice how many times
612 NEW YORK STATE MEDICAL ASSOCIATION.
they announce some wonderful (?) observations which
have been known and published here for years. If they
showed the true scientific spirit they would acknowl-
edge and make use of all available work accomplished
from whatever source, beginning their investigations
where others left off, and thus gain the glory, if they
need such, by improving on and perfecting what had
gone before ; but they are apparently so indifferent to
this spirit that they go to work at questions which have
long ago been taken up, settled and published, in order
to Originate for themselves, even though it be old matter.
It would seem that definite conclusions as to the
relative mortality of chloroform and ether could not be
justly drawn at this time any better than last year, as
a large proportion of fatalities have occurred either
from the use of the particular anaesthetic employed on
individuals in whom it was plainly contra-indicated,
or from carelessness in administration, and not from
impurities in either anaesthetic. This statement is
not intended, by any means, to underrate the impor-
tance of purity in the anaesthetics, but simply as a
protest against hypercritically laying so much stress
on the small amount of impurity found. In the direc-
tion of impurities, decomposition evolving a chlorine
vapor, in the case of chloroform, is the one thing to be
recognised in advance, and avoided. This can readily
be done by the administrator just before using.
It is very unfortunate, as was alluded to here a year
ago, under the head of “Ether versus Chloroform,” that
not only individual practitioners, but sections of country
are so unalterably wedded to their particular anaesthetic
that they insist on using it exclusively. Surely some
cases are, after even only a rough examination, found
suitable for chloroform and others for ether, so that
routine practice has its disadvantages.
The discussion on anaesthetics at the last annual meeting
of the British Medical Association, held in Bournemouth,
took a turn decidedly against many of the strongly
MATERIA MEDICA, PEIARMACY. THERAPEUTICS. 613
emphasised statements of the Hyderabad Commission,
and led to the appointment of a representative Com-
mittee to report on the whole subject from a clinical
standpoint. *
Also the Nyzam of Hyderabad, India, has thought the
subject of enough importance to appoint a third Commis-
sion to reconcile, if possible, the conflicting views now
prevalent, and Dr. H. A. Hare, of Philadelphia, has been
asked to undertake the task here. Dr. Hare now desires
to receive reports from American practitioners “of any
cases in which it was noticed that the heart stopped
beating before respiration, or respiration stopped before
the heart.”
Convallaria Majalis (Lily of the Valley) has by this
time reached the stage at which all newly pushed reme-
dies arrive if they can stand the strain of over-pushing.
Although a remedy long used in Russia for dropsical
affections, still its usefulness was not sufficiently empha-
sised until it was noted that it might take the place of
digitalis. This it still cannot do, but it does offer a very
efficient alternate for digitalis in many cases. It is to be
hoped that the Revision Committee will recognise it in
the forthcoming issue of the U. S. Pharmacopoeia.
Creasote obtained for medicinal use only from beech-
wood tar, still holds its own in professional popularity
in the treatment of pulmonary tuberculosis — largely
used, added to or in conjunction with cod-liver oil.
Larger doses are now urged than used to be given. In
Southern Germany they appear to be very bold and even
approach recklessness in the heroic doses employed.
Dr. Francis P. Kinnicutt, of New York City, in his
Middleton-Goldsmith Lecture for 1892 on “New Out-
looks in the Prophylaxis and Treatment of Tuberculosis,”
gives the most complete consideration of this subject
Which has been reported for some time back. One of his
most interesting series of records are those cases treated
by creasote and guaiacol. He concludes that large doses
* N. Y. Med. Record, Vol. 41, p. 561.
614 NEW YORK STATE MEDICAL ASSOCIATION.
apparently possessed no advantages over much smaller
ones, and had no greater effect upon hectic and night
sweats; that subcutaneous injections of the drug pos-
sessed no advantages over administration by the mouth ;
that whatever beneficial influence it might exert in pul-
monary tuberculosis could be effected with a compara-
tively small dosage, and that favorable results could be
expected only by its continuance and prolonged employ-
ment.
In Germany, Dr. Julius Sommerbrodt states that the
earlier it is used the better are the results. He therefore
has used it in so-called scrofulous children with very good
effect. He recommends it in larger doses than usual, as
he finds smaller ones are useless, and he continues it for
several months. It will thus be noticed that observers
differ in some of their conclusions.
In France, pertussis and laryngitis accompanying La
Grippe have both been treated by creasote with success.
Creolin—the coal-tar product — has not gained much
in popularity during the past year. A series of compari-
sons of the disinfecting values of lysol, creolin and
carbolic acid has been carried on, and their value is rep-
resented in the order here named. Creolin might have
assumed a more prominent place if some quite unfavor-
able results had not been reported from its use.
Cresol lodide (Ortho-Cresol Iodide) is another of the
numerous substitutes for iodoform. Cresol is the promi-
nent constituent of crude carbolic acid in varying propor-
tions of the ortho-meta and para-cresols. The iodide of
the Ortho-cresol is the one found to be efficient as a disin-
fectant, especially in nasal and laryngeal affections.
It is a fine, pale-yellow powder with a pronounced Odor,
but agreeable in comparison with iodoform ; it is insolu-
ble in water. All the compounds of cresol are powerful
antiseptics, but all have the disadvantage of a very
variable composition, of adhering to or rendering slip-
pery the operating instruments and hands, and of readily
oxidising in the air. These disadvantages apply to all the
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 615
various compounds of cresol known as lysol, solveol,
Solutol, saprol, etc.
This iodide has not been long enough in use to predict
its future, but, surely, almost anything is at once seized
upon which attempts to supply a satisfactory substitute
for iodoform.
Dermatol (Bismuth Subgallate)—last year's new sub-
stitute (or rather of two years ago) for iodoform—although
it has by no means supplanted the latter agent, still has
held its own pretty well and finds good use in suitable
cases. Considerable attention has been given during the
year to comparative observations with this agent and its
rivals. Colasanti has made comparative bacteriological
experiments on wet and dried cultures with aristol, der-
matol, and iodoform as to their microbicide potency.
Neither agent apparently had any effect on the microbes
in the dried cultures after three days contact, but in the
wet ones, dermatol was effective in little more than half
the time of the others.
One of the most complete investigations upon this
agent of late, is that of Dr. Arthur K. Stone, of Boston,
communicated in a paper' read at the last annual meeting
of the Mass. Med. Society, on “Bacteriological and
Clinical Investigations into the New Antiseptic, Der-
matol,” which is surely worth reading by those interested
in this subject.
Doernberger has made good use of a 10 per cent. vaseline
ointment of dermatol in the Children’s Hospital at Graz,
particularly in moist eczema and burns. In otorrhoea, he
still withholds his opinion, but in phlyctenular conjunc-
tivitis he finds it useless. Several others quite confirm
these results, but Davidsohn gets good results in quite a
Series of cases of otorrhoea.
The antiseptic property of dermatol is at this time
Somewhat in dispute, but its extraordinary desiccating
effect is still pronounced and remarked favorably upon
by all.
* Boston Med, and Surg. Journal, Vol. 127, p. 207.
616 NEW YORK STATE MEDICAL ASSOCIATION.
On the whole, then, last year's promises have been quite
well fulfilled—except that it has not supplanted iodoform.
Diaphtherin (Oxy-Chin-Aseptol) is one of the very
newest antiseptics—another of the interminable coal-
tar derivatives. Its shorter fancy name comes from
Öiaºpffeipo, to destroy, and it is prepared by a process
not yet made public, but its composition consists of two
molecules of oxychinolin and one of aseptol. It is
reported as a yellow powder, with an odor somewhat like
carbolic acid, and readily soluble in water and in most
of the ordinary solvents.
It is little heard of as yet outside of Germany, and
although Dr. Kronacher, of Munich, now states that he
has been using it successfully for a year in his surgical
practice, chiefly in a 1 per cent. Solution, but often in as
strong a solution as 50 per cent., still it was not presented
to the profession at large until the recent Eleventh Con-
gress for Internal Medicine, held in Leipzig, where
Prof. R. Emmerich, of Munich, presented a sample and
explained its alleged superiority over carbolic acid, corro-
sive sublimate, lysol and the like — showing less toxic
properties than all, and being a less costly agent than
carbolic acid. From its composition it should theo-
retically be the most potent antiseptic. It, however,
apparently cannot be used to disinfect operating instru-
ments, as it attacks even silver and nickel plating (nickel
less than others, especially when newly plated)—a dark
blackish deposit being formed, which, although not
poisonous in its action, still is quite an objectionable
feature. Apparently, the 1 per cent. Solution in water,
recommended by Dr. Kronacher, is fully strong enough
for surgical dressings. It is stated that it is non-caustic,
and does not produce eczema. It does stain the hands
and nails of a light yellow color, but this is not indelible,
and may be easily removed by washing. It is said to have
marked bactericidal properties, and its special applica-
tions are to burns, ulcers and operating wounds, even of
large extent.
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 617
From reports at hand, then, it may be stated that it
possesses marked antiseptic properties and very few
disadvantages.
Diuretin (Sodio-Theobromine Salicylate) has increased
somewhat in demand since last year, but some of the
statements in its favor have to be modified considerably
in the light of a year’s experience with an increasing
number of observers. Dr. R. Demme, of Berne, Switzer-
land, has been the most prominent extensive foreign
clinical reporter of its use during the year. He used it in
the Berne Children’s Hospital with marked success. In
cases of dropsy, where calomel and hot baths were
apparently unsuitable, and where the usual diuretics
were of little benefit, he met with success. He believes
its effects are due to its action upon the renal epithelium.
In the severe dropsical stage of scarlatinal nephritis and
of mitral disease, it has been of much service, even after
digitalis had had no effect. Although he and many
others have noted its non-cumulative effect, still he had
One case of amyloid degeneration of the liver, kidneys
and spleen, in which it caused an erythematous rash,
together with a profuse diarrhoea.
He does not give much encouragement in using it in
children less than one year old. As a dose for children
from two to five years of age, he recommends from 500
milligrammes (about 8 grains) up to 1.5 grammes (about
25 grains) in divided doses daily; from 6 to 10 years of
age, up to 3 grammes (about 45 grains). The administra-
tion was continued in many cases for weeks without
either cumulative or diminished therapeutical effect being
evident in any way, and the benefit in some of his cases
was very striking.
In our own country, on the other hand, Dr. H. A. Hare,
of Philadelphia, has not met with many favorable results
in administering it to adults as a diuretic. He even pushed
the dose in one case, that of an elderly man with enlarged
Drostate and very concentrated urine, to 7.8 grammes
(120 grains) daily, with the result of decreasing the flow
of urine instead of increasing it.
618 NEW YORK STATE MEDICAL ASSOCIATION.
Dr. E. L. Keyes, of New York City, feels now called
upon to retract some of the claims he had conscientiously
but modestly believed might be held concerning this
agent in “averting urinary or urethral fever,” and as he
promised, when he made his previous report, to continue
his observations, he feels in justice called upon now to
report his failures." He is still studying the matter, and
may have something further to say after another year's
experience with this and other diuretics.
It may be well to again allude to the very unstable
condition of this compound, and to caution practitioners
not to prescribe it with other things, on principle. It is
far better to give it by itself either in the powder form
or in solution. In either form it is necessary to keep
it well sealed from contact with the air on account of its
rapid decomposition. -
It may still be considered, then, on trial, for it surely
has given a good as well as poor record of itself in many
cases, and now that the price has been somewhat
reduced, its use may be stimulated thereby. Attention
is again called to the great discrepancy in price between
the article when bought under its shorter name of diure-
tin and under its chemical title of sodio-theobromide-
salicylate—the latter, when you insist on having it, cost-
ing less than half the former. Moral: always purchase
under the latter name.
Epidermin is the name given by S. Kohn to a Ger-
man preparation (evidently a mixture) to be used as an
effectual surgical dressing and artificial skin for wounds
and scratches. It is a smooth, milky-white mixture,
producing, after spontaneous evaporation, a thin flex-
ible pellicle. The exact composition of the compound,
as introduced, is not known, but an efficient substitute
may be prepared by triturating in a warmed iron mortar
15 parts of melted white wax, with 15 parts of powdered
acacia, until a thorough trituration is accomplished ;
15 parts of distilled water and 15 parts of glycerin are
* The Medical News, Vol. 61, p. 352.
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 619
then mixed and brought to boiling. This is added at
Once to the contents of the mortar and the whole stirred
constantly until cold. If it is desired to add any medi-
cinal property to the pellicle, the medicament should be
mixed with glycerin first.
Ethyl Chioride (Monochlor-Ethane) has apparently
steadily but slowly increased in use ever since M. Mou-
net, of Lyons, France, introduced it, put up in the form
of small glass tubes, in which it occurs as a colorless
liquid with a burning but sweetish taste. It is obtained
by passing chlorine gas through an alcoholic solution of
zinc chloride to saturation while surrounded by ice, to
keep its temperature well down. It is ordinarily gaseous
in form, but is easily condensed and introduced into
these small drawn-out tubes, and hermetically sealed.
The tube is to be broken off at a spot in the narrow
extremity marked by a scratch, so that by the warmth
of the hand holding it, a small jet of the vaporised liquid
is projected on the part to be anaesthetised. It is very
inflammable, and therefore must not be used in the
vicinity of fire. The above mode of using it is found to
be by far the best on account of being always available,
and no preparation has to be made up to the moment of
using. It has thus gained much favor in France and
Switzerland with dentists, and for minor surgical opera-
tions, but has not spread much further.
Eugenol-Acetamide is a new anaesthetic, patented
in Germany, analogous in action to cocaine. The foun-
dation element is eugénol (eugénic acid) obtained as an
oxidation product from oil of bay, oil of cloves or oil of
pimento, but chiefly commercially from oil of cloves.
The process of purification of eugénol has been much
improved of late, and we therefore should get better
results from the antiseptic and anaesthetic effects of not
Only eugénol itself, which has been in use for several
years past, but also more effectual results from the
acetamide compound. The latter is prepared by treat-
ing the sodium salt of eugénol with monochloracetic
620 NEW YORK STATE MEDICAL ASSOCIATION.
acid to produce eugénol-acetic acid. When alcohol and
chlorine gas are added, eugénol-acetic ethyl-ether is
formed, which, treated with a strong solution of
ammonia, gives eugénol-acetamide. This resulting crys-
talline product is rubbed up into a fine powder as being
the most effective form for practical use.
This is so new an article that few reports have yet been
made upon it, but it no doubt will be sought for by
those who have used eugénol with success—the dentists
and surgeons for minor operations.
Euphorin (Phenyl-Urethane)—the antipyretic—has
found a very satisfactory field for usefulness since last
year in obstetrical and gynaecological cases, and many
foreign observers give favorable reports. Dr. L. M.
Bossi, who has probably used it more largely in this line
than any other, is led to think, after a somewhat extended
experience, that it acts both more efficaciously and more
rapidly than any other substance hitherto in use, not
excepting iodoform.
Finally, in general, Dr. C. Curtis summarises his
experience after its use in some two hundred clinical
experiments and bacteriological researches made in the
Pharmacological Institute of the University of Rome:
1. It is a powerful and safe antipyretic. It acts better
when the fever is at its maximum and during the period
of subsidence, than in the early stage, showing itself in
from half an hour to two hours; its effect may last even
ten hours.
2. Defervescence is attended with a feeling of warmth
and moderate sweating, but when the temperature rises
again the accompanying rigor is not severe.
3. It does not cause any serious secondary effects.
Sometimes there is a little cyanosis, but never collapse.
4. It can be used in preference to any other antipyretic
when a rapid and marked lowering of the temperature is
required.
5. It answers fairly well in surgical fevers.
6. It is a most potent antirheumatic. In acute rheu-
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 621
matism it is certain ; in chronic rheumatism it is also
satisfactory — usually succeeding in cases which have
resisted all other remedies.
7. In simple fever the dose is 1.2 grammes taken in
from four to five doses. In febrile rheumatic affections
from 1 to 2 grammes should be given in twenty-four
hours. In chronic rheumatism, 1 gramme in three or
four doses. On the average, 1 gramme corresponds to 2
grammes of antipyrin.
8. It has a sure analgesic action in neuralgia, unless
when due to a specific cause.
9. It is a powerful antiseptic, being intermediate
between carbolic acid and corrosive sublimate.
10. It is one of the most effective disinfectants in
thrush.
11. In local applications, it has advantages over iodo-
form, iodol, aristol, etc. It is more powerfully antiseptic
and less desiccating than dermatol.
12. Used locally in powder or in an ointment with
vaseline or lanolin, it is also an anodyne, promoting the
healing of wounds and ulcers. It gives excellent results
in surgery, gynaecology, diseases of the skin, and
syphilis.
Europhen (Iso-Butyl-Ortho-Cresol Iodide)—one of
the most effective substitutes for iodoform—still gives
daily evidence of the very unwise practice of choosing
very similar names for very dissimilar agents, as it
has been repeatedly shown that more good luck than
good management has avoided poisoning results from
the confusion in name between this article and Eu-
phorin. It is not very difficult to see how readily one
might be written for the other in a hurriedly composed
prescription.
Europhen has had a largely increasing use during the
past year in throat and nose affections, in spreading
ulcers and in soft sores, with such gratifying results that
many claim that it excels iodoform.
Reports now come from Cuba that Dr. Juan Santos
622 NEW YORK STATE MEDICAL ASSOCIATION.
Fernandez, of the Havana Eye and Ear Clinic, has met
with beneficial effects from the use of a 9% to 1 per cent.
vaseline ointment in many eye affections. Only one ap-
plication to the conjunctiva often proved efficacious in
cases where other agents failed. He does not extol euro-
phen above its rivals, but finds it sufficiently useful to be
of marked service in many cases.
Its advantages—a far less disagreeable odor, and free-
dom from toxic effects—give it a good claim to rank well
with iodoform, and repeatedly call forth expressions of
approval from all.
Exalgin (Methyl-Acetanilid)—the analgesic—unfor-
tunately has had too many cases of poisoning attributed
to it since this time last year to much encourage many in
a more extended use of it. Several of these cases, how-
ever, were due either to popular use (abuse) of it, or it
was taken without medical direction.
In chorea, it appears to have made a favorable record
this year. Dr. Hugo Löwenthal, of Berlin, treated thirty-
five cases in all stages of severity. It was particularly
applicable when there was considerable mental excite-
ment. He found that it was of benefit in the majority of
cases, but he cannot attribute a specific action to it.
In our own country, Dr. C. L. Dana, however, considers
it does possess a specific action in ordinary chorea. He
treated sixteen cases with an initial dose of 130 milli-
grammes (2 grains), three times a day, and increased if
necessary up to about 200 milligrammes (3 grains), five
times a day, prescribing also the citrate of iron and qui-
nine after meals. Acute anaemia and cyanosis were the
only unpleasant symptoms he saw following its use. The
average duration of the chorea was five weeks.
Dr. John Gordon, of Aberdeen, Scotland, gives a very
concise account of some sixty-six clinical cases under his
observation.” “In fifty-five cases the action of exalgin
was successful in relieving the pain, while eleven cases
yielded results that were unsuccessful or doubtful. The
* The London Lancet, Vol. 1, for 1892, p. 1173.
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 623
benefit of exalgin was most marked in cases of nervous
headache, facial neuralgia, intercostal neuralgia, and
lumbago. Although the pain-subduing action of the
drug may be feeble, it has given in certain cases excel-
lent results. Further observations will at last fix its
full value as an analgesic, and possibly justify the hope
that it may take a valuable, if restricted, place in the
group of those bodies which relieve suffering.”
Finally, Dr. T. Churton, of Leeds, England, has met
with some success in the treatment of exophthalmic
goitre, and discusses the poisonous dose in connection
with his cases."
Exodyne is another one of those compounds put forth
by an enterprising stock company to catch the attention
of the lovers of novelty, and to win over a share of the
harvest accruing to like enterprises. It is urged as an
antipyretic in 650 milligramme (10 grain) doses. Dr.
Goldmann found it to be another of the now numerous
acetanilid mixtures :
Acetanilid, . e e © * * & . 90 per cent.
Sodium Bicarbonate, . [. * g e . 5 per cent.
Sodium Salicylate, . e & e e . 5 per cent.
Fuchsine (Rosaniline) is the well-known aniline
product occurring in bright iridescent crystals, giving a
deep-red solution in water, used in the arts as a dye, and
in medical science for staining purposes in histological
and bacteriological work.
In the process of manufacture in commercial quantities,
arsenic is retained in variable amount, which, of course,
is objectionable for both internal and external use.
When used in medicine, then, arsenic should be carefully
eliminated.
It has been used internally for albuminuria, and
externally in a one per cent. alcoholic solution in five
Cases of traumatic erysipelas with successful results in
all, after only two applications; but the best results
* The London Lancet, Vol. 1, for 1892, p. 1175.
624 NEW YORK STATE MEDICAL ASSOCIATION.
reported during the past year have been in throat affec-
tions. After a constant use since 1888, Dr. Karl G. Bog-
roff, of Odessa, reported over a year ago (and his con-
clusions may be repeated here), that—
1. Like all other aniline dyes, it is easily absorbed by
the laryngeal and faucial mucous membrane ;
2. Antiseptic fluids, when mixed with it, penetrate
into the tissues far more deeply and act much more
effectively than when employed alone;
3. When injected into the larynx “the superficial cel-
lular elements and intercellular spaces become infiltrated
with particles of the aniline dye, and thus a thin protect-
ive film is formed, which is impermeable not only by
any irritating fluids, but even by gaseous bodies”;
4. In cases of reactive laryngeal inflammation in pul-
monary tuberculosis from continual irritation by the dis-
charges, the intra-laryngeal injection of a two per cent.
watery solution of boric acid saturated with fuchsine,
rapidly removes the inflammatory phenomena and
relieves the difficulty in swallowing ;
5. It proves similarly beneficial in cases of “faucial
mycosis.”
Callacetophenon (Tri-Oxy-Aceto-Phenon) is a re-
cent and promising substitute for pyrogallol (pyrogallic
acid) in most skin affections, and principally in psoriasis.
For some time back pyrogallol has attracted some
attention in the treatment of psoriasis, but it has prac-
tically been abandoned on account of its poisonous
qualities. Recently Dr. L. von Rekowski, of Berne,
has recommended as its substitute this dye-stuff, gal-
lacetophenon—a derivative of pyrogallol, and known
commercially by the name of “alizarine-yellow C.”
It is prepared by bringing a mixture of 1 part of pyro-
gallol, 1% parts of acetic acid, and 1% parts of Zinc
chloride to a temperature of 145° C. to 150° C. When
pure, it occurs in needle-like crystals, which may be
incorporated in a very serviceable ten per cent. ointment,
which does not stain linen.
MATERIA MEDICA, PHARMACY. THERAPEUTIOS. 625
Foreign dermatologists are using this very successfully
at present, and among our own practitioners, Dr. Her-
man Goldenberg, of New York City, points out its
advantages, and recommends its extended use.”
Clycerin Suppositories have met with increasing
favor in the treatment of some forms of rectal inertia
and weak peristaltic action, particularly of the lower
intestinal tract.
Many formulas are in use, but the one which gives the
best satisfaction, according to Prof. J. P. Remington,
of Philadelphia (President of the American Pharmaceu-
tical Association), is as follows:
Sodium Carbonate, . ſº . 2.6 Grammes ( 40 grains).
Stearic Acid, & e d . 5.2 & 4 ( 80 “ )
Glycerin, . ſº g e . 70.0 & g (1080 “ )
Cuaiacol—the beechwood-tar product containing a
maximum of 90 per cent. creasote—has been in remark-
able demand during the past year. At one time it
seemed as if the manufacturers could not supply the
unusual calls upon them, and an inferior article was
offered for sale with customary failures in expected
results.
Its use, together with that of its salts, has been largely,
if not wholly, confined to the treatment of pulmonary
tuberculosis. Of all the agents used for this affection
there is probably none which has proved so uniformly
beneficial. It has been constantly increasing in favor
from its very introduction many years ago, and it is now,
perhaps, more generally used for this affection, in every
country in the world, than any other agent. The ben-
Zoate, salicylate, iodide and carbonate—all have found
their use in individual practice, but none of these has
been given more attention during the past year than the
Carbonate.
The irritation produced by guaiacol as well as by crea-
Sote is, in some cases, Sufficient to preclude the use of
1 N. Y. Med. Jour., Vol. 55, p. 153.
40
626 NEW YORK STATE MEDIOAL ASSOCIATION.
either, and therefore Drs. Richard Seifert and Fritz
Hölscher proposed to overcome this difficulty by substi-
tuting the carbonate—obtained by passing chlorine and
CO2 gases into a mixture of guaiacol and caustic soda.
The product is a tasteless and odorless crystalline pow-
der, insoluble in water.
In a healthy stomach it apparently is not split up—re-
maining unacted upon until it reaches the intestine—and
therefore it does not disturb the digestion. In an hour
after administration it may be detected in the urine.
According to the above observers the initial dose to be
used is from 20 to 60 milligrammes (about 9% to 1 grain),
and increased up to a maximum of 6 grammes (about 90
grains). No disturbance of the digestion, circulation or
nervous system was noted from even the maximum dose.
Out of four cases upon whom the carbonate was tried,
two had taken creasote, and one guaiacol itself with
trifling benefit, but were manifestly improved by the
carbonate. Again, other cases taking the carbonate reg-
ularly and improving, lost in weight and in general con-
dition when put upon creasote.
Dr. Francis P. Kinnicutt, of New York City, has given
us the most complete comparative results that we have at
the present time, in regard to this carbonate, guaiacol
itself, and creasote." His notes are very full and inter-
esting, and were alluded to under the head of Creasote.
Haemogallol is the haemoglobin of the blood oxi-
dised by the action of pyrogallol, thus furnishing a new
compound more easily assimilated, and more readily
supplying those ingredients of the blood which are
found lacking in such affections as chorea than the
ordinary iron preparations so universally prescribed.
Professor Kobert, of Dorpat, was the first to give at-
tention to this subject, and as far as he has gone he has
met with gratifying results.
It is a brownish-red powder, and has been patented,
which latter condition will unfortunately limit any im-
1 N. Y. Med. Record, Vol. 41, p. 561.
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 627
mediate chance it might have of usefulness by reason of
the accustomed restrictions of any enterprising firm who
gains possession of the patent rights.
It is given in doses from 100 to 500 milligrammes (1%
to 7% grains), shortly before each meal, in any conven-
ient vehicle which will not retard its rapid absorption, or
it may be given in capsules. The digestion is not dis-
turbed, and the anaemia disappears more rapidly than
under the usual form of treatment, although the quantity
of iron thus introduced only amounts to about 10 to 15
milligrammes daily. Professor Kobert considers this the
great advantage this agent possesses over the usual iron
preparations.
Of course, too short a time has elapsed since its intro-
duction to expect to see reports of much clinical experi-
ence, but no doubt we will hear more of this article
later.
Haemol is a closely allied preparation to haemogallol
(just spoken of), and is obtained by the same process,
except that the reducing agent used in this case is zinc–
presented in the form of a fine dust, and shaken up in
the presence of water. By this process, after proper
separation, a slight trace of the zinc is retained in the
resulting dark-brown, almost black, powder—haemol.
The zinc present theoretically appears to act efficiently
where there are lesions of the stomach or intestines which
tend to break down into ulcers. Given in this compound,
the zinc seems to lose its caustic effect, and does not pro-
duce nausea. The dose and mode of administering
haemol are the same as for haemogallol.
Helenin, the white acicular crystals obtained from
the root of Inula Helenium (Elecampane Root), which
has received some attention from foreign observers in
the treatment of tuberculosis, does not appear to pro-
gress very rapidly, owing chiefly to the cost of pro-
duction.
The crude article is a very effective antiseptic and has
been much used on the Continent as such.
628 NEW YORK STATE MEDICAL ASSOCIATION.
In Spain it is favored as a surgical dressing.
Ferran claims that it is more destructive to the cholera
bacillus than any other agent.
It has been used successfully in OZaena, and internally
in malarial fevers, diarrheal troubles and leucorrhoea. Dr.
M. Hamonic reports excellent results in the latter affec-
tion after internal use. He states, however, that it is a
failure locally, as it irritates the vaginal mucous mem-
brane. Parisot corroborates Hamonic after its successful
employment in twenty-seven cases.
The cost has been greatly against it, especially in
regard to the pure article, and although Dr. T. J. Boken-
ham, of St. Bartholomew’s Hospital, has been very suc-
cessful in his experiments on animals, he has not been
able to push it very far in his practice, as considerable
quantities have to be used and its use has to be continued
over an extended period in each case. Dr. Bokenham’s
investigations were very carefully made and deserve
attention.”
Hydrastinin is the oxidation product of Hydrastin,
one of the alkaloids found in the root of Hydrastis
Canadensis (Golden Seal). It has been used now for
about two years with increasing professional popularity,
particularly among the gynaecologists.
A stimulus to its increased employment has been
recently furnished in a reduction of the price, and thus a
more extended use may be expected. The hydrochlorate
is mostly used, and the salt appears to act as a haemos-
tatic, contracting the blood-vessels of the endometrium.
It cannot take the place of ergot, as it does not cause
contraction in the muscular tissue, and can act most
effectually only upon a relaxed uterus, as the blood-
vessels are then in a condition free to contract.
Although its haemostatic action is very pronounced in
over half the number of cases tried, still it appears to be
uncertain, and in fact may have no effect whatever, SO
that from all the testimony given by a now numerous Set
* Brit. Med. Journal, Vol. 2, for 1891, p. 838.
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 629
of observers, principally in Germany, it cannot by any
means show any advantages over the officinal fluid extract
of hydrastis, given in proportionate quantity, which is a
small dose, even at the maximum.
Hydrogen Dioxide (Peroxide of Hydrogen) has
been used much more largely during the year past. The
more that is learned, both as to its applicability and as
to its mode of preparation and keeping qualities, the more
reliable will be the therapeutical results, and the less ad-
verse criticism from unnecessary failures will be heard.
Its range of usefulness also has been somewhat ex-
tended since last year. In illustration, Dr. Altehoefer
recommends it as a disinfectant of polluted water. His
researches tell him that one part per thousand of water
containing sewage or infectious microbes, is quite suffi-
cient to destroy the various organisms if left to act for
twenty-four hours. Used in drinking water it does not
make it in the least unpotable, and the proportion of the
agent needed is so Small, that the cost is inappreciable.
It has had quite an increasing use as a cleansing agent
for foul wounds, abscesses and the like.
It is found to be a valuable diagnostic agent in deter-
mining the presence of pus, for Stuver found that when
injected into a part in which suppuration was suspected,
it would indicate its presence by causing an almost imme-
diate swelling up of the part. If such a discovered spot
was at once cut into, pain was avoided. He treated a num-
ber of suppurating buboes in this way with great success.
Dr. F. H. Wiggin, of New York City, desires the pro-
fession to try it in the treatment of typhoid fever, as he
has had one very successful case, in which he “prescribed
One ounce of a fifteen volume solution of peroxide of
hydrogen to eight ounces of water, to be taken every
three hours, by the mouth.” He is fully alive to the
fact that his one case cannot prove anything, and there-
fore urges others with more frequent opportunities to try
it and report their results."
1 N. Y. Med. Record, Wol. 40, p. 658.
630 NEW YORK STATE MEDICAL ASSOCIATION.
During the year it has been the chief work of the
manufacturing chemists in this line to either improve the
process, or to discover some agent to add to the finished
product that will render its keeping qualities far better
than they are at the present time. The presence of a free
acid appears to be absolutely necessary in all solutions
of this article, since without this, careful; comparative
tests have definitely proven that decomposition is rapid ;
but much free acid protects no better than a little, while
it renders the solution and its dilutions hurtfully irritant
to diseased and sensitive surfaces. Boroglyceride in
small proportion acts fairly well as a preservative, but
still decomposition occurs, and chiefly upon agitation.
Dr. S. S. Wallian, of New York City, has recently
intimated that this article can be made stable, and if
this be true, he knows more than all the investigators
before him, and we think he owes it to the profession to
either divulge his method of preparation, or present
some of the product for critical tests. If he has suc-
ceeded in accomplishing what he intimates, it will be an
inestimable boon to the whole community, as this is
rapidly coming to be a most important remedial agent in
the hands of practitioners in every quarter.
lchthyol (Ammonium Ichthyol-Sulphonate) is one of
the newer remedies which has been able, since last year,
not only to hold its own, but has increased its sphere of
usefulness.
Among foreign observers, Drs. Klein and S. J. Rad-
cliffe now ascribe almost specific properties to it in the
treatment of erysipelas.
Dr. C. W. Allen, of New York City, continues to give
as favorable reports of its use as he made a year ago. It
has had its largest use in eczema, erysipelas, and all
forms of rheumatism.
Its more extended use is reported by Eschen, in the
treatment of twenty-five cases of uterine complaints,
including metritis, parametritis, and inflammation of the
Ovaries.
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 631
One fatal case from its use has been reported by
Dr. Bergerio, at a meeting of the Turin Academy of
Medicine, in which “he was washing out the uterus of a
woman, suffering from endometritis, who on the previous
day, had had her uterine mucous membrane curetted
with a solution of one-third ichthyol to two-thirds
glycerin. Almost as soon as the washing out began, she
complained of a putrid fish taste in her mouth, the pulse
became like what it is in tachycardia, and symptoms of
general depression came on which lasted for about twelve
hours. Bergerio believes that the rapid absorption could
only have taken place through the recently scraped
uterine mucous membrane. He stated that it was the
first accident of the kind occurring in his hands, in an
experience of about one hundred cases, in which he had
used this agent in utero-ovarian disease. He did not
know whether it was to the ichthyol-sulphonic acid part
of the salt, or the base ammonium that the symptoms
were due. In discussing the case, Giacosa said toxic
symptoms caused by ammonium were referable to the
spinal cord, and therefore he had no doubt that, in the
present instance, it was the acid part that was respon-
sible. Peroni cited the case of a woman under his pro-
fessional care to whom he gave as much as 5 grammes
(about 75 grains), daily, for prurigo, without any
untoward effect, until one day being told that it was
obtained from “fossil fish ’’ (?), she was seized with
vomiting, headache, convulsions and diarrhoea.
Replying to this reflection, Bergerio said the element
of suggestion was excluded in his case from the fact that
she was ignorant of the nature of the medicament which
was being given to her for the first time.
lodoform—prepared by the action of chlorinated
Soda on acetone in the presence of an iodide—has appar-
ently lost little during the past year from the attention
paid to its increasing number of rivals. Its great draw-
back—an extremely disagreeable, penetrating and per-
sistent Odor—has undoubtedly been the means of dis-
632 NEW YORK STATE MEDICAL ASSOCIATION.
couraging its use somewhat, but its efficiency is so
marked wherever it is applicable that the disagreeable
odor is simply endured. The expedients used to dis-
guise this odor still accumulate and will continue to be
sought after until more desirable results are reached
than we possess now. A few prominent expedients out
of the many suggested during the past year may be
alluded to here :
When application is to be made to the skin, Camphoid
(spoken of under its proper head) makes a very service-
able agent. The volatilisation of the excess of camphor
serves to mask the iodoform odor.
Terpineol—the chemical name for the perfume Lilacin
found in several essential oils—imparts the odor of lilac,
and is claimed by some to answer better than all others.
A stick of menthol enclosed in a well-stoppered bottle
about half filled with iodoform is said to render the
latter inodorous after being thus enclosed together for
One or two hours.
Carbolic Acid, wº wº tº & & g g 1 part.
Peppermint Oil, . & tº e * g º 2 parts.
Iodoform, tº & o g { } º g . 197 parts.
is reported to work effectively.
Essential oil of coriander has lately been employed
in the proportion of 8 drops to 4 grammes (one dram).
It should be thoroughly mixed by trituration.
Finally, cumarin (the active constituent of tonka
bean), especially that artificially made, is also recom-
mended for almost entirely disguising the odor, and for
rendering it more agreeable as well by its own aromatic
odor. -
lodophenin—the combination of iodine with phe-
nacetin, containing 50 per cent. of iodine—has been
practically unheard from in this country during the
past year, and rather flat reports come from abroad.
Some favorable results come from the Paris Charity
Hospital, but elsewhere observers generally agree with
Dr. Siebel’s conclusions that it gives off iodine in excess
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 633
too readily and no specific action can be attributed to it
which iodine uncombined does not furnish.
lodopyrin—the chemical combination first prepared
by Dittmar, and obtained by replacing one atom of
hydrogen in antipyrin by one of iodine—has not been
used as universally as was expected. The observation
that its colorless, silky, needle-like crystals were only
slightly soluble in cold water, thereby rendering it prac-
tically tasteless, and that it was odorless, gave abundant
promise of a future for its use, but aside from favorable
results in a few cases of typhoid fever reported by Dr.
Egmont Munzer in the clinic of Prof. R. R. von Jaksch,
little is heard of it favorably. He also reports its use in
pulmonary tuberculosis, where profuse diaphoresis was
produced in conjunction with rapid reduction of temper-
ature to the normal. Theoretically it is split up into its
component parts in the stomach.
lodozone is the name given by Robin to a solution
of iodine in Ozone. The solution appears to be a com-
plete one, as no free iodine can be detected. The bene-
ficial expectations were first suggested by the well-known
value of pure sea air—containing traces of iodine (!). It
is recommended to be used as a spray in pulmonary
tuberculosis, and on Open wounds.
Ipecacuanha has again been alluded to as useful, in
cases of obstinate haemoptysis. A well-founded case is
now recorded where ergot and gallic acid utterly failed
and ipecac was effectual. Its administration must be
pushed to the point of producing nausea, as that condi-
tion is necessary to produce the desired effect."
Jambul (Jamun)—the seeds and bark of the Eugenia
Jambolana, a native tree of India—is rather in a mixed
state in regard to its proper position as an efficient rem-
edy in diabetes. Very conflicting testimony has been
reported, both from this and foreign countries; but since
the authorisation of the British Medical Association,
* Gaillard's Med. Jour., Vol. 53, p. 482.
634 JNETW YORK STATE MEDICAL ASSOCIATION.
given to its Therapeutic Committee to investigate it
thoroughly, a more strictly scientific turn has been given
to more general observations among the profession. Dr.
Sidney Martin, 10 Mansfield street, London, W., Secre-
tary of the Committee, invites all to coöperate in this
inquiry.
In keeping with this systematic spirit now awakened,
Dr. Thomas Stephenson, F. C. S., of Bombay, read an
interesting paper at the recent British Pharmaceutical
Conference, held in Edinburgh, in which he very defi-
nitely concludes that any preparation of jambul, as the
fluid extract, should be made from the fresh seeds, dis-
carding the pericarps and avoiding the application of
heat. He also finds that a weak alcoholic menstruum
exhausts the drug and gives a stable preparation.
The conflicting results heretofore reported may have
been due to a failure to follow the above plan of prepa-
ration, and not due, as some have stated, to the fact that
under the name of jambul are known a number of differ-
ent plants in India, and thus sophistication practiced.
This latter explanation of failure to obtain uniform
therapeutical results is refuted by Mr. G. Bidie, of Ros-
neath, England, as he states that the Eugenia Jambolana
is very widely dispersed and common in most jungles
of natural growth, and it would in most cases be more
difficult for the dealers to get the spurious than the
genuine seeds.
At some future date, then, we may confidently look
for the results of very definite scientific investigations.
Lysol—the saponified product of coal-tar, chiefly com-
posed of the cresols—has been widespread in its useful-
ness during the past year, particularly abroad. No
doubt the cholera epidemic has contributed largely
towards its consumption.
Notwithstanding its widespread use and undoubted
efficacy, it is not the me plus ultra which was claimed for
it in the beginning.
The conclusions for the year are best summed up by
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 635
Cadéac and Guinard, who have made a series of experi-
ments with it :
It is superior as a microbicide to carbolic acid, creolin,
cresyl and other analogous tar-products;
It has not, however, any advantages over the antiseptics
of established reputation ;
It is only really efficacious when used in solutions
which may be irritating or caustic ;
Although not destined to play a great part in Surgery,
it may often be useful in the prophylaxis and arrest of
epidemics;
It is likely to be particularly serviceable in the disin-
fection of premises, privies, ships and stables;
It is readily soluble, reasonably active and very cheap.
Methacetin (Para-Oxy-Methyl-Acetanilid) is the
colorless scaly crystals introduced by F. Mahnert in
1889 and which promises to supersede phenacetin. It
derives its name from its analogy to phenacetin. The
graphic formulas of these compounds show at a glance
the close relationship, but it will suffice here to state
simply that methacetin differs from phenacetin only in
containing a methyl group in the place of an ethyl
group ; phenacetin is oxy-ethyl-acetanilid and metha-
cetin is oxy-methyl-acetanilid.
It has been used successfully in typhoid fever, all
forms of rheumatism, neuralgias, pneumonia, and in
pretty much all forms of pyrexia, but from the record of
the past year it has not yet equaled the results obtained
by either phenacetin or antipyrin. Its use in pulmonary
tuberculosis was not favorable, principally on account of
the profuse night sweats produced.
Its advantages over all the other antipyretics, how-
ever, are its lack of poisonous properties and its com-
paratively ready solubility in water, being five times
more soluble than phenacetin—its greatest rival.
Methylene Blue (Tetra-Methyl-Thionine Chloride)
—the anilin derivative—not Methyl Blue, has secured a
more important place in the attention of observers dur-
636 NEW YORK STATE MEDICAL ASSOCIATION.
ing the past year. Formerly the commercial form only
was to be obtained, and that consisted of a double chlo-
ride of zinc and tetra-methyl-thionine, but by purification’
the zinc was eliminated, and now the agent freed from
this should only be asked for. The pure form is seen in
small, dark blue, scaly crystals with a copper bronze
tinge, soluble in water.
Just as Ehrlich and Leppmann previously reasoned
that as this dye manifested an affinity for nerve tissue,
and especially for the axis cylinders of sensor nerves, it
might prove to possess anodyne properties when intro-
duced into the system for neuralgias and rheumatic
affections, so in like manner the observation that it is the
best staining agent for the microbe found in malaria, has
suggested that it might act effectively in malarial affec-
tions. Thus Guttmann and Ehrlich took up the matter
and confirmed the expectation in two cases. Under this
treatment there is an increase of urine (colored from a
green to a deep blue, depending upon the length of ex-
posure to the air), and some strangury noted, but no
albuminuria. The faeces do not show the blue color at
once, as the methylene blue is apparently present there
in a reduced form, for upon oxidation by contact with
the air, the blue color is gradually developed. The
strangury was treated by giving small doses of powdered
nutmeg several times a day. This is apparently a remedy
often used in the south of Germany, to relieve the
uncomfortable feeling after drinking an excess of new
beer.
In our own country, Dr. John H. Huddleston, of New
York City, has treated three cases of malaria in children
successfully with this agent. No relapse followed.
Again, Dr. W. S. Thayer, Resident Physician to the
Johns Hopkins Hospital, Baltimore, Md., reports' on its
value in this affection, giving an account of his seven
cases, with temperature charts. He summarises as
follows:
1 Bulletin of the Johns Hopkins Hospital, 1891, Vol. 3, p. 49.
MATERIA MEDICA, PHARMACY. THERAPEUTICS, 637
1. It “has a definite action against malarial fever,
accomplishing its end by destroying the specific organ-
ism ; but it is materially less efficacious than quinine,
failing to accomplish its purpose in many cases where
Quinine acts satisfactorily.
2. The action appears to be rapid, the chills disappear-
ing, or the temperature in the remittent cases, falling to
normal during the first four or five days; but later,
however, if a sufficient number of organisms have re-
sisted the drug, they appear to develop again directly
under its influence, causing a return of the symptoms.”
3. It “seems to have no advantages over quinine,
which would warrant its further use.”
From abroad, Dr. G. Mya reports, in the same line of
treatment, on nine cases treated in the Ospedale di Santa
Maria della Scala, at Siene, giving substantially the
same results as those of Dr. Thayer. He even goes
further and states that by reason of its uncertainty and
the discomfort and even suffering frequently caused
when used for this affection, he would express “the
most absolute reserve with regard to its practical appli-
cability.”
Bourdillon details three cases of malaria successfully
treated with it, in two of which quinine had previously
failed. In using it for other affections, as neuralgia,
gonorrhoea, and tuberculosis, he remarks that perhaps
it is the malarial form of neuralgia in which it is of most
benefit. No effect was produced in tuberculosis, and he
even suggests that in doubtful cases it might be em-
ployed to distinguish tuberculosis from malaria.
Finally, Dr. G. Lava reports on two cases of malaria
without success, and concludes as follows:
1. It has no certain effect in this affection even after
five consecutive doses ;
2. Its action appears to be limited to a temporary
lowering of the maximum temperature, followed, how-
ever, later on by exacerbation and by shortening of the
period of intermission ;
638 JWEW YORK STATE MEDICAL ASSOOIATION.
3. The plasmodia are not only not destroyed, but not
even modified.
4. The enthusiasm of Guttmann and Ehrlich, above
spoken of, is somewhat premature.
It will thus be seen that opinions differ somewhat as
to its use in malaria, although it may be well used at
times as an alternate to quinine.
Among the other affections in which it has been em-
ployed Taube and others have used it successfully as
a local application in diphtheria in the form of a ten per
cent. solution, and Dr. Joseph N. Henry, of New York
City, reported at a meeting of the New York County
Medical Association, some months ago, his successful
use of it in two patients suffering from chronic cystitis.
He presented some of the characteristic blue urine for
examination.
Monochlorphenol is about the newest preparation
suggested for the treatment of pulmonary tuberculosis.
It is very little known as yet outside of Italy, where the
local physicians have been experimenting with it at the
suggestion of its introducer, the chemist Tacchini, of
Pavia.
It is prepared by the action of chlorine gas upon
phenol with the temperature kept low while the reaction
is going on. In fact, the completed preparation must be
kept at a moderately cool temperature up to the time of
using it, for theoretically it is to its extreme volatility
that it owes its beneficial effects, as the heavy vapor
given off is supposed to be destructive to the bacilli in
the lung tissue.
It is also recommended to be inhaled for various affec-
tions of the respiratory passages, but especially for pul-
monary tuberculosis.
We shall hope to hear something more definite of the
clinical reports before long.
Naphthalin (Naphthalene) is a hydrocarbon product
formed during the manufacture of ordinary coal gas.
When redistilled, it crystallises in colorless rhomboid
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 639
plates with a slight tarry odor. It is insoluble in water.
It is seen frequently in the form of moulded blocks
under such names as Alabastrine and Camphylene for
preserving furs and flannels from moths, and also placed
in urinals for disinfecting purposes.
It has been used also internally for some years past in
dysentery, all forms of diarrhoea, and somewhat as a
substitute for iodoform, but recently it has received
more prominence as a vermifuge and in the treatment of
pertussis. A Russian—Dr. Coriander, of Samarcand—
many years ago published the fact of its value for taenia
and ascarides, but it is only during the past year that
another Russian practitioner, Dr. Mirowicz, has called
attention to it again, and urged its more general use.
He claims for it, not merely that from its very character
it excludes the possibility of all unfavorable symptoms,
but that it is also thoroughly reliable in its anthelmintic
properties. He has given it for all kinds of intestinal
worms, and invariably obtained not only prompt but
complete results. Tape-worms were removed entire by a
single dose of one gramme. Adults are ordered a dose
of castor-oil to follow the naphthalin, but for children it
is preferable to give both together.
Of its use in pertussis, it no doubt will be interesting to
some to read what the London Lancet has to say in its
Annotations on the published paper of Dr. Chavernac,
of Aix: “Many remedies have been vaunted for the
cure of whooping-cough, but with little satisfactory
results in the great majority of cases. A proposal to
add naphthalin to the long list of so-called cures has
arisen in the following manner: Dr. Chavernac, of Aix,
during a recent epidemic, seems to have allowed his son,
who was eighteen years of age, while suffering from the
affection, to continue to attend school. One day the
lecturer on science heated some substance which gave
off very strong fumes, which, though disliked by many
Of the boys, had the effect on him of immediately stop-
ping a violent attack of coughing. As soon as the win-
640 NEW YORK STATE MEDIOAL ASSOOIATION.
dows were opened and the fumes passed away, the cough
recommenced as violently as ever. His father having
discovered that the fuming substance was merely naph-
thalin, had about an ounce of it burnt in the lad’s bed-
room, with the result that he breathed a great deal
more easily, and only had one slight attack during the
night. The next day, being at School, he had several
attacks, but they were somewhat less severe than they
had been previously. The next night the drug was
again burnt in the bedroom, and this second dose entirely
cured both the cough and the expectoration, which latter
had been rather profuse. The father was then attacked,
and in three days cured himself by the same treatment.
He subsequently tried it with several of his patients with
marked success, and with the concurrence of a friend,
who was medical officer to a convent school where the
epidemic was raging, he tried it on thirty affected chil-
dren. After the naphthalin had been burnt two success-
ive nights in their dormitory they were all cured. Two of
the nuns, however, found the fumes very irritating, and
on these ladies being examined it was discovered that
they were both suffering, quite unknown to themselves,
from incipient phthisis. From this and some further
observations Dr. Chavernac has come to the conclusion
that naphthalin is contra-indicated in phthisical persons,
and that it may sometimes serve to reveal the existence
of totally unsuspected tubercle. It may be remarked
that the so-called albocarbon used frequently for enhanc-
ing the lighting power of gas is somewhat crude naph-
thalin. The method employed by Dr. Chavernac is to
place about three-quarters of an ounce in a metal dish
surrounded by hot coals. It soon melts, and before long
fills the room with white fumes, which he considers
by no means unpleasant. The old custom of taking
children to gas-works for whooping-cough has gener-
ally been thought to depend on the curative effect of
gas-tar; but from the above it would appear that the
naphthalin which crystallises out in the retorts and
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 641
pipes is perhaps really to be more credited with efficacy
than the tar.”
Since the publication of Dr. Chavernac's paper, Dr.
Ivanoff has fully confirmed these results, but insists that
the treatment must be more thorough and prolonged.
He says he has treated all his cases of pertussis thus for
several years past, the results being invariably excellent.
He demands, however, that it is absolutely necessary
that the patient should inhale the fumes continuously
day and night until the treatment is complete. In very
severe cases he at times resorts to the use of sodium or
potassium bromide internally, in addition to the naph-
thalin fumes.
Naphthol (Naphthyl Alcohol) is the coal-tar deriva-
tive seen in the Sublimed, colorless, shining, laminar,
crystalline product, properly known as ſº-naphthol.
This has been in use for both internal and external ad-
ministration in a great variety of affections for more
than a decade.
Within the last year or two the a-form—a-naphthol—
has also been recommended as a marked antiseptic. It
apparently is more soluble and more efficient than £3-
naphthol, and possesses about one-third its poisonous
properties, but is more irritant. A solution of about
300 milligrammes (about 34 grains) to 1 kilogramme
(about 24 pounds) of water has been used to wash out
the intestines. Although the use of the two naphthols
has been pretty steady from the beginning, they have
been superseded somewhat by their near allies and deriv-
atives, such as Benzonaphthol, Betol, Hydronaphthol,
Iodo-Naphthol, Microcidin, Naphthol Camphor (cam-
phorated naphthol) and the like. The latter, although
now over two years old, has apparently taken a fresh
Start into prominence.
This is prepared by heating carefully one part of £3-
naphthol with two parts of finely powdered camphor,
until a homogeneous melted mass is obtained which is
of an oily consistency, insoluble in water. It should be
41
642 NEW YORK STATE MEDICAL ASSOCIATION.
kept well stoppered in dark colored bottles, as it readily
decomposes on exposure to air and light.
Since the first report of its use hypodermically by Dr.
Jules Reboul, of Marseilles, France, in the treatment of
twenty-seven cases of tuberculous glands, with only six
cases which did not show permanent improvement, he
has reported to the Paris Société de Chirurgie five more.
Out of the whole thirty-two cases, thirteen improved
perceptibly, but nineteen improved permanently. David
afterwards reported in an inaugural address fifteen cases
—Six of which simply improved, but nine improved per-
manently. The tuberculous adenitis did not entirely
disappear in all cases, but there could be no doubt as to
the remarkable improvement and favorable modification
of the condition. -
Dr. Reboul has since treated five cases of tuberculosis
of the testis, with very gratifying results. The treat-
ment appears to be perfectly harmless, and acts bene-
ficially both locally and generally.
It has had an extended use now in irrigating joints,
bony cavities, tendonous sheaths, cold abscesses in the
pleural and uterine cavities, and also in cases of tuber-
culosis of the bladder. All these localities seem to bear
well the undiluted fluid.
Finally, naphthol and all its derivatives cannot be said
to have superseded carbolic acid, although they no doubt
will find a permanent place on the list of valuable agents.
Orexin Hydrochlorate (Phenyl-Dihydro-Quino-
Azoline) a year ago did not give much promise for the
future, and it apparently has gained little since that
time. To be sure there are several who have re-
ported enthusiastically upon its use, but it is contra-
indicated in so many ways that its limit of usefulness
is necessarily restricted. - -
An Italian observer, A. Rizzi, has recently taken up
its study, and acknowledges that many conflicting State-
ments have been made by different observers as to its
action, and that there is a strong tendency to disbelieve
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 643
the claims originally made for it. His new research en-
courages one to believe that it may be of marked benefit
in certain cases of failure of appetite. He employed it
first on healthy subjects, and then on those with various
gastric disturbances. In the first class he found with
Prof. Penzoldt, of Erlangen (spoken of last year), that
it caused the appearance of a keen sense of hunger, and
produced increase both of the secretory energy and of
the peristaltic movements of the stomach. In cases of
atonic dyspepsia, complicated or not with chlorosis or
anaemia, he appears to have been equally successful with
Prof. Penzoldt, and to have obtained some very striking
results. He suggests that failure to obtain benefit has
probably been due in many cases either to the unsuita-
bility of the case, or to the fact that the salt used was
not pure. Gastralgia or hyperaesthesia of the gastric
mucous membrane should, however, always be taken as
a contra-indication to its employment, as in such condi-
tions it may do more harm than good by its irritant
action. He recommends giving it in the powder form,
enclosed in wafers, to be followed immediately by a few
swallows of water or broth to prevent it from remaining
confined to one locality of the stomach, and thus pro-
ducing too much irritation at that spot.
Ouabain is a glucoside obtained by extraction from
the root and wood of the ouabaio, growing in Africa, and
used there as an arrow poison.
It is sold in small pearly tabular plates, without odor,
only slightly bitter, and completely soluble in boiling
Water. -
Over a year ago Dr. Gemmell, of Glasgow, published
his successful results with it in pertussis, and believes
it to be of marked benefit in all stages of the disease.
For a child under five years he gave six-hundredths of a
milligramme (Tºry grain) every third hour, in Solution.
Stimulated by these results, Dr. J. Lindsay Porteous, of
Yonkers, N. Y., undertook to test it, and with very
gratifying results."
*New York Med. Jour., Wol. 54, p. 345.
644 MEW YORK STATE MEDICAL ASSOCIATION.
It had been used to some extent as an anaesthetic in the
eye, but had not previously been found to be as efficient
as cocaine. However, within the past year Dr. Joseph
Sailer, of Philadelphia, reports through the Therapeutic
Gazette, that he found it superior to cocaine as a local
anaesthetic. He has given an instructive series of conclu-
Sions based on his experiments on animals, a crude Out-
line of which may be of interest here: It causes a slow-
ing of the pulse, due to a stimulating action upon the
cardio-inhibitory function, and possibly in part to a
direct action upon the heart muscle. Along with this
action there is a primary vaso-motor spasm, due to an
action upon the vaso-constrictor fibres or the muscular
coats of the vessels. The slowing of the heart may be
SO pronounced in exceptional cases as to overcome the
vasomotor spasm and cause a fall of pressure. This
is at once followed, first by a great increase in the
pulse rate, caused by depression, and secondly, by paral-
ysis of the vagi and increase in pressure, due partly
to increased heart action, and partly to continued stim-
ulation of the vaso-motor system. Finally, the heart
muscle becomes paralysed, and the pressure rapidly falls
to Zero.
Therapeutically it may be classed as a potent emetic,
especially when given hypodermically. Defecation is
promoted, possibly by increasing the peristaltic action.
With great uniformity, it causes increased urination,
either by increasing the blood pressure, or by paralysing
the sphincter. The temperature of the body does not
seem to be affected.
Whether this agent will ever be of any practical value,
yet remains to be determined. Very small doses give
some evidence of a possible action similar to digitalis,
but if any great value is to be found in it, it will prob-
ably come from its potency as a local anaesthetic, as it
appears to be superior to cocaine in this respect. It
must be borne in mind, however, that it is an extremely
active poison.
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 645
Paraldehyde is still hampered by the same objec-
tionable features (taste and odor), previously noted, and
any progress made towards its more general use during
the past year has been in spite of its drawbacks.
For the purpose of ready reference, it may be well to
repeat here that it is the colorless liquid (at ordinary
temperatures), obtained by treating Aldehyde with dilute
sulphuric or nitric acid, and aldehyde is the oxidation
product of alcohol just preceding the formation of acetic
acid.
Since paraldehyde was introduced by Cervello, of
Palermo, in 1884, it has had a steadily increasing use,
there being remarkably few recorded cases of acute
poisoning, and a still smaller number of chronic poison-
Ing.
One case under treatment by Dr. Thos. Mackenkie, of
Douglas, Isle of Man, recovered after thirty-four hours
of sleep, from a dose of 99 grammes (34 ounces), and
furnished “a striking testimony to the safety of paralde-
hyde as a hypnotic.”
Several cases of tetanus have been successfully treated
with it of late, and it has given much benefit in the
insomnia of insanity and the milder forms of mania.
Most insane asylums now include this agent among their
indispensables.
Dr. J. Cockburn Syson, of Beith, N. B., has recently
given testimony' to its usefulness as a diuretic as well as
hypnotic : “In a case of senile arterial degeneration with
considerable mental depression, restlessness, marked
insomnia, and where there existed a double aortic mur-
mur, with a mitral regurgitant and enlarged left ven-
tricle,” he was induced to try it “after unsatisfactory
results from sulphonal, urethane, chloral, etc.” The
insomnia “was most intractable, and of all the hypnot-
ics used, with the exception perhaps of opium, paralde-
hyde on the whole gave the most satisfactory results,
and can be used where it would be decidedly risky to
* London Lancet, Vol. 2 for 1892, p. 195.
646 JWH) W YORK STATE MEDIOAL ASSOOIATION.
push the older drug.” To sum up, then, this agent
“may be looked to as a fairly reliable and safe hypnotic,
that its administration is followed by a well-marked
stage of excitement, that it does not depress the heart’s
action, does not interfere with the appetite or digestion,
possesses probably diuretic properties, and induces a
sleep which is described as ‘refreshing.’”
Pental (Tri Methyl-Ethylene) is the anaesthetic used
many years ago, under a slightly different form, con-
dition and name, and finally abandoned, but recently
restored to usefulness by Prof. J. von Mering, Director
of the Medical Policlinic in Halle. It takes its name
from having five carbon atoms in its composition. It is
obtained by distilling ordinary fusel oil from zinc chloride
after digestion with it for twenty-four hours. It is a
colorless liquid, very volatile and inflammable. It is
insoluble in water, and has an odor resembling mustard.
It is administered like chloroform, and requires only
20 cc. (about 54 fluidrachms) to produce in three to four
minutes an anaesthesia which, though not deep, is com-
plete enough for minor operations, such as extraction of
teeth. After administering it in one hundred cases, it
was found to be perfectly free from danger, and was fol-
lowed by none of the unpleasant after-effects of either
chloroform or ether. Even alcoholic subjects take it
well. The narcosis produced is not so deep as that after
the use of ethyl bromide, but it is far safer. It is not
necessary to push its administration to loss of conscious-
ness, as loss of sensation is produced before that stage
is reached.
There are now on record the reports of many observers,
each having his series of successful cases. Among them
may be mentioned Dr. Weber, reporting 200 ; Prof. L.
Holländer, 400 cases of minor operations about the jaw ;
and Dr. R. Breuer, of Vienna, with his 120 dental opera-
tions. The latter had one fatal case, and there have
been a few others reported, but their proportion to the
successful ones is extremely small, and it would Seem
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 647
that most, if not all, of these fatalities would have
occurred with any of the other anaesthetics.
A few foreign operators claim that they cannot succeed
with it at all, and are at a loss to explain the reason for
the success of the majority, but the unsuccessful ones
are so comparatively few in number, that they may be
recognised practically only so far as to invite investiga-
tion for some unusual cause.
Phenacetin (Para-Acet-Phenetidin), the acetyl com-
pound of phenetidin (the ethylic ether of para-amido-
phenol) occurring in shiny white laminar crystals, is well
known to every practitioner by this time. Its efficacy
is unquestioned, and during the past year it has not
only repeated its favorable impression, but has extended
its almost unbroken successful course.
In the treatment of influenza it has had its largest and
most favorable use, giving gratifying results almost
invariably. Fatal cases do still occur, but very infre-
Quently.
It may be useful, although the observations were made
over three years ago, to repeat here the results of “The
Comparative Value of Antipyrin, Antifebrin and Phena-
cetin as Antipyretics,” reported" by Dr. A. Crombie,
Surgeon-Superintendent to the General Hospital at Cal-
cutta, India, as they are not only none the less true to-
day, but have been abundantly confirmed and strength-
ened. The result left on Dr. Crombie's mind as the out-
come of his observations upon seven consecutive cases
were as follows: .
“First—As regards efficacy, antipyrin comes first, and
there is little to choose between antifebrin and phe-
nacetin in the doses in which I have prescribed them.
“Second—That as regards safety, the advantage lies
With phenacetin. I have never seen a sub-normal tem-
perature result from the use of that drug. I have seen
Subnormal temperatures as the result of the use of anti-
1 The Practitioner, Vol. 43, p. 266,
648 JNE W YORK STATE MEDICAL ASSOCIATION.
febrin, but never collapse, which I have once seen from
the use of antipyrin.
“Third—As regards rapidity of action, antipyrin,
probably on account of its solubility, comes first, anti-
febrin second, phenacetin third. The fall after the use
of phenacetin is more gradual, and the minimum is not
reached for three, four, or even five hours after the
administration of the drug.
“Fourth—As regards duration of effect the advantage
lies with phenacetin. *
“Fifth–As regards certainty of action, I would quote
them in the same order as that of rapidity—antipyrin,
antifebrin, phenacetin. And here let me give a warning
against the use of phenacetin tabloids. They are so hard
as to be practically insoluble in the stomach, or at least
to be so slowly dissolved that a very small quantity of
the drug enters and circulates with the blood at one
time, not sufficient to affect the temperature. It should
be prescribed either in powder or in lozenges which are
Soft and friable. -
“Sixth-As regards inconveniences, in the climate of
India, phenacetin is followed by just as profuse sweating
as either antifebrin or antipyrin, and this, to my mind, is
the great drawback in the use of antipyretics, patients
having to change their clothing once or twice in a night
after the use of any of these drugs. Whether or not an
antipyretic will yet be found which will be capable of
safely reducing abnormal temperature without causing
profuse perspiration remains to be seen, but as yet we
do not possess one.” -
Pheno-Salyl is the name given to a very recent anti-
septic introduced by Dr. De Christmas after experiment-
ing for some time at Pasteur's Institute in Paris. It is
little more than a mere mixture of
Carbolic Acid, about * e º tº g , 9 parts
Salicylic “ { { *. e e ſº e . 1 part.
Lactic & 4 4 & {} ſº * ſº tº . 2 parts,
Menthol { { tº gº º g * . Tº part.
MATERIA MEDICA, PHARMACY, THERAPEUTICS. 649
The menthol is added to the combined acids heated up
to the point of liquefaction. This mixture is soluble in
water to the extent of four per cent.
Von Yersin finds that it has almost double the anti-
septic effect of carbolic or salicylic acid, and is only
exceeded by corrosive sublimate. It is especially effect-
ive against the bacillus of anthrax.
Sufficient time has not yet elapsed for others to report
upon it.
Phenocoll (Amido-Acet-Para-Phenetidin) has re-
ceived increasing attention during the past year, al-
though the competition of such previously known and
tried agents as antipyrin, acetanilid (antifebrin) and
phenacetin have retarded its advance into the position it
seems destined to take in the near future.
The hydrochlorate is still the salt most used, although
the acetate, carbonate and salicylate are now furnished.
The acetate is so readily soluble, that it is well suited
and recommended for hypodermic use.
Dr. Paul Cohnheim reports his conclusions on a series
of cases. In five cases as an antipyretic, he found more
chilliness and more sweating than with antipyrin. In
twelve cases as an antineuralgic, seven of which had in-
fluenza, he reports it as equal to any of the remedies used
for a like purpose. He proves it useless in hysteria. In
two cases of acute rheumatism it proved serviceable, but
had no effect in chronic cases. It proved of no use in
two cases of bronchial asthma. He urges further trials
in neuralgia, especially when due to influenza.
Prof. Peter Albertoni has treated thirty-four cases of
malarial fever with this agent. Twenty-four were re-
ported cured ; in five there was no effect, and in the
remaining five the results were doubtful. The dose in
each case was one gramme (154 grains) given in powder
Or Solution from five to seven hours before the attack.
The attacks were aborted after one, or at the most two,
doses, but its use was continued for some days to prevent
a relapse.
.650 NEW YORK STATE MEDICAL ASSOCIATION.
Dr. P. Balzer used it in thirty cases in Prof. Eich-
horst's clinic in Zurich with satisfactory results in fifteen,
which included cases of typhoid fever, pulmonary tuber-
culosis, pneumonia and erysipelas.
Dr. Rudolph Bum has also made a careful study of
the whole subject, but only partially confirms the results
of the previous observers. Others also dissent somewhat
from the quite prevalent favorable reports, finding its
effect on the temperature quite pronounced, but the
duration short ; they would look for its proper field for
future usefulness in rheumatic and neuralgic affections.
Reports from our domestic observers are still meagre.
Phenolid is simply one of the now numerous mix-
tures containing fifty per cent. each of acetanilid and
sodium bicarbonate.
Little is heard of it practically anywhere, especially in
this country.
Piperazin (Di-Ethyline-Di-Amine)—formed by the
decomposition of ethylene-di-amine hydrochloride after
heating—has had an extended and almost uniformly
successful year.
During the later months of 1891 a series of experiments
were made by Dr. J. F. Holtz, in Schering's Laboratory,
On its action upon artificial urinary calculi, composed of
uric acid alone, and of calcium phosphate and of ammo-
nium urate, resulting in the observation that all of these
concretions were readily soluble in a one per cent. Solu-
tion within a comparatively short time. In a few of the
trials nothing remained but a honeycombed skeleton of
the concretion, consisting of solidified mucus. It was
very noticeable that the edges of some very sharp pieces
dissolved away quite rapidly.
Some months after this, Finzelberg recalled attention
to these points at a meeting of the Pharmaceutical So-
ciety of Berlin, and offered some suggestions as to its
administration and practical working, which may be
worth noting. He showed that in order to ensure its
complete action in dissolving the concretions in the cir-
MATERIA MEDICA, PELARMACY. THERAPEUTICS. 651
culation, it is desirable to retain it in the blood for a
considerable time. For this reason, then, it must not be
given in pill or powder form, but always in solution.
As it is capable of dissolving calculi, composed either of
single salts or of uric acid itself, a 3 to 5 per cent. Solu-
tion may be applied locally within the bladder, for the
purpose of dissolving calculi of mixed composition.
It was also pointed out by Dr. Hirsch, at the same
meeting, that from his experience, a 1 per cent. Solution
applied locally to open gouty sores, relieved the pain
and reduced the inflammation.
There is little doubt but that piperazin will now be
used more largely, as the price has been materially
reduced.
Pyoktanin (Methyl-Violet)—the anilin dye—still
continues to furnish confusing, and many times conflict-
ing, results. Observer A, for instance, will publish
astonishingly favorable results. Observer B will at once
rush into print stating he cannot see how A got such re-
sults, as he has been trying the antiseptic on similar
cases, and has rarely seen even improvement. Observer
C then comes to the rescue of A, and so on, so that if the
favorable and unfavorable reports were arranged in tabu-
lar form, they would not come far from balancing.
The oculists have apparently found good use for pyok-
tanin in a limited class of cases, and among others Dr.
Flavel B. Tiffany, of Kansas City. He seems to think it
especially indicated in deep-seated affections of the eye,
especially those of the uveal tract.
The laryngologists have met with some success in
treating the upper air-passages. Dr. R. P. Lincoln, of
New York City, has used it pretty generally in the dis-
eases of that locality, and also with many other prac-
titioners in diphtheria. With some of the observers’
results, however, it might be difficult to discriminate
between the beneficial effect of the corrosive sublimate
used and that of the pyoktanin. .
It has been used quite generally, particularly abroad,
652 NEW YORK STATE MEDICAL ASSOCIATION.
as an injection into malignant tumors, with very diverse
results. One successful observer in Paris goes so far as
to conclude his remarks with the statement that it may
well be discarded entirely “as one of so many remedies
which fill druggists’ shops without any advantage to
medicine.”
Pyridin | e º
and may be mentioned here for little else than
Pyrodin
to call attention to the striking similarity in name—
differing only by the vowel in the second syllable.
Pyridin has been known for some years as a remedy for
the dyspnoea of asthma and in angina pectoris. It is a
colorless, liquid, alkaloidal base, forming crystalline
salts with acids, and obtained principally from the tar
oils by the destructive distillation of bones. It is heard
little of in this country.
Pyrodin is the name given to an impure hydracetin
(acetyl-phenyl-hydrazin), a coal-tar derivative. It oc-
curs in the form of a white powder with alleged antipy-
retic properties, but the results are so uncertain and
variable that it is little sought after.
Pyrozone is the name given by a well-known manu-
facturer to a concentrated solution of hydrogen dioxide
in ether. It professes to contain about 50 per cent. Of
the dioxide, and is a very potent and efficient oxidiser,
intended for external use only. It has abundant appli-
cations known to most surgeons.
Quickine is the trivial, thoroughly unscientific, and
catchpenny name given to a so-called “new antiseptic,
antipyretic and antizymotic.” It consists of one part of
pure carbolic acid, two-hundredths of a part of corrosive
chloride of mercury, and one-thousandth of a part of a
mixture of alcohol and water, and manufactured by a
process of “dynamisation and potentialisation that
guarantees to the medical profession the absolute ac-
curacy and uniformity” of the product (!!!). The enter-
prising firm pushing this article has adopted the very
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 653
reprehensible custom, now all too common, of making
use of the name of some well-known practitioner, who
in the majority of cases, is totally averse to such pro-
ceedings, to indirectly promote their end by quoting
some article or isolated sentence of his to attract the at-
tention of the hasty reader, whereas probably the author
has not the remotest idea of even the existence of such a
product.
The loudly professed and much exalted liberty of our
good land is, in more ways than one, now rapidly being
extended to unwarranted license, and all without appar-
ent check or redress.
Resopyrin is occasionally heard of. M. Portes, some
time ago, called attention to it as being the name given
to the compound consisting of resorcin and antipyrin
mixed in solution in proportion to their chemical equiva-
lents. It occurs in colorless, oblique rhombic, prismatic
crystals, soluble in alcohol and insoluble in water.
Although it has been known for some years now, it has
not met with very general use.
Resorcin—one of the phenol derivatives—has not
Only held the position attained for itself a year ago, but
has steadily increased in favor by reason of the many
excellent results which have been added to its list.
It is accumulating much favor in the treatment of
diarrhoea of children, and the various forms of gastritis.
Pope recommends it in cases of gastric ulcer. Its
analgesic property is so marked here that the stomach is
enabled to tolerate food. He has also given it in cancer
of the stomach with some advantage.
Reports have been very favorable regarding its action
in producing quiet sleep in general nervous excitability,
and in the insomnia of typhus fever and pulmonary
tuberculosis.
In pruritus, apparently, the beneficial effect is quite
marked in the majority of cases, and the relief lasts for
SOme hours.
Tymowski recently speaks highly of it, as he reports
654 NEW YORK STATE MEDICAL ASSOCIATION.
having used it since 1884, applied locally to tuberculous
and other ulcerations of the larynx, in diphtheria, ton-
sillitis, pharyngitis, chronic rhinitis, etc. He uses solu-
tions of increasing strength up to a supersaturated
solution in cases where the ulcers are crateriform in
shape and are foul at the base. The application is quite
painless.
Moncorvo, of Rio de Janeiro, again calls attention to
his continued success in the treatment of pertussis,
by applications of this agent, to the peri-laryngeal mu-
cous membrane. By his method of application, which
he gives in detail, as he claims the technique is impor-
tant to secure favorable results, he affirms that he has
established a perfect prophylaxis for children compelled
to live with those who are suffering from the same
affection, has aborted an attack at the outset in twenty-
four hours, and has cured well-marked cases in from
nine to fourteen days.
Retinol (Resinol) — obtained by distillation of Bur-
gundy pitch—still continues to be used quite largely as
a solvent for many agents whose effects are enhanced by
the antiseptic property it furnishes.
Dr. E. Desnos, a French observer, is one of the most
recent who reports gratifying results from solutions of
Salol in Retinol—varying all the way from 5 to 10 per
cent., used in certain cases of subacute cystitis. The
peculiarity of this solution is that it will remain in the
bladder, in diminishing quantity of course, after six or
eight urinations. It has produced prompt relief in many
obstinate cases where other agents were of no avail.
Safrine is the fictitious name given to Safrol (to be
alluded to next), imported into this country as artificial
oil of Sassafras. Under such a name it has no medicinal
uses, but when mixed with citronella or cassia oil and a
small quantity of cedar-wood oil for preservative pur-
poses, it is extensively used, in the proportion of One
*Annales de la Policlinique de Paris for June, 1892, p. 265.
MATERIA MEDICA, PHARMACY, THERAPEUTICS. 655
part to one thousand, by our household soap manufac-
turerS.
Safrol is the principal constituent of Sassafras oil—
giving to it its characteristic odor. It is, however, now
obtained in much larger quantities from camphor oil.
This camphor oil is exported in large quantities from
Japan, and is a waste by-product in the production of
crude camphor. It is also exported to some extent from
the Islands of Formosa and Borneo. The Chinese have
used camphor oil for some time as a rubefacient in
rheumatism, and possibly this fact alone led to the closer
study of its constituents whereby safrol was isolated by
Schimmel.
Safrol has not by any means a general use, being little
known in this country, but it has been used apparently
with good effect in 1 to 2 cc. (16 to 32 minims) doses as
an anodyne in subacute rheumatism.
By far its largest use now, however, is in an industrial
way—to disguise the odor of the fatty bases in soap
making.
Salicylamide was first prepared by Limpricht by
treating oil of gaultheria with saturated ammonia water.
It has since been made, but not preferably, from methyl
Salicylate, the artificial oil of wintergreen. -
Dr.W. R. Nesbitt, of Toronto, Canada, has now report-
ed the results of his experiments with it, and has obtained
it pure in the form of perfectly colorless, thin, trans-
parent, plate-like crystals, moderately soluble in water.
It is quite tasteless, and leaves a grittiness in the mouth.
It is recommended as a substitute for salicylic acid,
having the several advantages of tastelessness, of greater
Solubility, of acting more promptly and in smaller doses,
and of greater analgesic properties.
The doses given were from 195 to 325 milligrammes (3
to 5 grains) several times a day. Clinical reports are yet
Wanting.
Salipyrin (Antipyrin Salicylate) is not yet obtainable
in this country, and all that has been seen of it here has
656 JNETW YORK STATE MEDICAL ASSOCIATION.
been brought over personally. There appears to be the
same conflict which existed a year ago between the rival
patentees of this and antipyrin, which prevents its free
introduction here.
From foreign reports of its use, it continues to have a
varied career. Many claim that they obtain effects from
its use in the different forms of rheumatism and in influ-
enza which are more favorable than those obtained from
either of its constituents; but as the fact of its being a
very loose combination at best has been still further con-
firmed, there would appear to be no good reason what-
ever for not administering the antipyrin and the salicylic
acid in conjunction, in proper doses to suit each individ-
ual case, with decided advantage of cheapness in favor of
this plan, as only about half the dose is necessary. From
careful consideration also of the reported favorable re-
sults, there would appear again no reason for not obtain-
ing as good results after the administration of the two
constituents in the proportion of about two parts of
antipyrin to three of salicylic acid—to be varied some-
what, according to indications in each case. It is to
be hoped that some observers will be induced to report
on such use of the constituents in comparison with
salipyrin itself.
Salol (Phenyl Salicylate), notwithstanding the many
unfavorable reports and toxic effects noted from various
sources, has made very substantial progress into a more
favorable recognition than looked probable for it this
time last year.
It has been generally taken for granted on theoretical
grounds that salicylic acid, when heated rapidly, is con-
verted chiefly into carbonic and carbolic acids. Wierp
and Ernert take exception to this, as they find by heating
salicylic acid up from 160° to 240° C., excluding the air,
it is converted into salol, water and CO3. Finding that
they could produce salol in quantity quite equal to that
indicated by theory, they patented the method.
The toxic effects noticed at times may be met, accord-
MATERIA MEDICA, PHARMACY, THERAPEUTICS. 657
ing to Dr. Chlapowski, by administering sodium sul-
phate, or (if not at hand) any other sulphate.
Drs. Lardier and Pernet recommend it in dysentery,
and Dr. Weber says that it is superior to any other rem-
edy in infantile diarrhoea. Dr. Mensi also confirms this
use of it. Dr. S. Rush Ketcham, of Philadelphia, speaks
of the dark staining of the children’s diapers, often
noticed, as due to the carbolic acid developed after ad-
ministering Salol.
The very conflicting reports from its use in cholera
have not by any means been so numerous as last year.
Much more has been accomplished than heretofore, and
yet there are a few observers who cannot yet understand
how the reported favorable results are obtained.
Dr. I. A. Mitropolsky speaks favorably of it in over
fifty cases of cholera. Dr. W. Loewenthal is also a be-
liever in it, and mentions that in the recent cholera epi-
demic on the Phillipine Islands the results were surpris-
ingly good, as Dr. F. J. Gonzales, of Salvador, claims to
have treated fifty-three cases with but three deaths.
Dr. Ph. Pégon reports good results from equal parts
of a heated mixture of camphor and salol when used for
suppurations of the middle ear. There is apparently no
pain and no irritation set up. -
Dr. E. Mansel Sympson, Surgeon to the Lincoln County
Hospital, England, makes good use of salol in the treat-
ment of chronic cystitis." It is much quicker in its action
upon the urine than benzoate of ammonium, as in a day
Or So, Ordinarily, the urine loses its foul odor and alka-
linity and becomes clear.
Gonorrhoea and genito-urinary troubles still continue
to be benefited.
Dr. B. Arnold, of Stuttgart, Germany, also reports
much benefit from its use in any acute or chronic
Catarrh of the bladder, and even goes so far as to
Compare it favorably with any other agent used for a
like purpose.
1 Practitioner, Vol. 48, p. 427.
42
658 METW YORK STATE MEDICAL ASSOCIATION.
As theoretically salol is not dissolved in the alimentary
canal until it reaches the pancreatic fluid, Dr. Le Ceppi
has suggested its use as a pill-coating. To carry out this
design, M. Yvon offers the formula:
Salol, $ © g g tº e ſº tº o Gm 2. 0
Tannin, . o e & e e © © e 0.5
Ether, e tº g tº 10.0
The pills should be carefully varnished with this so-
lution several times until a uniformly thick coating is
obtained.
Salophen (Acetyl-Para-Amido-Salol) is a new pat-
ented synthetic product manufactured by the F. Bayer
& Co. color works in Elberfeld, Germany. It is pre-
pared at the start by mixing equal parts of para-nitro-
phenol and salicylic acid. After a complicated process
it is presented as a complete product in small, thin,
laminar crystals, odorless, tasteless, and with a neutral
reaction. It is practically insoluble in water. -
The object intended to be attained in introducing this
compound was to obtain an agent which would not pro-
duce the unfavorable effects which have been thought to
result from the elimination of carbolic acid when salol
splits up in the intestines. The gastric juice has no ef-
fect on salophen, but it is split up when it reaches the
pancreatic fluid into salicylic acid and acetyl-para-
amido-phenol, which latter passes on with little further
change, and can be almost wholly accounted for in the
faeces and urine.
Up to very recently salophen has been used only in
isolated cases by foreign observers in minimum doses of
four to five grammes (60 to 75 grains) during a day—
chiefly in acute rheumatism. Frohlich recently reports
that in not one out of thirty cases of acute rheumatism
did this remedy fail. Like the other salicylates he finds
it cannot prevent relapses. He finds it can be given in
large doses and for a long period without unfavorable
effects. In chronic cases it is not nearly so efficacious.
It has only very slight antipyretic action.
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 659
In our own country, Dr. W. H. Flint, of New York
City, has made an interesting study of it in six hospital
cases with very gratifying results." He “concludes that
we possess in Salophen a remedy equally potent as the
other salicylates to control the symptoms of acute rheu-
matic arthritis, but devoid of their tendency to weaken
the heart’s action, to disturb the stomach, and to pro-
duce albuminuria and smoky urine. Whether these
claims for Salophen to superiority over the other deriva-
tives of Salicylic acid be well founded remains to be
definitely decided by accumulated statistical evidence.”
He finally expresses the “purpose to conduct a series of
experiments as soon as suitable opportunities present
themselves, with a view to ascertaining whether salo-
phen may be made available for the purpose of securing
intestinal antisepsis.” A more extended use is now
looked for.
“Sanitas.” Disinfecting Fluid (an unscientific trade
name) has been more widely used during the past year
as an external disinfectant and for surgical operations
generally.
It is an aqueous solution of turpentine, which has been
oxidised by exposure to air. It contains some camphor
in solution, thymol, hydrogen dioxide and a small pro-
portion of camphoric acid. The proportion of the latter,
however, is so small that it is hardly proper to claim, as
some do, any special efficiency of the Fluid as due to
this acid.
The Fluid has many combined advantages. It is a
good oxidising agent and antiseptic, is not poisonous,
and does not soil clothing when poured upon it.
Saprol (so-called “Disinfection Oil’’) is another new
disinfectant recently brought out. It is a dark-brown,
oily mixture, composed of the crude cresols in a great
excess of the liquid hydrocarbons obtained from the re-
fining of petroleum. This latter addition has the effect,
1 N. Y. Med. Jour., Wol. 56, p. 121.
660 NEW YORK STATE MEDIOAL ASSOCIATION.
by thus reducing the specific gravity of the mixture, of
rendering it so light that it will float as an oily film on
water and give up its soluble parts as disinfecting agents
to the offending fluid, leaving the remainder of the oily
film floating on the surface to prevent the escape of dis-
agreeable odors and the spreading of infecting spores.
An unfortunate drawback to its more general use is its
inflammability.
Laser has looked into its properties, and finds that
urine and faeces impregnated with micro-organisms like
the bacilli of cholera and typhoid fever, can be effectu-
ally sterilised by the application of about one per cent.
of saprol. It is cheap and can be well and economically
used on a large scale in barracks, prisons and Schools,
provided care be taken about proximity to fire. Laser
seems to have established the important point, of great
ultimate practical utility, that sewage treated with it
still retains its value as a manure.
Sodium Tetraborate is the name which has been
given to the comparatively new preparation obtained by
the combination of equal parts of Sodium diborate
(borax), boric acid and water. Heat is applied to com-
plete the reaction, and upon cooling, the new Salt (?) is
found to be neutral, thus apparently verifying the forma-
tion of an entirely new compound.
This salt (?) was introduced to furnish a more soluble
form of boric acid, as it has been well known for some
time that the solubility of boric acid was greatly in-
creased by simply adding borax.
It is at once recommended to be used wherever boric
acid is applicable, and it has so been used ; but Menz
finds upon investigation that it has the disadvantage of
forming hard crusts on dressings, and that these irritate
abraded surfaces.
This compound may yet find a place for itself and
claim more recognition than it has thus far received.
Solutol is one of the newest disinfectants belonging
to the same class as Creolin, Lysol and Saprol.
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 661
It was introduced with the idea of usefully disposing
of the by-products in the manufacture of carbolic acid.
The enterprising firm in Radebeul, near Dresden, which
has held from the first Kolbe's patent for the manufac-
ture of salicylic acid from carbolic acid, having reaped
all the benefit they could from the patent, which has
expired, now present this soluble form of cresylic acid
(cresol). Cresol itself being insoluble, and therefore
practically of little use as an effective disinfectant,
Sodium cresylate was added to produce that result.
Solutol is thus an alkaline solution of sodium cresylate
in an excess of cresol.
It is not suited therefore for surgical dressings or like
uses on account of its caustic alkalinity. It is, however,
of marked utility for very general and copious use in the
household, hospital and morgue for effectually disinfect-
ing water-closets, sinks, infected bed clothing, sputa and
deleterious discharges of all kinds. It is especially effec-
tive in the preservation of the cadaver.
Solveol is another useful disinfectant analogous to
Creolin, Lysol, Saprol and Solutol. It is another soluble
form, like solutol, of cresylic acid (cresol), but is ren-
dered so by the presence of sodium cresotate in place of
Sodium cresylate.
Its most striking qualification is its lack of that caus-
ticity present in solutol. It is a dark-colored, nearly
Odorless liquid, with a neutral reaction, and soluble in
water in all proportions, even giving a clear solution in
our ordinary hard waters.
It possesses a great advantage over creolin and lysol in
not exhibiting that greasiness so noticeable in these two.
In contradistinction to solutol it is especially appli-
Cable to surgical uses—a one-half per cent. Solution being
used in surgical dressings and a one to twelve for the
Spray apparatus. It is claimed that its antiseptic prop-
erties are far superior to those of carbolic acid, a half
per cent. Solution being more active than a two per cent.
Solution of carbolic acid.
662 NEW YORK STATE MEDICAL ASSOOIATION.
Somnal, the liquid hypnotic (made by the union of
chloral, alcohol and urethane) which was beginning to
receive a decided recognition from those who were not
expecting too much from it, has come to stay.
Its drawback, if it may be called such, has been, and
will continue to be its failure to be a general hypnotic,
applicable in all cases of insomnia, and those who expect
this of it will be repeatedly disappointed; but if all will
admit its applicability to certain classes of cases, favor-
able results may reasonably be expected in such cases in
almost every instance.
Dr. O. M. Myers, of Rochester, N. Y., has recently
made a careful and interesting experimental and clinical
study' of its physiological and therapeutic action, and
gives a summary which may very fairly be taken as the
present standing of Somnal: “Its sedative and somnifer-
ent action is strikingly efficacious in the insomnia occur-
ring during convalescence from acute disease. Where
an adynamic condition exists, it must of course be used
with caution. In whooping-cough, Spasmodic laryngitis,
asthma, “nervous cough,” and chorea, it possesses de-
cided sedative properties. A great element of safety is
that the action of somnal, so far as I have observed, is
never out of proportion to the amount ingested, nor does
it act in a cumulative or other unexpected manner. The
drug appears to possess little or no influence over insom-
nia due to acute inflammatory conditions.”
Sozal is the name applied to another very recent anti-
septic. It is the aluminum salt of para-phenyl-sulphonic
acid (sozonic acid), which latter is made from carbolic and
sulphuric acids, as described under the head of Sozo-Todol.
It is very soluble in water and keeps well. It occurs
in crystals with an astringent taste and slight carbolic
acid odor.
It is recommended for surgical dressings. It is a
rather weak antiseptic, and more experience and trials
are needed before it can come into more general use.
1 N. Y. Med. Record, Wol. 41, p. 286.
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 663
Practically nothing has been heard of it in this coun-
try, and very little of it in the old country as yet.
Sozo-lodol (Di-Todo-Para-Phenyl-Sulphonic Acid) is
another of the already numerous German antiseptics,
now patented in this country, but which has been far
less known here than abroad, where it has been used for
about six years.
An outline of the production of this agent may be of
sufficient interest to mention here : About two parts of
crude carbolic acid (phenol) are added very slowly to
one part of strong sulphuric acid. The reaction raises
the temperature to about 110°C. and continues for two
or three days, when para-phenyl-sulphonic acid (SOZonic
acid) is formed. Any excess of carbolic acid is removed,
and then iodine is added to form this Sozo-iodolic acid
(sozo-iodol). It contains about 54 per cent. of iodine,
20 per cent. of carbolic acid and 7 per cent of sulphur.
The ammonium, lead, mercury, potassium, Sodium and
zinc salts of this acid are the agents mostly employed,
being recommended as substitutes for iodoform on
account of their complete lack of odor. The sodium
salt, however, is the one most favored so far, and is seen
in bright needle-like crystals, somewhat prismatic in
form. A five to ten per cent. solution of this salt in
water is found to be about the most suitable limit.
Sozo-iodol and sozo-iodolates have been used in almost
every affection for which iodoform is applicable. In fine
powder it has been effectively used insufflated into the
nasal cavity and the larynx.
Dr. K. Witthauer has recently employed the mercury
Salt, as an emulsion, an insuftlating powder, and an
Ointment, with apparently good effect.
Nothing much has been heard from our own practi-
tioners as yet.
Spermin still claims attention from a few enthu-
siastic neurologists, but it has gained no place in the
estimation of conservative and rational observers.
664 NEW YORK STATE MEDICAL ASSOCIATION.
Styracol—the cinnamic ether of guaiacol—has made
no progress since last year, and little has been heard of
it either as an external antiseptic, in internal use in pul-
monary tuberculosis or in chronic catarrhs of the bladder,
stomach and intestines, from all of which something was
confidently expected by this time if expectations were to
be realised.
Sulphaldehyde –the new hypnotic of last year
(obtained by the action of sulphuretted hydrogen on
ethylic aldehyde)—has been little heard of either in this
country or abroad during the past year, and unless it is
being tried privately without reporting results, it may
practically be classed as dead. -
Sulphaminol (Thio-Oxy-Di-Phenyl-Amine) is a new
German antiseptic, introduced last year to replace iodo-
form on account of its lack of any odor. It is obtained
by the reaction between the salts of meth-oxy-di-phenyl-
amine and sulphur, and is seen as a light yellow powder
insoluble in water, and without taste or odor. Theoreti-
cally it is supposed to be decomposed into carbolic acid
and sulphur compounds by the digestive fluids. -
It acts after a fashion in checking suppuration in some
cases, and this may be said to be its chief claim, if any,
to recognition. It has been insufflated into wounds and
into the nasal fossae and sinuses of that region with
some reported beneficial effect.
A Polish practitioner, Wojtaszek, has now carried out
experiments on rabbits to test the claims of the intro-
ducer, and he finally “concludes that sulphaminol is
devoid of any physiological action. As regards its
alleged antiseptic properties, they also seem to be about
77,77.”
Very few reports have been made upon its use during
the past year.
Sulphonal (Di-Ethyl-Sulphon-Di-Methyl-Methane)—
produced by the oxidation of a mixture of ethyl-mercap-
tan and acetone—has been widely extending its sphere
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 665
Of usefulness during the past year, and has lost few of
its enthusiastic advocates.
Particularly gratifying results are noticed after its
employment in mental diseases of pretty much all classes.
The insane asylums throughout the world are now large
users of it, and pretty generally give favorable testimony.
It appears to be of special value in acute melancholia
and insanity. There are a few who claim, on the other
hand, that at times it exhibits a decided cumulative
action.
It is folly to claim, as some feel disposed to do, that it
is void of disagreeable results. One can hardly fail
noticing untoward effects, especially in cases where
much physical prostration is present. It has been stated
that it is looked upon with such suspicion in Turkey
that it has been interdicted throughout the Empire by
Imperial decree.
Surely caution should still be studiously observed in
its use, and the more so as its more frequent employ-
ment would tend naturally to render us quite oblivious
to its drawbacks and peculiarities. Fatal cases are still
being reported, but they are not by any means in pro-
portion to the increased number of successful ones.
As a striking contrast to this, Dr. Ernst Neisser
reports that a fifteen-year-old boy took 100 grammes
(34 ounces) of the fine powder at one dose with a copious
supply of water to wash it down. He slept continuously
for five days, but did not assume full consciousness un-
til the seventh. On the ninth day he left the hospital in
apparent good health. This case naturally should not
be taken as a precedent.
Dr. S. Grover Burnett, of Kansas City, Mo., has made,
and is still making quite a systematic study of its pres-
ent sphere of usefulness, and is continually looking for
new fields for it to occupy. He reports the results of his
Observations on four cases studied particularly to ascer-
tain the hypothesis to work upon in accounting for the
loss of reflex after large or continued doses. His obser-
666 NEW YORK STATE MEDICAL ASSOCIATION.
vations deserve reading by those who are at all interested
in this line of research."
Finally, the majority of the conclusions reported up
to this time are that, although by no means a perfect
hypnotic, sulphonal takes a very important place in the
treatment of sleeplessness and restlessness generally.
Sulphune (so-called “Pure Liquid Sulphur.”) is a
preparation introduced by a Western firm as a “cure-
all” for “diphtheria, ulcerated throats, open sores and
ulcers, skin diseases, rheumatism and other affections,”
which proves to be little else than an aqueous solution of
some of the higher sulphides of sodium and potassium
saturated with sulphur. Sulphides of calcium and mag-
nesium are present in small amounts, probably as im-
purities. .
The great imposition upon the public, however, is the
charge of $1.00 for a half-ounce vial of the product in a
pasteboard case with printed explanations, when the
whole get up of the thing should bring in a handsome
profit at a selling price of 25 cents.
It has not been as yet fully “sprung” on us here in
the East.
Terebene is produced by the action of strong sul-
phuric acid upon oil of turpentine and repeated distil-
lation to purify it. The latter part of the process has in
many cases proved tedious, and therefore ineffectual by
reason of the manufacturer's anxiety for too speedy
results. -
It is far from being simple in composition, for it con-
sists of camphene, cymene, borneol and terpilene. It is a
light yellow liquid with the pleasant odor of newly-cut
pine wood. It is practically insoluble in water, but may
be emulsified. It has been used for years as a very
decided and agreeable antiseptic, disinfectant and deo-
doriser, and has lost nothing thus far in usefulness. A
five per cent. solution makes a very serviceable surgical
1 N. Y. Medical Journal, Wol. 55, p. 406.
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 667
dressing, and its vapor, inhaled directly or through an
atomiser, acts well in bronchial affections and even in
pulmonary tuberculosis.
Thilanin is the name given by Seibel to a sulphuret-
ted lanolin—a new product. It is produced by allowing
sulphur to act on lanolin, and contains three per cent.
of sulphur. It is a yellowish-brown substance of very
much the appearance of Vaseline.
It is devoid of irritating properties, and has been
beneficially used by the dermatologists in most forms of
eczema, in acne, and in the many affections usually
treated by ichthyol and thiol, which latter it is designed
to replace. More extended use is necessary before very
decided opinions can be expressed.
Thiol-the German artificial ichthyol—has now been
in use somewhat over two years, and has made some
progress in its favorable results during the past year.
It is still used in the two forms of purer powder or scales,
and in the less pure liquid. The latter is about one-
third the cheaper because not purified, and therefore is
much oftener used. The liquid form is, again, much
cheaper than the natural ichthyol.
The gynaecologists have now come to be about the
largest users of the article, although the dermatologists
are not far behind them. The reports in its favor still
continue to be that it causes no pain, burning or other
irritation, does not cause bleeding from eroded parts,
promotes rapid absorption of effusions, and has advan-
tages over the natural ichthyol, besides being painless
and almost without odor, and that the stains produced
on linen are easily removed.
Thiophene is a hydrocarbon first pointed out by
Victor Meyer as occurring in all commercial benzenes
(from coal-tar). It is isolated from these by active agita-
tion with about one-tenth of the volume of concentrated
Sulphuric acid.
Thiophene itself has been little used therapeutically,
but its compounds, both lead and sodium thiophene-
668 NEW YORK STATE MEDICAL ASSOCIATION.
sulphonate and thiophene di-iodide, have been reported
on favorably by Dr. Edward Spiegler in Professor
Kapose's clinic in Vienna. The above lead and sodium
salts are of service in all forms of prurigo made up into
the form of ointments. Little irritation is produced, and
the lead salt acts slower than the sodium.
The thiophene di-iodide, occurring in small crystalline
plates insoluble in water, has been well used as a sub-
stitute for iodoform, and Dr. August Hock, of Vienna,
speaks well of its use clinically in the powder form in all
wound dressings, where it seems to retard the formation
of pus and to prevent exuberant granulations. It is also
of much service when applied by means of a gauze con-
taining ten per cent. The odor of such a gauze is not
only agreeable, but it acts as a deodoriser to suppurating
wounds, compound fractures, mastitis and caries of
bone, and in this it is far superior to iodoform. Eczema
complicating prurigo is better treated with this iodide
than with naphthol. Surgeons here have paid compar-
atively little attention to it, but no doubt more will be
heard of it later.
Thymacetin is a new analgesic remedy introduced
by Hoffmann, of Leipzig. It bears the same relation to
thymol that phenacetin does to phenol, and is a white
Crystalline powder, sparingly soluble in water.
Only a small quantity has as yet been available for
physiological tests, and therefore the reports are quite
limited, and little is known definitely of its action. Dr.
F. Jolly, of Berlin, however, read a paper recently giv-
ing his results after administering it to both the lower
animals and man. No definite results have yet been
obtained as to its antipyretic properties, but as an anal-
gesic and hypnotic it has shown something favorable.
In seven cases of migraine it had no beneficial effect, al-
though in other forms of headache it gave as good results
as phenacetin. In twenty-six cases of paralysis and de-
lirium with insomnia it produced quiet sleep in sixteen,
and had no effect in ten. The average dose required to
MATERIA MEDICA, PHARMACY. THERAPE UTICS. 669
produce the sleep was 500 milligrammes (7% grains).
The secondary effects noticed, were acceleration of the
pulse and a complaint of fullness, beating and noises in
the head.
Surely further trial is needed before any very definite
conclusions can be drawn as to its usefulness or fitness
for recognition among the great number of like remedies.
Trional ſº g
and are two comparatively new hypnotics
Tetronal
allied to sulphonal, which have been more or less on trial
for somewhat over three years. They are yet far from
widely known, and very little is reported on them in
this country.
They are produced by processes which are too techni-
cal to be reproduced here, but it may suffice to mention
that in 1889 Dr. T. Lauder Brunton reported on his in-
vestigations on the relation of chemical constitution to
physiological action, and thus led up to other investiga-
tions in this line. Among these was a report on the
physiological action of the disulphones, to which group
sulphonal and these two belong. It was found that only
those compounds containing ethyl groups were physio-
logically active, and the hypnotic activity increased with
the number of such groups. In Sulphonal there are
only two ethyl groups; in trional there are three, and in
tetronal there are four, as the etymology of the latter
two names indicate, and the hypnotic effect was found
to increase just in that proportion, tetronal requiring
Only half the quantity to produce the same effect as sul-
phonal.
Dr. Ernst Schultze, of Bonn, Schaefer, of Jena, and
the Italian A. Ramoni, have all reported favorably and
at length on the use of both these newer agents in series
of cases. Both agents are found to be superior to sul-
Phonal and chloral in being more prompt and vigorous,
in that the patient awakes more easily and generally no
unpleasant after-effects like nausea, vomiting and loss
670 JNEW YORK STATE MEDICAL ASSOCIATION.
of appetite follow, although occasionally there is slight
digestive disturbance, and in that the action is more
rapid. They both have a marked hypnotic and sedative
effect, but tetronal has more sedative action. Trional
acts more surely and promptly in the sleeplessness
accompanying the different forms of neurasthenia and
organic brain affections, and the sleep is more lasting
and sound. Therefore, it may be classed by some as
superior to tetronal, although it has less of the hypnotic
ethyl group in its composition. However, the sleep from
either lasts about six to eight hours, and is not generally
interrupted by dreams. No effect is produced in sleep-
lessness due to pain, and no untoward symptoms follow
the discontinuance of either.
Tuberculin (Parataloid) has had very considerable
attention paid to it in a much more quiet way during
this past year. The disappointed ones have dropped it
completely, and only those who love this kind of re-
search have pushed on with Professor Koch himself to
perfect it if possible.
In October last Professor Koch published his third
communication on the subject, dealing chiefly with his
chemical results, but he also gave at last the long waited
for and promised method of preparation. After reading
it carefully, it is very evident to all bacteriologists that
there was little need for having kept the process secret so
long, as his method of procedure had been known and
practiced by others before him, and although he must
have realised this fact if he did any current reading on
his subject at all, he gives the recognised investigators
no credit whatever, but rather takes all workers to task
for not accomplishing the results he would expect from
them.
Dr. W. Hunter is one of those who has made probably
the greatest step in advance in the preparation of the
fluid, but whose work, however, has been wholly ignored
by Koch. Dr. Hunter published his observations last
year, and now sufficient time has elapsed to see the im-
MATFRIA MEDICA, PHARMACY. THERAPEUTICS. 671
provement in clinical results obtained from experimen-
tation with his “A,” “B” and “C” modifications.
It may be well to repeat here that “modification A ’’
is the albumose precipitate thrown down from tuberculin
by the addition of ten times its bulk of alcohol. The
alcoholic filtrate left is the “modification C.” “Modifi-
cation B” is the solution obtained after isolating all the
salts from “modification C'' by precipitation with am-
monium sulphate and dialysis.
Numerous experiments upon cattle have been con-
tinued both in France and England with directly opposed
results.
Hospitals, dispensaries, and a few individual physi-
cians have experimented with the agent with very diverse
conclusions. The Hospital for Consumption and Dis-
eases of the Chest, at Brompton, England, reports its
results in cases of pulmonary tuberculosis and lupus.
It was used systematically for four months, during
which time thirty patients were treated with it, and the
conclusions reached were : “That the tuberculin did not
favorably influence the course of the disease in the
majority of cases; that in some the effects were detri-
mental; and that even in the stationary and improved
cases it was difficult to ascribe any distinct improve-
ment to the injections which might not have been equally
attained under the treatment ordinarily employed in the
hospital.”
It is reported that its further use in the military hos-
pitals of Russia has been absolutely forbidden on account
of both negative and injurious effects produced.
On the other hand, Dr. J. W. Springthorpe, of Mel-
bourne, Australia, publishes a second report of his
experience during three months with the use of Hunter’s
modification and with the ordinary fluid for more than
nine months, and concludes that “it seems probable that
the end will be, not the abandonment of the lymph, but
the elaboration of different modifications, each with a
Wide though somewhat different sphere of usefulness, and
672 NEW YORK STATE MEDICAL ASSOCIATION.
each, when properly used, operative and valuable beyond
all precedent in the treatment of tubercular disease.”
In our own country many prominent observers have
not only abandoned its use, but positively discounte-
nance its employment in any case.
Dr. Francis P. Kinnicutt, of New York City, however,
pushed his investigations in nineteen cases of pulmonary
tuberculosis treated in St. Luke's Hospital during last
winter with Hunter’s modifications. He concludes by
stating in substance that, although the number of cases
treated were very much too small to justly express a posi-
tive opinion in regard to its being a specific, still they
were sufficient to indicate the decided desirability of con-
tinuing investigations into its apparently specifically
beneficial effects.
Tuberculocidin (Alexin) is the name given by Dr.
E. Klebs, of Zurich, to his new preparation of tuberculin
obtained by treating the crude tuberculin with platinum
chloride. By such treatment the alkaloidal bodies are
precipitated, leaving a solution which differs from the
original by that much abstraction at least, and this elon-
gated name is given by Klebs On account of its supposed
antagonism to the tubercle bacilli itself, resulting in its
degeneration. This new derivative itself may be thrown
down from the solution as a precipitate by the addition
of alcohol, but it is usually retained in the form of solu-
tion for ready use.
Detter results have been obtained now in many ways
and by several observers from this modification than
from the tuberculin of Koch. Klebs claims from his
experiments upon animals that he has observed complete
regression of an apparently advanced tuberculosis, and
the sooner employed the better the result. He reports
on the treatment in man of seventy-five cases upon which
he feels ready to give his conclusions: Fourteen may be
classed as cured, forty-five as improved, fourteen unim-
proved ; and two died. The severest cases were among
the unimproved.
MATERIA MEDICA, PHARMACY. THERAPEUTICS. 673
These results are surely very encouraging, but after
the many failures already on record, observers will Con-
tinue to be sceptical as to the claim of tuberculin Or any
derivative being completely curative. *
Tumenol is another comparatively new compound
closely allied to ichthyol. It is obtained by treating the
unsaturated hydrocarbons of mineral oils with concen-
trated sulphuric acid. There are several compounds
formed by a more or less extended treatment, not of
moment here, known as “Commercial Tumenol,” “Tu-
menol-Sulphone” (Tumenol Oil) and “Tumenol-Sulpho-
nic Acid,” varying somewhat in their physical proper-
ties, and therefore applicable to somewhat different
cases. The first is a dark-brown almost black fluid, the
second is a thick, dark-yellow, syrupy fluid with a bitter
taste, and insoluble in water, and the third is a dark
Odorless powder, with a peculiar slightly bitter taste and
readily soluble in water. One is reminded strongly of
ichthyol by these preparations, and yet the former con-
tains, from the nature of the products used in its prepara-
tion, much more sulphur than these latter compounds.
Prof. A. Neisser, of Breslau, now reports to the Ger-
man Dermatological Society his results with these com-
pounds for the past two years. The “Commercial
Tumenol” was in general found to be most efficacious
and somewhat the cheapest form. Aside from a most
generally used ointment excipient, the tincture was most
Serviceable. He finds that unlike ichthyol, which de-
pends for its action on the sulphur in its composition,
the tumenols rather owe their therapeutic action to their
powerful reducing properties. Their action appears to
be chiefly superficial.
Almost universal success follows its use in all forms of
pruritus—particularly when the tincture is used. Moist
eczemata are specially benefited, and good results are
generally obtained when used in erosions of all kinds,
excoriations and superficial ulcerations. Although it
may act well in some deep ulcerations, still it does not
43
674 NEW YORK STATE MEDICAL ASSOCIATION.
possess this property as markedly as ichthyol. Neither
is it at all anti-parasitic in its action. It is not at all of
service in erysipelas, which ichthyol, or better thiol, is.
Little has been reported concerning it in this country
as yet. -
Urethan (Ethyl Carbamate), which was brought into
prominent notice about the middle of the year 1885
by the interesting and extended researches of Dr. O.
Schmiedeberg, Professor of Pharmacology in the Uni-
versity of Strassburg, “On the Pharmacological Action
and Therapeutic Application of some Ethereal Salts of
Carbamic Acid,” we hope may still be of sufficient interest
to recall here an outline of its preparation. Commercial
ethyl chloro-carbonate is treated with ammonia water,
shaking the liquid, after neutralisation, with ether, wash-
ing the ethereal extracted portion with water and distill-
ing off the ether, when the ethyl carbamate is left in the
flask—to be finally dried over sulphuric acid.
Since last year, it has been reported from some quar-
ters that this agent is “practically dead now.” This is
unfortunate if true, but can hardly be true. It is a mild
hypnotic at best, and therefore possibly more may be
expected from it than justly should be. There are now
so many not only very active and prompt, but powerful
and treacherous hypnotics in use, that this mild, moder-
ate, and safe one is possibly put into the background to
allow its more robust and vigorous rivals to occupy the
field, widely extended by remunerative advertising and
the too prevalent desire for novelty.
Urethan is such a safe and effective hypnotic to give
children that it would be undesirable, to say the least, to
retire it completely.
Weights and Measures by the Decimal (Metric)
System are in decidedly better favor now than at this
time last year. Much attention has been given to the
subject not only by individuals, but by societies—both
medical and pharmaceutical—to further its progreSS.
Scientific workers in all branches are presenting the
MATERIA MEDICA, PHARMACY, THERAPEUTICS. 675
subject to the public in all possible aspects to render
a trial use of it more inviting and easier of accomplish-
ment. The English are pushing the matter vigorously,
and in no more marked way than by their “New Decimal
Association (Established to promote the adoption of the
Decimal System of Weights, Measures and Coinage in
the United Kingdom).” They have a long list of their
prominent countrymen in their association in full Sym-
pathy with the work. They are wide awake to the stern
fact that their foreign trade and interests will insidiously
slip away from them if they do not join the fast increas-
ing number of those who have adopted this system per-
manently; and the United States are in the very same
predicament, with possibly the slight advantage in their
favor of having a coinage well fixed in that system
already. China is one of the latest nations about to See
the wisdom shown by their neighbors in Japan by throw-
ing over the old English system. “The countries which
have now already adopted this system represent a popu-
lation of 420,000,000.”
It has been pointed out by some objectors that there
are so many new terms to be learned that it is confusing,
but it should be recollected that about two-thirds of the
names usually given in the complete decimal tables are
Seldom used, even in France, and are surely not needed
in general use. In Germany only nine names are learned
and used for general every-day use.
The Revision Committee of the United States Pharma-
Copoeia are about completing their work, and physicians
and pharmacists should surely be ready for the approach-
ing edition with a reasonably clear knowledge of the
System to be used there exclusively.
DERMIC AND HYPODERMIC THERAPEUTICS.
By S. F. RogFRs, M. D., of Rensselaer County.
(Read by title November 17, 1892.)
[ABSTRACT.]
It is our purpose in this paper to consider the skin as
a medium for introducing medicines into the system. A
study of the anatomy and physiology of the skin, and its
relations to the underlying tissues, shows why our fore-
fathers in medicine looked upon it as a desirable avenue
for the entrance of their medicaments.
The skin not only serves as a protection for the deeper
tissues, but is an important organ of excretion and
absorption. Its anatomical structure shows clearly that
it is one of the four exits of water from the body. On
theoretical grounds there is every reason to believe that
the internal organs can be reached by medicines absorbed
through the skin, and there is abundant clinical evidence
to establish this theory as a fact. How often have we
all seen the constitutional effect of mercury produced
by its application to the skin as an ointment ; and how
often, too, has cod-liver oil proved a boon to humanity,
and bridged over a critical period, by supplying through
the skin the nutriment which could be obtained in no
other way ? I have found it the most readily assimilated
of all fats, and for our present purpose, the therapeutic
agent par eaccellence.
In cases of typhoid fever in which the administration
by the mouth of the mildest cathartic might give rise
to alarming symptoms, I have found that the dermal
method of administering castor-oil has often given fair
results. But it is not my purpose to enumerate all
the remedies which may gain entrance into the system
DERMIC A. WD BIYPODERMIO THERAPEUTICS. 677
through the skin ; I desire rather to insist on the
methods of administration.
Local diseases and injuries have always been treated
largely by local applications, and their use by the regular
profession has furnished an avenue for the entrance of
quackery into nearly every household. In enteritis,
peritonitis and pneumonitis, I never think of doing
without local treatment; and, indeed, the people have
come to look upon the poultice as an almost indispen-
sable part of the treatment of pneumonia.
Turning now to the subcutaneous cellular tissue, we
find that absorption through this channel is ordinarily
very rapid. It may be retarded experimentally * by
section or galvanisation of the sympathetic. But aside
from the influence of the nervous system, it is to be
remembered that the rate of absorption is in direct
proportion to the solubility of the substance. The local
action of some remedies induces inflammation, and so
interferes with absorption ; and, again, Some substances
prevent absorption by coagulating the albumen of the
tissues. This latter action is sometimes sought for, as
for example, in malignant pustule when we endeavor to
limit the formation of pus by peripheral injections of
iodine.
The hypodermatic injection of water as a substitute
for morphine has found some followers in the profession,
and Dr. Pollak actually quotes a case of Sciatica cured
by the injection of ice-water.
1 Claude Bernard, 1872, pp. 285–287.
SOME RECENT EXPERIENCE IN RENAL
- SURGERY.
By E. D. FERGUSON, M. D., of Rensselaer County.
November 17, 1892.
Statistics may or may not have value. Reports of in-
dividual experience may or may not possess interest.
Still we are in a measure dependent upon numerical con-
siderations in our estimate of the probabilities of the
effects of certain procedures. This mathematical method
cannot be vigorously applied to move or stay our hands
in surgical intervention, but it seems fairly applicable in
those cases in which general considerations would indi-
cate a notable hazard from interference—to those classes
of cases in which our average shortening of life may
equal or eacceed any increase we may induce.
This may be applied particularly to the class of cases
of which I am about to give examples, for renal surgery
has not entirely passed its tentative period, the details
certainly being debatable.
Recognizing the not unnatural tendency, which has
developed from safer surgical technique, to cut our way
through a tangle of morbid processes, it is manifestly the
part of wisdom occasionally to put the question, cut
bono, and seek the answer in an estimate of the probable
ultimate results rather than in the simple issue of life
or death as immediately related to our operative
measures. Some of our bold and brilliant operations
might not stand the test of such a tape-line, particularly
in the domain of malignant diseases of internal Organs,
and in that more recently assaulted portion of the human
anatomy—the brain.
RECENT EXPERIENCE IN RENAL SURGERY. 6.79
The cases I have to report present features and acci-
dents that impressed me as possessing sufficient interest
to warrant my putting them on record.
The first case:—A woman, aged about 40, consulted
me the last of May, 1891. She had been residing in the
city of New York, and her trouble had been variously
diagnosticated as consumption, malaria, uterine disease,
etc. She was greatly emaciated, had irregular chills and
some fever, evidently of a septic origin, but the presence
of a large amount of pus in the urine without corre-
sponding vesical symptoms, and a moderately movable
but enlarged and tender right kidney, taken in connec-
tion with a negative result from examination of the
other organs, rendered the diagnosis sufficiently com-
plete to justify interference.
She was sent to her former home in Plattsburgh, it
being the most satisfactory place to her for the rather
prolonged confinement to her room and bed likely to
follow operative work, and on June 23, 1891, I operated.
The delay was due to her inability to at Once accept an
operation, and the attendant preparations.
The lumbar incision was, of course, selected, and the
kidney was found largely distended with pus, in fact, it
was practically converted into a cyst, the amount of pus
being estimated at from twelve to sixteen ounces, but
the kidney had not been fixed by peri-renal inflamma-
tion.
The incision into the kidney was amply sufficient to
allow of a thorough exploration by means of the finger
and probe, and no calculus was found.
The absence of condensation of the peri-renal tissues
would have rendered the removal of the Organ a com-
paratively easy matter, but the profoundly weakened
condition of the patient would have rendered this major
proceeding quite hazardous at the time of the Operation ;
but the decision was in a measure influenced by the fact
that a quite common conclusion seemed to have been
reached that it was safer and better to do a secondary
680 NEW YORK STATE MEDICAL ASSOCIATION.
operation for nephrectomy rather than to remove the
Organ as a primary Operation, and so the kidney was
allowed to remain. Drainage by rubber tubes was pro-
vided, and the patient remained under the care of Dr.
E. M. Lyon, of Plattsburgh. Her fever subsided
promptly, irrigation was regularly practiced, her appetite
returned, slowly a fair degree of strength returned, her
urine was nearly free from pus, and she was in every
way apparently progressing favorably. In December
she came to Troy to be under my care, and soon after I
found some phosphatic deposits, apparently in the pel-
vis of the kidney—or the deeper portions of the sinus,
but from the fact that they were of a scale form led me
to hope that the deposit was limited, and that with irri-
gation, probe, spoon, and forceps I might get rid of them.
After a few weeks, failing to find any more, I hoped
that I had been successful.
During February, 1892, she contracted the prevailing
influenza, and suffered from a violent and persistent
cough, which after a few days seemed to develop some
mischief in the right renal region, for pain returned with
tenderness, and after a short time it was evident that
cellular inflammation was extending deeply in the direc-
tion of the psoas muscle toward the brim of the pelvis.
While unable to determine with certainty the method
of development of this complication, I was inclined to
attribute it to separation or tearing at the cortical portion
of the kidney where the sinus wall was attached, allow-
ing thus infection in the peri-renal tissues. The extreme
violence of the cough would render this plausible. The
fever associated with this new focus of inflammation, to-
gether with the bronchial trouble, made profound inroads
on her strength and rendered any serious operative meas-
ure extremely hazardous; but as she was now manifestly
sinking rapidly, she wished the chance that might come
from opening up the new focus of suppuration, and the
removal of the kidney if thought best. The progress of
the Suppuration downward had been such as to compress
RECENT EXPERIENCE IN REWAL SURGERY 681
the colon by means of inflammatory exudation and puru-
lent collection, so that severe attacks of colic became
frequent, and were evidently associated with the move-
ment of the intestinal contents in the region of the Caput
coli. The involvement of that portion of the bowel was
anticipated from the local condition and the symptoms,
and the expectation was confirmed a day or two before the
operation by the appearance of a faecal odor in the pus
discharging from the sinus—for this pocket opened into
the sinus, but could not be entered for purpose of drain-
age. On April 21st the operation was done. The outlook
was very unpromising, for she had again become ex-
tremely emaciated, and her pulse rate was from 130 to
140. On opening down to the locality of the disease, it
was found that the pus pocket had extended to the brim
of the pelvis and communicated with the colon, as shown
by seeing and hearing the escape of intestinal gas, as well
as the olfactory evidence. In order to afford any chance
for recovery, it seemed necessary to remove all sources
of a continuation of the inflammation, and to do this I
decided to remove the kidney. I can readily understand
why operators have been obliged to stop the operation
without completing the nephrectomy—all anatomical
landmarks are gone, the finding and isolating the kid-
ney, or what remains of it, from the surrounding dense
inflammatory exudate is a trying procedure, which can-
not be accomplished by any preconceived plan, but must
be managed as seems best in the individual case. After
a time the kidney was isolated and removed. The haem-
Orrhage from the pedicle was not profuse, but it required
Several ligatures before it was controlled, and then to
make it more probably secure, the actual cautery was
applied; the wound was packed with iodoform gauze
and the patient put to bed, in quite a profound degree of
Shock, and external warmth applied.
In the course of the removal of the kidney several
phosphatic concretions were found, but most of them
Were lost in the irrigations; but in the shrunken kidney
682 NEW YORK STATE MEDICAL ASSOCIATION.
which I show can be felt in one calyx a collection of
such concretions, which illustrates how readily they may
be overlooked, for I did not discover them until I had
examined it several times. I also show one of a nest of
calculi and a fragment of a larger concretion. The
future history of the case is what renders it particularly
interesting to me. I had met anuria following renal
and other operations several times, and it was antici-
pated as probable in this case. The shock gradually
passed off, and the time came for an investigation rela-
tive to the secretion of urine, but none was found.
Twenty-four hours passed, no urine; the prognosis very
grave. Thirty-six hours—no urine, the breath of a urin-
ous odor, mental faculties becoming sluggish. Forty
hours—still no urine, a notable stupor, the prognosis
unqualifiedly unfavorable, for I had never seen the func-
tion reëstablished after suspension for such a length of
time in a surgical case; but at about forty-four to forty-
six hours a little urine came ; it rapidly increased, and
in a day or two from three to five pints were secreted
daily. Though for a few days her life seemed in an
equipoised balance, improvement finally was manifest,
there was a complete subsidence of fever, the pulse fell
to about 90, and the ligatures came away on the ninth
day. The granulation process proceeded so rapidly that
at the end of two weeks the deep portions of the wound
had so filled as nearly to obliterate the pocket at the
side of the colon, the site of the ligatures was covered in,
the general functions were well performed, and she was
in every way comfortable on May 13th, the twenty-third
day after the operation. The wound had so far filled in
with new tissue that I proposed to begin the process of
strapping it on the following day, when a telephone
message late at night brought me the unexpected intel-
ligence that she had died within a few minutes from
secondary haemorrhage from the renal artery—an event
which I had feared in the early stages of the case, but
had come to regard as quite improbable.
RECENT EXPERIENCE IN RENAL SURGERY. 683
The second case was the wife of a physician, and her
first trouble resulted from a fall several years before I
saw her, when there was an injury from a nail to the
tissues adjoining the urethra. An irritable urethra re-
mained. During the winter of 1890–91 I first took
charge, and found her suffering from a probable pyelitis
of the left kidney. There was a free amount of pus in
the urine, considerable renal pain, and notable constitu-
tional symptoms. With rest in bed and the free use
of water the pus disappeared nearly entirely from the
urine, and her general health became good, but as the
urethra was sacculated and very sensitive just within
the meatus, I finally did a “button-hole” operation on
it in the summer of 1891, and with a few careful appli-
cations of nitric acid to the hypertrophied tissue lining
the anterior urethra through the button-hole opening, she
became quite comfortable and gained in flesh and strength
So as to consider herself as nearly recovered. Sud-
denly this favorable progress was interrupted by a recur-
rence of the pyelitis, and after a few weeks a tumor could
be felt in the left renal region. The constitutional symp-
toms were marked, the fever was high, the emaciation
rapid, so that about Christmas, 1891, I did a nephrotomy
Opening through quite normal renal tissue, but evacuat-
ing several ounces of pus. An exploration of the interior
of the kidney by the finger and the full use of the probe
failed to discover a calculus. With the exception of
Some trouble from the drainage tube, it being more diffi-
cult to maintain drainage where the kidney has not been
notably thinned by a large distention, she progressed
very satisfactorily, and was soon free from fever and
pain, had a return of appetite, and gained flesh so as to
be quite plump in her figure, while her color acquired a
healthy appearance.
During March, however, pain in the kidney returned,
and though drainage was well maintained, it was appar-
ent that new mischief was present in the kidney; the
fever and chills, the rapid emaciation and the severe pain
684. JNETW YORK STATE MEDICAL ASSOCIATION.
in the left renal region, while a free secretion of urine by
the bladder and the sinus still continued, led to the con-
clusion that disseminated foci of suppuration existed in
the kidney. The diminution of her strength was so rapid
that a fatal issue was apparently not very remote, and
she, realising fully the nature of the case, practically re-
quested the removal of the kidney. I neglected to state
that at the nephrotomy there had been a suppression of
urine for something over twelve hours after the opera-
tion, so that at the nephrectomy, after fully considering
the immediate and the remote risks, it was decided to
use chloroform. The operation was arranged for April
22, 1892, and just after I had made the incision through
the skin, the heart ceased to beat, and another case was
added to the list of those dying from cardiac syncope
under chloroform. After diligent efforts at resuscitation
had been made and it was apparent that life was extinct,
with the consent of her husband, I completed the incis-
ion and soon recognised what would have been a very
troublesome complication in completing the operation,
viz., a horseshoe kidney. While it is possible that the
diseased element of the compound organ might have been
removed by ligature of the connecting band, it is not
probable, in view of the continuity of renal tissue through
the connecting portion, that the patient could have Sur-
wived more than a few days.
The last case carries the lesson that very profound sys-
temic effects may be induced by moderate changes in the
renal structure; for, as will be seen by the specimen, but
little change had been produced; there was a moderate
pyelitis and a few small collections of pus in the renal
substance, none larger than a small bean.
In both these cases the pus contained in the urine had
been examined for tubercle bacilli with negative results,
and the foci of suppuration in the horseshoe kidney Were
also examined with the same result.
The apparent preference for a nephrectomy secondary
to a nephrotomy seems to me a doubtful surgical canon
RECENT EXPERIENCE IN REWA I, SURGERY. 685.
to apply in all cases. In the case of the horsehoe kid-
ney, had it not been for the malformation and the lethal
effect of the chloroform, the removal of the kidney would
have presented little trouble; but in this case the kidney
structure was but slightly changed at the nephrotomy.
In the first case, however, the kidney had been prac-
tically converted into a pus sac, and there was slight
ground to expect much function from it, and yet a very
large amount of urine escaped daily from the sinus from
the time of the operation until its removal. It could
have been removed at the time of the nephrotomy, and I
think I should have removed it, in spite of the general
opinion against such a procedure, had the patient not
been in such a feeble condition. In a similar case I
should be disposed to do so, and yet only a few weeks
ago I did a nephrotomy in which I allowed the kidney
to remain on account of the feeble condition of the
patient. He has progressed fairly so far, but the disease
was a pyelitis and pyelo-nephrosis due to cystitis, due in
turn to a traumatic stricture, and the cystitis not being
entirely relieved, while the pyelitis had placed him in
imminent danger, I felt that the lesser operation was all
that was justifiable under the circumstances. He may
improve so as to recover a fair degree of health without a
nephrectomy; but should a nephrectomy become neces-
sary, I should doubt its utility, from the fact that the
changes in the peri-renal tissue from the peri-renal in-
flammation, as shown by the sac-like condition of the
kidney at the time of the operation, would render the
procedure extremely difficult, possibly impracticable.
Those who have not undertaken the removal of a kidney
where there has been chronic peri-renal inflammation, so
as to cause the ordinary anatomical and usually easily
Separable layers of envelopes to be condensed into one
mass with the Organ itself, can form but little conception
of the difficulties of the procedure. It is quite possible
that this class of cases may show that operations pro-
duce a greater aggregate shortening than lengthening of
686 METAV YORK STATE MEDICAL ASSOOIATION.
life, and so on any true view of the office of surgery
should be allowed to pass on without interference. Ne-
phrotomy alone is so simple a procedure that it will be
justifiable in a large number of cases, for it will usually
prolong life, and may occasionally cure, but in the oper-
ation itself I feel that should the renal tissue be exten-
sively destroyed, and the patient’s condition will justify
the longer and more severe operation, it will occasionally
be justifiable to remove the organ as a primary procedure.
THE TREATMENT OF NEGLECTED CASES OF
ROTARY, LATERAL CURVATURE OF
THE SPINE.
By REGINALD H. SAYRE, M.D., of New York County.
November 15, 1892.
The correct treatment of lateral curvature consists in
never allowing a case to get into the condition of those I
shall describe to you this evening. After the patient
has become as distorted as those whose pictures I shall
show, it is impossible to remove the deformity, and your
efforts will simply be directed towards making the patient
as free from distress as possible, and in concealing instead
of remedying the deformity.
These cases all begin very insidiously. One of the
worst cases that I ever saw was said by her physician
to have lateral curvature at a time when the mother—so
she wrote me—could not believe that anything was the
matter with this child’s spine ; and yet, in after years,
when the case came to me for treatment, she was one of
the most distorted cripples I have ever seen.
When a mother brings a little child to you and asks if
there is anything the matter with its Spine, do not glance
at it hurriedly and Say, “There is nothing the matter
with it; she will grow out of all that,” but strip the
child to the hips, and let her stand in her own natural,
easy attitude, giving her time to accustom herself to her
surroundings, and allow her muscles to relax. In a
few moments you will notice a dropping of one shoulder,
and that the space between the body and the arms is not
the same on both sides. When first in the presence of
the physician these children very often hold themselves
quite erect for a few moments, but after the first feeling
688 NEW YORK STATE MEDICAL ASSOCIATION.
of strangeness has worn off, and their muscles grow a
little fatigued, they will allow themselves to drop into
the position which they habitually assume at home,
and then, and not until then, is the slight deformity
apparent.
Let the child then stand in front of you, hold its legs
between your knees, and, while its knees are straight, let
it bend forward and try to touch the ground with its
fingers. In this position, the scapulae fall forward and
the contour of the back becomes visible (Fig. 1), so that
slight degrees of rotation are thus perceptible which
escape observation while the child is in the upright post-
ure. This rotation is often more appreciable to the
hand than to the eye. In a certain number of cases you
will find that the starting-point of a lateral curvature is
a deformity of the last lumbar and first Sacral vertebrae,
and that the spine cants constantly to the right or left at
the lumbo-Sacral junction.
In some cases, the deformity is more apparent in front
than in the back. You will notice a prominence of one
hip, the flesh, at times, sinking in quite sharply above
the iliac crest, although the deformity in the back is
scarcely discernible.
Among the earliest evidences of rotation, is the in-
equality, which almost always exists, in the distance
from the umbilicus to the two nipples. This is fre-
Quently observed before any marked change in the back
has taken place. You will also usually find that the
breast on the side of the convexity is smaller than that
on the side of the concavity.
I have seen So many cases of bad lateral curvature,
where the mothers told me that they noticed an in-
equality in the two sides of the child when it was still
young, but that on consulting a physician they were
told that the child would “grow out of it,” that I feel I
cannot too strongly impress upon you the necessity of
observing these cases closely, and the importance of
taking measures to straighten these incipient curves.
TREATMENT OF LA TERAL CUR VATURE. 689
Rest assured, also, that if the child has a slight curve,
it will not “grow out of it” as it grows older, but rather
grow into it, and that when it comes to puberty, it
will have so decided a change in the ribs and vertebrae
that it will be impossible ever to wholly rectify the
deformity.
Fig. 1.
The generally received opinion that lateral curvature
develops between the ages of twelve and sixteen years, is
largely due to the fact that girls have their clothes fitted
more accurately at this time, and that in consequence, a
curve that has been present for a number of years is first
recognised – very possibly by the dressmaker—at this
period. Moreover, the increased bone growth which

690 NEW YORK STATE MEDICAL ASSOCIATION.
takes place at this age, causes the deformity to pro-
gress much more rapidly in a few months than it may
have done in the same number of preceding years. I
believe that rickets is a much more prominent factor
in the production of lateral curvature than is usually
believed. We all recognise those marked cases of rickets
in which the bones of the entire skeleton are more or less
deformed, but I feel convinced that many of the lateral
curvatures are due to a primary mal-nutrition which
manifests itself in unequal growth of the bodies of
the vertebrae, instead of finding its expression in the
lower extremities, as is usually the case. The fact that
these girls may be stout and well-nourished at the time
they come to you for treatment, does not invalidate this
statement, for after the active period of rickets has
passed by, the subject may develop into a robust,
healthy individual, simply bearing marks of his earlier
disease, and it is a frequent occurrence to see stout,
healthy men with aggravated bow-legs and other rickety
deformities.
In other cases, anterior poliomyelitis is the starting-
point for lateral curvature. I do not mean those cases
where there is a general involvement of the muscles,
which passes by, leaving one side paralysed, but those
milder cases in which the deeper muscles of the spine
are involved, possibly to such a slight extent as to
escape our observation, while yet establishing a want
of equilibrium in the muscular supports of the spine
sufficient to determine a lateral curvature, and one
which will be most resistant to treatment.
In some of the cases I shall describe this evening these
conditions have been present, and in others the curvature
has been consecutive to mal-formation of the ribs, to
pleurisy with adhesions, or to other complications which
we do not find in the true “idiopathic lateral curvature,”
So-called.
As I have said before, the most effective treatment for
lateral curvature consists in preventing it, as, after the
TREATMENT OF LATERAL CURVATURE. 691
occurrence of rotation and marked bone changes it is im-
possible by any system of treatment ever to restore
perfect symmetry. Some years ago I wrote more fully
on this subject of “prevention.” But even in these
badly distorted cases, although we cannot restore
symmetry, we can render the patients vastly more
comfortable, and can to a certain extent reduce their
deformity.
One of the great factors in causing rotary lateral
curvature of the spine, after the equilibrium between the
muscles of the trunk has been destroyed, that is, after
the normal curves of the spinal column have been dis-
turbed by some adventitious circumstance, is the super-
incumbent weight of the head and shoulders; and no
one can see many cases of lateral curvature without being
forcibly struck by the difference in the contour of the
body in the erect and prone positions. A patient who
looks very crooked while standing, will often present a
fairly symmetrical appearance while lying flat upon the
face.
In this spine which I now show you (Figs 2 and 3),
which is a model devised by Dr. Judson to illustrate the
action of the spinal muscles in causing rotation of the
vertebrae, you will perceive that when I press the button
there is a double curvature of the spine, like a letter S,
accompanied by rotation of the vertebrae, one upon the
other (Fig. 2), and you will notice that as long as I keep
my hand pressed upon this button, and so represent the
Weight of the head and shoulders pressing the spine
more and more out of the perpendicular, my efforts to
correct the curves by lateral pressure simply serve to
change the long curves into a number of small ones, and
that the spine is not made straight until I release the
button and allow the two ends of the S to recede from
each other (Fig. 3), or, in other words, take the weight
Of the head and shoulders off the spine, and allow it to
* New York Medical Journal, November 17, 1888.
44
692 NEW YORK STATE MEDICAL ASSOCIATION.
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become straight. As soon as I pull on this spine, I
Straighten it.
The practical application of this principle is of the
greatest assistance in eliminating the curves of the lateral
curvature. The amount that one of these badly distorted
spines will stretch while the patient partially suspends
herself by means of a head-swing and pulley is surprising
to one who has not measured it with a standard, and One
of the most important problems that presents itself to us
in the treatment of these cases is to find a suitable means
of retaining the improved position gained by this self-
Suspension.
In my own experience, nothing has been so satisfactory
for this purpose as a plaster of Paris jacket, and patients
who have been wearing for many years a great variety of
apparatus, applied by different gentlemen of large experi-
ence, tell me that they find the corset more comfortable
than steel braces; and as they increase in health and
vigor as well as in height, as shown by actual measure-

TREATMENT OF LATERAI, OUR VATURE. 693
ment, under treatment by suspension and plaster of
Paris corsets, I am convinced of the superiority of this
method of treatment over other mechanical means which
simply serve to make lateral pressure against the ribs.
In order to be effective in reducing the rotation of the
spine, which in these cases is the most serious element
t *
4.3 °
Fig. 4.—The arrow a shows the proper position for the application of
force in reducing rotation of the vertebrae; the 'arrows b b show the
improper direction.
in the production of deformity, vastly exceeding in im-
portance the lateral deviation of the spine, it is necessary
that the force be transmited to the ribs in a direction
away from the spinal column, and not towards it, as you
Will see by the accompanying diagram (Fig. 4). If the

694 IVEW YORK STATE MEDICAL ASSOCIATION.
force be directed as the arrow a points in Fig. 4, its
tendency is to twist the vertebrae towards the straight
position, whereas, if it impinges against the ribs, as
shown by the arrows bb, it tends to curve the ribs more
and more, and rotate the vertebrae in the wrong direction.
This second result is what practically takes place in all
portable, mechanical devices I have seen, which aim to
push the ribs into a straight position. They do not
practically carry out the principle which they are
theoretically supposed to embody, and the force which
is required to press these ribs into position is so great,
if concentrated at a single point, as in these mechanical
devices, that the pressure is more than can be endured
by the skin, without damage ; and I, therefore, prefer to
straighten the spine, as far as is practicable, by partial
self-suspension, then to apply a plaster of Paris jacket
while the patient is twisted as far as possible into the
correct position, and thus distribute the pressure equally
over the whole trunk. In this way I find that I can
support the weight of the body with much greater com-
fort to the patient, and much more efficiency than by
metallic straps and pads. I have often compared this to
pulling out an accordion and then preventing the accor-
dion from collapsing by means of plaster of Paris. It
has been objected to this principle that it practically
does not keep the accordion from collapsing, so, with a
view to settling this point, I have measured a number
of extremely bad cases of lateral curvature before treat-
ment and after they were supported in the plaster of
Paris jacket.
CASE I. E. O., fourteen years of age, whose picture I now pass around,
is a very striking example of improvement.
When first seen she was four feet eight and an eighth inches high. A
plumb-line dropped from the chin went outside of the right foot in front,
and behind ; a line from the nape of the neck passed one inch to the left of
the inner border of the left scapula. In front, the left nipple lay to the
right of the plumb-line dropped from the chin. After one month's exercise
she measured four feet nine and a quarter inches in her corset, a gain of one
and an eighth inches in one month. In three months' time she measured,
TREATMENT OF LATERAL OUR VATURE. (395
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Fig. 5. Fig. 6.
without the corset, four feet nine and a quarter inches, and with the corset
four feet ten and an eighth inches, being an increase in height of two
inches made by suspension and kept by the corset. Her first corset is
shown in Fig. 5, and her sixth corset in Fig. 6.
CASE II. N. H., fourteen years of age. On October 3rd, 1891, she
measured four feet six and three-quarter inches; after suspension, four feet
Seven and three eighth inches. This gain in height from the first suspension
was never entirely lost, as on the 5th of October she measured, before
stretching, four feet seven and an eighth inches, after stretching, four feet
Seven and a half inches. On October 7th she measured, after stretching,
four feet seven and five-eighth inches. On October 12th, in her jacket,
she measured four feet seven and seven-eighth inclies. On October 23rd a
new jacket was applied, and in that she measured four feet eight inches,
being a gain in less than one month of one and a quarter inches. This
patient has one of the most distorted lateral curvatures I have ever seen.
The deformity was congenital, and may possibly have been produced at
birth, as it was a transverse presentation. When the child was six years of
age she had pneumonia, followed by empyema on the right side. An in-
cision was made between the ribs, and the pus evacuated. There seems to
be an absence of ribs on the right side. The lower ribs project down
below the crest of the ilium, and between them and the upper ribs is a W-
shaped gap, through which the liver can be distinctly felt. It is possible
that, instead of there being an absence of ribs on this side, they are so
Crowded together as to give the impression that the full number is not
present. The mother thinks that these ribs were torn apart at the birth of
the child.





696 MEW YORK STATE MEDICALL ASSOCIATION.
CASE III. C. M., fifteen years of age. On September 24th, 1891,
height five feet one and one-eighth inch.
On October 15th, height five feet one and seven-eighths inches. Gain in
three weeks, three-quarters of an inch.
CASE IV. E. N., fourteen years of age. On July 7th, 1891, height
four feet eight inches.
On July 30th, height four feet nine and one-half inches. Increase in
three weeks, one and one-half inch. After stretching, height four feet ten
and one-quarter inches. -
August 5th, height in plaster of Paris corset, four feet ten and seven-
eighths inches, an increase in less than a month, while supported by his
corset, of two and seven-eighths inches.”
CASE W. W. K., fifteen years of age. On February 13th, 1891, four
feet nine and seven-eighths inches. After suspension, four feet ten and
five-eighths inches.
February 14th, suspended night and morning; height this evening,
after suspension, four feet eleven and one-quarter inches, a gain in one day
of one inch and three-eighths. -
February 20th, applied plaster of Paris corset. Patient has been exer-
cised daily and suspended ; height to-day, before suspension, four feet
ten and one-quarter inches; after suspension, and with corset, four feet
eleven and three-quarter inches.
February 24th, before suspension, without jacket, four feet eleven and
five-eighths inches; after suspension, with jacket, five feet one-quar-
ter inch.
March 2d, before suspension, without jacket, five feet one-eighth inch ;
after suspension, with the corset, five feet one-quarter inch, being an
increase in height in less than a month, of two and one-quarter inches in
actual height, and two and three-eighths inches in his height when the
corset was applied.
CASE WI. K. M., thirteen years of age, April; 19th, 1892. Height be-
fore suspension, four feet four and three-quarter inches; after suspension,
four feet five and three-eighths inches.
In October, height, without corset, four feet, six and three-eighths
inches; with corset, height four feet seven and one-half inches. (See Figs.
A, B, C, D, E, F, G.)
CASE WII. R. W., seventeen years of age. On September 28th, 1892, he
came to me wearing a metal support, which was designed to make lateral
pressure against his ribs, and which, from its construction, seemed to me
to be more efficient in compressing than in elongating his spine. I re-
quested his father to take the boy’s height in his brace in my office, and he
measured four feet eight inches; on removing his brace he measured four
1,This patient was shown after reading the paper. He measured without his corset
five feet one inch. A new plaster of Paris corset was then put on him, and he then meas-
ured five feet two and seven-eighths inches, an increase of one inch and seven-eighths.
TREATMENT OF LATERAL OUR VATURE. 697
feet eight and five-eighths inches. He was then suspended, and after
suspension, measured four feet eight and seven-eighths inches. This is not
the first case I have seen in which the patient was more crooked in his ap-
paratus than when left to nature. This patient suspended himself daily
until October 10th, when a plaster of Paris corset was applied, and in it he
measured four feet nine and one-eighth inches, being an increase in two
weeks' time of one inch and one-eighth of his height in his plaster corset
over his height in his iron brace.
CASE VIII. H. R., nineteen years of age, had spinal meningitis at the
age of three years which left him paralysed in various muscles of the trunk
and lower extremities. During convalescence he was allowed to sit in bed
propped up by pillows, and so developed a lateral curvature. He was
treated with a plaster of Paris corset and by braces for some time, when
his mother, becoming dissatisfied, sought other advice, and for years he
wore iron spinal braces of diverse kinds. After a length of time, he came
under observation once more, this time with an aggravated lateral curva-
ture, as you see in this photograph. His muscles are incapable of holding
the trunk upright, without artificial support, and I have tried wood,
leather and silicate jackets on him, but he says he prefers plaster of Paris.
I thought he looked much taller in his corset, and so wrote, asking him to
have his height taken, and send it to me. To day I received the following
letter :
- “YALE UNIVERSITY, \
November 14th, 1892. ,
“Just received your letter, and in reply would say that when I got my
new jacket on for the first time, I knew from the feeling there must be a
large difference in my height for I no longer felt a little man, but rather
that I had been drawn out by weight at bottom and pullies at top, to an
enormous height ; so, being anxious to know the exact fact, I measured
myself accurately and found to my great delight, as well as surprise, that
with my new jacket on (also shoes) I was five feet nine inches—how's that
for a stretch 7 Taking off my jacket, my height (with shoes) is five feet
Seven and one-eighth inches, making a clear gain of one and seven-eighths
inch. I now have hopes of reaching six feet some day by a good stretch.
“P. S. Since I received your letter, I have measured again with the
Same result.”
CASE IX. Emma D., twenty years of age. On March 23d, 1886,
She measured four feet six inches. -
March 30th. Patient has been suspended twice daily for a week;
to-day a plaster of Paris corset was applied ; height in corset, four feet
eight and one-eighth inches, an increase in height of two and one-eighth
inches, and a decrease around the waist of four and one-half inches.
September 27th, height, without corset, four feet seven inches.
October 1st, new corset applied ; height in it, four feet nine and one-
eighth inches. (See Figs. H, I, K, L.)
This patient was a most aggravated case of lateral
Curvature following infantile paralysis at the age of eight
years, which gradually passed off, leaving a few of the
698 NEW YORK STATE MEDICAL ASSOCIATION.
muscles of the trunk impaired. From the age of nine
she had always worn braces of some description, and had
grown steadily worse during this time.
You will notice in this case, as in all the others, that a
marked increase in height takes place at the first few
suspensions, but that after the initial gain the subse-
quent increase in height is only trifling. Of course, in
the younger patients, the increase in height which is ob-
served after the lapse of several months is attributable,
in part, to the natural growth of the body, but in a
woman of twenty the latter factor does not enter into
consideration, and she is only one of a number of cases
in which similar increase in height has been noticed.
I was long ago struck with the very great change made
in the spines of these patients by self-suspension, but it
was not until I had carefully examined the heights of a
number, both before and after suspension, and with and
without corsets, that I realised the enormous difference
made by treatment, the increase in many instances being
so great that I should have been inclined to discredit the
observation had I not made it personally.
In one case, with great distortion, in which there was
a marked presystolic and systolic murmur at the apex
of the heart, with great shortness of breath on exercise,
and pain in the right side on coughing, I noticed that
while the patient was suspended in the swing, the pulse
beats dropped from 140 to 122, from 144 to 116, from 122
to 100, from 100 to 86 on various occasions. Every time
I noted the pulse, it was from 18 to 28 beats slower while
suspended than when the patient was down; and with
the jacket applied, while it was not so slow as during sus-
pension, it was much less rapid than when the jacket was
not on—from 6 to 20 beats slower. This I attributed to
the fact that the heart was not so compressed, and was
therefore in better condition to perform its functions.
She noticed herself that her breath was not so short, and
that she was much better able to take exercise while
supported by the corset.
Severe lateral curvature, showing effect of self-
suspension and gain in height of five-eighths of an inch
retained by plaster of Paris corset.
FIG. A.

FIG. C.
FIG. B.

FIG. D.
FIG. E.

' ， ，
\， ，
， ， ，
Fig. G.
FIG. F.

Severe lateral curvature following infantile paralysis,
showing gain in height of three and one-eighth inches
from self-suspension retained by plaster of Paris corset.


Fig. K.

FIG. L.

TREATMENT OF LATERA L OUR VATURE. 699
I have noticed a similar slowing of the pulse in other
cases, but never to so marked an extent, and I have often
had patients remark the greater ease of breathing and
the relief of pain in the side while supported by their
COrsetS. -
While self-suspension, in the manner I have indicated,
is a most useful means of diminishing the curvature of
the spine, it is not practicable for a patient to suspend
herself for a long period of time; and, in many cases, I
am accustomed to add to self-suspension, Suspension by
means of a weight and pulley attached to a chin-piece,
which is fastened to the patient’s head while she lies on
her back on an inclined plane which is slightly convex.
The father of one of my patients has devised a most
beautifully constructed folding couch to be used for this
purpose, and which I show here. It is capable of being
taken apart and carried in a trunk, so that this treatment
can be constantly employed even during the summer
while the patient is away from home.
In correcting the rotation which, as I have before re-
marked, is a vastly more prominent element in the pro-
duction of deformity than the lateral deviation of the
Spine, I find great benefit from having the patient lie
face downward upon the floor or a firm table covered
with a thick rug, while I make strong pressure upon the
projecting scapula, pushing in a direction forward and
away from the central line of the body, so as to rotate
the vertebrae towards the median line (Fig. 4a). In some
cases I allow the patient to lie for half an hour in this
position with a sand-bag weighing twenty or thirty pounds
resting upon the shoulder, if it can be placed so that the
Weight falls in the proper direction.
To correct rotation, Dr. Beeley, of Berlin, has devised a
frame in which the patient leans forward, with the elbows
resting upon a couch, while the back is parallel with the
floor—very much in the position of a boy playing leap-
frog–while a strap passes across the back, sustaining a
heavy weight at its end. The objection to it is that the
700 NEW YORK STATE MEDICAL ASSOOIATION,
weight instead of twisting the spine around in the proper
direction acts to compress the ribs laterally, which objec-
tion Schede has recently tried to overcome in an apparatus
of his devising, by attaching the weight to broad bands
of adhesive plaster which are secured to the walls of the
chest. By these he endeavors to twist the spine around
a perpendicular axis, while the hips and shoulders are
held immovably fixed by means of iron props extending
from a circular frame which passes around the patient.
I have had no personal experience with Schede's
apparatus or with that of Bradford, which is designed
to accomplish very much the same purpose, but I have
been able with my hands to produce this twisting of the
spine. In Bradford’s apparatus the patient is partially
suspended by the hands and arms, the pelvis being
firmly fixed on a chair by means of a large screw. Pres-
sure is made against the chest walls at different points
by means of padded screws which pass from a circular
band of iron which encircles the thorax, at some distance
from it, and is firmly fastened to two uprights passing
from the chair.
In correcting the rotation of the spine, any apparatus
of this sort must pass to the floor for a base of support ;
and all the machines which have been designed to rotate
the upper part of the thorax, while the machine takes
its point of origin from the pelvis or thighs, are futile,
and are lacking in the mechanical power to perform the
work they are called upon to do. All that any machine
fastened to the body can do is to retain the improved
position which is gained by manipulation or force applied
from some fixed point outside the body, and to obtain
this improved position I am fully convinced that appara-
tus in the form of a corset, which completely encircles
the body, is preferable to those appliances which make
prºssure merely at certain points.
The material of which this corset is to be made is not
of vital importance, provided it is light and strong and
not impervious to the air. I personally prefer the plaster
TREATMENT OF LATERAI, OUR WATURE. 701
of Paris corset as being perfectly efficient and vastly
easier to construct than anything else. The wood corset
of Waltuch, if properly made, is as firm as the plaster
jacket and a little lighter; but as usually constructed, it
does not retain its shape, but warps, and when exposed
to the heat of the body is very apt to separate into its
component layers. The leather jackets, I have found,
are also apt to curl up along the edges, and in summer
time frequently acquire a disagreeable odor. The same
is true of those made of rawhide. The silicate of soda
jackets are lighter than those of plaster of Paris, but
have the objection that they retain the perspiration on
the body, and act more or less as a poultice. The wire
corset is very much cooler than anything else, and, in
certain cases, is probably the most comfortable retentive
appliance, but in others it does not retain the increase in
height so well as a more solid material. In one of the
cases I report this evening, who is now wearing a wire
corset, the height is seven-eighths of an inch less than
while she wore one of plaster of Paris.
The great objection, however, which I would urge
against all these forms of appliance is the difficulty with
which they are constructed. A plaster of Paris corset
has, first of all, to be made, in which a cast is made, and
Over the latter the leather, felt, wood, paper, celluloid,
Water-glass, or wire corset is constructed, requiring either
the services of an instrument-maker or the expenditure
of a great deal of time by the physician himself, and to
those who are not living in the large business centres, all
of these appliances are much more difficult to manufact-
ure than the ordinary plaster of Paris corset. In cases
of marked distortion, and for small children, these second
Casts do not fit so accurately as those made directly on
the body. Properly made, the latter, for a girl of six-
teen, should weigh from two and a half to two and three
Quarters pounds, or, if very heavy, three pounds; and
Yet I have frequently seen plaster corsets which weighed
from ten to twelve pounds. If the best dental plaster
702 JWEW YORK STATE MEDICAL ASSOCIATION.
be used, and well rubbed by hand into the meshes of
crinoline from which the sizing has been previously re-
moved by washing, and care be taken not to roll the
bandage too tightly or to put in too much plaster of
Paris, a corset ought never to weigh more than four
pounds for the largest person ; and those who complain
of want of success, and produce corsets like the one I
here show you, should only blame themselves for inabil-
ity to learn the proper manner of making a plaster of
Paris corset. -
You see that this one is like a section of the wall of a
house. It is almost solid plaster throughout, and in-
capable of being bent, and is not shaped to the patient’s
figure. On the other hand, I occasionally meet with
corsets which seem to consist almost wholly of crinoline,
contain no plaster of Paris in the meshes, and are as
useless as a handkerchief tied around the body. Or-
dinarily, it is the failure to use plaster of Paris properly
which makes physicians resort to felt and leather.
In putting the jacket on, it is important in these
greatly distorted cases that the patients should be sus-
pended some little time before the corset is made, in
order to gain as good a position as possible. Just before
beginning the application of the bandages, the patient
may come down and rest for a few moments, if the neck
be tired, and then stretch up to the fullest extent pos-
sible. The physician sits behind the patient and grasps
her legs tightly between his knees so as to steady the
pelvis, and then applies the bandages, beginning at the
waist, and passing from left to right in the ordinary
cases of lateral curvature in which the right shoulder is
prominent, as putting the bandages around the body in
this direction tends to remove the rotation. It is often
desirable to have an assistant push the prominent
shoulder forward, and hold it in this position, untwist-
ing the rotation as it were, while the jacket is applied.
It is always best to have an assistant in front of the
patient to keep the bandages smooth as they are applied,
TREATMENT OF LATERA L OUR VATURE. 703
and rub the layers together very thoroughly. The
bandages should be put, one at a time, in water of about
blood-heat, end up, the length of time required to put
on one bandage being about the proper time during
which the next one should soak. For padding the hips,
I use piano felt, made by Alfred Dolge, 120 East Thir-
teenth street; it costs $1.50 per pound. This quality is
too thick to be used for padding unless split in two.
The knitted shirts which are put on next to the skin,
and on which the best jackets are made, are knitted for
me by the Lawson Company, 783 Broadway, and come
down to the knees. The end of the shirt is reversed
after the jacket has been trimmed out, and is stitched
along the upper edge, thus completely covering in the
plaster of Paris. The ordinary Jersey-fitting underwear
can be used for this purpose in case of necessity. Between
the jacket and the skin, I slide a thin piece of tin, two
inches wide, as I can cut the jackets down much more
easily and quickly with this protection, and it also adds
greatly to the patient’s feeling of security. In growing
girls and adult females, it is necessary to put pads over
the breasts; except in the case of very thin people or
little children, the “ dinner pad” is usually not neces-
sary. It takes from twelve to fifteen minutes to com-
plete a plaster jacket. As soon as the jacket is made, it
is cut down in front on the piece of tin which passes
down the median line of the body, and is then removed.
In almost all cases, a thin slice is taken off each edge,
as, except in very thin persons, it is impossible to draw
the bandages quite tightly enough in the waist without
making wrinkles; and the addition of the kid which
covers the edge of the jacket, also makes it a little too
large unless this slice be removed. The edgets of the
jacket are then brought together, and retained in posi-
tion by an ordinary roller bandage. If the weather be
Very damp, the jacket may be laid near the fire to dry;
in ordinary weather, this is not necessary.
The next day, the patient suspends herself again, and
704 NEW YORK STATE MEDICAL ASSOOIATION.
the corset is put on, and fastened with a roller bandage.
It is then trimmed out under the arms and over the front
of the thighs until the patient can move her arms and
legs with comfort. After the jacket has been trimmed
out, and the end of the shirt reversed over the plaster of
Paris, the shirt is stitched to itself along the free border
of the corset. The front edges are bound with kid
pasted over the stitching, and a piece of leather con-
taining hooks, such as are used upon
shoes, is sewed with an awl and ºliº

ºš
waxed thread along each edge of the ºf
corset, the stitching passing through ºf
and through the plaster of Paris. ) ;
(Fig. 7.) Additional strength is given : A
to the jacket if this leather be wide º
enough to cover a thin strip of corset ºffl
steel, half an inch wide, which is \s（*
placed under it. In exceptional sº
cases of great deformity, it is some- Fig. 7.
times necessary to fasten a strip of thin steel on the
outside at the point where most strain is thrown. If
the cases be very badly deformed, it is expedient to put
padding inside of the shirt when it is reversed, in order
to make the jacket as symmetrical as possible, and thus
avoid the necessity of padding the clothes.
The corset having been made while the patient is
stretched out, it should always be applied to the patient
in this position. For this purpose, the patient is pro-
vided with a pulley-wheel and head swing at home by
which she can suspend herself in the morning, while the
corset is applied by some member of the family, and re-
tained in position by lacings joining the hooks on the
front of the jacket. The lacing should pass first around
the two central hooks at the waist, and then run down
to the bottom, be reversed, and pass up again to the top.
Applied in this manner, the corset fits better than if the
lacing is begun at either end. It is a mistake to cut cor-
sets down in two places, as I have frequently seen done
TREATMENT OF LATERAL OUR VATURE. 705
and the corset should not be made so stiff as to render it
impossible to remove it unless it is cut in two places.
I show you here two little plaster of Paris jackets
which have been made over a tumbler; the tumbler then
being removed, the open end of the box has been covered
with more plaster of Paris bandages. In the end of each
box is a hole which admits the stem of a tobacco pipe.
One of these boxes is varnished, and the other has been
left unvarnished, as all plaster of Paris jackets should be.
You will notice that when I blow smoke through the
pipe into the unvarnished box, the smoke passes through
the plaster of Paris on all sides; while, when I blow
smoke in a similar manner into the varnished box, it re-
mains inside, showing that this box is impervious to air.
As I have seen, in medical journals, articles advising
the application of shellac to plaster jackets in order to
render them more durable, I wish to draw your attention
to the folly of this procedure, as a jacket thus rendered
impervious to air becomes a poultice. In one instance,
which came under my father's observation, the whole
epidermis peeled off on the removal of a solid plaster
jacket which had been coated in this manner. -
The same objection, the impermeability to air, applies
to the silicate of soda and leather jackets, unless they
are punched full of holes.
Some of these cases of great distortion, especially those
dependent on paralysis, require artificial support as long
as they live, but others may have their muscles developed
to Such an extent that they can dispense with artificial aid.
The following are among the exercises I have found
most useful in these cases. They may be repeated three
times each at the commencement, and later on a greater
number of times, stopping short of fatigue in all cases.
In beginning the exercises a mat or thick shawl is laid
On the floor and the patient lies prone, the arms at right
angles to the trunk, palms down, face turned to the
Convex side, and the back as straight as possible (see
Fig. 8). The patient supinates the hands, throws the
706 ME W YORK STATE MEDICAL ASSOCIATION.
scapulae well back, raises the hands from the floor, and
lifts the trunk, while the surgeon holds the feet down
(see Fig. 9). This is repeated three times; later on it
can be done oftener. The breath should not be held
during any of these exercises, but the patient should
breathe naturally. If necessary to secure this, make
them count out loud while exercising.
With the hands behind the head, the patient raises the
elbows from the floor, and raises the trunk as before, the
feet being held by the surgeon (see Fig. 10).
With the hands behind the head and the elbows
raised, the body is swayed toward the convex side, the
patient trying to “pucker in ’’ the bulging ribs and not
to bend in the lumbar concavity. The feet are fixed as
before.
With the arm on the side of the convexity under the
body, the other arm over the head, the heels fixed, the
patient raises the trunk from the floor.
Sometimes the arm on the side of the concavity is put
on the opposite buttock (see Fig. 11), while the patient
raises the trunk (see Fig. 12). Sometimes the arm on the
convex side is put on the buttock (see Figs. 13 and 14),
and in cases of marked lordosis, with great stooping of
the shoulders, both hands are put on the buttocks while
the patient raises the trunk.

TREATMENT OF LATERAL OUR VATURE. 707
The patient now lies on the back, arms at the sides,
palms up, and lifts first one foot in the air, while the
surgeon makes resistance graduated to the patient’s
Fig. 9.
power; repeated, say, five times. The same is done with
the other foot, and then with both. The feet are next
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Eig. 10.
Separated and then brought together once more while the
Surgeon resists. Each leg then describes a circle, first
from within out, then from without in.







45
708 NEW YORK STATE MEDICAL ASSOCIATION.
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Fig. 11.
If there is special weakness at the ankles, with a ten-
dency to flat-foot, the patient flexes the foot and extends
it against resistance, and turns the sole of the foot
toward its neighbor, the surgeon resisting ; and it is
then forcibly everted again by the surgeon, the patient
resisting. -
The patient now lifts the arms from the sides, passing
perpendicularly to the floor till they are stretched as far
beyond the head as possible, and then, going at right
angles to the trunk and parallel with the floor, returns
them to the sides, palms up.
Fig. 12.
When the heels are held, the patient rises to the sit-
ting position, hands at the sides; then she rises from the
floor with the hands behind the head and the elbows at
right angles to the trunk.






TREATMENT OF LATERA L OUR VATURE. 709
The patient now stands with the heels together, toes
turned slightly out, hands behind the head, elbows at
right angles to the trunk (see Fig. 15); then rises on
tip-toe, bends the knees and hips, keeping the back as
straight and erect as possible, and rises up once more.
With the arm on the concave side high above the head,
the arm on the convex side at right angles to the body
(see Fig. 16), she rises on tip-toe, bends the hips, knees,
el * h. •--> - -
sº ºs, -º/* **
sºs
ss=s=
T-
* *
Fig. 14.
and ankles So as to Squat, then rises and stands. All
this time care must be taken to push the body as straight
as possible, and gradually educate the patient to hold it
So without Wriggling during
these movements.
Let the patient practice walk-
ing in these positions, both on
the flat foot and tip-toe, and also
Step high, as if walking up-
stairs. With the palm of the
patient’s hand on the convex
side against the ribs, pushing
them in, the hand on the con-
Cave side, she pushes a slight Žiž º
Weight up in the air, while the | / |
body swings so as to straighten - |
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* AN
º
*W
\\
Out the curves. Fig. 15.




710 JNETW YORK STATE MEDICAL ASSOCIATION.
Sit behind the patient, fix her thighs with your knees,
while she holds both arms above the head and bows
toward the floor, keeping her knees stiff while you keep
her ribs as straight as possible with your hands.
With the arm on the concave side across the top of the
head, and the arm on the convex side around in front
of the abdomen, the patient bends to the convex side
through the ribs and not through the waist (see Fig. 17).
The patient sitting with the back toward the surgeon,
the latter pushes one hand against the most projecting
part of the convexity, and, with the other hand passed
under the shoulder of the concave side, straightens out
the curve as much as possible, the hand on the “bulge”
acting as a fulcrum in Straightening the curve.
The patient sits on a stool in front of the surgeon, who
fixes the pelvis with his knees. The patient then twists
the projecting shoulder to the front while the surgeon
holds the elbows, which are at right angles to the trunk,
the hands being behind the head, and makes resistance.

TREATMENT OF LATERA I, OUR WATURE. 711
In the same position the patient swings forward and
back, Swinging through the hips, keeping the back stiff,
and not bending in the waist. -
The patient pushes in the ribs on the
convex side with the hand, and pushes
up with the hand on the concave side, the
same as when standing. She also lifts
the arm on the concave side up at right
angles with the body while holding a
weight.
In cases of round shoulders, wind-
mill motions of both arms and to-and-
fro movements of the head against re-
sistance are advisable.
The patient lies prone on the couch,
all the body above the waist projecting
from it, while the surgeon holds the
feels. With the hands behind the head, the elbows
thrown back, the body is bent toward the floor, then
raised up ; later on, resistance is made by the surgeon.
The patient lies on the concave side and rises up later-
ally. The patient lies with the convexity on the edge of
the couch, and hangs off as far and as long as possible.
One of the best exercises for removing the curve is for
the patient to place the head in a collar attached to a
cross-bar above the head suspended from the ceiling by
a compound pulley and rope. The patient now grasps
the rope as high up as possible, and pulls up hand over
hand until the toes iust touch the floor (Figs. D and E).
While hanging thus she takes three deep, full, slow in-
spirations and expirations. While she is hanging thus
the surgeon corrects the rotation by pushing the ribs
with one hand while he steadies the pelvis with the other.
Another good thing is for the patient to have a belt
passing around the pelvis, with a handle at each side.
Holding these in the hands, she straightens the arms out,
and the spinal column is thus stretched and straightened
much in the same way as by self-suspension.
Fig. 17.

712 NEW YORK STATE MEDICAL ASSOCIATION.
The patient stands bent forward as if playing leap-
frog, her hands on a chair, while the surgeon, with one
hand under the shoulder on the convex side and one hand
on the projecting ribs, corrects the rotation. It is advis-
able to steady the patient with the knee while doing this.
In keeping a record of cases, I find that photography
is a great help, and I also make use of tracings of the
thorax, taken while the patient is bending forward with
the arms drooped toward the floor. These tracings can
be taken either with a piece of flexible lead tape or with
this machine, invented by Dr. Beeley, of Berlin, which
consists of a number of steel rods, sliding loosely upon
each other, whose points conform to the outlines of the
trunk when the apparatus is pressed upon the back at
right angles to the long axis of the body, and held per-
pendicular to the floor, after the manner of the machines
used by hatters in getting an outline of the head. By
means of a lever, the steel rods are then locked in posi-
tion, and the machine is laid upon a piece of paper placed
on a thin sheet of felt ; then, with a little roller, the teeth
on the under surface of the steel rods are pressed into the
piece of paper, forming a line which gives the outline of
the back at the level where the instrument was applied.
By taking the outline of the trunk at each vertebra, in
this manner, the difference in outline of the trunk at
different portions and at different times can be recorded;
and such tracings, taken at intervals of Several months,
serve as excellent records of the progress of the case.
This method is, however, very much more tedious than
photography, and I employ the latter most frequently.
The following method of taking an outline of the entire
circumference of the thorax has been recommended and
employed by Dr. Mary Putnam Jacobi ; it gives a cross
Section of the body at any given point.
A piece of flexible metal tape, provided with a hinge
in the centre, is passed around the body at any desired
point, and made to closely conform to the contour of the
thorax. It is then removed by opening the hinge, laid
TREATMENT OF LATERAL OUR VATURE. 713
upon a smooth table, the ends of the tape being brought
into the same position they occupied when on the body,
and plaster of Paris mixed with water to the consistence
of cream is poured into the space enclosed by the tape
until it is completely filled to the upper edge of the lat-
ter. When the plaster of Paris has set, the tape is
removed, leaving a thin slice of plaster of Paris, which
represents accurately a transverse section of the body at
the point at which the tape is applied.
In these sections which I show you, and which were
made in this manner, the rotation of the spine is
very conspicuous, and the sharp angle of the ribs is
clearly brought out. I have marked on these sections
the line corresponding to the antero-posterior and lateral
diameters of the body, and the sections through the mid-
dorsal region show excellently the great increase of one
oblique diameter and diminution of the other, with prom-
inence of the right scapula; while the section through the
lumbar region shows the exact reverse of this condition.
These sections show very clearly the very adverse cir-
cumstances under which the heart and lungs labor in
performing their functions in
advanced lateral curvature,
and no one can perform per-
cussion or auscultation on one
of these chests without being
struck with the unusual num-
ber of abnormal sounds. Dis-
orders of digestion are also of
very frequent occurrence, and
many of the cases suffer from
severe neuralgias, due to pres-
sure on the intercostal nerves
as they emerge from the fora-
mina of exit between the
vertebrae.
Here is a preparation which
shows very clearly the great

714. NEW YORK STATE MEDICAL ASSOCIATION.
compression which sometimes takes place between the
ribs, and also how the bodies of the vertebrae may be rota-
ted around the perpendicular axis of the body, almost to
a right angle (Fig. 18). You will observe that the lumbar
and cervical vertebrae in this preparation are in the same
plane, while those in the dorsal region are rotated at an
angle of 85°, and the ribs are so compressed against the
bodies of the vertebrae that one wonders how the lungs
managed to expand at all. The rotation in this case was
So sharp that during life the projection was mistaken by
a number of gentlemen who examined him, for an antero-
posterior curvature of Pott's disease, the angles of the
ribs being mistaken for the spinous processes of the
Vertebrae.
In exceptional instances, where the ribs are so twisted
as to press against each other or against the crest of the
ilium, it may be necessary to resect one or more ribs in
order to give relief from pain in some cases, and in
others, to avoid caries from pressure.
While I formerly thought that many of these cases
were so distorted that it was useless to attempt to treat
them, I have, in a number of instances, yielded to their
solicitations, applied plaster of Paris jackets, and com-
menced a system of exercise, with so much benefit to
them that I have now changed my mind, and have come
to the conclusion that I have yet to see a case of lateral
curvature so bad that it cannot be rendered more Com-
fortable by treatment. If we can make these miserable
cripples less unsightly, can help them to conceal their
deformity, or can relieve it, even in a moderate degree,
the result is well worth the time and trouble spent upon
them.
JDISCUSSIOW. 715
DISCUSSION.
DR. DOUGLAS AYREs, of Montgomery county, asked for the author's
opinion regarding paper jackets made over plaster casts.
DR. SAYRE replied that the paper jacket was used about a dozen years
ago by Dr. Vance, of Louisville, and while it possesses the merit of great
lightness, it has the disadvantage of being impermeable, like the shellac
and plaster of Paris jackets, and of being very difficult to make. Jackets
may be made of paper, celluloid, wire, or wood, but the wire jacket must
be given the preference on the score of coolness, although it does not give
quite as good support. Thus, the girl whose picture he had just shown,
gained three and a half inches in about one year while wearing the plaster
of Paris jackets. She then changed to a wire jacket, and with this on she
measured seven-eighths of an inch less than when wearing the plaster
jacket. Notwithstanding this, it was so much cooler that she preferred to
wear it. The construction of the wire jacket demands the services of a
skilled mechanic, and hence it is not so well adapted for use in country
practice. The objection to all jackets made over a second cast is that the
imprint is not so sharp, just as the hundredth imprint from an engraving
is not as sharp as the first impression. Even slight variations are quite
important in the treatment of children. The wood and paper jackets are
lighter than the plaster of Paris ones, but they must be punched full of
holes. There are objections to all the various forms of jackets : plaster of
Paris softens; leather curls, and sometimes softens; wood warps, and wire
rusts, even though nickel plated. For steady, every-day use he preferred
the plaster of Paris jacket to all the others.
In answer to questions from DR. FERGUSON, Dr. Sayre said that the life
of a plaster jacket when it is not necessary to make changes for alteration
in the figure, depends very largely upon the patient. In making a plaster
jacket, he ordinarily employed about twelve bandages three inches wide,
and about fourteen yards long ; he generally used about five or six layers
of the crinoline, and rubbed the layers together well with his hands to
prevent the jackets from crumbling to pieces.
MEMOIR OF ABRAM DU BOIS, M. D.
BY SAMUEL S. PURPLE, M. D., OF NEW YORK COUNTY.
With a portrait.
Read November 17, 1892.
On the twenty-ninth day of August, 1891, Dr. Abram Du Bois, of the
city of New York, died. He was one of the founders of the New York
State Medical Association, and a distinguished member of the medical
profession. He was cut down by the grim messenger, like a shock of corn
ripe in its season. It is a wise custom, fragrant with Sweet influence, that
makes it a duty, at our annual meetings, to halt for a brief period from our
scientific labors, and pay a dutiful tribute to the memory of departed
members, to enumerate their virtues and commemorate their labors. To
the personal friends of Dr. Du Bois but little can be said which will add to
the sum of their recollections of his generous impulses and many virtues,
but there are those here who to-day are enjoying the fruits of his wise
counsels and the benefits of his earnest and indefatigable labors, and who
are not familiar with the events of his life.
On Dr. Du Bois' paternal side he was of French Huguenot descent, his
first ancestor in America being Jaques Du Bois, father of Peter Du Bois,
who was born in Holland in 1674, and came to America the same year with
his parents, and finally settled in Wiltwyck, now Kingston, N. Y. He
married Janneke Burhans.
The subject of our sketch was a descendant of Jaques Du Bois in the
fifth generation, and was the fourth son of Coert Du Bois and Mary Thorn.
He was born in Red Hook, Dutchess County, N. Y., on the fifth day of April,
1810. Shortly after his birth his parents removed to Rhinebeck, where he
remained until he was fifteen years old. He was then sent to a private
School kept by a Mr. Holcomb at Granby, Ct., where he was fitted for col-
lege. In 1827-28 he entered the sophomore class of Washington (now
Trinity) College in Hartford, Ct. He was graduated in arts from that in-
stitution in 1830, and returned then to Rhinebeck, where he commenced the
study of medicine under the direction of Drs. Platt and Nelson. In 1832,
by the advice of Dr. Nelson, he came to this city and entered the office of
Dr. John Kearny Rodgers, as a pupil. He found in Dr. Rodgers an able
teacher and a kind and ever valued friend. It was to him, as he once said
to me, that he was largely indebted for the success he afterwards attained.
He always remembered this kindness, as shown in his request to his OWn
family shortly before his death.
In 1832 he entered as a student the College of Physicians and Surgeons,
then located in Barclay street, and in which his preceptor was demonstrator
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MEMOIR OF ABRAMſ DU BOIS, M. D. 717
of anatomy. He received the degree of doctor of medicine from that insti-
tution in 1835. It was during the last two years of his pupilage that he
discharged the duties of an assistant to Dr. Benjamin Ogden, who was then
resident physician of Bellevue Alms House Hospital. In the July following
his graduation, with the advice of his friend and preceptor, he sailed from
New York for Paris, where he followed with diligence and commendable
assiduity the clinics of Louis, Andral and Chomel, in medicine, and Welpau,
Lisfranç and Sichel, in Surgery. He returned to New York in the month
of December, 1836, and shortly after, he and his former associate, Dr. D. L.
Eigenbrodt, received the appointment of assistant resident physicians to
Bellevue Hospital, which was still under the care of Dr. Ogden. Soon
after entering upon their duties in that hospital, Dr. Ogden was appointed
resident physician of Bloomingdale Asylum for the Insane, and while nom-
inally retaining the position of resident physician, he relinquished the duties
and compensation incident to the office, to Drs. Du Bois and Eigenbrodt.
He often said that this appointment was of the greatest value to him, as it
afforded him ample opportunity for testing, in daily practice, the views of
Louis and other distinguished teachers of Paris.
During this second residence in Bellevue an epidemic of typhoid fever
prevailed in this city, and the wards of the hospital were filled with pa-
tients suffering from this disease. The physicians of the city, he told me,
named it jail fever, ship fever, and camp fever, and their treatment con-
sisted in bleeding, and in administering calomel, James powder, spiritus
mindereris, etc. Dr. Du Bois and his associate, Dr. John A. Swett, who
was also his fellow student while in Paris, advised that a long, narrow,
two story building on the hospital grounds, which had been formerly used
for small-pox cases, be converted into a fever ward. This building was
thoroughly fumigated, cleansed and refurnished, and all typhoid cases
were transferred at once to it. The treatment in vogue at that time was
changed to the following: Cold sponging, cooling effervescent drinks,
plenty of fresh air until the fever had subsided, and then small doses of
quinine, with more nourishing food and stimulants. Under this treatment
the mortality greatly diminished, and it continued to do sountil the epidemic
ceased. As an evidence of the virulence of the epidemic, it may be said
that Dr. Du Bois and Dr. Swett were both attacked with the disease, but
recovered. He has often told me that the experience in the treatment of
diseases he acquired during his residence in this hospital was of the greatest
service to him in after years of practice. On retiring from the manage-
ment of the hospital, the commissioners of the Alms House, in appreciation
of his valuable services, presented him with a valuable case of Surgical in-
struments, accompanied by appropriate resolutions.
On the eighth of November, 1838, he married Catharine M. Brinkerhoff,
of Fishkill, N. Y., who proved a most worthy and loving companion, and
who with two sons and one daughter, mourn his departure. Dr. Du Bois,
Owing to his close relations and intimate friendship with Dr. Rodgers,
became strongly interested in ophthalmic medicine and surgery, and While
in Paris listened attentively to the lectures and clinics of Jules Sichel, the
718 NETW YORK STATE MEDICAL ASSOCIATION.
most eminent practitioner and teacher of ophthalmic medicine of that day.
In his preceptor's more important operations upon the eye, he was his as-
sistant, and these relations led to his appointment in 1843 as surgeon of the
New York Eye Infirmary, then under the direction of Drs. Delafield, Rodg-
ers and Wilkes, and located at 47 Howard street, New York. It was here
that I made his acquaintance in 1844, while attending the clinic of the In-
firmary. It was my privilege, as well as pleasure, to listen there to his
teachings and to observe the results of his skillful treatment. As surgeon,
secretary, trustee and vice-president he served this institution faithfully for
forty-eight years, or up to the time of his death. He ever felt a warm and
enduring interest in the institution, as evidenced by his large contributions
toward its support and development, which interest has been most gener-
ously continued by the surviving members of his family.
Dr. Du Bois held numerous offices of honor and trust in the profession
and society. He was consulting surgeon to the New York Institution for
the Blind ; consulting surgeon to the Northern Dispensary; consulting phy-
sician to the Home for Incurables; honorary fellow and benefactor of
the New York Academy of Medicine; honorary member of the New York
Medical and Surgical Society; founder of the New York State Medical
Association ; founder of the New York County Medical Association; mem-
ber of the Saint Nicholas Society; life member of the New York Historical
Society; benefactor of the New York Society for the Relief of Widows
and Orphans of Medical Men ; honorary member of the New York Physi-
cians' Mutual Aid Association; honorary member of the American Ophthal-
mological Society ; life member of the Charity Organisation Society, and
life member of the Huguenot Society of America. In the formation of the
library of this last named society he contributed liberal and important aid.
We have said that Abram Du Bois became a pupil of Dr. John Kearny
Rodgers, and here permit me to say a few words of this honorable member
of the profession. He was one of the most accomplished surgeons and
skillful physicians who has graced the profession of this city. He was the
grandson of that eloquent, popular and devout clergyman of this city, the
Bev. John Rodgers, D. D. His father was Dr. John R. B. Rodgers, a
graduate in medicine of the University of Edinburgh in 1785, a distinguished
patriot and surgeon of the American Revolution, and Professor of Obstetrics
in the first medical school established by Columbia College. A son of this
worthy sire was John Kearny Rodgers, who early became a favorite pupil
of that skillful and renowned surgeon, Dr. Wright Post, the Professor of
Anatomy in, and President of the College of Physicians and Surgeons of
New York. He was graduated in arts at Princeton College, N.J., in 1811,
and in medicine in the College of Physicians and Surgeons of New York
in 1816; he was also Demonstrator of Anatomy for his preceptor, house
surgeon of the New York Hospital, and for many years surgeon of the
same. He visited London in 1817, and became a pupil of the London Eye
Infirmary, then lately founded by Dr. J. C. Saunders. It was here that he
and the late Dr. Edward Delafield imbibed and formulated those ideas that
led to the final establishment of the New York Eye Infirmary in 1820, of
MEMOIR OF ABRAM DU BOIS, M. D. 719
which he was the leading Surgeon for more than thirty years. As an oper-
ator he was distinguished for ease, dexterity, and skill, and his operation
of ligation of the left subclavian artery within the scalenus muscle, for
aneurism, in October, 1845, was one of the surgical sensations of the day,
and brought honor to him from the surgical world ; it was the crowning
glory of his surgical career. He was in an eminent degree truthful in
all his habits, a man of sterling integrity, and a bold and earnest advo-
cate of conservative surgery, believing most firmly in the truth of John
Hunter's remark, that “When the surgeon takes up the knife he lays down
his science.” He abhorred quackery in all its forms, both in and out of
the profession—hence we find him an early advocate in 1846 of the forma-
tion of the New York Academy of Medicine, which was instituted in 1847
by “men good and true” for the expressed purpose of reorganising the
medical profession and purifying it from quackery in its various forms.
His name leads its list of charter members, as mentioned in that instru-
ment, granted by the Legislature of New York in 1851. If alive, there
would be no doubt where he would stand to-day—his position would be
that advocated so firmly and adhered to so nobly by his worthy pupil,
Abram Du Bois.
Dr. Du Bois possessed a generous and active philanthropy. He was
ever watchful of the needs of the profession, ever ready to extend a gener-
ous aid towards supplying means that would advance the good of the pro-
fession. When in 1876 the New York Academy of Medicine had, after
years of zealous labor, purchased a building and furnished the requisites
for a medical home, pledged for the improvement of the profession; and
when the rapid growth of the institution caused thereby had extended be-
yond the funds and means at its command, Dr. Du Bois, observing the
wants of the institution, although not a member, volunteered, unsolicited,
gifts which, in the aggregate, amounted to nearly fifteen thousand dollars,
and which led to improvements that greatly increased the usefulness of the
institution. But these generous gifts served as incentives for further bene-
factions, and at the time of the secession of the New York State Medical
Society in 1882, he had nearly completed plans for erecting a fire-proof
building for the Academy, at his own expense ; and to-day, but for that dis-
astrous movement, the institution would have been the better by, at least,
One hundred thousand dollars.
And now it becomes my duty to speak of Dr. Du Bois’ zeal and labor in
helping to found this Association, an institution in which he ever felt a deep
and abiding interest. When, in the month of February, 1882, fifty-two
medical men, more zealous than wise, severed abruptly the relations of the
greater part of the organised profession of the State of New York from
affiliation with their brethren of the United States, and when in February,
1883, ninety-five in an aggregate vote of two hundred could not restore the
desired affiliation, thereby confirming a great disaster, and bringing disre-
pute upon the good name of the profession of this State, Dr. Du Bois, in
keeping with his life convictions on the subject of the relations of special-
ism to the general practice of medicine, became a member of the Central
720 WEW YORK STATE MEDICAL ASSOCIATION.
Council which was formed in this city, and which formulated the plan
that led to the final organisation in 1884 of this honorable Association.
His wise counsel and his active labors did much to facilitate and hasten the
desired results which we here enjoy to-day. He ever watched with an earn-
est and appreciative interest the scientific work of this Association, and so
long as his health permitted, was present at its annual meetings. At the
annual meeting of 1891 the Association passed resolutions of respect to his
memory.
Dr. Du Bois, we have intimated, was a man of strong convictions, and
in the quiet discharge of what he believed to be duty, his courage never
failed. He was of a generous and noble nature, ever ready to defend the
right with his whole soul, and to extend unseen aid to the needy and un-
fortunate of the profession. His benefactions to various objects of public
and private charity, and to medical organisations were, during the last
eighteen years of his life (and I violate no confidence of the living by de-
claring it), more than seventy-five thousand dollars.
We have made allusion to his convictions on the relations of specialism
to the general practice of medicine. Like Dr. Thomas Addison he dreaded
becoming a specialist, for it savored of quackery. He looked upon the in-
troduction of specialism, as his keen foresight comprehended its antagonistic
propensities to manly relations between the family physician and his par
tient, as detrimental to a community of interests, and as most likely to be
subversive of the best interests of harmony in the profession. What has
the development of its workings in modern times proved ? The answer
comes rolling in from over the length and breadth of our land—“the loss
of confidence of the community in medical honor, and a gradual and steady
diminution of courtesy in professional relations.” These results he pre-
dicted with unerring certainty, and with an earnest and commendable zeal
he labored with us, until prostrated by his fatal sickness, to diminish, if not
prevent, their disastrous effects.
MEMOIR OF M. CALVIN WEST, M.D.”
BY THOMAS M. FLANDRAU, M. D., ONEIDA COUNTY.
Death, always solemn, is rarely more startling and impressive, than
when a prominent man...in full health and vigor is suddenly stricken down.
The city of Rome was greatly shocked by the announcement on the 20th
October last, that Dr. M. Calvin West, the subject of this brief sketch, had
been thrown from his carriage and that his life was despaired of. Within
thirty-six hours from the occurrence of the accident he was dead. Possess-
ing a fine physical development, unusual strength and activity, and almost
uninterrupted health, it was difficult to realise that he could not recover,
and that his familiar figure was never more to be seen. The ancient and
awful admonition of Notker, was again most painfully verified ; “Media
wita in morte sum us,” “In the midst of life we are in death.”
Dr. West was born in Rome, September 11, 1834. His father, John
West, was a successful farmer residing many years in that town. The
family was of English extraction, and had early settled in the State of
Vermont. The doctor received an academic education and graduated at
the age of eighteen. In 1857 he began the study of medicine in Hagers-
town, Indiana, with an uncle. Dr. Calvin West took the regular course of
instruction at the University of Michigan, at Ann Arbor, and obtained his
diploma in 1860. He commenced to practice his profession in Indiana,
and was a member of the Wayne County Medical Society of that State, of
which organisation he was also President. In 1861 he removed to Floyd,
in this county, and in 1863 to Rome, where he resided till his death. He
was for many years a member of the Oneida County Medical Society, of
the New York State Medical Association, of the New York State Medical
Society, and was a permanent member of the American Medical Associa-
tion. In 1861 Dr. West was united in marriage to Miss Felicia H. Williams.
She and their four children survive him.
Possessing a mind of excellent power, a quick and clear judgment, great
energy, and an agreeable address, he rapidly advanced to the front rank of
his profession, and to his death held a large practice, extending through
many of the northern towns of this county. There are few physicians who
possess more completely the confidence of their patients than he did, and few
Will be more widely missed or more sincerely mourned. His activity and
Capacity for affairs led him into many business enterprises. He was long a
director in the Central National Bank of Rome, and a stockholder in Rome's
Various manufactories. He was ever ready to contribute liberally to what-
ever would forward the progress of the city. For several years he was a
1 Read at the meeting of the First District Branch, July, 1892.
722 MEW YORK STATE MEDICAL ASSOCIATION.
member of the Board of Education of Rome, and was for ten years physi-
cian to Oneida County Almshouse and Asylum, but though strong in his
political convictions, which were those of the Democratic party, he was not
an aspirant for elective office.
The laborious character of the practice of medicine in the country and
smaller cities leaves little time for literary pursuits, and it was only in early
life that he was able to write on professional subjects or read papers before
medical societies. An article on “Hypodermic Injections,” of much prac-
tical merit, was published by him in the Cincinnati Lancet. I do not know
of any late contributions to the journals. If not a frequent writer, he was
always well read in the literature of medicine, keeping fully abreast of the
times; and while not willing to abandon the established results of the
experience of the past, was ready to accept and apply the discoveries of the
present, which with wonderful originality add continually to the science of
disease and to the armamentarium for its cure.
In his intercourse with the profession, Dr. West was always frank and
courteous, and the many members of it, who have come in contact with
him in consultation, will testify to the honorable treatment received from
him. Strong in all his convictions, he was strong in his faith in the prin-
ciples and doctrines of the regular faculty, having no tendency to any form
of empiricism. Deeply must all regret that one so capable by culture and
long experience of doing good to his fellow-men could be taken away in
the full development and fruitage of a successful career. We can only
explain such mysteries by a reference to that highest power, who con-
trols every incident of the Universe.
MEMOIR OF MYRON N. BABCOCK, M. D. 1
BY T. B. REYNOLDs, M. D., OF SARATOGA COUNTY.
MR. PRESIDENT AND GENTLEMEN OF THE ASSOCIATION : It becomes
my melancholy duty at this time to communicate the fact that since our last
gathering, death, the inevitable, has penned to the ever-increasing necro-
logical record the name of a distinguished brother, one who will be greatly
missed by the profession in general, and his many friends in particular. He
was one of the most prominent and influential founders of the New York
State Medical Association, of which this Second District Association is a
part or branch. Dr. Myron N. Babcock passed away quietly, peacefully, and
contentedly at his Ballston avenue residence in Saratoga Springs, Saturday,
May 21, 1892. It was the sunset of his useful life, and the chapter of his
existence closed while the day was merging into night; and as the curtain
of gloom was lowering about the household, there were gathered about
him ministering loved ones—wife, son and daughter. For about two years
he had not enjoyed good health, but still he continued his professional
duties, and it was not until a few weeks previous to his demise that his con-
dition became serious and he realised that the beginning of the end was not
far distant. He was a most heroic sufferer, and without a murmur pat-
iently awaited the result—dissolution. Eminent as both physician and
surgeon, his many years spanned an active life, and his memory, like the
many beautiful floral emblems of springtime, when he took his departure,
will always be fragrant with the many deeds so kindly, generously and
unostentatiously performed by him. Dr. Babcock was the oldest practis-
ing physician of the village, which for more than fifty years had been hon-
Ored by his cheerful presence, valued counsel and skilled attention. Oc-
cupying a dignified and praiseworthy position at the head of the
profession he so faithfully and devotedly honored, he furnished a shining
example, and one that commands both our admiration and commendation.
Dr. Babcock possessed an exalted nobility of character, sterling integrity,
strong convictions and generous impulses. The younger members of the
profession always found him a wise counsellor and most devoted friend and
brother, ever prompt to assist. They, with others, will cherish his mem-
Ory.
Dr. Babcock was born in West Berkshire, Vt., in 1819. He studied medi-
cine at Vermont Medical College in that State, and was admitted to prac-
tice. Subsequently he resumed his studies in New York city, where he
practiced for a brief period. Afterwards he located in Schuylerville, where
1 Read at the meeting of the Second District Branch, 1892.
46
724 JNE W YORK STATE MEDICAL ASSOCIATION.
he remained only a short time. In 1853 he made Saratoga Springs his
home, and was for many years associated with the late Dr. R. L. Allen,
the firm name being Allen & Babcock. Dr. Babcock leaves a widow,
whose maiden name was Blanche W. Shaw, and two children, Dudley C.,
and Grace S. Babcock. The funeral took place from the family residence
on the Tuesday following the demise. Rev. Dr. Alexander Proudfit
officiated.
MEMOIR OF LUCIEN DAMAIN WILLE, M.D.”
BY AUSTIN FLINT, M. D., OF NEW YORK COUNTY.
“LUCIEN ANTOINE DAMAINVILLE was born in Erie, Pennsylvania,
November 27, 1839. He died December 15, 1891, at the age of fifty-two
years and eighteen days. A pupil of the Collège Louis-le-Grand, he was
always among the first in his class, and almost always took the first prizes.
“At the age of fourteen years it was thought to make an artist of him
on account of his taste for music. With this intention he was made to enter
the Conservatoire de Paris. His father, fearing for him this career, decided
that he would return to America, and he finished his education, already
quite advanced. At the age of seventeen years he was sent to Dr. Hamil-
ton, under whose direction he studied medicine. He accompanied him to
New York and passed his examinations brilliantly in Brooklyn, where he
received his diploma of Doctor of Medicine. He always assisted Dr.
Hamilton in his operations and in his lectures in Brooklyn, and finally went
as his assistant-surgeon to the War of Secession.
“His Character.—His uncle says that he always did him honor, and that
he never had a reproach to make to him ; that he never regretted an hour,
even five minutes that he had charge of him. Dr. Hamilton said to his
father (who asked him what he thought of Lucien) that he had taught
many young men in his life, but that few had been so intelligent and had
given him so much satisfaction.
“This is all I have to say about my poor child.”
I have translated literally this touching memorandum received from the
aged mother of the late Dr. Damainville, whose sole dependence he was.
Dr. Damainville was never married, perhaps for the reason that he felt it
his duty to devote his life to the care of his mother and sister.
I write this brief memoir with more than ordinary feelings of friendship
for its subject. In the fall of 1858, Dr. Damainville, then a young medical
student, assisted me at the first lecture I ever gave. He continued to act
as my assistant during the session of 1858–59 at the Medical Department of
the University of Buffalo. In 1860 he was graduated in medicine at the
Long Island College Hospital. The records of the War Department show
that he was mustered in as an assistant-surgeon, New York Volunteers,
June 18, 1861, and as surgeon, November 27, 1862. He was mustered out,
June 4, 1863, after service in the Sixth Corps, Army of the Potomac. He
Was again mustered in as assistant-surgeon, Second New York Veteran
Cavalry, November 9, 1863, and as Surgeon, August 10, 1864. After serv-
ice in Mississippi and Louisiana, he was finally mustered out, November
8, 1865. After his discharge from military service, Dr. Damainville began
practice in the city of New York, and acted as assistant to Dr. Frank H.
Hamilton. He was for many years one of the surgeons of the French
* Read at the Eighth Annual Meeting of the Fifth District Branch, May 24, 1892.
726 JWEW YORK STATE MEDIOAL ASSOCIATION.
Hospital of the City of New York, and recently one of the attending sur-
geons to the Class of Genito-Urinary Surgery, Bureau of Medical and Sur-
gical Relief for Out-door Poor, Bellevue Hospital. He was appointed
police surgeon, New York city, in 1885, and assigned to the Thirty-third
and Thirty-fourth Precincts. On the retirement of Dr. Varian he was
transferred to the Thirty-second and Thirty-fifth Precincts. He removed
to Kingsbridge and became associated in practice with Dr. Varian in the
spring of 1890. Dr. Varian writes me that, “He made many friends in his
district, and was accumulating a large practice about him, and if he had
been spared a few years would have had one of the most lucrative practices
in this city.”
The duties of Dr. Damainville as a police surgeon involved much labor
and exposure, often in severe weather. After an unusually hard day's
work, when he had been for many hours exposed to cold and wet, he had a
severe chill, followed by a circumscribed pneumonia, with low delirium.
After a few days he improved considerably, but without much diminution
in temperature. The characteristic appearance of typhoid fever afterward
became developed, and he died of exhaustion, December 15, 1891.
Dr. Damainville was endowed with an eminently artistic temperament,
which probably interferred somewhat with his success as a practitioner.
He was not only an accomplished violin virtuoso, with a purity and volume
of tone, as well as technique, which would have given him a high rank as a
professional performer, but a perfect reader and a thorough musician. In-
deed, in his early struggles in New York, he supplemented his professional
income by giving lessons to orchestral players and occasionally performed
at public concerts. He was so jealous, however, of his status as a phy-
sician, that he concealed his work as a musical performer and teacher, and
never appeared as such in this city. His exquisite musical organisation
and accomplishments, with tastes more or less Bohemian, in the best sense
of the term, led him to seek the Society of artists, and he enjoyed the ac-
quaintance of our best resident and visiting musicians, especially Vieux-
temps, with whom he was on terms of close friendship. With such tastes
and acquirements, it must often have been difficult for him to forego artistic
reunions for the dry work of ordinary practice.
Dr. Damainville contributed little to professional literature. Educated
in France, he never acquired complete command of the English language.
Nevertheless, he was a good practitioner, a careful, self-reliant and skillful
surgeon, and devoted to his profession. At an age when most men of his
ability and experience should have long since passed the struggles and dis-
couragements of professional life, he was on the threshhold of material Suc-
cess, and was building up a lucrative practice when he was taken away in
the full enjoyment of health and strength. He had just sent his mother to
visit her native land, which she had not seen for more than half a century,
thus realising for her the dearest wish of her declining years.
It is a melancholy satisfaction to pay this small tribute to one Whose
professional career I have followed from the first ; an honorable physician,
a good son, a charming companion, a true and devoted friend.
MEMOIR OF NATHANIEL CLARK HUSTED, M. D.
BY RICHARD B. COUTANT, M. D., OF WESTCHESTER COUNTY.
Born October 22, 1825. Died November 19, 1891.
The time intervening between these dates measures the mortal existence
of our former associate, NATHANIEL CLARK HUSTED, whose memory we
are assembled to honor and to receive honor from.
The character of a man's life is determined by his inborn qualities and
inclinations, modified by the purposes and habits which have been de-
veloped by education and environment.
In the life that we are about to consider there was a happy blending of
those forces, resulting in a well-poised organisation, which fitted its pos-
sessor for earnest, skillful, sustained work, and made him through his
mental activity and his integrity a leader among men.
The Husted, or Hustis family, as the name is sometimes written, was of
Dutch origin, and some of its members were among the first settlers of
Connecticut. Robert A. Husted witnessed the deed which conveyed the
present towns of Stamford and Greenwich from their native owners to the
white pioneers of 1640, just twenty-five years after the discovery of that
part of the continent. In another instrument, executed about the same
time, the name of Angell Husted appears for a similar purpose. These men
acted with authority from the New Haven Colony, and were distinguished
personages in the early history of New England. Thirty years later Angell
Husted was one of the twenty-seven proprietors of this region, and the
name has been a prominent one in the annals of Greenwich and its vicinity
from that time to the present.
Among recent representative members of the family may be mentioned
Jabez W. Hustis, of Westchester, one of the trustees of the University of
the City of New York; James W. Husted, of Peekskill, whose ability is
too well known to require comment ; John A. Husted, for years an attorney
and counsellor-at-law at Tarrytown, N. Y.; Nathaniel W. Husted, lately
one of the leading business men of the same place; Jarvis P. Husted, M.D.,
of New York city; Nehemiah Husted, a prosperous farmer and a selectman
of Greenwich, Conn.; Harvey P. Husted, of White Plains, stenographer to
the Westchester County Court; and Nathaniel Clark Husted, the subject
of this sketch.
The characteristics of the Husted family are a close-grained, fine-fibered
Organisation, fitted for persistence and endurance, making its members by
nature capable, self-reliant and painstaking men and women of good habits,
industry, and thrift, whose faults are mainly exaggerations of their natural
endowments. Dr. Husted boasted of a double line of descent from this
728 NEW YORK STATE MEDIOAL ASSOCIATION,
stock, his father being Nathaniel Husted, the son of a revolutionary soldier
of the same name, and his mother, Mary E., daughter of Amos Husted.
His career, as we shall see, exemplified the family traits and did ample
credit to his origin. .
N. C. Husted was born in the family homestead at Round Hill, Fair-
field County, Conn. He was the second of a family of six children, four
of whom, Jarvis N., Emily, Sarah Griffin and Ruth Knapp still survive.
During the first twelve years of his life young Husted was inclined to be
delicate, having suffered from the various diseases of childhood in a severe
form. On this account he was excused from manual labor and from regu-
lar attendance at school. As his feebleness of body did not encourage him
to indulge in sports requiring activity and strength, he acquired a fond-
ness for books, and laid the foundation of a taste for literature which in-
creased with his age, and was the chief solace of his later years. At the
age of thirteen he was put steadily at school, where he began the study of
the classics. In his fifteenth year he was placed under the care of the Rev.
Chauncey Wilcox, at Quaker Ridge, in his native town. This gentleman
was an accomplished scholar and teacher, and a man of excellent character
as well, who considered it his duty to instil into the minds of his pupils the
principles of moralty as well as of scholarship. Dr. Husted always spoke
of him with affectionate regard, and ascribed to him the awakening of the
aspirations which led to his advancement in life. At the early age of
seventeen he was prepared to enter college, but the money necessary to
defray his expenses was lacking, and he determined to earn it by teach-
ing school. At this period he was very frail, and being harassed by a
severe cough, the future did not seem very bright to him, and his friends
expected his rapid decline. His first engagement was at North Castle,
N. Y., where he became intimately acquainted with Dr. Mackay, in whose
family he boarded. The doctor took a warm interest in the young peda-
gogue, cured him of his cough, and undoubtedly spoiled his college career
by encouraging him to study medicine. After a year and a half of hard
work at North Castle, he was induced to open a select school at Stanwich,
Conn. Having made this a success, he disposed of it to other parties and
returned to North Castle for another year, after which he wended his way
to the village of Rye, where he taught for six months. During this en-
gagement he registered himself as a student in medicine with Dr. Sands,
of Portchester. His next school was at Colaburg, now Croton Station, on
the Hudson, where for six months he continued his reading with Dr. Caleb
W. Haight. In the summer of 1848 he gave up teaching, and located in
Pleasantville, where he devoted his entire time to the study of his profes-
sion under the same preceptorship. In the Fall of this year he matriculated
at the Medical Department of the University of the City of New York, and
came under the personal influence of such men as Valentine Mott, Granville
S. Pattison, Samuel H. Dickson, John W. Draper, Martin Paine and Gunning
S. Bedford. At the close of the session Dr. Haight obtained a position for his
student at the Westchester County Alms House, where his duties combined
the functions of resident physician and head nurse. This term of service
MEMOIR OF NATHANIEL CLARK HUSTED, M. D. 729
proved to be one of the most eventful periods of his life. Ship fever was
epidemic at the time, and nearly two hundred cases occurred in the institu-
tion to mark its ravages. At a time when the young interne was thor-
oughly exhausted by attention to his duties, he succumbed to the disease,
and for weeks his recovery seemed impossible. Thanks, however, to the
skill and care of Dr. Haight and the other visiting physicians, he finally
began to Inend, and later in life dated his permanent improvement in
health from this illness. No sooner had this epidemic subsided than
cholera made its appearance, causing a number of deaths; and in the Fall,
smallpox broke out and spread rapidly among the inmates. In October,
feeling much richer in practical knowledge of disease, he renewed his rela-
tions with the University, and on the 8th of March, 1850, received his de-
gree of “Doctor of Medicine.” In April he opened an office at 353 Sixth
Avenue, having scarcely money enough to pay for his sign, and neither
books, instruments nor apparatus to aid him in his work. He found a
boarding place near his office with Wm. B. Riker, the well-known drug-
gist, who showed his appreciation of his lodger's talent and pluck to such
a degree, that, coupled with his own exertions, he felt it prudent, so great
had been his success, to marry when a year had passed.
Dr. Husted was now twenty-six years of age. He had by his earnest
endeavors overcome many of the disadvantages of his youth, and Saw
before him the certainty of success in his calling. For over a year he had
been engaged to Miss Mary J. Palmer, of New York city, and we can easily
fancy his joy as he contemplated the step he was about to take, marking as
it did his advance in happiness as well as in prosperity. They were mar-
ried as he had planned, but alas for huſman hopes, ere a year had passed he
laid his wife and new-born child in a single grave, and returned to his
desolate home to begin life over again, broken in spirit and thoroughly un-
fitted for the duties he had to perform.
Rallying from his depression by degrees under the stimulus of enforced
Work, he devoted himself more earnestly than ever before to the science as
well as to the art of his calling, and came to be so favorably known in the
district in which he lived that he was considered the leading practitioner
there, and began to be well known outside of its limits. As his life broad-
ened and his burdens multiplied, he felt more and more in need of com-
panionship and of the comforts of a home, and when a suitable time had
elapsed he was married to Miss Deborah Fairchild, the daughter of Benja-
min P. Fairchild, Esq., of New York city, who survives her husband, hav-
ing proved the wisdom of his choice by nearly forty years' devotion to his
interests. -
For two years after his marriage Dr. Husted resided near his Sixth
Avenue office, but in 1855, yielding to the solicitations of many influential
patrons, he moved to Forty-second Street between Eighth and Ninth
Avenues, and opened an office there. For the next ten years he devoted
his entire time and energy to the practice of his profession, with the most
fortunate results, becoming as well and as favorably known to the profes-
Sion of the city as he was among the laity. He associated himself with all
730 NEW YORK STATE MEDICAL ASSOCIATION.
the leading medical societies of the city and of the State, and was promi-
nent famong those who took an active part in their proceedings. In 1862
he volunteered for surgical service in the United States Army hospitals,
and was sent by the Surgeon-General of the State to Fortress Monroe,
where he spent several weeks in company with Drs. Willard Parker, J. R.
Wood, Stephen Smith, A. C. Post, T. M. Markoe, Alden March, Robert
Watts and others from New York State, ministering to the wounded
brought there from the battlefields of Virginia.
In 1866 Dr. Husted’s father and mother, who had continued to reside
upon the old homestead at Greenwich, died within a week of each other
after brief illnesses, and the shock, coupled with the effect of his over-
doing, enforced him to retire temporarily from work. A little before his
parents' death he had taken Drs. White and Dumond, who had passed the
period of their pupilage in his office, as his assistants, and relinquishing his
practice into their hands, he removed to the country for rest and recrea-
tion. His purpose was to give up work for a year, but he returned to the
city before the vacation he had planned had expired, and with Dr. Charles
Bliss as his associate he opened an office in Fifty-first Street, and remained
there until his old office was vacated at the end of the year. In April,
1871, he removed to West Fifty-sixth Street, and in the following month
entered into equal partnership with Dr. Bliss, with whom he remained as-
sociated until the Spring of 1878, when on account of permanent failure of
health he retired from metropolitan practice and established himself at
Tarrytown. Diabetes mellitus, the disease from which he was suffering,
had been diagnosed by himself in November, 1877, and for a year his de-
cline was so rapid that his case was pronounced hopeless by the best
authorities, and he had constantly before him the expectation of speedy
death. Failing to secure relief from the treatment of the disease in vogue
at the time, the doctor began experimenting himself, and finally discovered
a combination of remedies which in connection with a rigid diet produced
an improvement in his symptoms, and eventually freed him from the dire
effects of his disease. As soon as he began to mend his old activity reas-
serted itself, and in a short time he established a large office practice, mak-
ing something of a specialty of diabetes and renal diseases, and before he
realised the consequences, he was again absorbed in general practice and
working with his old-time energy and success. The wide circle of his pro-
fessional acquaintance caused him to be called long distances in consultation
and to perform operations, and patients often came to his office from points
fifty miles away. In addition, he visited his office in the city once or twice
a week, where his old-time friends thronged about him and availed them-
selves of his counsel, years after they had ceased to employ him at their
homes.
On Thanksgiving Day, 1878, the Semi-Centennial of the Methodist
Episcopal Church at Round Hill, Conn., was celebrated, and Dr. Husted,
whose ancestors were largely instrumental in establishing it, delivered the
historical address, and afterward prepared the volume published by the
church in commemoration of the affair.
MEMOIR OF NATHANIEL CLARK HUSTED, M. D. 731
At the meeting of the New York State Medical Society, held at Albany
in February, 1879, Dr. Husted was elected vice-president of the Society,
and read a paper on diabetes, which was favorably received. A fortnight
later he read a similar paper before the Westchester County Medical So-
ciety, at Sing Sing, and was given a place upon the list of honorary mem-
bers of the Society. In July of this year he revived the memories of his
youth by attending the convention of the New York State Teachers' Asso-
ciation, held at Penn Yan, and was made a member of the same. In the
Fall he was made President of the Board of Health of Tarrytown, and was
elected one of the trustees of the Westchester County Historical Society.
About the same time he began to take an interest in the affairs of the Syra-
cuse University, and later he was made a member of its Board of Managers.
In June, 1880, he received the honorary degree of M. A. from the Wes-
leyan University at Middletown.
Early in the summer of 1880, Dr. Husted became interested in the pro-
posed celebration of the capture of Major André. at Tarrytown. He was
made corresponding secretary of the organisation, and the wonderful suc-
cess of the affair was largely due to his untiring efforts. The United States
Government and the State were represented, and over sixty thousand peo-
ple attended the exercises. The preparation of the volume relating to the
celebration devolved upon the corresponding secretary, and he made it one
of the best of the many records of such affairs published at the time.
In July, 1881, the doctor visited Europe as a delegate from the Ameri-
can Medical Association to the International Medical Congress held in Lon-
don, and embraced the opportunity of making himself familiar with as
much of foreign life and scenery as the limited time at his disposal would
allow.
On January 1st, 1883, thirty-four years after his first term of service in
that institution, Dr. Husted was appointed one of the visiting physicians
to the Westchester County Alms House, and continued to be a member of
its medical staff until the time of his death. The work engaged in there
Was greatly to his liking, as it constantly reminded him of his younger days
and their associations, and at the same time brought him into contact with
a class whose misfortunes awakened his warmest sympathy, and whose
necessities called forth his highest skill.
In April of the same year his only daughter was married to Dr. Frank
E. Russell, of New York city, a young man of fine promise in his profes-
Sion, whom he welcomed into his family with the same affection that he
Would have bestowed upon a son had one been born to him.
In June, 1884, the Faculty of Syracuse University bestowed upon Dr.
Husted the honorary degree of LL.D., in recognition of his scholarly attain-
ments and of his valuable services to the institution as one of its trustees.
For several years a growing conviction of the uncertainty of the pres-
ent life and of the desirability of preparing for the life to come, had dis-
turbed the doctor's somewhat materialistic views, and finally turned him to
* Saving faith in Christ. On February 1st, 1885, he united with the
Methodist Episcopal Church at Tarrytown, and the same evening noted in
732 JNEW YORK STATE MEDIOAL ASSOCIATION.
his journal, “The happiest day of my life.” Very naturally, in his new
found joy, Dr. Husted's thoughts turned to the place where his forefathers
worshipped, and for years the Methodist Church at Round Hill was a place
of pilgrimage to him and an object of his benefactions. His interest there
centered in the Sunday-school, and never a Christmas passed that he was
not the Santa Claus of the occasion, in spite of bad health or unpleasant
Weather.
Dr. Husted spent many years in collecting a library of general litera-
ture, making his selections according to his own taste, from the old and the
new ; caring more for solid reading than for light, and more for the matter
of books than for the covers that inclosed them. A wisely selected medical
library kept pace with his general one, and whenever he shut his office
door upon the world, he had at his command between eight and nine thou-
sand books to amuse himself with or to work among.
In the Fall of 1886 the United States Government established a Pension
Examining Office at Tarrytown, for the convenience of claimants in Rock-
land County and along the lines of the Hudson River and Northern Rail-
roads. Dr. Husted filled the position of president of the board to the time
of his death, a period of five years. The doctor was the warm friend of all
honest claimants, but the uncompromising foe of all dishonest ones. It is
related that after a certain examination he was beckoned out upon his
piazza by a veteran whose disabilities were a myth, and there offered a
bribe for a favorable report upon his case. A noise as if the house was fall-
ing called the rest of the board to the window in time to see the claimant
pick himself up at the bottom of the steps, and limp away followed by the
doctor's execrations.
After a while it began to be noticed at some of the meetings of the
board that the president's interest flagged; that he sat down in the midst of
his work, and that he occasionally retired from the room. Later he con-
fessed to attacks of neuralgia in the chest, accompanied by feelings of pros-
tration. These attacks gradually increased in frequency and severity, until
activity became a burden and even rest had no charm. A diagnosis of
angina pectoris from imperfect nutrition of the heart, which had been made
at an early date, was confirmed by the highest medical authorities, and no
hope of cure was entertained. All remedies were tried, and all, with the
exception of those which afforded relief at the time of the attack, Were
tried in vain and abandoned. As there was no help in repose and there Was
diversion in work, the poor sufferer kept about, doing more than he was
able to, until the end came quickly and he was translated to a life of more
abundant joy.
In appearance Dr. Husted was somewhat under medium height, but he
was deep-chested and broad-shouldered, and gave an impression of great
vital force if not of muscular strength. His head was large, the broW
being high and wide, and his cranial capacity was much greater than the
average. The expression of his face was kind but strong. His manner
was genial, and he was inclined to sociability, easily winning the friend-
ship and confidence of his patients. In matters of difference he W88
MEMOIR OF NATHANIEL CLARK HUSTED, M. D. 733
unyielding, and equally tenacious of purpose, allowing no obstacle to thwart
him that perseverance could overcome. His every instinct was honest,
and all his intentions were good. Man-like, his convictions were some
times at fault, but this was due to imperfect judgment, not to perversity,
and when convinced of error he was always ready to make amends. Dr.
Husted was domestic in his habits, preferring his home and the compan-
ionship of his family, his library, and a few chosen friends, to anything
that society could give. The following lines of Shelley, found inscribed
in one of his books, give a key to his taste in this particular:
“I love tranquil solitude,
And such society
As is quiet, wise and good.”
Being of a studious habit Dr. Husted was well read in his profession,
and was alive to all its improvements, fertile in resources, prompt in
action, thoroughly to be depended upon. His knowledge of practical
therapeutics was something marvelous, so accurately could he apply a
remedy from his vast armamentarium to the relief of a particular symptom
or disease. His skill in surgery was greater than that of most all-round
practitioners, and during his career he performed a majority of the opera-
tions of general surgery, and many others requiring special knowledge
and skill. Obstetrics, however, was his favorite branch of practice, and
in his days of activity he performed every operation known to it, from
Caesarean section down. A forceps of his invention possesses many ad-
mirable features, particularly an exaggeration of the pelvic curve to facil-
itate delivery at the superior strait.
Dr. Husted's studies extended beyond the lines of medicine, and he was
Well informed in literature and in science. History had a particular fas-
cination for him, and books relating to it were his delight. Being absorbed
in active work he found but little time to write, but in addition to the vol-
umes and papers referred to above, he read essays before the United States
Hay Fever Association, the Microscopical Society of New York, and the
New York State Medical Society, and contributed reports of cases to vari-
ous medical journals.
The office of a practitioner of marked ability has always an attraction
for students of medicine, and Dr. Husted's was no exception to the rule.
He acted as preceptor to the following physicians: Drs. J. C. Dumond,
Edward White, G. Frazer, James Sullivan and Warren Chapin, of New
York City; Dr. W. A. Miner, of Sing Sing, and Dr. C. P. Freeland, of
Kansas.
Dr. Husted was a member of and in many cases served as an officer in
the following societies: The American Medical Association, the New York
State Medical Society, the New York State Medical Association, of which
he was one of the founders; the New York County Medical Society, the
New York Academy of Medicine, the United States Sanitary Association,
New York Gynaecological Society, New York Obstetrical Society, New
York Pathological Society, New York Microscopical Society, Connecticut
734 NEW YORK STATE MEDICAL ASSOCIATION.
State Medical Society, Westchester County Medical Society, New York
Historical Society, Tarrytown Historical Society, Monument Association
of the Capture of André, the New York Statistical Society, and the United
States Hay Fever Association.
To the very few who knew Dr. Husted intimately he unfolded a rich-
ness of nature totally unknown to the outside world, betraying suscepti-
bilities and emotions, and sometimes a gayety, even, which, added to his
more solid attributes, made him a most charming companion and a model
friend. To those few his individuality was unique, and his place can never
be filled. -
MEMOIR OF JAMES FERGUSON, M. D.
BY G. R. MARTINE, M. D., OF WARREN COUNTY.
DIED of paralysis, October 27, 1892, at his home in Glens Falls, N. Y.,
Dr. James Ferguson, aged seventy-four years.
He was born in Kortright, Delaware County, N. Y., in 1818, and was
graduated from the Medical College in Castleton, Vermont, in 1841. He
commenced practice in North Blenheim, but removed to Glens Falls in
1852, where he continued his practice until disabled by sickness shortly
previous to his death.
He was married at North Blenheim to Miss Cornelia Hager in 1843. His
wife still survives him. Of two children, Walter J., and Margaret E., the
latter is still living. Walter J. died a few years since.
Dr. Ferguson was a man of fine physique, of well balanced mind, of
unostentatious, but kindly sympathies. As a physician he was sound in
judgment, careful and attentive in practice, never giving needless pain by
words or remedies. His medical labors extended over a wide field, marked
by success, proving his life one eminently useful to the community in
which he lived.
MEMOIR OF WILLIAM CHACE, M. D.
BY THos. D. STRONG, M.D., OF CHAUTAUQUA COUNTY.
HE was born January 4, 1833, at St. Catharine's, Canada, where he ob-
tained his literary education. In 1858 he graduated at the College of
Physicians and Surgeons, New York City, and at once commenced his
practice at Mayville, Chautauqua connty, N. Y., where he spent the re-
mainder of his life, engaged in active medical work.
Early he took a prominent place in his profession, and year by year
rose in the esteem of his brother practitioners, occupying a most desirable
position among the best medical men in Chautauqua county. In all
emergencies he was a power, and his level head and steady hand never
failed him. Towards the profession his bearing was always high toned
and honorable. With disgust he looked upon all unprofessional ways.
Self-sacrifice in behalf of his patients and friends was a marked charac-
teristic, and especially to the poor was he faithful. Though under a severe
attack of influenza, he visited in the evening a patient for whom he was
anxious, and the next day, December 27, 1891, he died of heart failure.
His practice was large and remunerative. He leaves a wife and four
sons—the eldest of whom, Wm. C. Chace, is a practicing physician in
Buffalo, N. Y.
He was a vestryman in the Episcopal church. His social qualities
surrounded him with a large circle of friends, who, with his brother
physicians, most heartily unite with his family in mourning his loss.
He was a founder of New York State Medical Association.
REPORTS OF THE DISTRICT BRANCHES.
FIRST DISTRICT BRANCEI.
THE eighth annual meeting of the First District Branch was held at
Stanwix Hall, Rome, on Wednesday, July 20, 1892.
The meeting was called to order by the President, W. D. Garlock, M.D.,
at 11.30 A. M. -
There were present fifteen Fellows and three invited guests.
The minutes of the last meeting were read and approved.
The Treasurer then read his report, showing a balance of $5.00 from
last year, disbursements of $6.00, and a collection of $12.00 at this meet-
ing, leaving a balance of $11.00 in the treasury at present. The report was
accepted and adopted.
Dr. W. H. Robb presented a case of multiple cerebral sclerosis, which
was examined and commented upon by several.
The President then read an address on general medicine, which was
listened to with manifest interest.
Dr. E. D. Ferguson then spoke of the difficulties of operations in old and
large non-reducible umbilical herniae, and gave some experience in renal
Surgery, with specimens.
Dr. Douglas Ayres read a paper on “Puerperal Eclampsia.”
Dr. W. H. Robb then read a paper on “The Use of Electricity, as Ex-
emplified in a certain case of Uterine Fibroid.”
This was followed by a paper by Dr. J. B. Harvie, on Endometritis,
in which he advocated thorough curetting after dilatation. Drainage he
did not consider essential.
The Secretary then read a paper on “Typhoid Fever; its Causation
and Therapeutical Management.”
Dr. T. M. Flandrau presented a Memoir of Dr. M. Calvin West, which
Was referred to the State Association for publication in the Transactions.
On motion it was decided to hold the next annual meeting at Little
Falls, in the month of July, 1893, the day to be determined by the Presi-
dent and Secretary.
The present secretary and Executive Committee were then continued for
another year. -
W. D. GARLOCK, President.
EZRA GRAVES, Secretary.
SECOND DISTRICT BRANCH.
THE Second District Branch of the New York State Medical Association
met pursuant to call at Schenectady, June 23, 1892, for its eighth annual
meeting.
The meeting was called to order by the President, Dr. McDonald.
Twenty-five members were in attendance.
The minutes of the last annual meeting were read and approved.
The Secretary spoke of an error he had made in the printed programme
of the meeting, in which the title of a paper to be presented by Dr. W. W.
Seymour had been omitted.
Dr. Van Zandt read the report of the Committee of Arrangements, which
was received and adopted.
Dr. Seymour was given permission to present his papers first, as he was
obliged to return to Troy in answer to a telegram. He accordingly read a
report of “A Successful Case of Total Extirpation of the Womb for
Cancer,” and a paper on “Trendelenburg's Posture in Abdominal and Pelvic
Surgery,” with report of cases and exhibition of apparatus. -
After the discussion on these papers, the President, Dr. McDonald, read
a paper entitled, “The Diagnostic Aid of Anaesthesia in Fractures and
Dislocations.”
Dr. Hodgman, of Saratoga, presented a report of a case of appendicitis,
in which an operation was performed, the appendix removed, and the
patient died in a few hours. A post-mortem examination revealed no
obstruction of the intestine, death being due to shock occasioned by rupture
of the abcess.
Dr. T. B. Reynolds reported the death of Myron N. Babcock, one of the
founders of the Association, and moved the appointment of a committee to
draft suitable resolutions.
The President appointed as such committee Drs. T. B. Reynolds, W. H.
Hodgman, G. F. Comstock, W. E. Swan, of Saratoga Springs, and Dr. I. G.
Johnson, of Greenfield, who subsequently reported the following which was
adopted unanimously :
WHEREAs, Death has inscribed upon the necrological roll of our associa-
tion, the name of one of its most distinguished members, Dr. Myron N.
Babcock, who passed away at his Saratoga Springs home Saturday evening,
May 21, 1892, and who was one of the founders of the New York State
Medical Association, of which this Second District Association is an
auxiliary; therefore, be it
ReSolved, That this Association take this means of paying tribute to the
exalted memory of one whose record as a physician covered over half a
PROCEEDINGS SECOND DISTRIOT BRANCH, 739
century, and during the better portion of his active and useful life stood at
the head of the profession in the village that was honored by his presence;
and
Resolved, That this Association also points with pride to the fact that our
departed brother possessed preeminent ability in the broad field in which he
had been such an active worker, and that he was a shining example to the
profession which he adorned, and that he was always ready and willing to
counsel and assist his younger medical brethren.
Resolved, That by his sterling integrity, nobility of character, generous
impulses and other eminent characteristics, as well as his devotion as a
husband, father, and a citizen, the memory of the departed reflects great
credit on the Association, the members of which unite in extending words of
condolence to the family in their bereavement.
Resolved, That the above preamble and resolutions be given to the press
for publication.
The next paper was by Dr. H. E. Mitchell, and was entitled, “Why
Oculists Should Treat Nasal Diseases.”
Dr. J. P. Marsh then read a paper entitled, “Haemorrhage from the
Normally Implanted Placenta.”
Dr. J. B. Harris then read a paper with the title, “Endometritis, with
Treatment by Curetting and Washing out the Cavity.”
The next paper was by Dr. Ferguson, on “Some Recent Kidney Sur-
gery,” with a report of two cases, and the presentation of post-mortem
specimens, one being a “horseshoe” kidney.
Dr. S. W. Houston reported a case of Hydramnois.
On motion, the Executive Committee was retained another year.
The thanks of the Association were voted the Local Committee for their
successful efforts for the entertainment of those attending the meeting.
Resolved, That when the meeting adjourn it be to meet at Saratoga,
June 22, 1893.
Adjourned.
GEO. E. McDONALD, President.
CHARLES H. BURBECK, Secretary.
47
THIRD DISTRICT BRANCEI.
The eighth annual meeting of the Third District Branch, N. Y. S. M.
ASSociation, was held in Owego, at Ahwaga Hall, June 16, 1892.
In the absence of the President, the meeting was called to order at 10:30
A. M. by the Secretary.
Dr. J. G. Orton was called to the chair, and presided over the meeting
until the arrival at noon of the President, Dr. L. J. Brooks.
The following members registered : W. L. Ayer, Ely Van de Warker,
Leroy J. Brooks, F. W. Higgins, J. G. Orton, Dwight Dudley, of Maine,
Broome County; R. A. Seymour, H. C. Rogers, John E. Beers, L. H. Hills,
George M. Cady, F. W. Ross, C. W. Greene, C. L. Squires, Elias Lester,
William Fitch, J. H. Chittenden, E. Lester, F. G. Seaman.
New members: C. L. Stiles, Owego ; A. J. Harris, Camlor; George B.
Lewis, Owego, all of Tioga County.
The following invited guests were present : Drs. Morrow, of Warren;
Glover, Knapp and Burr, of Newark Walley; Barrett and Lounsbery, of
Owego ; Brown, of Elmira; Chittenden, of Allison; and Bassett, of Bing-
hamton.
The President appointed the following Nominating Committee : L. H.
Hills, Binghamton; F. W. Ross, Elmira; H. O. Jewett, Cortland; F. G.
Seaman, Seneca Falls; George M. Cady, Nichols; William Fitch, Dryden.
The Nominating Committee reported, through its chairman, L. H.
Hills, that they would recommend the next annual meeting to be held in
Elmira; that Dr. C. L. Squires be made Secretary, and that the following
gentlemen constitute the Executive Committee : H. C. Rogers, Bingham-
ton; W. R. Laird, Auburn; F. W. Ross, Elmira; F. W. Higgins, Cort-
land; W. B. Morrow, Walton ; F. O. Donohue, Syracuse; J. J. Sweet,
|Unadilla; H. C. Lyman, Sherburn; B. T. Smelzer, Havana; Elias
Lester, Seneca Falls; William Fitch, Dryden; John K. Leaming, Coop-
erstown ; M. Cuvana, Oneida.
The next order of business was the President's address, but in the
absence of that officer the Secretary moved the by-laws as to the order of
business be suspended, and at once proceed to the reading of papers.
The first paper read was by Dr. F. W. Ross, of which the following is
an abstract :
CEIRONIC RECURRING APIPENDICITIS,
The recent investigations and brilliant operations for the relief and cure
of appendicitis have created a new era in the surgery of the digestive tract
and its appendages. What the function of this troublesome little rudiment-
ary third stomach may be no one has attempted to prove or explain.
PROCEEDINGS THIRD DISTRIOT BRAWOBI. 74.1
I believe that all operations for appendicitis should be performed just
as soon as the diagnosis is positively made, and there is the least tendency
to suppuration or indication of grave trouble at McBurney's point, for the
chances are many times in favor of there being a lesion of the appendix—
in fact many go so far as to doubt the existence of typhilitis, peri- and
para-typhilitis, in the sense in which we formerly understood these terms,
and lay most of the blame to the appendix. Here is where all the contro-
versy arises. The general practitioner who has had many cases of typhºlitès
8tercoralis which have recovered cannot understand why the surgeon finds
so many cases of appendicitis. When there has been a case of what has
been considered as a suppurative typhilitis, which has pointed and been
opened, or aspirated, and a cure followed, we are not certain that the
appendix was not the seat of the mischief. Recent investigations in
the pathology of these conditions about the head of the large intestines
tend to throw the preponderance of evidence against the appendix, which
is the real seat and origin of the trouble. The following is an illustrative
C8 Se .
J. W. H., merchant, good habits and family history, forty-five years of
age, had always been of spare build and Sedentary habits, and was inclined
to be constipated. I first saw him in December, 1890, for what I diagnosed
at the time as a mild attack of typhilitis. After keeping quiet for two
weeks he returned to his business. In August, 1891, he had a severe attack
of pain in the right inguinal region, slight elevation of temperature, and
a small tumor in the right groin, which was firm, hard and smooth. It
gradually disappeared entirely in about six weeks, but he had only been
about his business for about two weeks when the trouble returned. He
remained quiet two or three weeks, returned to business for four or five
weeks, but again had a relapse, characterised by quite sudden pain at
McBurney’s point, uneasiness, and a distinct tumor, as before, which was
not very tender; there was slight constipation, but no obstruction. The
tumor gradually disappeared in about two weeks, only to return suddenly
after a week. This was repeated eight or nine times up to April 13, 1892.
Hoping against hope for a cessation, and satisfied that at least an explora-
tion was necessary, I took him to New York and consulted Dr. W. T. Bull,
who advised an exploration, but expressed doubts as to my diagnosis of
appendicitis. He thought it might be cancer of the gut ; he had never
seen the appendix as low down as in this case. I argued that it could not
be a malignant growth and completely and entirely disappear, and so sud-
denly return. At the operation, which was in St. Luke's Hospital, an
incision was made directly over the tumor, and the caput coli brought to
view. The appendix was found enlarged and twisted upon itself, and
bound to the omentum and gut by plastic adhesions. The lumen of the
tube was obstructed in two places. The tissues, as if erectile in structure,
seemed capable of distention, and the bowel, filling with gas from below,
Would raise the mass in position, thus forming, through the thin abdom-
inal walls, a well marked and easily felt tumor. The appendix was loos-
ened from its adhesions and ligated close to the head of the caecum, and
742 NEW YORK STATE MEDICAL ASSOCIATION,
the cavity thoroughly sponged out. The wound being thoroughly clean
it was immediately and permanently closed. The patient has since re-
turned to his home completely recovered.
The paper was discussed by Drs. Hills, Jewett, Lester and Higgins.
Dr. C. L. Squire, of Elmira, then read a paper on “The Natural His-
tory of Diphtheria" (not furnished to the Secretary).
Dr. H. C. Rogers read a paper on “Typho-Mania”—
The motor agitation, the psychic exaltation, the whole picture of simple
acute mania is familiar. Typho-mania, on the other hand, is an unusual
brain disease, an acute delirious mania, in which the reductions sink to the
most profound depths.
If to excessive restlessness, trembling and tottering, persistent sleep-
lessness, incessant loquacity, wild delirium, and absolute incoherence of
thought and speech—symptoms connoting an acute delirious mania—be
superadded, rise of temperature—a symptom found nowhere else in mania
—a rapid, feeble, easily compressed pulse ; marked diminution, or even
suppression, of urine ; loss of control over the sphincters; prostration, so
great that the patient lies helplessly on his back rocking from side to side—
we have the clinical outline of typho-mania.
In simple acute mania, violent though the storm may be, the brain
meets the demands upon it, and eliminates through its vascular system the
increased products of tissue metamorphosis. The delicate lymph-connect-
ive system, enveloping so intimately the brain cells, remains passive as in
health. In tpyho-mania the brain cannot meet the demands upon it. The
ceaseless activities of innumerable cells, their tremendous molecular inter-
changes, throw more debris into its vascular system than can be eliminated
through those channels. The lymphatics spring to the rescue, and, taxed
beyond measure, swell with effete products. Herein lies the essential
pathology of typho-mania.
Typho-mania is overwhelming. Unless immediate relief be at hand,
exhaustion and somatic death soon end the scene.
As to this relief, with chloral, paraldehyde, and allied drugs, we
accomplish something ; perhaps, can Sooth the struggling cells and check
the accumulating debris. But this is very doubtful. Moreover, it is not
so much the subduing of the vös a tergo, as it is the establishing and main-
taining of a free escape for the results of the vis a tergo, which confront us
as the main indication; and we accomplish far more by taking up the
remedy of one, Dr. Langrode, over whose exploits in Gil Blas, we doubt-
less all have laughed—water. With it, in the form of generous colon baths,
we stimulate and flush the kidneys, eliminate through them the debris
from the lymph-connective system, and let the surcharged brain wash ēt-
Self. Under this line of treatment I can bear witness to the most gratifying
results. Under it I have seen the psychosis promptly rise to the level of
simple mania, and pass off.
Dr. L. H. Hills then read a paper on “Insanity in its relation to crime,”
but no copy was furnished.
Dr. E. Van de Warker then read an instructive and practical paper on
PROCEEDINGS THIRD DISTRIOT BRANCEI. 743
“Chronic Uterine and Pelvic Pain,” and treated the subject from a thera-
peutical standpoint.
By invitation, D. M. Totman, of Syracuse, read a report of a case of
double osteotomy for correction of deformity resulting from Colles'
fracture.
Also by invitation, Dr. E. G. Drake, of Elmira, read a paper on “A
Study on the Identity of Diphtheria, Membranous Croup and Follicular
Tonsillitis ‘’—
Evidence of a fixed law upon the question of identity or non-identity in
the diseases, diphtheria, membranous croup and follicular tonsillitis does
not appear to stand out conspicuously in the pages of our modern, or
moderately ancient history.
Contributors of eminence, of enviable position in the medical world, are
numerous, and theories likewise, both for and against the question, but it is
a striking, a singular, and a significant fact, that those who believe them to
be one and the same disease, with a variety of manifestations, provide
time, space and special classification for them under distinct and separate
titles.
After quoting the opinions of many well recognised authorities, the
writer continued :
Many of the older members of the profession, who had abundant oppor-
tunities for studying the membranous croup when diphtheria was unknown
and where it did not exist, recognised the clinical and pathological differ-
ences between the two affections. From 1775 to 1850 the cases of mem-
branous croup occurring in this country, as well as Great Britain, were local
in character, the lesions being confined for the most part to the upper air
passages, and causing death by suffocation. Septic symptoms were not
observed, nor did the disease appear to be contagious. Diphtheria was
quite unknown, and many practitioners with large opportunities for obser-
vation never saw a case of the disease.
The record of mortality from croup and diphtheria in Philadelphia
during the past forty years is both interesting and instructive. From 1846
to 1859 the annual mortality from croup varied from 111 to 312. No deaths
from diphtheria during that period were recorded. From 1860 to 1879 the
annual death rate from croup ranged from 185 to 455, while that from
diphtheria was from 110 to 708. Is it possible that the 3,078 deaths
recorded as due to membranous croup during those thirteen years previous
to 1859 were all caused by diphtheria, while not a single fatality from that
malady was reported in the city during that time 2 Had the croup of these
days been diphtheritic, surely the other forms of diphtheria must also have
existed. The history of the advent of diphtheria into the city of New York
is likewise interesting.
Previous to 1858 only three deaths were recorded as being due to diph-
theria during the present century. While the deaths from croup ranged
from 338 to 378, those from diphtheria varied from 5 to 2,329. Dr. Smith
thus remarks: In the first years after the introduction of diphtheria, the
deaths assigned to croup so greatly outnumbered those of diphtheria, as in
744 NEW YORK STATE MEDICAL ASSOCIATION.
1858 when 5 died of diphtheria and 478 of croup, that it is evident that
most of the cases of croup in those years were attributable to other causes
than diphtheria. It is strange that for three-quarters of a century an
affection so grave and characteristic in its manifestations as is diphtheria
should have repeatedly occurred in the practice of thousands of intelligent
physicians solely as a local lesion of the larynx without presenting one of
its most prominent features, namely, septicaemia. After making due
allowance for the unavoidable errors of statistics, the above data would
seem to furnish pretty strong evidence in the support of the correctness of
my vision—namely: that pseudo-membranous laryngitis may not always
be due to the diphtheritic poison. The words of Dr. Gay, referred to
earlier, would express my idea pretty well. Unless primary (membranous)
and secondary (diphtheritic) croup are separate and distinct affections as
regards their aetiology—or in other words, unless pseudo-membranous
laryngitis under certain circumstances arises from other causes than the
contagion of diphtheria—it must be admitted that either the character of
the disease has changed very greatly during the past thirty years, of which
there is little or no evidence, or the observations of the older practitioners
were imperfect and untrustworthy.
But the one great distinction which is pathological and which is ques-
tioned, though it would seem of great importance, is the difference in the
exudation, that of membranous croup lying upon the surface of the mucous
membrane, while the other is imbedded in it.
In diphtheria we recognise a disease epidemic and eminently contagious,
of an asthenic type from its very commencement. An exudation forms
upon the tonsils, spreading upward and downward, with a tendency to
form upon distant surfaces, e.g., blisters; the throat emitting an intensely
disagreeable odor; it occurs at all ages, and paralysis is a prominent
sequel. On the other hand, croup is found to be a sporadic disease, doubt-
fully if at all contagious, and of rather asthenic character at first. In it the
larynx and trachea are the parts first attacked, the tendency to spreading
is far less marked, there is no accompanying odor, it is exclusively a disease
of childhood, and paralysis is not a sequel. In diphtheria, albuminuria is
almost always present ; it is not present in membranous croup. In diph-
theria the glands of the neck are swollen and tender ; in croup they are not.
The argument against this is that the mucous membrane of the larynx has
no communication with the superficial cervical glands, and as an example,
attention is called to the fact that in cancer of the pharynx the cervical
glands are always enlarged, while in cancer of the larynx they are seldom,
if at all, affected. In answer to the statement that paralysis follows in
diphtheria, we are met with the argument that it is rare in croup because
nearly all of the cases terminate fatally, and that paralysis is occasionally
met with.
Membranous croup generally begins as an ordinary cold, more or less
cough, hoarseness and fever. The throat is usually sore, and the cough is
rather harsh and metallic and attended with very little expectoration. In
diphtheria, we have a prodromal stage of a day or two, during which the
PROCEEDIWGS THIRD DISTRIOT BRANCH, 745
patient feels somewhat indisposed, has slight fever, and may complain of
somewhat painful deglutition—more marked when swallowing fluids than
solids—some headache and occasional vomiting. This would pretty fairly
represent the early stages of the two affections, and to a casual observer
they would appear identical. An inspection of the fauces in the early
stages of membranous croup is likely to reveal little Save congestion and
perhaps a thin exudation, confined for the most part to the tonsils. In the
diphtheritic variety, the exudation is seen early, and is more abundant,
Spreading over more surface, frequently being upon the uvula, soft palate,
cheeks and nares. At this time the fever is usually marked, the glands of
the neck Swollen and tender, and the membrane, instead of appearing as a
Whitish gray, is of an ashy-gray color.
In membranous croup there is an entire absence of these symptoms, and
instead, a persistent hoarseness, increase of the metallic breathing, and at
about the time Septic symptoms are well developed in diphtheria, dyspnoea
occurs in membranous croup. With the ashy-gray exudation we do not get
the same train of prodomal symptoms that we find with the whitish-gray
exudate, nor do we find the same tendency to implicate or extend to the
larynx. In the author's experience, the whiter the deposit, the greater the
tendency to extend to the larynx.
Thus it would seem plausible that there is a wide distinction between
membranous croup and diphtheria, both in the early and latent stages, as
well as in the character of the membranes; that a disease of the follicles of
the tonsils is not necessarily diphtheria is shown by the fact that the deposit
in the former is pulpy and can be wiped from the surface of the mucous
membrane, and does not come off in strips, with the usual result to the
underlying membrane, as in diphtheria; the patches are never prominent,
are usually more circumscribed, and dip down into the lacunae, or rather
project from the crypts upon the surface of the tonsils.
This paper was discussed by Drs. Ross, Seymour, Lester, Greene and
Dudley.
The drift of opinion was that diphtheria and croup were identical dis-
63SeS.
At this time the President arrived, took the chair, and read his address.
A recess was now taken for dinner, which was furnished at the Ahwaga
House, by the members of the Association.
The afternoon session was opened by the presentation of the Orton
Prize Essay. Dr. J. G. Orton introduced the reader of the paper as fol-
lows:
MR. PRESIDENT : It is my pleasure to report to this Association that
the Essay entitled “The Control of Scarlet Fever,” has been awarded the
prize I had the honor to offer at our last meeting. I am also pleased to
announce that the author of this Essay is Dr. F. H. Higgins, of Cortland,
and that the Committe of Examination considered it as not only entitled to
the prize, but as worthy of special commendation as a paper in the line of
popular sanitation.
746 NEW YORK STATE MEDICAL ASSOCIATION.
ORTON PRIZE ESSAY. 1
THE CONTROL OF SCARLET FEVER.
By F. H. Higgins, M. D., Cortland, N. Y.
WHEN an ambush is unmasked the fear of it is gone. Diseases were
mysteries; they were dispensations of Providence ; they were punishments
to be submitted to. So long as the cause was unknown, and no method of
prevention recommended itself, it was the part of philosophy to endure
Stoically what could not be cured.
By the revolution in our knowledge of the contagious diseases brought
about by the germ theory, this position is radically changed. It is within
the last decade that a sure basis for our belief in the bacterial origin of
disease has been reached. But already so much has been made clear that
tame submission to epidemic is criminal.
The first struggle against such diseases as scarlet fever, diphtheria and
measles, was a defensive one. Long ago it was found that after such a
malady had gained an entrance into the system, almost nothing could be
done to arrest its course until its force was spent. In spite of a vast
amount of experimentation, this fact still remains true. After one of these
contagious diseases has once developed, good nursing may help the stricken
One, but we are entirely unable to reach the fons et origo in his case.
There is something, however, that we can do. One of these attacks is
as much an accident as to be struck by a rifle ball. It is the result of an
extraneous cause acting upon the system. The feeble and the strong are
equally liable.
The earliest efforts of physicians and friends were confined to serving as
an ambulance corps to care for the wounded. Then, as some idea of the
direction of the invisible arrows was obtained, defenses began to be erected.
By isolation, diseases were not allowed to spread so rapidly from one to
another until whole families and communities were laid low. Common
observation had taught us this before the microscope had clearly revealed
Our enemies to us.
Now, by the great increase in the exactness of our knowledge, we may
begin an aggressive warfare. We are just beginning to reach that import-
ant principle that the best defense is an attack. We are just finding out
that there is a possibility of annihilating such diseases as scarlet fever SO
that we need fear its ravages no more. If such an end shall be reached, it
is essential that not only physicians, but every member of the community,
shall know the plan of attack and assist in carrying it out. *
In the first place, it needs to be thoroughly, radically, and once for all
understood that scarlet fever is a contagious disease, and that when any
case occurs, it has been contracted from some other case, either directly or
indirectly.
1 This essay was awarded the prize (a complete set of the Medical and Surgical His-
tory of the War), offered by Dr. J. G. Orton, of Binghamton, in aid of popular Sanitary
Science.
PROCEEDINGS THIRD DISTRICT BRA. WOBI. 747
Generally by careful investigation this can be shown. Cases do occur,
however, in which the connection cannot be discovered. When we re-
member that the contagium is something unappreciable to the ordinary
senses; that momentary contact with a garment that has been worn by a
person who has had the disease is sufficient to cause it ; that the disease
does not manifest itself until some days after it has been received into the
system ; that it can be carried by the milk we drink, caught in a street car
from one just recovering, or brought by a well person from the sick room,
it is little Wonder that in some cases an exact statement of the cause cannot
be given. There was a time when farmers explained the appearance of
thistles on a piece of new ground by spontaneous generation, and when
frogs were thought to come from clouds. After all the world had con-
ceded that animals and plants such as these came from an ancestor like
themselves, there still remained scientific men, who believed that the micro-
scopic life which always appears in standing water or organic infusions,
was of spontaneous origin. The careful experiments of Pasteur, repeated
many times by scientific men everywhere, have shown that in every case the
development of living organisms, even of the minutest and simplest kinds,
is owing to the presence of germs carried thither by the air or some other
medium. The ordinary kitchen operation of canning is an every day ex-
periment proving the same thing. If mould appear in the fruit, no woman
explains it by chance or by development inside the can, but knows that
the cover has become loose, and outside air, germ laden as it is, has
gained entrance there. Precisely the same is it with the germ of scarlet
fever. We may be sure if we find it present that it came from somewhere.
How did the first case originate 7 We know as little about this as about
the origin of life anywhere else ; but this we know : snakes, tigers and Eng-
lish sparrows will not develop spontaneously if we can get rid of those now
On hand.
We need have no fears, then, that our labors of extermination may be
frustrated by the disease all at once appearing de novo.
Although there is still some dispute as to the exact appearance and
Scientific name of the disease germ of scarlet fever, something may be stated.
It is probably a bacillus. These bacilli are long, narrow, rod-like germs,
often in chains by attachment end to end. It has been called provisionally
bacillus Scarlatinae. It has been cultivated and grown outside the body on
the serum of ox blood. We know some of the conditions most favorable
to its growth, and what substances are prejudicial to it. This part of our
knowledge is still fragmentary, but owing to the zealous work of micro-
Scopists, is rapidly increasing. By comparing what has been learned by
direct observation of this germ with what we positively know of its con-
geners, a very clear idea of its behavior may be obtained.
After the entrance of the germs into the system, about three days are
devoted to their multiplication before they have reached a sufficient num-
ber to produce any visible effect. This time may vary according to the
number and activity of those introduced ; then languor and vomiting are
followed by red throat and strawberry tongue; this soon by a bright red
748 NEW YORK STATE MEDICAL ASSOCIATION.
rash. At the first stage of the disease every part of the system is reached by
the germ and may give it off to someone else. The germs floating in the
breath and in the exhalations from the body may carry the disease, but not
a long distance. It has been discovered that one must come as near as
three feet to receive the disease at this time. This is contagion by personal
contact. It rarely occurs. Fortunately it does not occur at all until after
the fever is plainly manifest. It is like a rattle-snake, and gives fair warn-
ing before it strikes. It is very different from measles in this respect, for
this is most dangerous to others when the child is first coughing and no
rash has yet appeared.
During the height of the disease it is said that the bacill: Scarlatinae
cannot be found. It would not be safe to say that the disease was not then,
to any degree, contagious, but with careful isolation it certainly can be
kept from spreading. It is after the height of the fever has passed, and
the little one in a fair way to being well again, that the danger is greatest.
Now the skin is flaking off in shreds and scales all loaded with the germs,
seeking new fields to conquer. The skin is the peculiar location of the dis-
aase, and from it the contagion spreads. It is not now by exhalations in-
nocuous at arm’s length, but by floating scales bearing the bacilli upon
them like warriors in their chariots. These lodge in clothing, propagate
themselves in milk, and are even transported by the mails for hundreds of
miles. It indeed appears like one of the labors of Hercules to follow and
destroy these myriads; and so it is. But to prevent their escape is not
so desperate an undertaking. When the lid to Pandora's box was raised,
by no possibility could all the evils there contained be recaptured or sub-
dued. In the past we have been as foolish as she.
By simply keeping the skin greased, the far and wide dissemination of
the disease during convalescence may be stopped. By adding to the un-
guent some substance detrimental to the germ, and not harmful to the
patient, such as thymol, or eucalyptolor carbolic acid, the safety is rendered
nearly absolute. A small amount of oil of eucalyptus in lard or sweet oil
makes almost an ideal preventative of danger at this period, and is rather
beneficial than otherwise to the sufferer.
So confident are some practitioners in the efficacy of systematic unctions
to prevent contagion that they do not hesitate to allow intercourse with
other members of the family, even while the desquamation is going On.
But it is not wise to trust to this alone.
Before the patient is restored to society he should be given a final,
thorough bath ; especial attention should be paid to the hair and any place
that might afford lodgment to the bacteria. With a final greasing and
clean clothing throughout, he may return to the family or to School.
It would be a grave oversight, however, to carefully disinfect the patient
and neglect to destroy all the contagium in the bedding and room which
he occupied. It is to simplify this part of the work that it is so much bet-
ter at the commencement of the disease to put the bed into a bare room.
In such a room, with no lurking places under carpets and behind curtains,
our enemy stands but poor chance in a hand to hand conflict with such
PROCEEDIWGS THIRD DISTRIOT BRANCH, 749
modern weapons as carbolic acid, corrosive sublimate and boiling water.
These germs are weak individually ; they are strong only in numbers.
Let one case in an ordinary family illustrate just how we may get rid of
Scarlet fever there.
The oldest boy in a family of four had just begun to attend the public
school. Some of the Scholars had scarlet fever about their clothes and gave
it to our little friend, for which, in my opinion, an action for damages
would be perfectly justifiable. As soon as the rash began to appear, a bed-
room upstairs was emptied completely. A bed, stand, and two wooden
chairs were allowed in the room, with a small stove. A sheet dampened
with carbolic acid water was hung over the door. The mother or nurse
attending him was directed to go to the other parts of the house as little as
possible. If obliged to leave the room, she was to wash and change her
gown. After the fever subsided and peeling commenced, the child was
well greased all over twice a day.
At the end of about three weeks, although four weeks is the rule, he
was well washed, especially the hair, greased, dressed in clean clothes, and
allowed to go down stairs. The bedding was thrown out the window on
a low roof, and allowed to air all day. It was then boiled in chlorine
water made by adding two ounces of white vitriol and four ounces of salt
to the gallon of water. The room was washed and mopped with corrosive
sublimate in the proportion of one dram to the gallon of soft water. If
there should be any nooks or corners, or any material in the room that
could not be reached with the scrubbing brush, then sulphur should be
burned. It must always be accompanied by steam, and used in large
amounts. The proportion recommended by Dr. Edson, health officer for
New York City, is three pounds for each one thousand cubic feet, used for
two hours. An ordinary ten by twelve bedroom contains about one
thousand cubic feet. The dish containing it should be set in a pan of
boiling water in the middle of the room, a little alcohol poured over it and
lighted ; then the room closed tightly and left for two hours. There is no
danger, but some kinds of goods will be bleached by it.
It must not be forgotten that fresh air and sunlight are death to these
germs, and are two of our best weapons.
In this case that has just been detailed, not one of the little brothers or
sisters took the scarlet fever, nor did any case arise from it. At that par-
ticular point scarlet fever was annihilated.
That the fortunate result was due to care, not luck, was illustrated in
less than a month, when this little one broke out with chicken-pox. While
Scarlet fever is the most terrible scourge of childhood, chicken-pox is the
mildest. So the children were allowed to play together, and as a result, as
might have been expected, it affected them all. The means taken to limit
the spread of scarlet fever in this case are no more than can be easily car-
Tied out by any ordinary family. It is certainly less trouble than to nurse
another child through the sickness. The happy results when the plan,
simple as it is, is well carried out, certainly justify the effort. The details
in each house may be varied intelligently, provided we are acquainted with
750 NEW YORK STATE MEDICAL ASSOCIATION.
the object to be attained, and the means adequate. For we fight not as
one that beateth the air now that we know as much of the habits and
nature of the germ as if it were a visible enemy.
Diseases of foreign importation, as the plague, cholera and yellow fever
have been held at bay by such means as these. Is it not time to plan a
campaign against some of our intestine foes?
The inducements to such action are certainly strong enough. At least
one-ninth of all the cases of deaf-mutism are owing to scarlet fever. Of
the large number of cases, deaf in one ear, perhaps one-half are due to the
same cause. A large contingent of cases of kidney affections date back to
scarlet fever. A chronic sore throat is often the result of the disease.
The number of deaths directly due to it is excelled by none of the child-
ren’s diseases.
The excuse given for allowing children to catch the measles—that they
had better have it and done with it—cannot apply here. Scarlet fever is
most severe and dangerous in younger children; older persons escaping
altogether.
These is no other contagious disease whose habits are better understood
or that can be more easily arrested in the present state of our knowledge.
Whatever excuse there may be in allowing all other fevers to spread a
their own sweet will, there is none for scarlet fever.
When we shall be successful in subjugating this, the armament and ex-
perience obtained may be hopefully turned to such lurking enemies as
diphtheria.
That so general and horrible a disease as small-pox has been thoroughly
controlled by vaccination, has ever since been an inspiration in the efforts
to obtain similar results in others. But although thousands of experiments
have been made, no vaccine has yet been discovered for the disease under
consideration. Pasteur's inoculation for hydrophobia is promising, a
yellow fever inoculation is being investigated, and there is still a ray of
hope in Koch’s consumption cure. But none of them is yet beyond the
experimental stage. Enough has been found out to warrant the hope that
some virus may be discovered which, introduced into the system, shall for-
tify it against these diseases. Possibly some phagocyte may be found
which shall defend the system of a child from the scarlet fever germ.
But these studies are after all working at the wrong end of the prob-
lem. An attack is the best defense. We do not in this age erect high
walls around our cities, but place cannon there. Soldiers do not encase
themselves in steel armor, but depend on their guns and the generalship of
their leaders to defend them. We may better strike the enemy than to
spend all our time manufacturing improved breast plates.
Can such a campaign be practically carried out 7 There are doubtless
difficulties. If there were not, it would not have now been left unaccom-
plished. Nor is there any other way to surmount them than by steady
persistence in some well directed plan. It must be as Grant captured
Petersburg. Convinced that our forces are superior to those that are
against us, we must move on the enemy and fight it out on this line if it
takes all summer.
PROCEEDIWGS THIRD DISTRIOT BRAWOH. 751
Paradoxical as it seems, one of the most perplexing difficulties is the
occurrence of mild cases of the disease. Although the disease is one of the
most malignant known, a large proportion of the cases are of a very mild
type. The child does not complain, the rash is very slight, and the whole
case is managed by the mother as “Scarlet rash ;” or perhaps a doctor is
called in and does not like to frighten the family, and so calls it scarlatina.
Scarlatina means nothing less than scarlet fever, and “Scarlet rash ’’ given
to a neighbor’s child, may be fatal scarlet fever as well as if caught from
the most Severe Case.
Isolation, cleanliness, inunctions and antiseptics are just as important in
these light cases as in any, if the disease is to be stamped out from among
us. Fortunately, at least for general interests, selfishness alone will lead
to a proper care of these cases if the whole matter is properly understood.
No physician who has seen the dropsies, rheumatisms and running ears
resulting from the neglect of these mild or unrecognised cases of scarlet
fever, can conscientiously fail to warn his families of the results of such
laxness. As the public generally come to understand medical matters
better, as they are doing, these light cases will be better cared for.
It should be thoroughly and generally understood that a “scarlet rash”
is a snake in the grass, both to the patient and to the community.
Certain epidemics of scarlet fever, especially in England, have been
thought to originate from cows afflicted with a disease of similar nature.
If this be so, it would seem to complicate the situation very materially.
If new centres of infection may appear at any time from contact with the
lower animals, then there is some excuse for despairing of ever ridding
ourselves of this scourge. The result of all the investigations on the Hen-
don outbreak, however, seems to be that the disease among the cows was
not scarlet fever. It is more likely that in such cases the milk becomes in-
fected from some cause after it is drawn, and that is a matter which we
may and should control.
Criminal proceedings are none too severe for a milkman who will allow
a case of scarlet fever in his family to communicate the disease to all the
children on his route through the medium of the milk.
Another practical difficulty in securing general co-operation is the cases
which occur in indigent families. With only one room in the house, with
Only one fire and no possibility of getting another, with no conveniences
and no help, the task of carrying out the prophylaxis described, simple as
it is, looks impossible. Many times with such conditions the physician
abandons all attempt to separate the sick from the well, with the inevitable
result that all the children in the family are affected, with more or less fatal
result. The neighbors' children follow, and from them a local epidemic.
Pessimists among physicians and health officers point to such occurrences
and Say all efforts are hopeless. To them the idea of overcoming the disease
looks as Utopian as the decree of a king to abolish death in his domains.
But would it not be policy for the government to take charge of such
Cases, and do for them what the families themselves cannot do 2 Does not
the loss to the State now resulting from the devastation of the disease
752 NEW YORK STATE MEDICAL ASSOCIATION.
more than counterbalance, on a money basis alone, all the expenditure
which would be involved in combating it 2
It is true that in poverty stricken homes no adequate measures for pre-
venting the spread of disease to the families about, or to the children of
the same public school, can be depended on. But if an officer were ap-
pointed in each town or ward, with sufficient authority and compensation,
the thing could be done. Either by supplying proper nurses, or taking the
case to a hospital, such care could be given that the rest of the family could
be spared and the community at large not imperilled. In all this work, too,
the object would not be simply to protect certain individuals at certain
localities, but to know that the spread of the disease itself was checked.
It will add much to the enthusiasm with which conscientious physi-
cians and families now endeavor to meet the disease, to know that the same
work is being done all along the line. By a general oversight it should be
possible to trace a steady and rapid decrease in the amount of scarlet fever
in the land. What louder call on the knight-errantry of the nineteenth
century than to endeavor to destroy this hydra-headed monster that has
been devouring our children ?
SUMMARY.
The cause and transmission of scarlet fever is now sufficiently under-
stood to enable its spread to be controlled.
By concerted action and State supervision, it is possible to rid our
country of this one disease.
The factors favorable to such a result are:
1. The disease is seldom given during the first stages or when it cannot
be recognised.
2. Immunity extends to within three feet of the patient, in the first stages.
3. The spread of the disease is due almost entirely to the epithelial
scales exfoliated from the skin.
4. The danger from this exfoliation can be controlled.
5. Simple rules carried out render safe the room in which the patient
has been confined.
6. A general destruction of the disease germs wherever they manifest
themselves, will soon greatly diminish its prevalence and the difficulty of
its control.
The difficulties which beset the practical carrying out of such a general
campaign are :
1. The neglecting of mild cases, which must be met by more general
education and stricter reports to health officers.
2. The possibility of new centres of infection from lower animals,
although this is rare and doubtful.
3. The lack of definite information on the subject, which must be met
through the public press.
4. The occurrence of the disease in homes of poverty, where means for
its suppression will not be carried out by the family. These cases must be
cared for by the State, which can well afford to do it.
PROCEEDINGS THIRD DISTRIOT BRANCH, 753
The last paper was by Dr. J. G. Orton, and was entitled “An Inter-
cranial Lesion; Ante-Mortem Localisation; Autopsy.”
A lady about fifty years of age, while at the seashore near New York
City in June, 1890, was suddenly seized, without former cerebral symptoms
except headache, with left hemiplegia (face, arm and leg) but without
complete loss of consciousness, and without marked sensory disturbances
of previous clonic spasms, and without other speech derangement than the
usual dysarthria of hemiplegia; but after being removed to her boarding
place in New York, she exhibited mental confusion, and at times, con-
siderable delirium. She was placed under treatment by competent physi-
cians, who diagnosed at One time cerebral haemorrhage, at another, a tumor,
and at still another, a possible abscess. Improvement of the paresis fol-
lowed in a few weeks, but the mental symptoms did not disappear. She
had a good appetite, and was able to go out of doors for a walk, and at
times seemed quite herself; but there soon supervened a second attack in
which paresis became worse in the same parts as before. I learned this
history of the case from her attendants.
In the early part of August she was removed to Binghamton, and came
under my care. On the day of her arrival she readily knew me, and could
talk quite well. She was, however, easily confused as to her surround-
ings; tongue clean, bowels regular, appetite good, pulse 80, temperature
100°, pupils normal, body well nourished. She had so far recovered from
the paralysis of the left side as to use her limbs fairly well, and sensation
was nearly normal. On my visit to her the next day, she was unable to
help herself and could only utter a few inarticulate sounds, but evidently
understood what was said to her, as was indicated by squeezing with her
right hand when requested. The left side was completely paralysed ; the
tongue could be protruded, but the eye-lids could not be opened wide.
Coma gradually increased until these movements were also abolished, and
paraplegia was fully established.
A third nerve paresis of the right side was evinced by the ptosis,
position of the eye-ball and dilatation of the pupil. The stupor was quite
Continuous, although she could be partially aroused long enough to take
liquid food if carefully given. She made no effort to move the extremities
or tongue on request ; possibly there was a slight effort to squeeze with the
right hand on being thoroughly aroused. Sensibility seemed normal to
painful impressions, such as pricking ; but tactile sensibility could not be
determined. The superficial (skin) reflexes were preserved in the lower
extremities. The knee-jerks were present, but were more active on the left
side. There was some contraction of both the left arm and leg; no quick
clonic movements, but slowly increasing and relaxing tonic spasms, when
She would also frequently moan and cry out. The facial movements ex-
hibited slight facial paresis (cerebral type); deglutition was as in states of
partial coma. The pupils responded to light sluggishly, the left more
than the right, but would suddenly dilate when she was moved or aroused.
There was no persistent conjugate deviation, but the eyes would move
about, sometimes resting to one side, sometimes to the other. The fundus
754. JNE W YORK STATE MEDICAL ASSOCIATION.
appeared under the ophthalmoscope normal; there were no signs of optic
neuritis or atrophy.
About the first of October, there appeared a discharge of pus from the
right ear, and also from the mouth. This continued for three weeks, and
then gradually ceased. This circumstance naturally led to the suppo-
sition of a possible abscess either in the mastoid cells, or even intercranial,
and the subject of surgical interference was discussed.
As this case had continued so long, and its true nature unrecognised,
or rather the intercranial lesion unlocalised to my satisfaction, I had taken
pleasure in inviting several of our local physicians to examine the case ;
but our consultations did not result in any very positive views as to the
exact location of the intercranial lesion. In order to settle, if possible, the
advisability of resorting to surgical measures, I asked that a neurologist
be called in consultation, and accordingly, at my suggestion, the late Dr.
W. R. Birdsall, of New York City, visited the patient on the 24th of
December, 1890. He made an exhaustive examination, and after his return
home wrote me a letter from which, with your permission, I will quote
freely, and I am sure you will be pleased with the light which he throws
upon the case, and his positive opinion in regard to the impossibilities of
relief from surgical interference. It will also be interesting to see how his
diagnosis has been remarkably corroborated by the autopsy.
In this connection it is indeed sad for me to record the sudden death
during the past week of this comparatively young but already dis-
tinguished physician, justly eminent as a neurologist.
Dr. Birdsall said in his letter: “The sudden onset of the first attack
without former local, sensory or motor disturbances, and the complete
hemiplegic character of the attack (face, arm, leg and dysarthria) without
occular symptoms, pointed to a lesion of the right internal capsule—being
too extensive for a cortical lesion—probably an arterial lesion concerning
whose nature, whether from haemorrhage, embolism, thrombosis or occlu-
sion, could only be inferred from the probabilities in favor of the different
causes of these states. The second attack would have to be considered as
of a similar nature to the first, but its location not easily determined ; the
prolonged coma was the most difficult thing to account for, the probable
view being a large area of softening from extension into some area not
giving rise to sensory or motor phenomena, though the rapid accession of
the coma may have masked many symptoms.
“The third nerve (right, crossed paresis) pointed to an intercranial
peduncular lesion ; such lesions, however, are more frequently due to
neoplasms than to disruption from haemorrhage or the products of soften-
ing. The prolonged coma is also more consistent with tumor or abscess
than with arterial disease, but the character of the first attack and the ab-
sence of optic neutritis are opposed to either tumor or abscess, nor Was
there any history of deafness or former ear disease. The subsequent dis-
charge of pus fom the ear opposite the paralysed side again raises the
question of abscess, but the nature of the attack is strongly opposed to ab-
scess. The examination of the ear shows a large perforation which has
PROCEEDINGS THIRD DISTRIOT BRANCH, 755
destroyed more than one-half of the tympanum. There were no signs of
active suppuration, and no thickening of the walls of the canal indicating
bone disease. The patient has doubtless had an abscess of the middle ear
as an intercurrent affair not connected with the intercranial trouble. Ten-
derness over the mastoid could not be elicited ; which test, however, is of
little value when so much stupor is present.
“I can see no warrant for surgical interference concerning the ear trouble
The cessation of the discharge of pushad no effect on the cerebral symptoms.
“From the history of the patient since the second attack, and the
examination recently made, I should say there is but little change as
regards the motor, Sensory and reflex phenomena. There is an increase in
the tonic spasms or attacks of general rigidity which supervene when she
is not in a proper position, and which are bilateral. There is no rigidity
of the neck, and no vomiting. The third nerve paresis is not as marked as
earlier in the course of the disease, but is still present. There are still traces
of facial paresis. The knee-jerks are more active, the left preponderating.
Elbow jerks are present, right and left. The fundus occuli does not show any
signs of choked disks or optic neuritis, but the disks are decidedly changed
in color. They present a degree of whiteness which must be considered
atrophic, but without signs of former optic neuritis. To a feeble light the
pupils do not react, but to a strong electric light they react sluggishly.
“From the history of this interesting case and the examinations which
have been made of the patient, I am of the Opinion that there has been an
arterial occlusion followed by softening, involving the right internal
capsule and afterward other deep seated and central portions of the brain.
There can, therefore, be no warrant in my opinion for intercranial surgery,
and no justification for attempting to remove the products of cerebral
softening. The indications of a localised cortical lesion are not evident.”
The prognosis of this case was of course unfavorable, and treatment
could afford nothing in the way of repair of damage done to completely
occluded arteries, or restore function to softened areas of cerebral tissue.
The patient died on the 9th of March, 1892, nearly two years from the
date of her first attack, apparently from congestion of the lungs.
At the autopsy, sixty hours after death, kindly performed by Doctors
Moore and Rodgers, of Binghamton, we found the inner surface of the
skull smooth and free from any signs of disease. The dura mater and pia
mater were normal in character. The convolutions and superficial vessels
were also normal. There were no evidences of disease of the mastoid.
We found an area of sclerosis involving nearly the entire right cuneus;
an area of softening of a considerable portion of the interior of each thalamus
(certainly three of the four ganglia of the right side); the greater portion
of the right lenticular nucleus, and also some of the fibres of the adjacent
posterior segment of the right internal capsule. All other portions of the
brain seemed normal in character.
After the transaction of some miscellaneous business, the Association
adjourned.
L. J. BROOKS, President.
48 W. L. AYER, Secretary.
FOURTH DISTRIOT BRANCH.
The eighth annual meeting was held at the Hotel Iroquois, Buffalo, on
Tuesday, May 10, 1892.
The morning session was called to order at 11 A. M. by the President,
Dr. J. B. Andrews.
The minutes of the previous meeting were read by the Secretary, and
were approved.
President Andrews read the annual address upon the subject, “Inebrie-
ty—a Vice, a Crime, or a Disease ?” -
The Treasurer presented his annual report, showing a balance on hand
of $35.28. Upon motion of Dr. Putnam, the report of the Treasurer was
adopted.
The Secretary moved that the order of business be changed, and that we
proceed with the scientific programme. Carried.
The first paper was presented by Dr. James W. Putnam, and was
entitled, “Brain Tumor, With Report of Cases.”
Dr. Wm. H. Bergtold, who had made the autopsy in one of the cases
referred to, presented the specimen to the Association.
Dr. C. C. Frederick then read a paper upon the subject, “Why is
Intra-Uterine Irrigation so Often Ineffectual in Puerperal Septicaemia 7”
The paper was discussed by Drs. Stockton, Parmenter and Hayd.
Dr. John C. Parmenter next read a paper on “A Case of Gun-Shot
Wound of the Brain.” The paper was discussed by Drs. Putnam, Phelps
and O’Brien.
The President requested the members present from each county to select
a member of the Nominating Committee.
AFTERNOON SESSION.
The meeting was called to order by the President.
The Nominating Committee presented their report, and the following
named Executive Committee was duly elected for the ensuing year:
J. A. Stephenson, M. D., Scio, Alleghany County.
S. J. Mudge, M. D., Olean, Cattaraugus County.
Nelson G. Richmond, M. D., Fredonia, Chautauqua County.
C. C. Frederick, M. D., Buffalo, Erie County.
M. W. Townsend, M. D., Bergen, Genesee County.
F. H. Moyer, M. D., Moscow, Livingston County.
R. M. Moore, M. D., Rochester, Monroe County.
W. Q. Huggins, M. D., Sanborn, Niagara County.
F. D. Wanderhoof, M. D., Phelps, Ontario County.
PROCEEDIWGS FOURTET DISTRIOT BRAWOH. 757
John H. Taylor, M. D., Holley, Orleans County.
Jeremiah Dunn, M. D., Bath, Steuben County.
Darwin Colvin, M. D., Clyde, Wayne County.
A. G. Ellinwood, M. D., Attica, Wyoming County.
William Oliver, M. D., Penn Yan, Yates County.
Dr. G. W. Goler, of Rochester, presented the ovaries and tubes from a
prostitute, thirty-one years of age, showing interstitial changes in the tubes
due to gonorrhoea, the invasion of which occurred sixteen years before
death. The tubes were atrophied and presented nodules of cicatricial
tissue, occluding their calibre at various points. The fimbriae were not
invaginated, but their stunted remains formed a canal covered in by peri-
metritic adhesions directly continuous with the ovary. The ovaries were
small and markedly cystic.
Dr. F. W. Bartlett reported the successful treatment of a large number
of cases of acute dysentery by flushing out the lower bowel with a stºry
solution of bichloride of mercury, using about two quarts at blood tem-
perature. He had also used similar treatment in eighteen cases of typhoid
fever, and had had no fatalities in this disease since beginning this
treatment.
Dr. C. C. Frederick spoke in favor of flushing the colon in dysentery
and all forms of entero-colitis, and in cholera infantum. In all cases he had
met with favorable results,
Upon motion, the meeting adjourned.
J. B. ANDREWS, President.
WM. H. THORNTON, Secretary.
FIFTH DISTRICT BRANCH,
The eighth annual meeting of the Branch was held at 315 Washington
street, Brooklyn, on Tuesday, May 24, 1892.
In the absence of the President, the morning session was called to
order by the Secretary at 11.30 A. M. On motion, Dr. W. T. White was
called to the Chair. The Secretary read the minutes of the last meeting,
which were approved.
The report of the Committee of Arrangements was read and ordered
On file. - -
The Chairman appointed Drs. W. G. Russell and J. R. Wanderveer to
act with the Secretary as Registration Committee.
The next order of business was the President's Address, but as Dr. Van
Hoevenberg had not yet appeared, the meeting proceeded with the order.
There were no reports of delegates.
There was no formal report from the Executive Committee, but the
Secretary read the minutes of the committee for the past year. These
were approved as read.
The Treasurer's annual statement was then read and approved.
Under the head of Report of Special Committees, the Committee on
Necrology reported that there had been five deaths among the Fellows of
Our District since the last annual meeting—two of whom were founders :
Dr. David Matthews,
Dr. Abram DuBois,
Dr. N. C. Husted,
Dr. Lucien Damainville,
Dr. Rutson Maury.
There was no unfinished business.
Under new business, the Secretary announced that he had received
programmes of the Seventh Annual Meetings of the Second District
Branch, to be held in Troy on June 25, 1891, and of the Third District
Branch, to be held in Binghamton on June 18, 1891, also for the Eighth
Annual Meeting of the Fourth District Branch, to be held in Buffalo On
May 10, 1892. -
The biographical sketches were then called for.
In the absence of Dr. Flint, the Secretary read Dr. Flint's memoir of
the late Dr. Lucien Damainville. As Drs. Purple and Coutant were not
present with their sketches, Dr. McLeod was called upon to read his re-
marks on the late Dr. David Matthews. As some very recent data had
been obtained in regard to the life of Dr. Matthews, Dr. McLeod asked
PROCEEDINGS FIFTH DISTRIOT BRANCH, 7.59
permission to retain his sketch until he had perfected it. The Secretary
announced that, according to the custom, these sketches would be referred
to the Committee on Necrology of the State Association for publication.
As Dr. Rutson Maury had died so recently, there had not been sufficient
available time to secure any extended remarks, but the Secretary read the
following newspaper clipping, which might suffice for the present : “Dr.
Rutson Maury died at 9.30 A. M., Thursday, May 5, 1892, at St. Luke's
Hospital, from pneumonia. He was taken sick from overwork on the Fri-
day before, and removed to the Hospital.
“He was born on August 15, 1865, at Milton, N. C. Son of the late
William Lewis Maury of the United States and Confederate States navies,
he attended Grammar School No. 40 in New York City, and was gradua-
ted from the College of the City of New York in 1884. The same year he
entered Bellevue Medical College, and was finally graduated at the head of
his class. He was the first student in the college who ever received a per-
fect mark in everything in his final examinations. After going through
the Bellevue Hospital course, he became associated with Dr. Lusk, and was
his assistant up to his death.”
The scientific papers were then taken up. Dr. John Blake White's
paper was called for, but as he was not present it was announced to be
called up during the afternoon session.
Dr. T. H. Burchard next read his exhaustive paper on “The Therapeu-
tic Efficacy of the Saratoga Mineral Waters.” Discussed by Drs. Newman,
McCollom, McLeod, Paine, and the following invited guests : Drs. E. H.
Bartley, M. C. O’Brien, J. R. Goffe and E. Reynolds, and closed by the
author.
The Secretary here stated that all the papers read would be published.
Choosing a Nominating Committee to nominate members for an Execu-
tive Committee for the ensuing year was then in order. The Secretary
called off each county in the District in alphabetical order, and the Fellows
present from each county named the Fellow to represent that county on
the following
Momčnating Committee :
Dutchess County, I. D. Le Roy.
Kings County, J. D. Sullivan.
New York County, J. G. Truax.
Orange County, M. C. Conner.
Putnam County, G. W. Murdock,
Queens County, None present.
Richmond County, F. U. Johnston.
Rockland County, None present.
Suffolk County, Walter Lindsay.
Sullivan County, None present.
Ulster County, None present.
Westchester County, Nome present.
The committee was then requested to meet during the coming inter-
mission. Adjourned for lunch at 1.40 P. M.
760 NEW YORK STATE MEDIOAL ASSOCIATION.
The afternoon session was called to order at 2.45 P. M., Dr. W. T.
White still in the chair.
The Scientific work was immediately resumed by Dr. J. E. Janvrin
reading his paper on “The Limitations for Waginal Hysterectomy in Ma-
lignant Disease of the Uterus.” Dr. George Tucker Harrison opened the
discussion by reading from notes. Dr. Alex. J. C. Skene, as an invited
guest, was called upon, but as he could not be present he sent his apolo-
gies and his remarks written out, which the Secretary read in full.
The paper was further discussed by Drs. A. F. Currier and J. R. Goffe,
both invited guests, and finally closed by the author.
Dr. J. R. Wanderveer next read his note on “Retention of Menstrual
Blood from Imperforate Hymen.” Discussed by Drs. Janvrin, Harrison,
Minard and Burchard, and closed by the author.
By special request, Dr. S. E. Milliken was permitted at this time to
demonstrate Bassini's Operation for the radical cure of Hernia. Colored
plates were used, so arranged as to make the demonstration clear. Dis-
Cussed by Drs. Armstrong, Harrison, Burchard and A. F. Currier (guest),
and then closed by Dr. Milliken.
Dr. W. D. Granger's paper was then called for, but as he had to leave
before it was called, he desired to have his paper read by title—“Voluntary
Patients in Asylums for the Insane.”
Dr. S. W. Smith was next called upon for his paper, but he had pre-
viously begged to be excused, as he was called away.
Dr. S. T. Armstrong then read his paper on “Brown-Sequard’s Par-
alysis Resulting from Syphilis.” No discussion.
Dr. J. B. White was now called upon to read his paper, which had been
postponed from the morning session on account of his absence. Owing to
the lateness of the hour he begged to be excused.
The scientific business having been completed, the Nominating Com-
mittee made its report as follows :
For Member of Faecutive Committee to represemi–
Dutchess County, I. D. LeRoy.
Rings County, J. D. Rushmore.
New York County, T. H. Manley.
Orange County, M. C. Conner.
Putnam County, G. W. Murdock.
Queens County, E. G. Rave.
Richmond County, F. U. Johnston.
Rockland County, Wm. Gowan.
Suffolk County, W. D. Woodend.
Sullivan County, W. H. DeKay.
Ulster County, H. Wan Hoevenberg.
Westchester County, H. E. Schmid.
On motion, the report was accepted and approved, and the committºº
discharged.
PROCEEDIWGS FIFTH DISTRICT BRA. WCH. 761
The chairman then called for a meeting of this new committee immedi-
ately after adjournment, but it was seen that there were only two of the
committee present, therefore a meeting could not be held. Adjournment
was then declared at 5 P. M., to meet next one year from this date.
The register showed 42 Fellows, 3 delegates from the Kings County
Medical Association, and 9 invited guests present.
H. WAN HOEVENBERG, President.
E. H. SQUIBB, Secretary.
*º-mºs
EXECUTIVE COMMITTEE.
A called meeting of the Executive Committee was held at 315 Wash-
ington street, Brooklyn, on Tuesday, May 24, 1892.
In the absence of the President, Dr. Van Hoevenberg, Dr. White was
asked to act as temporary chairman until the President arrived, and the
meeting was called to order at 10.15 A. M.
Present—Drs. W. T. White, M. C. Conner, F. U. Johnston, I. D. Le
Roy, G. W. Murdoch, W. G. Russell, E. H. Squibb. Seven members
present, six absent (one vacancy).
The Secretary read the minutes of the last meeting, which were adopted.
The Secretary reminded the members of a circular vote dated February
20, 1892, which had been taken to choose a Committee of Arrangements for
this meeting, and gave the result of that vote as 12 in the affirmative, no
reply from one and no reply from another on account of a vacancy. The
full committee consists of 14.
The report of the Committee of Arrangements was then read as fol-
lows:
REPORT OF THE COMMITTEE OF ARRANGEMENTS FOR THE ANNUAL
MEETING, 1892.
The undersigned committee have little to report in regard to their ef-
forts for this meeting, as the arrangements and contracting terms through-
out were so satisfactory last year, that they have presumed to simply
repeat them in all particulars.
The hour of 11 A. M. was decided upon for opening the morning session.
Respectfully submitted :
J. D. RUSHMORE, M. D., Chairman.
J. C. BIERWIRTH, M. D.
T. M. LLOYD, M. D.
WM. McCOLLOM, M. D.
R. M. WYCKOFF, M. D.
H. WAN HoHVENBERG, M. D., President, e
E. H. SquEEB, M. D., Secretary, } Ev-Officio.
On motion, the report was accepted.
The Chairman then appointed Dr. W. G. Russell to act with the Secre-
tary as Registration Committee, and stated he would appoint the third
member later.
762 JNETW YORK STATE MEDICAL ASSOCIATION.
The Secretary announced that there had been five deaths among the
Fellows of our District during the year:
Dr. David Matthews, on July 9, 1891.
Dr. Abram DuBois, on August 29, 1891.
Dr. N. C. Husted, November 19, 1891.
Dr. Lucien Damainville, December 15, 1891.
Dr. Rutson Maury, May 5, 1892.
The Secretary then read the note of resignation received on June 5.
1891, from Dr. James W. Guest, owing to his removal to Kentucky, and
stated it had been accepted according to the By-laws.
The Treasurer next read his itemized expenses and his annual state-
ment as follows: .
TREASURER's ANNUAL STATEMENT, MAY 26, 1891, To MAY 23, 1892.
Fifth District Branch New York State Medical Association,
with E. H. Squibb, Treasurer.
Dr. Cr.
To balance as per | By rent of meeting rooms . . $10.00
statement, May 26, 1891, $97.06 || Catering... . . . . . . . . . . . . . . . . 60.00
Assessments collected... . . . . 48.00 | Postage... . . . . . . . . . . . . . . . . . 11.00
Interest. . . . . . . . . . . . . . . . . . . . 68.95 | Printing. . . . . . . . . . . . . . . . . . 4.50
Balance, cash on hand. . . . . . 123.51
$209.01 $209.01
PERMANENT FUND ACCOUNT.
- * Ch".
To total amount of fund By investment in railroad
as per statement, May bonds (5% interest). . . $830.00
26, 1891. . . . . . . . . . . . . $1,000.00 | Balance on hand at inter-
Contributions to fund to est. . . . . . . . . . . . . . . . . . 260.00
date. . . . . . . . . . . . . . . . 90.00
$1,090.00 $1,090.00
The cash book and vouchers were presented for verification, and the
Chairman appointed Dr. F. U. Johnston to audit the accounts.
The time and place for the next meeting was then discussed, and it
was finally decided by vote that the next meeting, the ninth annual, would
be held in Brooklyn, on Tuesday, May 23, 1893, as provided for by the
By-laws.
The following names were read as those to be guests of our present
meeting :
Invited by request of Dr. Janvrin—
Dr. John Byrne, of Brooklyn.
Dr. Charles Jewett, of Brooklyn.
Dr. A. J. C. Skene, of Brooklyn.
Dr. H. C. Coe, of New York City.
Dr. C. Cleveland, of New York City.
Dr. A. F. Currier, of New York City.
Dr. J. R. Goffe, of New York City.
PROCEEDIWGS FIFTH DISTRIOT BRANCH, 763
As delegates from Kings County Medical Association :
Dr. F. C. Raynor.
Dr. Jonathan Wright.
Dr. L. A. W. Alleman.
Dr. E. Reynolds.
Dr. R. H. Sullivan.
Dr. W. P. Beach.
On motion, a cordial welcome was extended to the gentlemen, and they
were invited to full privileges of the floor.
In regard to the publication of the papers to be read at this meeting,
the Secretary was instructed to adopt the same plan as followed for the
past two years.
The Treasurer was next authorised to send out assessment bills as
heretofore for $1.00 to all those Fellows who have not joined in the Per-
manent Fund scheme, as dues for 1892, and to append to each bill the
usual slip inviting voluntary deposit to exempt from future assessments.
|Upon recommendation, the five Fellows who had very recently joined
our Association were exempted from assessment for the ensuing year.
The Secretary was directed to continue to act as the Committee on
Necrology.
Dr. Johnston here reported that he had found the Treasurer's figures
correct, and the committee then passed approval on the Treasurer's
Statement.
The committee had no formal report to present to the General Meeting
this year, and the Chairman declared the meeting adjourned at 10.45 A. M.
E. H. SQUIBB, Secretary.
EINGS COUNTY MEDICAL ASSOCIATION.
ANNUAL REPORT.
Officers of the Kings County Medical Association :
President, T. M. Rochester, M. D.
Vice-President, R. M. Wyckoff, M. D.
Recording Secretary, F. C. Raynor, M. D.
Corresponding Secretary, H. C. Riggs, M. D.
Treasurer, P, H. Squibb, M. D.
Elected Members of the Evecutive Committee :
E. R. Squibb, M. D., Term expires January, 1894.
T. M. Lloyd, M. D.. Term expires January, 1895,
Jonathan Wright, M. D., Term czpires January, 1896.
J. D. Rushmore, M. D., Term expires January, 1897.
In furnishing this report it is the desire of the Association to present a
series of abstracts from the minutes of the stated meetings for the year
1892, such as will show in concise form the quality and quantity of the
scientific business transacted for that time. The one or more papers pre-
sented at each meeting have been valuable and interesting, and have, in
most instances, evoked free discussion and interchange of opinion and ex-
perience scarcely less important in their benefits than the communications
which called them forth.
The attendance at the meetings has been fairly representative of the
Association's membership, and denotes a constant and steadfast interest in
the life and work of the Association.
STATED MEETING, JANUARY 12, 1892.
At this, the forty-third stated meeting of the Association, the President,
Dr. J. D. Rushmore, occupied the chair.
The papers of the evening were “Appendicitis,” by Dr. W. H. Big-
gam, and a “Report of a Case of Laryngeal Growth,” by Dr. F. C.Raynor,
STATED MEETING, FEBRUARY 9, 1892.
The President, Dr. J. D. Sullivan, in the chair.
The following memorial note was adopted by the Association respecting
the death of their late fellow-member, Samuel Curtis Robinson, M. D. :
“This Association has learned with profound regret of the loss by
PROCEEDIWGS KINGS COUNTY ASSOCIATION. 765
death of one of its early and most attentive members in the person of Dr.
S. C. Robinson, and has ordered that a minute expressive of their esteem
and regret shall be framed for permanent record.
“In the death of our late Fellow we have lost one of the earliest advo-
cates of the purposes of this organisation. While not an active practitioner
of medicine and not prominent in public discussion of medical questions,
he was thoroughly interested in matters bearing upon life insurance,
health protection, and the progress of therapeutics, and was an eminently
clear and logical judge in discussions of these questions.
‘‘ Dr. Robinson was a native of Guilford, Connecticut, born there in
September, 1830. He was prepared by his father for Yale College, from
which institution he graduated in his twenty-second year. In 1855 he was
granted his degree of M. D. at the Medical Department at New Haven.
After taking an additional course at the College of Physicians and Sur-
geons, New York, he traveled in the West and engaged in medical prac-
tice. He returned to New York and for a few years held the position of
surgeon on one of the transatlantic steamship lines. During the war he
served on the government transport McClellam and others. In 1865 he
again resided in New York, and for several years occupied the position of
medical examiner for the North American and other life-insurance compa-
nies. In 1867 he married the only daughter of the late Dr. James H.
Henry, of Brooklyn, in which city he has ever since resided. His wife,
one son and one daughter, survive him.
“. He died after a short illness, December 20, 1891.
“Resolved, That this Association keenly regrets the untimely loss of
their associate member, and will feel the absence of his sincere counsel and
co-operation, and most feelingly sympathise with the members of his
family in their sorrowful bereavement.
[Signed] W. * §:º | Committee.
The paper of the evening was by the Retiring-President, Dr. J. D.
Rushmore, on “Anaesthesia with Ether.”
STATED MEETING, MARCH 8, 1892.
The President, Dr. J. D. Sullivan, in the chair.
The paper of the evening was on “Approximate Estimation of Urea
in Urine,” by Dr. E. R. Squibb.
Dr. Charles A. Doremus and Dr. E. H. Bartley, as guests of the Associ-
ation, discussed the paper.
STATED MEETING, APRIL 12, 1892.
The President, Dr. J. D. Sullivan, in the chair.
The papers of the evening were “On the Treatment of Diabetes Melli-
tus,” by Dr. H. C. Riggs, and an abstract of a paper of Hirschberg's on
“Diabetic Retinitis,” by Dr. L. A. W. Alleman.
766 NEW YORK STATE MEDICAL ASSOCIATION.
STATED MEETING, MAY 10, 1892.
The President, Dr. J. D. Sullivan, in the chair.
The papers of the evening were by Dr. W. H. Bennett on “Dust and a
Polluted Atmosphere as Prime Factors in the Causation of Chronic Naso-
Pharyngeal Catarrh : with some Remarks on Deviations of the Nasal Sep-
tum and Treatment; ” and by Dr. E. R. Squibb, on “Solutions of Dioxide
of Hydrogen or Peroxide of Hydrogen.”
STATED MEETING, JUNE 14, 1892.
The President, Dr. J. D. Sullivan, in the chair.
Dr. Thomas H. Manley, of New York, read the paper of the evening
on “The Therapeutic Value of the Mercurial Salts in General Surgery.”
A vote of thanks was tendered by the Association to Dr. Manley for his
valuable and interesting paper.
STATED MEETING, NOVEMBER 9, 1892.
After the summer intermission, and the omission of the regular October
meeting because of the Columbus celebration, the Association held its fif-
tieth stated meeting on Wednesday evening, November 9th.
The President, Dr. J. D. Sullivan, in the chair.
Dr. Adolph Wilber presented a specimen of a foetal sac thrown off by
a woman two months pregnant, in which examination failed to detect a
foetus.
The paper of the evening was by Dr. T. M. Rochester, on “The After
Treatment of Haemorrhage.”
STATED MEETING, DECEMBER 13, 1892.
The President, Dr. J. D. Sullivan, in the chair.
Dr. Jonathan Wright read the paper of the evening on “Nasal Sprays
and Douches.”
T. M. ROCHESTER, M. D., President.
H. C. RIGGS, M. D., Corresponding Secretary.
NEW YORK COUNTY MEDICAL ASSOCIATION.
ANNUAL REPORT.
This report is respectfully presented to the State Association as a record
of the scientific work of the organisation in the County of New York. The
promotion of the science and art of Medicine, and the co-operation of the
State and County organisations, are the objects desired in its presentation.
IN THE DEPARTMENT OF SURGERY.—At the meeting October, 1891,
DR. FREDERIC S. DENNIS presented some surgical cases of special interest.
1st.—A case of non-traumatic acute suppurative Osteo-myelitis.
2d.—One of non-traumatic acute suppurative arthritis of the knee-joint,
of gomorrhoeal origin.
3d.—One of aneurysm of the iliac artery, with enormous distention of
the limb. This was on the right side, and followed an aneurysm of the left
popliteal artery which was cured by compression with an Esmarch
bandage, the patient being under the influence of ether for one hour and a
half. Dr. Dennis then described three cases of stab wound of the abdomen
in which laparotomy was performed and recovery resulted. Finally he
exhibited two cases of undescended testicle. In each a truss was worn, and
it was hoped that the desired result would be obtained without a resort to
operation. These several cases were brought in ambulances to the place of
meeting, and, in lieu of discussion, Dr. Dennis's remarks in answer to the
many questions of the members were most instructive and useful to all
interested in surgery.
At the meeting in December, 1891, DR. WON DONHOFF read a paper on
“Tracheotomy Without the Use of the Tube.” The author said that for
Seventeen years he had in ordinary cases performed tracheotomy without
using the tube or canula. He did so to avoid the difficulties and dangers
attending the introduction and removal of the canula. The opening into
the trachea is kept open by ligatures—one on each side—which are fastened
together behind the neck. Very little after management was required.
The paper was discussed by Dr. Truax and others.
At the meeting March 21, 1892, was presented the subject of “New
Ideas in Bandaging,” by DR. DANIEL BROWN. The doctor demonstrated a
Substitute for the ordinary roller bandage, which consisted of the applica-
tion of cheese cloth stretched over sheets of cotton, which, with a large
needle and coarse strong thread, was drawn snugly together ; if more
768 JWH’W YORK STATE MEDICAL ASSOCIATION.
pressure is desired another Seam may be made with gores. In case of
gathered breasts it may be made to fit neatly, and is capable of forming a
very meat and comfortable jacket. One of the advantages of this bandage
is that a nurse or unskilled helper could easily be instructed to apply it,
and it is less likely to slip down than the roller bandage. It also allows of
greater freedom of movement.
At the meeting May 16, 1892, DR. THOS. H. MANLEY read a paper, being
“A Few Notes on the Morbid Anatomy, Pathology and Treatment of
Umbilical and Ventral Herniae of the Congenital and Acquired Types.”
This paper was a very full and interesting description of the various con-
ditions of which it treats, and of the choice of various lines of treatment. It
was discussed by Drs. Milliken, Sayre, Von Donhoff, H. B. Tucker, and
De Garmo. The discussion was closed by Dr. Manley.
On the same evening, DR. S. E. MILLIKEN gave a short description of
Bassini's operation for inguinal hernia.
DR. A. B. JUDSON then read a paper on the subject of the “Treatment
of Congenital Club-Foot.” Dr. Judson confined himself to the considera-
tion of two or three important points, viz.: Early treatment, i.e., while in
arms; the first twelve months are the most important in the history of the
case. It should be placed in such a position that its own motion would
tend to correct the deformity. In the apparatus an upright bar should be
used, which may be bent as the foot gradually assumes the correct position.
This paper was discussed by Drs. L. A. Sayre, S. E. Milliken, and Won
Donhoff, and closed by Dr. Judson.
In addition to these scientific subjects a paper was read by Dr. C. B.
MEDING on the subject of “Physician Heal Thyself.” The characteristics
of this paper may be better shown by reading some of its sentences.
“Two factors are sureto force the medical profession to higher ground,
whether it will or no—first, an universal mental advance; second, the growing
strength of public opinion.” “Public opinion, a consequence and an index
of public education, affects us in common with all others, by stripping the
profession of every unearned honor.” “Every profession has had to change
its basis, not, alas ! without the loss of many misled conservatives. Priests
are now spiritual pastors, not confessors; lawyers are advisors, not pugi-
lists; physicians must be teachers, not semi-magicians.” “But while med-
icine is growing into the dignity of a science, we must not forget that it is,
always has been, and ever will be an art. It is an art because it must be
thought, and thinking is an art.” “Astronomy leaped when men hunted
for stars of destiny; physics found advance in heat, light, water, Sound,
and to-day in electricity, by exaggerated applications of the same to the
body; chemistry is at present devoted to remedy seeking ; and the various
studies of psychology, philosophy, etc., find their grandest use in appli-
cation to disease. Then should not the physician be as capable a master 88
possible 2—remedies are slaves.”
“Probably after this age of bacteriological research, surely some time
in the future, will come the age of the study of the human mind.”
PROCEEDINGS WEW YORK COUNTY ASSOCIATION. 769
“It is an age of advance; true, but all progress is not advance. ‘To ad-
vance,’ says Emerson, “something of the old must forever mingle with
the new,’ and that something is a thoughtful resumé, a brief but particular
condensation. For the healing of ourselves, then, a considerate following
of present demands; attention to the details of modern research and discovery
without necessarily an absolute surrender to the same ; a wise moderation
in praise, an ability to instruct, an education to prepare us for such duties.”
“These are the medicines we need, and it is the duty of this—of every
Society to urge, aye, to enforce the wholesale manufacture and wide dis-
tribution of these remedies.” -
“We must teach : Therapy is not the open sesamé to the glorious
heaven of health, but knowledge ; not expressed in an incomprehensible
terminology, but told in plain truth ; knowledge of right and wrong, of
habit and surroundings, of the Hippocratean trio : air, water and places.
Such is the golden gate to the throne of true greatness to which we of all
men have a God-given right.”
DISEASES OF THE Nos.E AND THROAT.—At the meeting November 16th,
1891, DR. J. W. GLEITSMAN read a paper on “A New and Simple Method
of Lessening Reaction After the Use of the Galvano-Cautery for Nasal
Hypertrophies.” The subject was thoroughly explained and illustrated,
and the desirability of lessening reaction justified. This paper was dis-
cussed by Drs. Quinlan, Tyndale, Friedenburg, and Mac Gregor, and closed
by Dr. Gleitsman.
DISEASES OF THE EYE were presented in two papers, one by DR. OPPEN-
HEIMER, at the same meeting. Subject : “Sympathetic Ophthalmia and
Other Causes of Permanent Blindness.” The author of the paper presented
statistics of blindness in different parts of the world, and especially as ap-
plied to the city of New York. Much could be done by the general prac-
titioner in giving due attention to injury or disease of one eye before the
Other became affected. The paper was of great practical importance, and
was discussed by Drs. Hepburn, Friedenburg, Wan Fleet, Agramonté,
Cocks, and the Chair, and discussion was closed by Dr. Oppenheimer.
At the meeting April 18th, 1892, DR. N. J. HEPBURN read a paper on
“Foreign Bodies in the Eye.” This paper was brief, but comprehensive.
“If foreign bodies are loosely attached to the conjunctiva or cornea, a
probe armed with a piece of cotton will usually bring it away. If it be firmly
attached, a needle or sharp pointed instrument will be required. If the
particle should be sharp, or hot, it becomes serious, and removal is difficult.
Attempts at extraction should be preceded by the application of a few
drops of a two per cent. solution of cocaine. If firmly embedded,
it should be drawn out with forceps. When it enters the eyeball it
becomes more serious, and its removal requires the careful consideration of
the ophthalmic surgeon. The electro-magnet may also play an important
part.”
*
770 ME}|W YORK STATE MEDICAL ASSOCIATION.
SKIN DISEASE.-At the meeting December 21st, 1891, a paper was read
by DR. L. DUNCAN BULKLEY on the “Non-Contagiousness of Leprosy.”
In this paper the history, diagnosis and etiology were all taken into con-
sideration with a view of showing its relation to contagion. The author
concluded with presenting the following results of his study : “1. There is
no warrant for the popular terror surrounding the name ‘leprosy' as a
disease. 2. The disease is not contagious in the ordinary acceptation of
the term as applied to such diseases as smallpox, Scarlatina or syphilis.
3. Leprosy is probably due to the presence of a bacillus. 4. There is
strong reason to suspect that it may first be introduced into the system by
food, and especially fish. 5. There is evidence that when acquired the dis-
ease may, under favorable conditions, be transferred from one person to an-
other. 6. Heredity probably accounts for a share of the cases, but the dis-
ease is not necessarily transmitted by inheritance. 7. Inoculation with
leprous matter may be the means of conveying the disease when all the
conditions are favorable. 8. There are far more and greater reasons for
the restriction of syphilis and tuberculosis by isolation and segregation, than
for the necessity of these regulations in regard to leprosy.” This paper was
discussed by Drs. Fernandez, L. S. Seaman, J. H. Tyndale, and closed by
Dr. Bulkley.
PRACTICE of MEDICINE.—At the meeting February 15th, 1892, DR.
AUSTIN FLINT read a paper on “Urinary Analysis,” exhibiting a portable
case for clinical examination of urine. Dr. Flint showed the utility of the
case by testing several samples of urine for albumen, sugar, etc. He said
that if an absolutely reliable test was required, the urine for examination
should be gathered for at least twenty-four hours. He then gave a number
of tests approximately reliable in every case of urinary analysis. The
principal advantage of the apparatus was that within a few minutes an
analysis could be made at the bedside. Discussion by Drs. H. M. Biggs
and C. A. Doremus.
In connection with the discussion, Dr. Joseph N. Henry exhibited two
specimens of urine, from two separate patients, which were colored by the
internal administration of methylene blue for the relief of chronic bladder
disease. -
On March 21st, 1892, DR. J. LEWIS SMITH presented the subject of
“Recent Investigations relating to the Prevention of Diphtheria and Scarlet
Fever.” Dr. Smith related many interesting facts in connection with the
contagiousness of these diseases. He believes it always originates from the
presence of a specific microbe, and while relying on throat disinfection, he
has little faith in sulphur for that purpose. A strong solution of corrosive
sublimate or a five per cent. Solution of carbolic acid, is better. When ex-
amining the patient the physician should place himself either to one side
or behind, not in front. While smallpox is thoroughly controlled in this
city, it is impossible to gain the same control of these two diseases. This
paper was discussed by Drs. Leale, Tyndale, Nye, and Koplik.
PROCEEDINGS WEW YORK COUNTY ASSOCIATION. 771
At the April meeting a paper was read by DR. J. HILGARD TYNDALE on
“Chronic Adhesive Pleurisy, Inflammatory and Tubercular.” “All
pathological conditions in the lung, other than tumors and surgical lesions,
can be classed under two headings, viz.: mechanical hindrances to respira-
tion, and tubercular infiltration.” The paper was taken up with the
various conditions occurring, and with the treatment, which consists of
three parts, viz.: 1. Internal remedies. 2. Hypodermic medication. 3.
Surgical procedures. These three are the same whether the disease is
inflammatory or tubercular. Iodine and mercury, sodium salicylate,
arsenic and the hypophosphites are internal remedies. Iodine is best for
hypodermic use. The paper was discussed by Drs. Gibier, Leale, White,
and J. G. Truax, and closed by Dr. Tyndale.
On June 20th, 1892, DR. J. BLAKE WHITE presented a paper entitled,
“Observations on the Hypodermic Use of Gold and Manganese in Tuber-
culosis, with Reports of Cases.” The author of this paper gave very strong
reasons for his estimate of the value of these remedies, and expressed him-
self thus: “If we have, as my experience leads me strongly to believe,
antidotal remedies in the preparations of gold and manganese, we are
approaching that much desired stage in the therapeutics of tuberculosis
when we can look with greater certainty to masterful aid from medicine
in combating this dread destroyer of human life.” This paper was dis-
cussed by Drs. MacGregor, Tyndale, and F. J. Quinlan, and closed by
Dr. White.
OBSTETRICS.—At the same June meeting a paper was read by DR.
T. J. McGILLICUDDY, entitled “Notes on Conservative Obstetrics, with
Exhibition of New Instruments.” The instruments presented were Dr.
McGillicuddy's traction forceps and anti-craniotomy forceps. The author
of the paper spoke of conservative in contra-distinction to destructive
midwifery, and explained in eatenso the modus operand of his forceps.
With this, he stated some cases where they proved useful in saving the
lives of children.
DR. BELL, of Glasgow, Scotland, being present, was invited by the
President to take a seat upon the platform and to open the discussion,
which he did. After this, the discussion was continued by Drs. Geo. T.
Harrison, James Stafford, C. A. Von Ramdohr, and C. D. Meding. Discus-
sion was closed by Dr. McGillicuddy.
At the meeting May 16th, 1892, the subject of “Nervous Disease” was
treated of in a paper by DR. R. HARCOURTANDERSON, on “Graphospasmus,
or ‘Writer's Cramp.’” The author described several varieties. He considered
that the subject had not received from the profession the attention it
deserved, and that its presence was an evidence of reduced witality, and
might be the precursor of serious trouble in the nervous system ; he believed
the source of the trouble was in the cerebellum. After defining several
plans of treatment, he exhibited an apparatus which he had devised, and by
means of which the affected muscles could be rested.
49
772 NEW YORK STATE MEDICAL ASSOCIATION.
It may thus be seen that in the form of papers and discussions thereon
we have had formal dissertations on “Surgery ; ” “Diseases of Throat and
Nose; ” “Skin ; ” “Practice of Medicine ; ” “Obstetrics,” and “Nervous
Disease.”
In addition to these, pathological specimens have been shown at almost
every meeting. Specially among these may be noticed two specimens
presented by DR. THos. H. MANLEY — one from a case of inguinal hernia,
and one from a ventral hernia in a female suffering from uterine fibroids.
A specimen was presented by DR. Von DoNHoFF, i.e., a benign tumor
of the breast, a result of mastitis. This tumor he lately removed. After
removal, the neighboring glands, which had become enlarged, regained
their usual size ; and the patient's general health, which had been deterio-
rated, was fully restored.
A specimen was presented by DR. Dw1GHT L. HuBBARD,-a “mon-
strosity’ delivered at eight months, in which there was a lack of develop-
ment of pelvic and external genitals, and with undivided lower extremities.
It may not be uninteresting to know something of the working of an
Association aside from that which is strictly scientific.
At the meeting October 19, 1891, on motion of DR. NoLL, the following
resolution was adopted, viz.:
Resolved, That it is the sense of the New York County Medical Associa-
tion, that the Legislature of this State should secure all land constituting
the Adirondacks for a State park, acquiring such land either by purchase
or condemnation proceedings; and be it further
l Itesolved, That a copy of these resolutions be transmitted to the Legis-
ature.
These resolutions were duly sent to the Legislature by the Secretary.
The Association has also appointed a Committee on Legislation, consist-
ing of DRS. T. H. MANLEY, A. D. RUGGLEs, and S. S. PURPLE.
DR. C. A. LEALE, President of St. John's Guild, invited the members to
send patients, where parents were too poor to pay for medical attendance,
to the New York Hospital for Sick Children, opened by the Guild at 157
West Sixty-first street. This was heartily approved, and commended
to the attention of all.
Transmitting the request of the Grant Monument Association that the
medical profession should join in making contributions, the President
made the announcement and requested co-operation, which was cheerfully
given.
At the request of the President, DR. MANLEY made a report in regard to
the recent meeting of the American Medical Association in Detroit, and
suggested the preparation of a statement in regard to the representation
of the profession in New York State in the Association.
DR. FERDINAND KING, editor of the Doctor's Weekly, kindly offered to
send a copy of such statement to every member in the State. DRS. TRUAX
and MANLEY were appointed as a committee to prepare the statement,
which was done.
PROCEEDINGS NEW YORK COUNTY ASSOCIATION. 773
The meeting in January is devoted to the election of officers and the
reading of annual reports. At that meeting the following officers were
elected :
President, S. B. W. McLEOD, M. D.; Vice-President, WM. T. WHITE,
M. D.; Corresponding Secretary, AUGUSTUs D. RUGGLEs, M. D.; Record-
ing Secretary, P. BRYNBERG PortER, M. D.; Treasurer, JoBN H. HINTON,
M.D.; Member of Executive Committee, Won BEVERHOUT THOMPSON, M.D.
At the February meeting the President, DR. McLEoD, delivered the
annual address. The general subject of the address was : “The Difficul-
ties Attending the Practice of Medicine at the Present Time, and the Duties
of the Physician in View of These.” After enumerating some of the diffi-
culties, the address closed with an exhortation to the members of this
Association to unite heartily in the performance of the great work before the
medical profession of the United States.
The Association continues to increase and harmony to prevail. The
membership at the end of June, 1892, was eight hundred and nine (809).
We feel it to be our duty to the living to report our progress, and strive for
still greater results. To the dead—to honor their memory and place on
record their unforgotten names.
DRs. GOODMAN, DAMAINVILLE, BEDFORD, HILTON, EMBREE, MooRE,
MAURY, MOLLER, SEARING, SMITH, DONLIN, and TAYLOR, have served
their day and generation, and left the world in peace and hope.
S. B. W. McLEOD, President.
PROCEEDINGs.
NINTH ANNUAL MEETING
OF THE
NEW YORK STATE MEDICAL ASSOCIATION,
HELD AT THE MOTT MEMORIAL HALL, 64 MADISON AVENUE, NEW
York CITY, NovKMBER 15, 16, and 17, 1892.
FIRST DAY, TUESDAY, Nov. 15, 1892.
MORNING SESSION.
The meeting was called to order at 10.30 A.M., by the PRESIDENT, DR.
JUDSON B. ANDREws, of Erie county,
The report of the Committee of Arrangements was presented by the
Chairman, D.R. JoHN G. TRUAx, and, upon motion, it was accepted and
adopted. (See page 15.)
The SECRETARY then moved the postponement of the President's
Address until after the routine business had been transacted. Carried.
The annual report of the Council was then read by the SECRETARY.
On motion, the report of the Council was received and adopted.
The SECRETARY moved, in accordance with a communication in the
report of the Council, that a committee of five be appointed to meet a
committee of the American Medical Association ; this committee to be
appointed by the PRESIDENT during the present session. Carried.
The SECRETARY then moved that a committee of three be appointed by
the PRESIDENT to report before the close of this meeting upon some plan
relative to the creation of a delegateship for affiliated organisations in the
State of New York. He said that this would result in increasing the
number of delegates who would be sent from the State to the American
Medical Association. Carried.
The reports of the various District Associations were then read by title.
PROCEEDINGS. 775
AFTERNOON SESSION.
The meeting was called to order by the PRESIDENT.
The SECRETARY announced the appointment of the following Nomi-
nating Committee :
First District, DR. Doug LAs AYREs, DR. A. P. DoDGE.
Second District, DR. E. M. Lyon, D.R. G. R. MARTINE.
Third District, DR. GEORGE Doug LAs, DR. JAMES HENCHLEY.
Fourth District, DR. T. D. STRONG, DR. F. H. Moy ER.
Fifth District, DR. J. W. S. GoulBy, DR. R. C. WAN Wyck.
At large, DR. JOHN CRONYN.
EVENING SESSION.
The evening was occupied with the reading of scientific papers.
SECOND DAY, WEDNESDAY, Nov. 16, 1892.
MORNING SESSION.
The meeting was called to order by the PRESIDENT.
The following committee was appointed by the PRESIDENT to meet a
similar committee from the American Medical Association :
DR. E. M. MOORE.
DR. D. COLVIN.
DR. M. W. TownsEND.
DR. J. G. TRUAX.
- DR. E. D. FERGUSON.
The PRESIDENT appointed the following committee to consider the
creation of a delegateship for affiiliated organisations in the State :
DR. A. L. CARROLL.
DR. T. D. STRONG.
DR. E. D. FERGUSON.
The following committee to examine the TREASURER's accounts was ap-
pointed :
DR. DOUGLAS AYRES.
DR. JoBIN CRONYN.
DR. WILLIAM GOVAN.
AFTERNOON SESSION.
The meeting was called to order at 2 P. M. by the WICE-PRESIDENT, DR.
L. J. BROOKs.
The session was devoted to the reading and discussion of scientific
papers.
EVENING SESSION.
This session was opened by the delivery of the “Address on Surgery,”
by DR. FREDERIC S. DENNIS, of New York County. After the reading
and discussion of a paper by DR. H. D. DIDAMA, the Association ad-
journed to partake of a collation.
776 NEW YORK STATE MEDICAL ASSOCIATION.
THIRD DAY, THURSDAY, NovKMBER 17, 1892.
MORNING SESSION.
The meeting was called to order by the PRESIDENT.
The SECRETARY presented the report of the Nominating Committee.
Report of the Nominating Committee.
For President : S. B. W. McLEOD, of New York County, Fifth Dis-
trict.
For Vice-Presidents :
R. N. CooDEY, Oswego County, First District.
J. C. HANNAN, Rensselaer County, Second District.
N. JAcobson, Onondaga County, Third District.
Z. J. LUSK, Wyoming County, Fourth District.
For Secretary and Treasurer : E. D. FERGUSON, Rensselaer County.
For Chairman of the Library Committee :
J. W. S. Gouley, New York County.
For Members of the Council :
First District, A. P. DoDGE, Oneida County.
Second District, J. B. HARVIE, Rensselaer County.
Third District, M. CAVANA, Madison County.
Fourth District, F. H. MoyFR, Livingston County.
Fifth District, A. L. CARROLL, New York County.
The PRESIDENT-ELECT appointed JoHN SHRADY, New York County,
as member of the Council at large.
Upon motion, this report was accepted.
It was moved and seconded that the SECRETARY be instructed to cast
an affirmative ballot for the list of officers as read. Carried.
These gentlemen were then declared elected.
It was moved and seconded that the members of the committee
appointed to meet the committee of the American Medical Association, be
empowered to appoint alternates in case of their inability to attend.
Carried.
DR. J. LEWIS SMITH, of New York County, presented an invitation
from the New York Foundling Asylum for the Association to inspect that
institution any day during the week of meeting, between the hours of two
and four in the afternoon.
The Committee on By-Laws made the following report :
It is suggested that ARTICLE II., Section 6, of the Constitution, should
be amended as follows:
In addition to the foregoing Fellows of the Association, delegates not
being Fellows of the New York State Medical Association may be sent
from medical organisations throughout the State in affiliation with this
Association, in the proportion of one delegate for each ten members of said
PROCEEDIWGS. 777
subordinate organisation. Such delegates shall serve for the annual meet-
ing next succeeding their appointment; they shall be entitled to vote on
all questions not involving a change of the Constitution and By-Laws, and
shall not be chargeable with any fee or due, though they may secure a
copy of the Transactions of the meeting at which they served, at the cost of
extra copies to regular Fellows. No medical organisation can be entitled
to send delegates unless its Constitution and By-Laws are in harmony with
those of the State Association, the same having been approved by the
Council of this Association; nor shall it be subordinate to any other State
medical organisation. -
Under the rules, no action can be taken on this report until the nex
annual meeting.
AFTERNOON SESSION.
The meeting was called to order by the PRESIDENT.
The Committee on Treasurer's Accounts reported that they had ex-
amined the same and found them correct. On motion, the report was
accepted.
After the reading and discussion of the papers, the PRESIDENT, DR.
ANDREWs, expressed his thanks for the courtesy exhibited by the Associa-
tion to him, and the honor conferred upon him, both of which he should
never forget. He then introduced the newly-elected PRESIDENT, DR. S. B.
W. McLEOD, of New York County.
DR. McLEOD expressed his regret at seeing DR. ANDREWS retire from
the Chair, and that this interesting meeting should so soon have come to a
close ; nevertheless, he said, in the process of evolution, even presiding
officers must change, and while it had been the retiring President's pleas-
ant duty to see the members assemble and to bid them welcome, it was his
less pleasant duty to see them disperse and to bid them farewell.
The minutes were then approved.
On motion of the SECRETARY, the ninth annual meeting of the
Association was declared adjourned.
E. D. FERGUSON,
Secretary.
ANNUAL REPORT OF THE COUNCIL,
AND
MINUTES OF THE SESSIONS OF THE COUNCIL,
FOR THE YEAR 1892.
The ninth annual meeting of the Council was held in its rooms in the
Mott Memorial Library, on Tuesday evening, November 14, 1892.
The meeting was called to order by the Secretary at 8.30 P. M.
Present : Drs. Brooks, Carroll, Douglas, Ferguson, Gouley, Harvie,
Jewett, McCollom, Strong, Truax, Van Hoevenberg, and Wilson.
In the absence of the President, Dr. Van Hoevenberg, Vice-President
for the Fifth District, took the Chair.
The Secretary reported the following applicants for Fellowship in the
Association, as having been appointed by circular vote since the last meet-
ing of the Council, viz.:
W. B. Webster, Michael F. Phelan, John L. Andrews, Henry Smith
Williams, A. Reading Gulick, Charlton R. Gulick, Joseph E. Baynes, John
E. Weeks, Leonard S. Rau, W. B. De Garmo, M. Christopher O’Brien, F.
H. Daniels, Wm. E. Swan, Andrew T. Weeder, John F. Fitzgerald, John
C. Fisher, Thomas P. Scully, J. O. Davis, J. S. Parent, Charles F. Town-
send, Electra B. Whipple, Allen A. Jones, Bernard Cohen, W. H. Berg-
told, Percy Bryant, Charles F. Howard, H. C. Abrams.
The following applicants were appointed Fellows, viz.:
Franklin D. Clum, Clarence G. Campbell, Eden W. Delphey.
The Treasurer then submitted his annual report as follows, viz.:
The Treasurer is gratified to be able again to show an increase in the
balance in the treasury, the net increase in the funds of the Association
amounting to $692.10, being a somewhat larger increase than was made
the year before. Nearly $500 was collected from those in arrears for dues
of two or more years, and dues were paid by quite a number who had re-
*Ceived remission for arrears for illness or financial embarrassment, a fact
which is very gratifying to the Treasurer and creditable to the Association.
While the events for the future do not admit of prophecy, the Treasurer
is persuaded that there are good grounds to anticipate a still more favor-
able showing at the next annual report, but he feels the importance of a
continuance for some time of the plan of accumulating a reserve fund.
AWWUAJ, REPORT OF THE COUNCIL, 779
ANNUAL REPORT OF THE TREASURER FROM OCTOBER 15, 1891,
To NovKMBER 1, 1892.
BECEIPTS-GENERAL FUND.
Balance from last report, . . . . . . . . . . $1,085.01
Dues, . . . . . . . . . . . . . . . . 2,733.00
Initiation fees, . . . . . . . . . . . . . 180.00
Sale of Transactions, . . . . . . . . . . . 80.00
—— $4,078.01
- DISBURSEMENTS.
Sundries, including printing the Transactions, . . $2,232.60
Postage stamps, . . . . . . . . . . . . . 99.41
Expressage and freight, . . . . . . . . . . 68.89
—— 2,400.90
Balance in the general fund November 1, 1892, . . . . $1,677.11
LIBRARY AND BUILDING FUND.
Balance from last report, . . . . . . . . . . $2,482.41
Interest, , , . . . . . . . . 100.00
— 2,582.41
Total funds in treasury November 1, 1892, . . . . . $4,259.52
The report of the Treasurer was accepted and approved.
On motion, the Secretary and Treasurer were authorised to remove
from the list of Fellows such names as persistently and without adequate
reason neglected to pay arrears of dues.
The Secretary then presented the
REPORT OF THE COMMITTEE ON PUBLICATIONS.
Volume 8 of our Transactions, containing 780 pages of printing, was
issued within a reasonable time after the closing of our annual meeting,
and, though a few typographical errors, as in paging, etc., escaped the
proof-reading of the editor and the printer, still, on the whole, it is felt, in
view of the rapidity with which the work was done and the many things
to do, that indulgence can be asked and expected for the defects.
The increased size of the volume added over $200 to the expenses con-
nected with the printing and distribution, but fortunately the treasury was
able to meet that increase without a diminution of its met balance.
The subscriber, while glad to have been able to discharge the duties
and receive the honor of the editorship of the Transactions, feels that his
strength will not allow of his undertaking the work for the ensuing year.
[Signed] E. D. FERGUson, Chairman.
The Secretary then read the
EIGHTH ANNUAL REPORT OF THE LIBRARY COMMITTEE OF THE
NEW YORK STATE MEDICAL ASSOCIATION.
Movember 14, 1892.
This eighth annual report of the Library Committee indicates an in-
crease of ninety-one (91) volumes. The number of volumes given in the
780 NEW YORK STATE MEDICAL ASSOCIATION.
last report being eight thousand nine hundred and twenty-one, this addi-
tion of ninety-one (91) volumes makes a total of nine thousand and twelve
(9,012) volumes at present in the library, which is open to the Fellows of
the Association, to other physicians, to medical students, and to non-
medical persons.
J. W. S. Gouley, M. D.,
Director of the Library and Chairman of the Library Committee.
On motion, the report was accepted and adopted.
NOTES BY THE SECRETARY.
Since our last annual meeting certain events have occurred regarding
our relations to the American Medical Association, which, in some partic-
ulars are only matters of history now, and do not call for comments on
our part other than to commend the judicious and truly conservative
action of the national organisation on what seems to us as fundamental
principles in its own and our plan of constitution.
In connection with the appointment of delegates to the American
Medical Association, it became necessary this year for me to emphasise the
fact that our Association is the only medical organisation in the State of
New York entitled to representation in that body. While our doors are
open to all regular physicians who would be qualified to act as delegates,
still it may not be good taste or even justice on our part to insist that no
other means shall exist, if it can be done with a proper care for the interests
of all concerned. The only method would be the creation of a system of
representation in the State Association on the part of local organisations in
affiliation with us—as the King's County and New York County Associa-
tions, they being authorized to send delegates in a certain proportion to
their membership, and from those not already Fellows of the State Asso-
ciation. Such delegates can have full or limited rights during the year of
delegateship in the State Association, but such privilege would give the
local organisations authority to send delegates to the American Medical
Association. I would suggest that the subject be referred to a committee
to report at present meeting of the Association.
On motion, the suggestion of the Secretary in reference to the proposal
to provide for delegates from organisations within the State in affiliation
with the State Association, was approved, and the subject was referred to
the Secretary to suggest a plan of procedure.
The following communication from the Permanent Secretary of the
American Medical Association was read, viz.:-
DEAR DOCTOR: At the session held in Detroit, June, 1892, it was
Resolved, That a committee of five be appointed by the President of
this Association, who shall be instructed to meet a like committee from
the State Medical Society of New York, and the State Medical Association
of New York, for the purpose of adjusting all questions of eligibility of
members of said State Medical Society of New York, to membership in
this Association; said committee to report at the next annual meeting of
this Association. Yours truly,
WM. B. ATKINSON.
Please acknowledge.
A WNUAL REPORT OF THE COUNCIL. 781
Committee: N. S. DAVIs, Chicago; JoHN H. RAUCH, Chicago; WM. T.
BRIGGS, Nashville; DUDLEY S. REYNoLDs, Louisville; WILLIs P. KING,
Kansas City.
The following communication was then read :
PHILADELPHIA, May 20, 1892.
DEAR SIR : At our session held this day in Harrisburg, the following
resolutions were adopted :
Resolved, That the Medical Society of the State of Pennsylvania hereby
expresses its highest disapprobation of the practice of giving certificates or
testimonials to secret preparations alleged to be of medicinal virtue, and
calls the attention of the affiliated county societies to the fact that such
action on the part of members of the said societies is in derogation of the
dignity of the profession, and in violation of the letter and the spirit of the
Code of Ethics of the American Medical Association and of this Society.
Resolved, That this Society likewise expresses its disapprobation of the
practice of inserting advertisements of secret preparations in the columns
of medical journals, such action being an insult to the intelligence of the
profession, and a degradation of journals indulging therein to the level of
the patent medicine almanac. Especially to be condemned is the action of
the Journal of the American Medical Association in admitting such adver-
tisements.
ReSolved, That copies of these resolutions, duly attested by the Per-
manent Secretary, be sent to all county societies in affiliation with this
Society, to the American Medical Association, to State medical societies in
affiliation therewith, and to the publishers and editors of American medical
journals.
Yours respectfully,
WM. B. ATKINSON,
Permanent Secretary.
On motion, the foregoing resolutions were indorsed.
A communication from the Fless & Ridge Printing Co., relative to the
printing of the Transactions, was received, and referred to the Committee
on Publications with power relative to the proposal.
Drs. James B. Murdock and James McCann, of Pittsburgh, Pa., were
nominated for non-resident Fellowships by Drs. Gouley, Carroll, and
Truax, and, on motion, they were appointed.
A bill of Angell's Printing Office, to the amount of $73.83, for printing
the Programme, was then audited, and the Treasurer directed to pay the
S8, D16.
On motion, the Council adjourned, after approving the minutes.
E. D. FERGUSON.
Secretary.
The new Council met in its room in the Mott Memorial Library, at 4
P. M., on Thursday, November 17, 1892.
Present : the President, Dr. McLeod, and Drs. Carroll, Cavana, A. P.
Dodge, Ferguson, Gouley, Hannan, Z. J. Lusk, Moyer, Strong, and
Truax,
782 NEW YORK STATE MEDICAL ASSOCIATION.
On motion, the members of the Council for the Fifth District were con-
stituted the Committee of Arrangements for the next Annual Meeting,
with power to add to their number.
On motion, the sum of $100 was directed to be added this year to the
$100 which the Association gives annually to the Trustees of the Mott
Memorial Library. -
The following applicants were appointed Fellows, viz.: Frank R.
Baker, John T. Cahill, Charles E. Congdon, E. G. Drake, George A. Him-
melsbach, O. A. Holcomb, James F. Huntley, Dennis L. Shea, John
Eliot Shrady, Won Beverhout Thompson, J. C. Wanderveer, Frederick
Holme Wiggin.
The members of the Council for the Fifth District were appointed the
Committee on Publications, with Dr. O. C. Ludlow as Editor of the
Transactions, and the Secretary was authorised to expend $100 in editorial
work connected with the printing of the Transactions.
A bill of the Angell Printing House for $7.50 was audited and approved.
After approving the minutes of the session, the Council adjourned.
E. D. FERGUSON,
Secretary.
LIST OF FELLOWS.
BY DISTRICT AND COUNTY.
FIRST OR NORTHERN DISTRICT.
FRANKLIN COUNTY.
Founder. Gillis, William. Fort Covington.
1
|FULTON COUNTY.
Original. Blake, Clarence R. Northville.
Founder. de Zouche, Isaac. Gloversville.
Drake, D. Delos. Johnstown.
Edwards, John. Gloversville.
4
HAMILTON COUNTY.
McGann, Thomas. Wells.
1
HERRIMER COUNTY.
Casey, J. E. Mohawk.
Douglass, A. J. Ilion.
Garlock, William D. Little Falls.
Original. Glidden, Charles H. Little Falls.
Green, H. H. Paine's Hollow.
Original. Potter, Vaughan C. Starkville.
Original. Sharer, John P. Little Falls.
Original. Southworth, Mark A. Little Falls.
Original. Young, John D. Starkville.
9
784
NEW YORK STATE MEDICAL ASSOCIATION.
Founder.
Founder.
Original.
Original.
Original.
Original.
Original.
Founder.
Original.
Original.
Original.
Original.
Original.
JEFFERSON COUNTY.
Abell, Ira H. Antwerp.
Crawe, J. Mortimer. Watertown.
Johnson, Parley H. Adams.
w 3
LEWIS COUNTY.
Crosby, Alexander H. Lowville,
Douglass, Charles E. Lowville.
Joslin, Albert A. Martinsburgh.
Kelly, John D. Lowville.
Kilborn, Henry F. Crogham.
5
MONTGOMERY COUNTY.
Ayres, Douglas, Fort Plain.
Caldwell, Nathan A. Hageman's Mills.
French, S. H. Amsterdam.
Graves, Ezra. Amsterdam.
Johnson, Richard G. Amsterdam.
Klock, Charles M. St. Johnsville.
Leach, H. M. Charlton City, Mass.
Parr, John. Buel.
Parsons, W. W. D. Fultonville.
Robb, William H. Amsterdam.
Rulison, Elbert T. Amsterdam.
Simons, Frank E. Canajoharie.
Smyth, Arthur W. H. Amsterdam.
13
ONEIDA COUNTY.
Armstrong, James A. Clinton.
Babcock, H. E. New London.
Bagg, Moses M. Utica.
Barnum, D. Albert. Cassville.
|Blumer, G. Alder. Utica.
Bond, George F. M. Utica.
Booth, Wilbur H. Utica.
Brush, Edward N. Towsen, Md.
Churchill, Alonzo. Utica.
Clarke, Wallace. Utica.
Dodge, Amos P. Oneida Castle.
LIST OF FELLOWS. 785
Douglass, James W. Booneville.
Ellis, J. B. Whitesborough.
English, G. P. Booneville.
Flandrau, Thomas M. Rome.
Fraser, Jefferson C. Ava.
Fuller, Earl D. Utica.
Gibson, William M. Utica.
Holden, Arthur L. Utica.
Original.
Founder.
Original.
Hughes, Henry R. Clinton.
Hunt, James G. Utica.
Euhn, William. Rome.
Munger, Charles. Knoxboro.
Nelson, William H. Taberg.
Palmer, Henry C. Utica.
Palmer, Walter B. Utica.
Phelps, George G. Utica.
Porter, Harry N. Washington, D. C.
Quin, Hamilton S. Utica.
Reid, Christopher C. Rome.
Hussell, Charles P. Utica.
Scully, Thomas P. Rome.
Sutton, H. C. Rome.
Sutton, Richard E. Rome.
Swartwout, Leander. Prospect.
Tefft, Charles B. Utica,
West, Joseph E. Utica.
*West, M. Calvin. Rome.
38
OSWEGO COUNTY.
Bacon, Charles G. Fulton.
IBates, Nelson W. Central Square.
Cooley, F. L. Oswego.
Cooley, R. N. Hannibal Centre.
DeWitt, Byron. Oswego.
Huntington, John W. Mexico.
Johnson, George P. Mexico.
Marsh, E. Frank. Fulton
Todd, John B. Parish. 9
ST. LAWRENCE COUNTY.
Cook, Guy Reuben. Louisville.
1
* Deceased.
786
NEW YORK STATE MEDICAL ASSOCIATION.
Founder.
Founder.
Founder.
Original.
Founder.
Founder.
SECOND OR EASTERN DISTRICT.
ALBANY COUNTY.
Abrams, H. C. Newtonville.
Bailey, Theodore P. Albany.
Haynes, John U. Cohoes.
Peters, Samuel. Cohoes.
Rulison, L. B. West Troy.
Sabin, William B. West Troy.
Van Vranken, Adam T. West Troy.
Witbeck, Charles E. Cohoes.
Zeh, Merlin J. West Troy.
9
CLINTON COUNTY.
Dodge, Lyndhurst C. Rouse's Point.
Holcomb, O. A. Plattsburgh.
Lyon, E. M. Plattsburgh.
3
COLUMBIA. COUNTY.
Original. Benham, John C. Hudson.
Bradley, O. Howard. Hudson.
Clum, Franklin D. Cheviot.
Fritts, Crawford Ellsworth. Hudson.
Original. Lockwood, J. W. Philmont.
Original. Smith, H. Lyle. Hudson.
Wedder, George W. Philmont.
Wheeler, John T. Chatham.
Founder. Wilson, Thomas. Claverack.
Woodruff, R. Allen. Philmont.
Woodworth, T. Floyd. Kinderhook.
11
ESSEX COUNTY.
Founder. Barton, Lyman. Willsborough.
Church, Charles A. Bloomingdale.
Original. D'Avignon, Francis J. Au Sable Forks.
Original. LaBell, Martin J. Lewis.
Original. *Pollard, Abiathar. Westport.
Original. Rand, Hannibal W. Keene.
Original. Riley, Andrew W. Au Sable Forks.
Original. Robinson, Ezra A. Jay.
Original. Turner, Melvin H. Moriah.
9
* Deceased.
LIST OF FELLOWS.
787
Original.
Original.
Original.
GREENE COUNTY.
Conkling, George. Durham.
Getty, A. H. Athens.
Howland, George T. Athens.
EIuestis, W. B. Kiskatom.
Selden, O. G. Catskill.
Selden, Robert. Catskill.
6
RENSSELAER COUNTY.
Original.
Founder.
Original.
Founder.
Original:
Founder.
Founder.
Original.
Founder.
Founder.
Founder.
Founder.
Original.
Original.
Original.
Original.
Founder.
Founder.
Founder.
Original.
Allen, Amos. Grafton Centre.
Allen, Charles S. Greenbush.
Allen, William L. Greenbush.
Baynes, Joseph E. Troy.
*Baynes, William T. Troy.
Bissell, James H. Troy.
Bonesteel, H. F. Troy.
Bonesteel, William N. Troy.
Bontecou, Reed B. Troy.
Boyce, Elias B. Averill Park.
Burbeck, Charles H. Troy.
Burton, Matthew H. Troy.
Cahill, John T. Hoosick Falls.
Cooper, William C. Troy.
Crounse, Andrew C. Melrose.
Dickson, Thomas Gordon. Troy.
Ferguson, E. D. Troy.
Finder, William. Troy.
Greenman, C. E. Troy.
Hannan, James C. Hoosick Falls.
Harvie, J. B. Troy.
Heimstreet, Thomas B. Troy.
Houston, David W. Troy.
Hull, William H. Poestenkill.
Keith, Halbert Lyon. Upton, Mass.
*Lamb, Milton M. Lansinburgh.
Lyon, George E. Troy.
Lyons, Edward L. Troy.
Magee, Daniel. Troy.
Marsh, James P, Troy.
Mitchell, Howard E. Troy.
Nichols, Calvin E. Troy.
Nichols, William H. West Sand Lake.
Phelan, Michael F. Troy.
Rogers, S, Frank. Troy.
* Deceased.
50
788
NEW YORK STATE MEDICAL ASSOCIATION.
Founder.
Founder.
Original.
Original.
Founder.
Founder.
Original.
Original.
Founder.
Original.
Founder.
Original.
Founder.
Original.
Original.
Founder.
Original.
Original.
Rousseau, Zotique. Troy.
Seymour, W. Wotkyns. Troy.
Skinner, Smith A. Hoosick Falls.
Tompkins, Fred J. Lansingburgh.
Traver, Richard D. Troy.
Ward, R. H. Troy.
- 41
SARATOGA, COUNTY.
Allen, Henry J. Corinth.
*Babcock, Myron N. Saratoga Springs.
Comstock, George F. Saratoga Springs.
Crombie, Walter C. Mechanicsville.
Curtis, P. C. Round Lake.
Dunlop, John J. Waterford.
Gow, Frank F. Schuylerville.
Grant, Charles S. Saratoga Springs.
Hall, William H. Saratoga Springs.
Hewitt, Adelbert. Saratoga Springs.
Hodgman, William H. Saratoga Springs.
Hudson, George. Stillwater.
Humphrey, J. F. Saratoga Springs.
Inlay, Erwin G. Conklingville.
Johnson, Ianthus G. Greenfield Centre.
Keefer, Charles W. Mechanicsville.
Kniskern, A. C. Mechanicsville.
McEwen, Robert C. Saratoga Springs.
Moriarta, D. C. Saratoga Springs.
Murray, Byron J. Saratoga Springs.
Palmer, F. A. Mechanicsville.
Parent, J. S. Birchton.
Preston, John R. Schuylerville.
Reynolds, Tabor B. Saratoga Springs.
Rice, George. Mechanicsville.
Sherer, John D. Waterford.
Sherman, F. J. Ballston.
Smith, F. A. Corinth.
Stubbs, Roland H. Waterford.
Swan, William E. Saratoga Springs.
Swanick, A. A. Saratoga Springs.
Sweetman, J. T., Jr. Ballston.
Thompson, Amos W. Saratoga Springs
Warney, Miles E. Saratoga Springs.
Webster, W. B. Schuylerville.
Zeh, Edgar. Waterford.
36
* Deceased.
IIST OF FELLOWS. 789.
Original.
Original.
Original.
Original.
Original.
SCHENECTADY COUNTY.
Fuller, Robert. Schenectady.
Hammer, Charles. Schenectady.
McDonald, George E. Schenectady.
McDougall, R. A. Duanesburgh.
Reagles, James R. Schenectady.
Van Zandt, Henry C. Schenectady.
Weeder, Andrew T. Schenectady.
7
SCEIOHARIE COUNTY.
Hagadorn, William. Gilboa.
Ringsley, Henry F. Schoharie.
2
WARREN COUNTY.
Original. *Ferguson, James. Glens Falls.
Original.
Fitzgerald, David J. Glens Falls.
Martine, Godfrey R. Glens Falls.
3
WASEHINGTON COUNTY.
Lambert, John. Salem.
Long, Alfred J. Whitehall.
2
THIRD OR CENTRAL DISTRIOT.
BROOME COUNTY.
Founder.
Original.
Original.
Allen, S. P. Whitney's Point.
Chittenden, Joseph H. Binghamton.
Dudley, Dwight. Maine.
Ely, Henry Oliver. Binghamton.
Farnham, Le Roy D. Binghamton.
Farrington, John M. Binghamton.
Forker, Frederick L. Binghamton.
Fitzgerald, John F. Binghamton.
Greene, Clark W. Chenango Forks.
Hills, Lyman H. Binghamton.
Hough, F. P. Binghamton.
Ingraham, Charles W. Binghamton.
Enapp, W. H. Union Centre.
* Deceased.
790
MEW YORK STATE MEDICAL ASSOCIATION.
Founder.
Founder.
Original.
Founder.
Original.
Original.
Founder.
Original.
Original.
Original.
Original.
Original.
Original.
Original.
Original.
Original.
Meacham, Isaac D. Binghamton.
Moore, William A. Binghamton.
Orton, John G. Binghamton.
Pierce, Edward A. Binghamton.
Pierson, G. E. Kirkwood.
Place, John F., Jr. Binghamton.
Putnam, Frederick W. Binghamton.
Race, W. F. Kearney, Neb.
Richards, Charles B. Binghamton.
Rogers, Harris C. Binghamton.
Seymour, Ralph A. Whitney's Point.
Slater, Frank Ellsworth. Binghamton,
Wagner, Charles Gray. Binghamton.
Wells, E. H. Binghamton.
27
CAYUGA COUNTY.
Allison, Henry E. Auburn.
Kenyon, M. Moravia.
Laird, William R. Auburn.
Sawyer, Conant. Auburn.
Tripp, John D. Auburn.
5
CHEMUNG COUNTY.
Brown, Charles W. Washington, D. C.
Drake, E. G. Elmira.
Ross, Frank W. Elmira.
Squire, Charles L. Elmira.
Wales, Theron A. Elmira.
5
CHENANGO COUNTY.
Blair, Louis P. McDonough.
Brooks, Leroy J. Norwich.
Copley, Herman D. Bainbridge.
Douglas, George. Oxford.
Guy, John D. Coventry.
Hand, S. M. Norwich.
Hayes, Philetus A. Afton.
Johnson, Leonard M. Greene.
Lyman, Elijah S. Sherburne.
Lyman, H. C. Sherburne.
Packer, Thurston G. Smyrna.
Smith, Samuel L. Smithville.
IIST OF FELLOWS.
791
Original.
Founder,
Founder.
Founder.
Original.
Original.
Original.
Original.
Original.
Founder.
Founder.
Founder.
Thompson, R. A. Norwich.
Van Wagner, L. A. Sherburne.
Williams, George O. Greene.
15
CORTLAND COUNTY.
Bradford, George D. Homer.
Clark, DeWitt. Marathon.
Didama, E. A. Cortland.
*Green, Caleb. Homer.
Halbert, M. L. Cincinnatus.
Hendrick, Henry C. McGrawville.
Higgins, F. W. Cortland.
Jewett, Homer O. Cortland.
Kenyon, Benjamin. Cincinnatus.
9
DELAWARE COUNTY.
*Allaben, Orson M. Margaretville.
Drake, James B. Hancock.
Morrow, William B. Walton.
Smith, George C. Delhi.
Travis, Edward M. Masonville.
5
MADISON COUNTY.
Birdsall, Gilbert. N. Brookfield.
Burhyte, O. W. Brookfield.
Cavana, Martin. Oneida.
Carpenter, Henry W. Oneida.
Drake, Frank C. Oneida.
|Huntley, James F. Oneida.
Nicholson, A. R. Madison.
7
ONONDAGA COUNTY.
Aberdein, Robert. Syracuse.
Allen, Henry B. Baldwinsville.
Brown, Ulysses H. Syracuse.
Campbell, A. J. Syracuse.
Dallas, Alexander J. Syracuse.
Didama, Henry D. Syracuse.
* Deceased.
792
WEW YORK STATE MEDIOAL ASSOCIATION.
Original.
Original.
Original.
Founder.
Original.
Founder.
Original.
Founder.
Original.
Original.
Founder.
Original.
Founder.
Original.
Original.
Founder.
Original.
Original.
Original.
Donohue, Florence O. Syracuse.
Earle, George W. Tully.
Edwards, Amos S. Syracuse.
Edwards, George A. Syracuse.
Elsner, Henry L. Syracuse.
Flanigan, John R. Syracuse.
Frazee, A. Blair. Elbridge (Altoona, Pa.)
Hatch, C. A. Syracuse. -
Head, Aldelbert D. Syracuse.
Jacobson, Nathan. Syracuse.
Rneeland, Jonathan. South Onondaga,
Magee, Charles M. Syracuse.
McNamara, Daniel. Syracuse.
Munson, W. W. Otisco.
Parsons, Israel. Marcellus.
Saxer, Leonard A. Syracuse.
Sears, F. W. Syracuse.
Stephenson, F. Halleck, Syracuse.
Van de Warker, Ely. Syracuse.
Whitford, James. Onondaga Valley.
26
OTSEGO COUNTY.
Barney, C. S. Milford.
Church, B. A. Oneonta.
Ford, M. L. Oneonta.
Leaning, John K. Cooperstown.
Martin, John H. Otego.
Merritt, George. Cherry Walley.
Sweet, Joseph J. Unadilla.
Sweet, Joshua J. Unadilla.
8
SCEIUYLER COUNTY.
Ring, James K. Watkins.
Roper, P. B. Alpine.
Leffingwell, E. D. Watkins.
Smelzer, Baxter T. Havana.
Stewart, F. E. Watkins.
Woodruff, E. Gerald. Watkins.
6
SENECA COUNTY.
Bellows, George A. Waterloo.
Blaine, Myron D. Willard.
LIST OF FELLOWS. 793
Founder.
Original.
Original.
Founder.
Founder.
Lester, Elias. Seneca Falls.
Pilgrim, Charles W. Willard.
Seaman, Frank G. Seneca Falls.
Welles, S. R. Waterloo.
6
TIOGA COUNTY
Ayer, W. L. Owego.
Cady, George M. Nichols.
2
TOMPRINS COUNTY.
Beers, John E. Danby.
Biggs, Chauncey P. Ithaca.
Fitch, William. Dryden.
Flickinger, John. Trumansburg.
4
Original.
Original.
Original.
Founder.
Founder
FOURTH OR WESTERN DISTRICT.
ALLEGEIANY COUNTY.
Stephenson, James A. Scio.
Wakely, Benjamin C. Angelica.
2
CATTARAUGUS COUNTY.
Eddy, John L. Olean.
Lllsworth, Victor A. Wellsville.
Lake, Albert D. Gowanda.
Mudge, Selden J. Olean.
Tompkins, Orren A. East Randolph.
5
CHAUTAUQUA COUNTY.
Ames, Edward. Kalamazoo, Mich.
Bemus, Morris N. Jamestown.
Bemus, William Marvin. Jamestown
*Chace, William. Mayville.
* Deceased
794
JNETW YORK STATE MEDICAL ASSOCIATION
Founder.
Founder.
Dean, Harmon J. Brocton.
Richmond, Nelson G. Fredonia.
Rolph, R. T. Fredonia.
Strong, Thomas D. Westfield.
- 8
Founder.
Original.
Original.
Original.
Original.
Original.
Original.
Original.
Founder.
Original.
Original.
Original.
Original.
Founder.
Original.
Original.
Founder.
ERIE COUNTY.
Andrews, Judson B. Buffalo.
Atwood, H. L. Collins Centre.
Banta, Rollin L. Buffalo.
Bartlett, Frederick W. Buffalo.
Bartow, Bernard. Buffalo.
Bergtold, W. H. Buffalo.
Boies, Loren F. East Hamburgh.
Briggs, Albert H. Buffalo.
Brown, George L. Buffalo.
Bryant, Percy. Buffalo.
Burghardt, Francis Augustus.
*Burwell, George N. Buffalo.
Cohen, Bernard. Buffalo.
Congdon, Charles E. Buffalo.
Cronyn, John. Buffalo.
Dagenais, Alphonse. Buffalo.
Daniels, Clayton M. Buffalo.
Dayton, C. L. Buffalo.
Dorland, Elias T. Buffalo.
Fell, George E. Buffalo.
Fowler, Joseph. Buffalo.
Frederick, Carlton C. Buffalo.
Buffalo.
Gould, Cassius W. Buffalo.
Green, Stephen S. Buffalo.
Greene, DeWitt C. Buffalo.
Greene, Joseph C. Buffalo.
Greene, Walter D. Buffalo.
Harrington, D. W. Buffalo.
Hartwig, Marcell. Buffalo.
Hayd, Herman E. Buffalo.
Heath, William H. Buffalo.
Himmelsbach, George A. Buffalo.
Howard, Charles F. Buffalo.
Hoyer, F. F. Tonawanda.
Hubbell, Alvin A. Buffalo.
Hunt, H. L. Orchard Park.
Ingraham, Henry D. Buffalo.
Jackson, William H. Springville.
* Deceased,
IIST OF FELLO WS. 795
Original.
Original.
Original.
Original.
Founder,
Founder.
Original.
Founder.
Founder.
Original.
Original.
Original.
Johnson, Thomas M. Buffalo.
Jones, Allen A. Buffalo.
Lapp, Henry. Clarence.
Long, Ben. G. Buffalo.
Macfarlane, William A. Springville.
McPherson, George W. Lancaster.
Murray, William D. Tonawanda.
Park, Roswell. Buffalo.
Pettit, John A. Buffalo.
Phelps, William C. Buffalo.
Pohlman, Julius. Buffalo.
Putnam, James W. Buffalo.
Rochester, DeLancey. Buffalo.
Stockton, Charles G. Buffalo.
Strong, Orville C. Colden.
Taber, R. C. Tonawanda.
Thornton, William H. Buffalo.
Tremaine, William S. Buffalo.
Trull, H. P. Williamsville.
Twohey, John J. Buffalo.
Wall, Charles A. Buffalo.
Wheeler, Isaac G. Marilla.
Whipple, Electa B. Buffalo.
Willoughby, M. Buffalo.
Wyckoff, Cornelius C. Buffalo.
63
GENESEE COUNTY.
Andrews, Lewis B. Byron.
Crane, Frank W. Corfu.
Jackson, Albert P. Oakfield.
Prince, Alpheus. Byron.
Stone, Frank L. Le Roy.
Townsend, Morris W. Bergen.
6
LIVINGSTON COUNTY.
Briggs, Wm. H. Hemlock Lake.
Brown, J. P. Tuscarora.
Dodge, Frank H. Mount Morris.
Jones, George H. Fowlerville.
Eneeland, B. T. Dalton.
Menzie, R. J. Caledonia.
Moyer, Frank H. Moscow.
7
796
NEW YORK STATE MEDICAL ASSOOIATION.
Original.
Original.
Original.
Original.
Original.
Founder.
Founder.
Original.
Original.
Original.
Original.
Original.
Original.
Original.
Founder.
Original.
Founder.
Founder.
Original.
MONROE COUNTY.
Backus, Ogden. Rochester.
Briggs, C. M. Fairport.
Buckley, Charles. Rochester.
Buckley, James. Rochester.
Burke, John J. A. Rochester.
Curtis, D. F. Rochester.
Dunning, J. D. Webster.
Fenno, Henry M. Rochester.
Goler, George W. Rochester.
Gray, John P. Rochester.
Hovey, B. L. Rochester.
Jones, S. Case. Rochester.
Maine, Alva P. Webster.
McDougall, William D. Spencerport.
Moore, Edward M. Rochester.
Moore, Edward M., Jr. Rochester.
Moore, Richard Mott. Rochester.
Nold, John B. Rochester.
O'Hara, Thomas A. Tºochester.
Pease, Joseph. Hamlin.
Reitz, Charles. Webster.
Schopp, Justin H. Rochester.
Snook, George M. Parma.
Stockschlaeder, P. Rochester.
24.
NIAGARA COUNTY.
*Clark, Simeon T. Lockport.
Eddy, George P. Lewiston.
Huggins, William Q. Sanborn.
3
ONTARIO COUNTY.
Allen, Duncan S. Seneca.
Allen, James H. Gorham.
Bentley, Francis R. Cheshire.
De Laney, John Pope. Geneva.
Hicks, W. Scott, Bristol.
Nichols, H. W. Canandaigua.
Simmons, E. W. Canandaigua.
Wanderhoof, Frederick D. Phelps.
8
* Deceased.
LIST OF FELLOWS. 797
Original.
Founder.
Original.
Founder.
Original.
Original.
Original.
Original.
Founder,
Founder.
Original.
Original.
Original.
Original.
Original.
Original.
Original.
ORLEANS COUNTY.
Bailey, William C. Albion.
Chapman, James. Medina.
Curtis, Daniel. Jeddo.
Taylor, John H. Holley.
Tompkins, H. C. Knowlesville.
5
STEUBEN COUNTY.
Chittenden, Daniel J. Addison.
Dunn, Jeremiah. Bath.
Ellison, Metler D. Canisteo.
Fowler, Thomas B. Cohocton.
Gilbert, Horatio. Hornellsville,
Hubbard, Chauncey G. Hornellsville.
Hunter, Nathaniel P. Jasper.
Jamison, John S. Hornellsville.
Perry, Nathaniel M. Troupsburgh.
Wallace, Edwin E. Jasper.
10
WAYNE COUNTY.
Arnold, J. Newton. Clyde.
Brandt, J. S. Ontario Centre.
Colvin, Darwin. Clyde.
Horton, David B. Red Creek.
Ingraham, Samuel. Palmyra.
Landon, Newell E. Newark.
Nutten, Wilbur F. Newark.
Sprague, John A. Williamson.
Sprague, L. S. Williamson.
Young, Augustus A. Newark.
10
WYOMING COUNTY.
Ellinwood, A. G. Attica.
Fisher, John C. Warsaw.
Hulette, G. S. Arcade.
Lusk, Zera J. Warsaw.
Palmer, George M. Warsaw.
Rae, Robert. Portageville.
Rudgers, Denton W. Perry.
7
YATES COUNTY.
Oliver, William. Penn Yau.
1
798
INEW YORK STATE MEDICAL ASSOCIATION.
Original.
Original.
Original.
Founder.
Founder.
Original.
Founder.
Founder.
Founder.
Founder.
Original.
Original.
FIFTH OR SOUTHERN DISTRICT.
DUTCHESS COUNTY.
Baker, Benjamin N. Rhinebeck.
Barnes, Edwin. Pleasant Plains.
Barton, Thomas J. Tivoli.
Bates, Xyris T. Poughkeepsie.
Bayley, Guy Carleton. Poughkeepsie.
Bird, J. S. Hyde Park.
Codding, George H. Amenia.
Cramer, William. Poughkeepsie.
Fletcher, Charles L. Wing's Station.
Hicks, Edward E. Poughkeepsie.
Julian, John M. Moore's Mill.
Rittredge, Charles S. Fishkill-on-Hudson.
Leroy, Irving D. Pleasant Valley.
Porteous, James G. Poughkeepsie.
Pultz, Monroe T. Stanfordville.
Van Wyck, Richard C. Hopewell Junction.
Young, John. Fishkill-on-Hudson.
17.
Founder.
Original.
Original.
Original.
Original.
Original.
Original.
KINGS COUNTY.
Alleman, L. A. W. Brooklyn.
Baker, Frank R. Brooklyn.
Baker, George W. Brooklyn, E. D.
Beardsley, William E. Brooklyn.
Bell, A. Nelson. Brooklyn.
Benton, Stuart H. Brooklyn.
Bierwirth, Julius C. Brooklyn.
Biggam, William H., Jr. Brooklyn.
Brundage, Amos H. Brooklyn.
Conway, John Francis. Brooklyn.
Coffin, Laurence. Brooklyn.
*Creamer, Joseph. Brooklyn, E. D.
Creamer, Joseph, Jr. Brooklyn, E. D.
Criado, Louis F. Brooklyn.
Feeley, James F. Brooklyn, E. D.
Gardiner, William F. Brooklyn.
Hughes, Peter. Brooklyn.
Hull, Thomas H. Brooklyn.
Ilgen, Ernst. Brooklyn.
Jenkins, John A. Brooklyn, E. D.
Jewett, F. A. Brooklyn.
Leighton, Nathaniel W. Brooklyn.
Little, Frank. Brooklyn.
*Deceased.
LIST OF FELLOWS. 799
Original.
Original.
Original.
Original.
Original.
Original.
Original.
Founder.
Original.
Founder.
Original.
Original.
Founder.
Founder.
Original.
Original.
Original.
Founder.
Original.
Original.
Original.
Original.
Founder.
Lloyd, T. Mortimer. Brooklyn.
Lung, Jesse B. Brooklyn.
McCollom, William. Brooklyn.
Minard, E. J. Chapin. Brooklyn.
Newman, George W. Brooklyn.
North, Nelson L. Brooklyn.
Ostrander, George A. Brooklyn.
Paine, Arthur R. Brooklyn.
Pray, S. R. Brooklyn.
Price, Henry R. Brooklyn.
Raynor, F. C. Brooklyn.
Reed, Henry B. Brooklyn.
Richardson, John E. Brooklyn.
Risch, Henry F. W. Brooklyn.
Rochester, Thomas M. Brooklyn.
Rushmore, John D. Brooklyn.
Russell, William G. Brooklyn.
Segur, Avery. Brooklyn.
Shepard, A. Warren. Brooklyn.
Sizer, Nelson Buell. Brooklyn.
Squibb, Edward H. Brooklyn.
Squibb, Edward R. Brooklyn.
Steinke, Carl Otho Hermann. Brooklyn.
Sullivan, John D. Brooklyn.
Thwing, Clarence. Brooklyn.
Waterworth, William. Brooklyn.
Wieber, George. Brooklyn.
Williams, William H. Brooklyn.
Wyckoff, Richard M. Brooklyn,
52
NEW YORK COUNTY.
Adams, Calvin Thayer. New York.
Agramonte, E. W., New York.
Allen, S. Busby. New York.
Allen, Thomas H. New York.
Andrews, John L. New York.
Arango, Augustin. New York.
Arcularius, Lewis. New York.
Armstrong, S. T. New York.
Arnold, Edmund S. F. New York.
Arnold, Glover C. New York.
Baldwin, F. A. New York.
Ballou, William R. New York.
Bermingham, Edward J. New York.
Biggs, Herman M. New York.
Bozeman, Nathan. New York.
800
IVEVW YORK STATE MEDICAL ASSOCIATION.
Original.
Original.
Original.
Rozeman, Nathan G. New York.
Broderick, William P. New York.
Bryant, Joseph D. New York.
Buchanan, Alexander. New York.
|Bull, Charles Stedman. New York.
Bull, William T. New York.
Burchard, Thomas H. New York.
Original.
Founder.
Original.
Original.
Original.
Founder.
Original.
Original.
Original.
Founder.
Original.
Original.
Original.
Founder.
Founder.
Original.
Campbell, Clarence G. New York.
Carroll, Alfred Ludlow. New York.
Carter, H. Skelton. New York.
Chauveau, Jean F. New York.
Chrystie, T. M. Ludlow. New York.
Collins, Stacy B. New York.
Comfort, John E. New York.
Conover, William S. New York.
Conway, John R. New York.
Curry, Walker. New York.
Dallas, Alexander. New York.
*Damainville, Lucien. Kings Bridge.
Daniels, F. H. New York.
Davis, J. Griffith. New York.
Davis, Robert C. New York.
De Garmo, W. B. New York.
Delphey, Eden W. New York.
Denison, C. Ellery. New York.
Denison, Ellery. New York.
Dennis, Frederic S. New York.
de Quesada, Gregorio J. New York.
Du Bois, Matthew B. New York.
Dudley, A. Palmer. New York.
Dunham, Edward K. New York.
Pastman, Robert W. New York.
Einhorn, Max. New York.
Eliot, Ellsworth. New York.
Prdmann, John F. New York.
Farrington, Joseph O. New York.
Eield, Matthew D. New York.
Flinn, Thomas W. P. New York.
Flint, Austin. New York.
Flint, Austin, Jr. New York.
Flint, William H. New York.
Fogg, John S. New York.
Foster, George W. New York.
Frankenberg, Jacob H. New York.
Furman, Guido. New York.
Gleitsmann, J. W. New York.
Goldthwaite, Henry. New York.
* Deceased.
LIST OF FELLOWS. 801
Founder.
Original.
Founder.
Founder.
Founder.
Founder.
Founder.
Founder.
Founder.
Original.
Original.
Founder.
Gouley, John W. S. New York.
Grauer, Frank. New York.
Gray, Joseph F. New York.
Gulick, A. Reading. New York.
Gulick, Charlton R. New York.
Hammond, Frederick Porter. New York.
Harrison, George Tucker. New York.
Haubold, H. A. New York.
Hepburn, Neil J. New York.
Hillis, Thomas J. New York.
Hinton, John H. New York.
Hodgman, Abbott. New York.
Hogan, M. K. New York.
Holmes, Martha C. New York.
Hubbard, Dwight L. New York.
Hubbard, George E. New York.
Hubbard, Samuel T. New York.
Jackson, Charles W. New York.
Janeway, Edward G. New York.
Janvrin, J. E. New York.
Jenkins, William T. New York.
Judson, A. B. New York.
Remp, William M. New York.
King, Ferdinand. New York.
Kneer, F. G. New York.
Knipe, George. New York.
Leale, Charles A. New York.
Lewis, Robert. New York.
Little, Albert H. New York.
Lockwood, Charles E. New York.
Ludlow, Ogden C. New York.
Lukens, Anna. New York.
Lusk, William T. New York.
Lynch, Patrick J. New York.
MacGregor, James R. New York.
Mackenzie, J. C. New York.
McBurney, Charles. New York.
McGillicuddy, T. J. New York.
McGowan, John P. New York.
McIlroy, Samuel H. New York.
McLeod, Johnston. New York.
McLeod, S. B. Wylie. New York.
McLochlin, James A. New York.
McNamara, Laurence J. New York.
Manley, Thomas H. New York.
Marshall, Francis F. New York.
*Matthews, David. New York.
* Deceased.
802
MEW YORK STATE MEDICAL ASSOCIATION.
Original.
Original.
Original.
Original.
Original.
Original.
Founder.
Original.
Original.
Original.
Original.
Founder.
Original.
Original.
Founder.
Original.
*Maury, Rutson. New York.
Meier, Gottlieb C. H. New York.
Miller, William T. New York.
Milliken, S. E. New York.
Miranda, Ramon L. New York.
Mitchell, Hubbard W. New York.
Moran, James. New York.
Mott, Walentine. New York.
Murphy, John. New York.
Murray, Sandford J. New York.
Newman, Robert. New York.
Nicoll, Henry D. New York.
Obendorfer, Isidor P. New York.
O’Brien, Frederick William. New York.
O'Brien, M. Christopher. New York.
Ochs, Benjamin F. New York.
Oppenheimer, H. S. New York.
Oppenheimer, S. New York.
Palmer, Edmund J. New York.
Parsons, John. New York.
Perry, John Gardner. New York.
Phelps, Charles. New York.
Pooler, Hiram A. New York.
Porter, P. Brynberg. New York.
Pritchard, R. L. New York.
Purple, Samuel S. New York.
Ransom, H. B. New York.
Rau, Leonard S. New York.
Read, Ira B. New York.
Ricketts, Benjamin M. Cincinnati, Ohio.
Roth, Julius A. New York.
Ruggles, Augustus D. New York.
Sabine, Gustavus A. New York.
Sanders, E. New York.
Sayre, Lewis A. New York.
Sayre, Reginald H. New York.
Seaman, Louis L. New York.
Shaw, Henry B. New York.
Shea, Dennis L. New York.
Shrady, John. New York.
Shrady, John Eliot. New York.
Shunk, Albert. New York.
Silver, Henry M. New York.
Simmons, Charles E. New York.
Smeallie, James A. New York.
Smith, J. Lewis. New York.
* Deceased.
LIST OF FELLOWS. 803
Original.
Original.
Founder.
Founder.
Original.
Founder.
Founder.
Founder.
Founder.
Original.
Original.
Founder.
Founder,
Smith, Samuel W. New York.
Smith, Stephen. New York.
Spicer, Walter E. New York.
Thomas, T. Gaillard. New York.
Thompson, Won Beverhout. New York.
Tiemann, Paul E. New York.
Truax, J. G. New York, *
Tucker, Carlos P. New York.
Van Fleet, Frank. New York.
Vincent, Ludger C. New York.
Won Dönhoff, Edward. New York.
Wallach, Joseph G. New York.
Walsh, Simon J. New York.
Ward, Charles S. New York.
Warner, Frederic M. New York.
Warner, John W. New York.
Weeks, John E. New York.
Weston, Albert T. New York.
White, Charles B. New York.
White, J. Blake. New York.
White, Whitman W. New York.
White, William T. New York.
Wiener, Joseph. New York.
Wiggin, Frederick Holme. New York.
Williams, Henry Smith. New York,
Williamson, Edward A. New York,
Woodend, William E. New York.
Wyeth, John A. New York.
183
ORANGE COUNTY.
Conner, Milton C, Middletown.
Davis, J. O. Howells,
*Hunt, James H. Port Jervis.
Potts, E. Port Jervis.
Swartwout, H. B. Port Jervis.
Townsend, Charles E. Middletown,
Vanderweer, J. C. Monroe.
Wanderweer, J. R. Monroe.
8
PUTNAMI COUNTY.
Murdock, George W. Cold Spring.
Young, William. Cold Spring.
2
* Deceased.
51
804. NEW YORK STATE MEDICAL ASSOCIATION.
QUEENS COUNTY.
Original. Burns, William J. Roslyn.
Original. Rave, Edward G. Oyster Bay.
- 2
RICHMOND COUNTY.
Founder. *Johnston, Francis U. New Brighton.
Johnston, Henry C. New Brighton.
Martindale, F. E. Port Richmond.
Walser, William C. Port Richmond.
4
ROCKLAND COUNTY.
Founder. Govan, William. Stony Point.
1
SUFFOLE COUNTY.
Original. Chambers, Martin L. Port Jefferson.
Hamill, Edward H. Newark, N. J.
Hulse, William A. Bay Shore.
Original. Lindsay, Walter. Huntington.
Founder. *Woodend, William D. Huntington.
5
SULLIVAN COUNTY.
Original. Bennett, Thomas W. Jeffersonville.
Crocker, Edwin. Narrowsburgh,
DeKay, William H. Parksville.
Johnston, N. B. Barryville.
McWilliams, F. A. Monticello.
Original. Munson, J. A. Grahamsville.
Piper, Charles W. Wurtsborough.
7
ULSTER COUNTY.
Original. Chambers, Jacob. Kingston.
Original. Hoorn Beek, Philip Du Bois. Wawarsing.
Founder. Hühne, August. Rondout.
Original, Hühne, Frederick. Rondout.
Original. Van Hovenberg, Henry. Kingston.
Ward, John J. Ellenville.
6
* Deceased,
LIST OF FELLOWS. 805
WESTCHESTER COUNTY.
Acker, Thomas J. Croton-on-Hudson.
Original. Banks, George B. Hartsdale.
Original. Brush, Edward F. Mount Vernon.
Original. Coutant, Richard B. Tarrytown.
Dunham, Theodore. Irvington. ---
Original. Furman, J. Henry. Tarrytown.
Granger, William D. Mount Vernon.
Original. Huntington, Henry K. New Rochelle.
Founder. *Husted, Nathaniel C. Tarrytown.
Original. Lyons, G. A. New Rochelle.
Original. Schmid, H. Ernest. White Plains.
Small, John W. New Rochelle.
Original. Southworth, Richmond Joseph. Yonkers.
Original. Wells, William L. New Rochelle.
14
*Deceased.
SUMMARY OF FELLOWSHIP BY DISTRICT,
First District, & * * * e tº * * ſº & 84
Second District, . g * * g & tº e * . 129
Third District, e gº e . gº * & e e . 125
Fourth District, . e g * e wº e e g . 159
Fifth District, te g e e º e g e & . 301
Non-resident, * gº & & & * & * © o 2
Total Fellowship, * & {º g © * * . S00
ALPHABETICAL LIST OF FELLOWs.
Abell, Ira H., Antwerp, Jefferson Co. Founder.
Aberdein, Robert, Warren and Fayette Sts., Syracuse, Onondaga Co.
Original. -
Abrams, H. C., Newtonville, Albany Co.
Acker, Thomas, J., Croton-on-Hudson, Westchester Co.
Adams, Calvin Thayer, 8 W. 33d St., New York, New York Co.
Agramonte, E. W., 267 W. 45th St., New York, New York Co.
*Allaben, Orson M., Margaretville, Delaware Co. Original.
Alleman, L. A. W., 64 Montague St., Brooklyn, Kings Co.
Allen, Amos, Grafton, Rensselaer Co. Original.
Allen, Charles S., Greenbush, Rensselaer Co. Founder.
Allen, Duncan S., Seneca, Ontario Co. Original.
Allen, Henry B., Baldwinsville, Onondaga Co. Founder.
Allen, Henry J., Corinth, Saratoga Co.
Allen, James H., Gorham. Ontario Co. Original.
Allen, S. Busby, 164 E. 89th St., New York, New York Co.
Allen, S. P., Whitney’s Point, Broome Co.
Allen, Thomas H., 52 W. 45th St., New York, New York Co.
Allen, William L., Greenbush, Rensselaer Co.
Allison, Henry E., Asylum for Insane Criminals, Auburn, Cayuga Co.
Ames, Edward, 123 E. Lovell St., Kalamazoo, Mich. Founder.
Andrews, John L., 323 E, 86 St., New York, New York Co.
Andrews, Judson B., State Hospital, Buffalo, Erie Co. Founder.
Andrews, Lewis B., Byron, Genesee Co.
Arango, Augustin, 125 E. 36th St., New York, New York Co.
Arcularius, Lewis, 121 E. 25th St., New York, New York Co. Original.
Armstrong, James A., Clinton, Oneida Co.
Armstrong, S. T., 166 W. 54th St., New York, New York Co.
Arnold, Edmund S. F., 64 Madison Ave., New York, New York Co.
Original.
Arnold, Glover C., 115 E. 30th St., New York, New York Co.
Arnold, J. Newton, Clyde, Wayne Co. Founder.
Atwood, H. L., Collins Centre, Erie Co. Original.
Ayer, W. L., Owego, Tioga Co. Original.
Ayres, Douglas, Fort Plain, Montgomery Co. Original.
Babcock, H. E., New London, Oneida Co. Original.
* Deceased,
ALPEIABETICAL LIST OF FELLOWS. 807
* Babcock, Myron N., Saratoga Springs, Saratoga Co. Founder.
Backus, Ogden, 67 S. Fitzhugh St., Rochester, Monroe Co. Original.
Bacon, Charles G., Fulton, Oswego Co. (Retired list.)
Bagg, Moses M., Utica, Oneida Co. Original. (Retired list.)
Bailey, Theodore P., 95 Eagle St., Albany, Albany Co. Founder.
Bailey, William C., Albion, Orleans Co. Original.
Baker, Benjamin N., Rhinebeck, Dutchess Co.
Baker, Frank R., 540 Bedford Ave., Brooklyn, E. D., Kings Co.
Baker, George W., 540 Bedford Avenue, Brooklyn, E. D., Kings Co.
Founder. *
Baldwin, F. A., 329 W. 23d St., New York, New York Co.
Ballou, William R., Oakland Heights Sanitarium, Asheville, N. C.
Banks, George B., Hartsdale, Westchester Co. Original. (Retired list.)
Banta, Rollin L., 330 Elk St., Buffalo, Erie Co. Original.
Barnes, Edwin, Pleasant Plains, Dutchess Co. Original.
Barney, Charles S., Milford, Otsego Co. Original.
Barnum, D. Albert, Cassville, Oneida Co.
Bartlett, Frederick W., 523 Delaware Ave., Buffalo Erie Co. Original.
Barton, Lyman, Willsborough, Essex Co. Founder. (Retired list.)
Barton, Thomas J., Red Hook, Dutchess Co.
Bartow, Bernard, 220 Franklin St., Buffalo, Erie Co.
Bates, Nelson W., Central Square, Oswego Co.
Bates, Xyris T., Poughkeepsie, Dutchess Co. Original.
Bayley, Guy Carleton, Poughkeepsie, Dutchess Co. Original.
Baynes, Joseph E., 2419 5th Ave., Troy, Rensselaer Co.
*Baynes, William T., 2419 5th Ave., Troy, Rensselaer Co. Original.
Beardsley, William E., 101 Taylor St., Brooklyn, Kings Co.
Beers, John E., Danby, Tompkins Co. Founder.
Bell, A. Nelson, 291 Union St., Brooklyn, Kings Co.
Bellows, George A., Waterloo, Seneca Co.
Bemus, Morris N., Jamestown, Chautauqua Co.
Bemus, Wm. Marvin, Jamestown, Chautauqua Co.
Benham, John C., Hudson, Columbia Co. Original.
Bennett, Thomas W., Jeffersonville, Sullivan Co. Original.
Bentley, Francis R., Cheshire, Ontario Co. Original. (Retired list.)
Benton, Stuart H., 1063 Bergen St., Brooklyn, Kings Co.
Bergtold, W. H., 56 Allen St., Buffalo, Erie Co.
Bermingham, Edward J., 7 W. 45th St., New York, New York Co.
Bierwirth, Julius C., 187 Montague St., Brooklyn, Kings Co.
Biggam, William H., Jr., 1095 Dean St., Brooklyn, Kings Co.
Original.
Biggs, Chauncey P., 14 E. Seneca St., Ithaca, Tompkins Co.
Biggs, Hermann M., 58 E. 25th St., New York, New York Co. Original.
Bird, J. S., Hyde Park, Dutchess Co.
Birdsall, Gilbert, North Brookfield, Madison Co. Original.
Bissell, James H., 2187 5th Ave., Troy, Rensselaer Co.
* Deceased.
808 NEW YORK STATE MEDICAL ASSOCIATION:
Blaine, Myron D., Willard, Seneca Co.
Blair, Louis P., McDonough, Chenango Co. Original.
Blake, Clarence R., Northville, Fulton Co. Original.
Blumer, G. Alder, State Hospital, Utica, Oneida Co. Original.
Boies, Loren F., 286 Howard Ave., Buffalo, Erie Co. Original.
Bond, G. F. M., State Hospital, Utica, Oneida Co.
Bonesteel, H. F., Mill St., Troy, Rensselaer Co.
Bonesteel, William N., Mill St., Troy, Rensselaer Co. Founder. (Re-
tired list.)
Bontecou, Reed B., 82 4th St., Troy, Rensselaer Co. Original.
Booth, Wilbur H., 172 Genesee St., Utica, Oneida Co. Original.
Boyce, Elias B., Averill Park, Rensselaer Co.
Dozeman, Nathan, 9 W. 31st St., New York, New York Co. Founder.
Bozeman, Nathan G., 9 W. 31st St., New York, New York Co.
Bradford, George D., Homer, Cortland Co.
Bradley, O. Howard, Hudson, Columbia Co.
Brandt, J. S., Ontario Center, Wayne Co.
Briggs, Albert H., 267 Hudson St., Buffalo, Erie Co. Original.
Briggs, C. M., Fairport, Monroe Co.
Briggs, William H., Hemlock Lake, Livingston Co. Original.
Broderick, William P., 272 Willis Ave., New York, New York Co.
Brooks, Leroy J., Norwich, Chenango Co. Original.
Brown, Charles W., 902 14th St., N. W., Washington, D. C. Original.
Brown, George L., 121 Franklin St., Buffalo, Erie Co.
Brown, J. P., Nunda, Livingston Co.
Brown, Ulysses H., 312 Warren St., Syracuse, Onondaga Co.
Brundage, Amos H., 609 Madison St., Brooklyn, Kings Co. Original.
Brush, Edward F., Mount Vernon, Westchester Co. Original.
Brush, Edward N., Shepperd Asylum, Towsen, Md. Original.
Bryant, Joseph D., 54 W. 36th St., New York, New York Co. Original.
Bryant, Percy, State Hospital, Buffalo, Erie Co.
Buchanan, Alexander, 358 W. 30th St., New York, New York Co.
Original.
Buckley, Charles, 127 E. Main St., Rochester, Monroe Co, Original.
Buckley, James, 127 E. Main St., Rochester, Monroe Co. Original.
Bull, Charles Stedman, 47 W. 36th St., New York, New York Co.
Original.
Bull, William T., 35 W. 35th St., New York, New York Co.
Burbeck, Charles H., 91 First St., Troy, Rensselaer Co. Founder.
Burchard, Thomas H., 7 E. 48th St., New York, New York Co. Original.
Burghardt, Francis Augustus, 632 Elm St., Buffalo, Erie Co.
Burhyte, O. W., Brookfield, Madison Co.
Burke, John J. A., 65 East Ave., Rochester, Monroe Co. Original.
Burns, Wm. J., Roslyn, Queens Co. Original.
Burton, Matthew H., 754th St., Troy, Rensselaer Co. Founder.
*Burwell, George N., 130 Pearl St., Buffalo, Erie Co. Original.
*Deceased.
ALPHABETICAL LIST OF FELLO WS. 809
Cady, George M., Nichols, Tioga Co.
Cahill, John T., Hoosick Falls, Rensselaer Co.
Caldwell, Nathan A., Hageman’s Mills, Montgomery Co.
Campbell, A. J., 332 Warren St., Syracuse, Onondaga Co.
Campbell, Clarence G., 36 W. 33d St., New York, New York Co.
Carpenter, Henry W., Oneida, Madison Co. Original.
Carroll, Alfred Ludlow, 30 W. 59th St., New York, New York Co. .
Carter, H. Skelton, 130 E. 24th St., New York, New York Co. Original.
Casey, J. E., Mohawk, Herkimer Co.
Cavana, Martin, Oneida, Madison Co. -
*Chace, William, Mayville, Chautauqua Co. Founder.
Chambers, Jacob, Kingston, Ulster Co. Original. -
Chambers, Martin L., Port Jefferson, Suffolk Co. Original.
Chapman, James, Medina, Orleans Co. Founder.
Chauveau, Jean F., 31 W. 60th St., New York, New York Co. Original.
Chittenden, Daniel J., Addison, Steuben Co.
Chittenden, Joseph H., Binghamton, Broome Co. Founder.
Chrystie, T. M. Ludlow, 216 W. 46th St., New York, New York Co.
Original.
Church, B. A., Oneonta, Otsego Co.
Church, Charles A., Bloomingdale, Essex Co.
Churchill, Alonzo, 189 Genesee St., Utica, Oneida Co. (Retired list.)
Clark, Dewitt C., Marathon, Cortland Co. Original.
*Clark, Simeon Tucker, Lockport, Niagara Co. Original.
Clarke, Wallace, 136 Park Ave., Utica, Oneida Co.
Clum, Franklin D., Cheviot, Columbia Co.
Codding, George H., Amenia, Dutchess Co. Founder.
Coffin, Lawrence, 473 Bedford Ave., Brooklyn, Kings Co.
Cohen, Bernard, 540 Niagara St., Buffalo, Erie Co.
Collins, Stacy B., 106 E. 35th St., New York, New York Co.
Colvin, Darwin, Clyde, Wayne Co. Founder.
Comfort, John E., 1315 Franklin Ave., New York, New York Co.
Comstock, George F., Saratoga Springs, Saratoga Co. Founder.
Congdon, Charles E., 1034 Jefferson St., Buffalo, Erie Co.
Conkling, George, Durham, Greene Co. Original.
Conner, Milton C., Middletown, Orange Co.
Conover, William S., 237 W. 132d St., New York, New York Co.
Founder.
Conway, John Francis, cor. Buffalo and Union Sts., Brooklyn, Kings Co.
Original.
Conway, John R., 130 Lexington Ave., New York, New York Co.
Cook, Guy Reuben, Louisville, St. Lawrence Co.
Cooley, F. L., 210 First St., Oswego, Oswego Co.
Cooley, R. N., Hannibal Centre, Oswego Co.
Cooper, William C., 81 3d St., Troy, Rensselaer Co. Original.
Copley, Herman D., Bainbridge, Chenango Co.
*Deceased.
810 NEW YORK STATE MEDICAL ASSOCIATION.
Coutant, Richard B., Tarrytown, Westchester Co. Original.
Cramer, William, 136 Mansion St., Poughkeepsie, Dutchess Co. Founder.
Crane, Frank W., Corfu, Genessee Co. Original.
Crawe, J. Mortimer, Watertown, Jefferson Co. Founder.
*Creamer, Joseph, 154 Hewes St., Brooklyn, E. D., Kings Co.
Creamer, Joseph, Jr., 168 N. 6th St., Brooklyn, E. D., Kings Co.
Criado, Louis F., 147 Fort Green Place, Brooklyn, Kings Co.
Crocker, Edwin, Narrowsburgh, Sullivan Co.
Crombie, Walter C., Mechanicsville, Saratoga Co. Original.
Cronyn, John, 55 W. Swan St., Buffalo, Erie Co. Founder.
Crosby, Alexander H., Lowville, Lewis Co.
Crounse, Andrew C., Melrose, Rensselaer Co.
Curry, Walker, 21 E. 61st St., New York, New York Co. Original.
Curtis, Daniel, Jeddo, Orleans Co.
Curtis, D. F., 95 South Ave., Rochester, Monroe Co.
Curtis, P. C., Round Lake, Saratoga Co. -
Dagenais, Alphonse, 473 W. Virginia St., Buffalo, Erie Co. Original.
Dallas, Alexander, 65 W. 36th St., New York, New York Co.
Dallas, Alexander J., 48 Warren St., Syracuse, Onondaga Co. Founder.
*Damainville, Lucien, 3007 Broadway, New York, New York Co.
Daniels, Clayton M., 868 Main St., Buffalo, Erie Co. Original.
Daniels, F. H., 126 W. 126th St, New York, New York Co.
D'Avignon, Francis J., Au Sable Forks, Essex Co. Original.
Davis, J. Griffith, 132 W. 12th St., New York, New York Co.
Davis, J. O., Howells, Orange Co.
Davis, Robert C., 150 E. 128th St., New York, New York Co.
Dayton, C. L., 246 Dearborn St., Buffalo, Erie Co. (Retired list.)
Dean, Harmon J., Brocton, Chautauqua Co. Founder.
De Garmo, W. B., 56 W. 36th St., New York, New York Co.
DeKay, William H., Parksville, Sullivan Co.
De Laney, John Pope, Geneva, Ontario Co.
Delphey, Eden W., 339 W. 59th St., New York, New York Co.
Denison, Charles Ellery, 124 W. 13th St., New York, New York Co.
Original.
Denison, Ellery, 124 W. 13th St., New York, New York Co. Original.
Dennis, Frederic S., 542 Madison Ave., New York, New York Co.
Founder.
de Quesada, Gregorio J., 307 W. 28th St., New York, New York Co.
De Witt, Byron, Oswego, Oswego Co. Original.
de Zouche, Isaac, Gloversville, Fulton Co. Founder.
Dickson, Thomas Gordon, Troy, Rensselaer Co.
Didama, Emory A., Cortland, Cortland Co.
Didama, Henry D., 112 S. Salina St., Syracuse, Onondaga Co. Founder.
Dodge, Amos P., Oneida Castle, Oneida Co.
Dodge, Frank B., Mount Morris, Livingston Co.
Dodge, Lyndhurst C., Rouse's Point, Clinton Co. Founder.
*Deceased.
ALPHABETICAL LIST OF FELLOWS. 811
Donohue, Florence O., 410 Warren St., Syracuse, Onondago Co. Original.
Dorland, Elias T., 86 N. Division St., Buffalo, Erie Co. Original.
Douglas, George, Oxford, Chenango Co. *
Douglass, A. J., Illion, Herkimer Co.
Douglass, Charles E., Lowville, Lewis Co.
Douglass, James W., Booneville, Oneida Co.
Drake, D. Delos, Johnstown, Fulton Co.
Drake, E. G., 312 W. Church St., Elmira, N. Y.
Drake, Frank C., Oneida, Madison Co.
Drake, James B., Hancock, Delaware Co.
Du Bois, Matthew B., 156 Broadway, Manhattan Life Ins. Co., New York,
New York Co. Original.
I)udley, A. Palmer, 640 Madison Ave., New York, New York Co.
Dudley, Dwight, Maine, Broome Co.
Dunham, Edward K., 347 Lexington Ave., New York, New York Co.
Dunham, Theodore, 347 Lexington Ave., New York, New York Co.
Dunlop, John J., Waterford, Saratoga Co. Original.
Dunn, Jeremiah, Bath, Steuben Co. Original.
Dunning, J. D., Webster, Monroe Co. Original.
Earle, George W., Tully, Onondago Co.
Eastman, Robert W., 170 W. 78th St., New York, New York Co. Original.
Eddy, George P., Lewiston, Niagara Co.
Eddy, John L., Olean, Cattaraugus Co.
Edwards, Amos S., 1506 N. Salina St., Syracuse, Onondaga Co. Original.
Edwards, George A., Catherine and Lodi Sts., Syracuse, Onondaga Co.
Original.
Edwards, John, Gloversville, Fulton Co.
Einhorn, Max, 107 E. 65th St., New York, New York Co.
Eliot, Ellsworth, 48 W. 36th St., New York, New York Co. Original.
Ellinwood, A. G., Attica, Wyoming Co. Original.
Ellis, J. B., Whitesborough, Oneida Co.
Ellison, Metler D., Canisteo, Steuben Co. Original.
Ellsworth, Victor A., Wellsville, Cattaraugus Co.
Elsner, Henry L., 308 N. Salina St., Syracuse, Onondaga Co. Founder.
Ely, Henry Oliver, Binghamton, Broome Co. Original.
English, G. P., Booneville, Oneida Co.
Erdmann, John F., 141 W. 34th St., New York, New York Co.
Farnham, LeRoy D., Binghamton, Broome Co.
Farrington, John M., Binghamton, Broome Co.
Farrington, Joseph O., 1991 Madison Ave., New York, New York Co.
Feely, James F., 296 Lorimer St., Brooklyn, E. D., Kings Co.
Fell, George E., 72 Niagara St., Buffalo, Erie Co.
Fenno, Henry Marshall, 77 W. Main St., Rochester, Monroe Co.
Ferguson, E. D., 1 Union Place, Troy, Rensselaer Co. Founder.
*Ferguson, James, Glens Falls, Warren Co. Original. (Retired list.)
Field, Matthew D., 115 E. 40th St., New York, New York Co.
* Deceased.
812 NEW YORK STATE MEDICAL ASSOCIATION.
Finder, William Jr., 2 Union Place, Troy, Rensselaer Co. Founder.
Fisher, John C., Warsaw, Wyoming Co.
Fitch, William, Dryden, Tompkins Co. Founder.
Fitzgerald, David J., Glens Falls, Warren Co.
Fitzgerald, John F., State Hospital, Binghamton, Broome Co.
Flandrau, Thomas M., Rome, Oneida Co.
Flanigan, John R., Syracuse, Onondaga Co.
Fletcher, Charles L., Wing's Station, Dutchess Co. Original.
Flickinger, John, Trumansburg, Tompkins Co.
Flinn, Thomas W. P., 137 E. 28th St., New York, New York Co.
Flint, Austin, 60 E. 34th St., New York, New York Co. Founder.
Flint, Austin, Jr., 252 Madison Ave., New York, New York Co.
Flint, William H., 37 E. 33d St., New York, New York Co. Founder.
Fogg, John S., 602 Tremont St., Boston, Mass.
Ford, M. L., Oneonta, Otsego Co.
Forker, Frederick L., Binghamton, Broome Co.
Foster, George W., 109 E. 18th St., New York, New York Co.
Fowler, Joseph, 31 Church St., Buffalo, Erie Co.
Fowler, Thomas B., Cohocton, Steuben Co.
Frankenberg, Jacob H., 142 E. 74th St., New York, New York Co.
Fraser, Jefferson C., Ava, Oneida Co.
Frazee, A. Blair, Altoona, Pa.
Frederick, Carlton C., 64 Richmond Ave., Buffalo, Erie Co.
French, S. H., Amsterdam, Montgomery Co.
Fritts, Crawford Ellsworth, Hudson, Columbia Co.
Fuller, Earl D., 66 Varick St., Utica, Oneida Co.
Fuller, Robert, Schenectady, Schenectady Co.
Furman, Guido, 125 W. 73d St., New York, New York Co. Original.
Furman, J. Henry, Tarrytown, Westchester Co. Original.
Gardiner, W. F., 1756th Ave., Brooklyn, Kings Co.
Garlock, William D., Little Falls, Herkimer Co.
Getty, A. H., Athens, Greene Co.
Gibson, William M., 187 Genesee St., Utica, Oneida Co.
Gilbert Horatio, Hornellsville, Steuben Co.
Gillis William, Fort Covington, Franklin Co. Founder.
Gleitsmann, J. W., 46 E. 25th St., New York, New York Co.
Glidden, Charles H., Little Falls, Herkimer Co. Original.
Goldthwaite, Henry, Fifth Avenue Hotel, New York, New York Co.
Goler, George W., 54 S. Fitzhugh St., Rochester, Monroe Co.
Gould, Cassius W., 1428 Main St., Buffalo, Erie Co.
Gouley, John W. S., 324 Madison Ave., New York, New York Co.
Founder.
Govan, William, Stony Point, Rockland Co. Founder.
Gow, Frank F., Schuylerville, Saratoga Co.
Granger, William D., Bronxville (Vernon House), Westchester Co.
Grant, Charles S., Saratoga Springs, Saratoga Co. Founder.
Grauer, Frank, 326 W. 46th St., New York, New York Co.
ALPFIABETIOAL LIST OF FELLOWS, 813
Graves, Ezra, Amsterdam, Montgomery Co. Original.
Gray, John P., 270 Alexander Ave., Rochester, Monroe Co.
Gray, Joseph F., 326 W. 31st St., New York, New York Co.
*Green, Caleb, Homer, Cortland Co. Founder.
Green, H. H., Paine's Hollow, Herkimer Co.
Green, Stephen S., 384 Swan St., Buffalo, Erie Co.
Greene, Clark W., Chenango Forks, Broome Co.
Greene, De Witt C., 1125 Main St., Buffalo, Erie Co. Original.
Greene, Joseph C., 124 Swan St., Buffalo, Erie Co. Founder.
Greene, Walter D., 444 Elk St., Buffalo, Erie Co. Original.
Greenman, C. E., 575 1st St., Troy, Rensselaer Co.
Gulick, A. Reading, 30 W. 36th St., New York, New York Co.
Gulick, Charlton R., 30 W. 36th St., New York, New York Co.
Guy, J. D., Coventry, Chenango Co.
Hagadorn, William, Gilboa, Schoharie Co. Original.
Halbert, M. L., Cincinnatus, Cortland Co.
Hall, William H., Saratoga Springs, Saratoga Co. Original.
Hamill, Edward H., 302 6th Ave., Newark, New Jersey.
Hammer, Charles, Schenectady, Schenectady Co.
Hammond, Frederick Porter, 157 E. 115th St., New York, New York Co.
Hand, S. M., Norwich, Chenango Co.
Hannan, James C., Hoosick Falls, Rensselaer Co. Founder.
Harrington, D. W., 1430 Main St., Buffalo, Erie Co. Original.
Harrison, George Tucker, 221 W. 23d St., New York, New York Co.
Original. -
Hartwig, Marcell, 34 E. Huron St., Buffalo, Erie Co.
Harvie, J. B., 6 Clinton Place, Troy, Rensselaer Co. Founder.
Hatch, C. A., 110 E. Onondaga St., Syracuse, Onomadaga Co. Original.
Haubold, H. A., 225 E. 72d St., New York, New York Co.
Hayd, Herman E., 78 Niagara St., Buffalo, Erie Co.
Hayes, Philetus A., Afton, Chenango Co.
Haynes, John U., 103 Mohawk St., Cohoes, Albany Co.
Head, Adelbert D., 322 S. Salina St., Syracuse, Onondaga Co. Founder.
Heath, William H., 415 Pearl St., Buffalo, Erie Co.
Heimstreet, Thomas B., 14 Division St., Troy, Rensselaer Co. Original.
Hendrick, Henry C., McGrawville, Cortland Co. Founder.
Hepburn, Neil J., 369 W. 23d St., New York, New York Co.
Hewitt, Adelbert, Saratoga Springs, Saratoga Co.
Hicks, Edward E., Poughkeepsie, Dutchess Co.
Hicks, W. Scott, Bristol, Ontario Co. Original.
Higgins, F. W., Cortland, Cortland Co.
Hillis, Thomas J., 51 Charlton St., New York, New York Co.
Hills, Lyman H., Binghamton, Broome Co. Original.
Himmelsbach, George A., 30 12th St., Buffalo, Erie Co.
Hinton, John H., 41 W. 32d St., New York, New York Co. Founder.
Hodgman, Abbott, 141 E. 38th St., New York, New York Co. Founder.
*Deceased.
814 NEW YORK STATE MEDICAL ASSOCIATION.
Hodgman, William H., 109 Caroline St., Saratoga Springs, Saratoga Co.
Founder.
Hogan, M. K., 226 W. 34th St., New York, New York Co.
+Holcomb, O. A., Plattsburgh, Clinton Co.
folden, Arthur L., 116 South St., Utica, Oneida Co.
Holmes, Martha C., 75 W. 126th St., New York, New York Co.
HoornBeek, Philip Du Bois, Wawarsing, Ulster Co. Original. (Retired list.)
Horton, David B., Red Creek, Wayne Co.
Hough, F. P., Binghamton, Broome Co.
Houston, David W., 44.2d Street, Troy, Rensselaer Co. Original.
Hovey, B. L., 34 N. Fitzhugh St., Rochester, Monroe Co. Founder.
Howard, Charles F., 1458 Main St., Buffalo, Erie Co.
Howland, George T., Athens, Greene Co.
Hoyer, F. F., Tonawanda, Erie Co. Founder.
Hubbard, Chauncey G., Hornellsville, Steuben Co.
Hubbard, Dwight L., 344 W. 33d St., New York, New York Co.
Hubbard, George E., 257 W. 52d St., New York, New York Co.
Hubbard, Samuel T., 27 W. 9th St., New York, New York Co. Founder.
Hubbell, Alvin A., 212 Franklin St., Buffalo, Erie Co.
Hudson, George, Stillwater, Saratoga Co.
Huestis, W. B., Kiskatom, Greene Co.,
Huggins, William Q., Sanborn, Niagara Co.
Hughes, Henry R., Clinton, Oneida Co.
Hughes, Peter, 275 Berry St., Brooklyn, Kings Co.
Hulette, G. S., Arcade, Wyoming Co.
Hühne, August, Rondout, Ulster Co. Founder.
Hühne, Frederick, Rondout, Ulster Co. Original.
Hull, Thomas H., 55 Lee Ave., Brooklyn, Kings Co.
Hull, William H., Poestenkill, Rensselaer Co.
Hulse, William A., Bay Shore, Suffolk Co.
Humphrey, J. F., Saratoga Springs, Saratoga Co.
Hunt, H. L., Orchard Park, Erie Co.
Hunt, James G., 5 Gardner Block, Utica, Oneida Co. Original.
*Hunt, James H., Port Jervis, Orange Co. Original,
Hunter, Nathaniel P., Jasper, Steuben Co.
Huntington, Henry K., New Rochelle, Westchester Co. Original.
Huntington, John W., Mexico, Oswego Co.
Huntley, James F., Oneida, Madison Co.
*Husted, Nathaniel C., Tarrytown, Westchester Co. Founder,
Ilgen, Ernst, 369 Herkimer St., Brooklyn, Kings Co. Original.
Ingraham, Charles W., Binghamton, Broome Co.
Ingraham, Henry D., 405 Franklin St., Buffalo, Erie Co.
Ingraham, Samuel, Palmyra, Wayne Co. Original, (Retired list.)
Inlay, Erwin G., Saratoga Springs, Saratoga Co.
Jackson, Albert P., Oakfield, Genesee Co. Founder.
Jackson, Charles W., 168 W. 81st St., New York, New York Co.
*Deceased.
ALPEIABETICAL LIST OF FELLOWS. 815.
Jackson, William H., Springville, Erie Co.
Jacobson, Nathan, 430 S. Salina St., Syracuse, Onondaga Co. Original.
Jamison, John S., Hornellsville, Steuben Co. Original.
Janeway, Edward G., 36 W. 40th St., New York, New York Co. Founder.
Janvrin, J. E., 191 Madison Ave., New York, New York Co. * \.
Jenkins, John A., 271 Jefferson Ave., Brocklyn, E.D., Kings Co. Original.
Jenkins, William T., I09 E. 26th St., New York, New York Co.
Jewett, F. A., 282 Hancock St., Brooklyn, Kings Co.
Jewett, Homer O., Cortland, Cortland Co. Founder.
Johnson, George P., Mexico, Oswego Co.
Johnson, Ianthus G., Greenfield Centre, Saratoga Co. Original.
Johnson, Leonard M., Greene, Chenango Co. Original.
Johnson, Parley H., Adams, Jefferson Co. Original.
Johnson, Richard G., Amsterdam, Montgomery Co. Original.
Johnson, Thomas M., 418 Main St., Buffalo, Erie Co. Original.
*Johnston, Francis U., New Brighton, Richmond Co. Founder.
Johnston, Henry C., New Brighton, Richmond Co.
Johnston, N. B., Barryville, Sullivan Co.
Jones, Allen A., 436 Franklin St., Buffalo, Erie Co.
Jones, George H., Fowlerville, Livingston Co.
Jones, S. Case, 39 N. Fitzhugh St., Rochester, Monroe Co.
Joslin, Albert A.,, Martinsburgh, Lewis Co.
Judson, A. B., 38 E. 25th St., New York, New York Co.
Julian, John M., Moore's Mill, Dutchess Co.
Keefer, Charles W., Mechanicsville, Saratoga Co.
Keith, Halbert Lyon, Upton, Mass.
Relly, John Devin, Lowville, Lewis Co.
Kemp, William M., 267 W. 23d St., New York, New York Co.
Kenyon, Benjamin, Cincinnatus, Cortland Co.
Kenyon, M., King's Ferry, Cayuga Co. Original.
Kilborn, Henry F., Croghan, Lewis Co.
King, Ferdinand, 315 W. 58th St., New York, New York Co.
King, James K., Watkins, Schuyler Co.
Kingsley, Henry F., Schoharie, Schoharie Co. Original.
Kittredge, Charles S., Fishkill-on-Hudson, Dutchess Co. Founder.
Klock, Charles M., St. Johnsville, Montgomery Co.
Knapp, W. H., Binghamton, Broome Co.
Kneeland, B. T., Dalton, Livingston Co.
Kneeland, Jonathan S., Onondaga, Onondaga Co. Founder. (Retired
list.)
Kneer, F. G., 236 W. 51st St., New York, New York Co.
Knipe, George, 354 W. 24th St., New York Co.
Kniskern, A. C., Mechanicsville, Saratoga Co.
Kuhn, William, Rome, Oneida Co.
LaBell, Martin J., Lewis, Essex Co. Original.
Laird, William R., 98 Wall St., Auburn, Cayuga Co. Original.
*Deceased,
816 NEW YORK STATE MEDICAL ASSOCIATION.
Lake, Albert D., Gowanda, Cattaraugus Co.
*Lamb, Milton M., Lansingburgh, Rensselaer Co.
Lambert, John, Salem, Washington Co.
Landon, Newell E., Newark, Wayne Co. Original.
Lapp, Henry, Clarence, Erie Co.
Leach, H. M., Charlton City, Massachusetts. Original.
Leale, Charles A., 604 Madison Ave., New York, New York Co. Founder.
Leaning, John K., Cooperstown, Otsego Co. Founder.
Leffingwell, E. D., Watkins, Schuyler Co.
Leighton, N. W., 143 Taylor St., Brooklyn, E. D., Kings Co. Original.
Le Roy, Irving D., Pleasant Valley, Dutchess Co. Founder.
Lester, Elias, Seneca Falls, Seneca Co. Founder.
Lewis, Robert, 19 E. 38th St., New York, New York Co.
Lindsay, Walter, Huntington, Suffolk Co. Original.
Little, Albert H., 158 W. 20th St., New York, New York Co.
Little, Frank, 114 Montague St., Brooklyn, Kings Co.
Lloyd, T. Mortimer, 125 Pierrepont St., Brooklyn, Kings Co. Original.
Lockwood, Charles E., 59 W. 36th St., New York, New York Co.
Lockwood, J. W., Philmont, Columbia Co. Original.
Long, Alfred J., Whitehall, Washington Co.
Long, Ben G., 1408 Main St., Buffalo, Erie Co.
Ludlow, Ogden C., 210 W. 135th., New York, New York Co.
Lukens, Anna, 1068, Lexington Ave., New York, New York Co.
Lung, Jesse B., 382 Marion St., Brooklyn, Kings Co. Original.
Lusk, William T., 47 E. 34th St., New York, New York Co. Founder.
Lusk, Zera J., Warsaw, Wyoming Co.
Lyman, Elijah S., Sherburne, Chenango Co. Original.
Lyman, H. C., Sherburne, Chenango Co. Original.
Lynch, Patrick J., 216 E. 13th St., New York, New York Co.
Lyon, E. M., Plattsburgh, Clinton Co. Founder.
Lyon, George E., 1915 5th Ave., Troy, Rensselaer Co. Original.
Lyons, Edward L., 298 4th St., Troy, Rensselaer Co.
Lyons, G. A., New Rochelle, Westchester Co. Original.
Macfarlane, William A., Springville, Erie Co.
MacGregor, James R., 1125 Madison Ave, New York, New York Co.
Mackenzie, J. C., 432 W. 22d St., New York, New York Co.
Magee, Charles M., West and Seymour Sts., Syracuse, Onondaga Co.
Magee, Daniel, 1163d St., Troy, Rensselaer Co. Original.
Maine, Alvah P., Webster, Monroe Co.
Manley, Thomas H., 302 W. 53d St., New York, New York Co. Founder.
Marsh, E. Frank, Fulton, Oswego Co.
Marsh, James P., 1739 5th Ave., Troy, Rensselaer Co.
Marshall, Francis F., 56 W. 56th St., New York, New York Co.
Martin, John H., Otsego, Otsego Co. Original.
Martindale, F. E., Port Richmond, Richmond Co.
Martine, Godfrey R., Glens Falls, Warren Co. Original,
*Deceased.
AIPHABETICAL LIST OF FELLOWS. 817
*Matthews, David, 73 E. 54th St., New York, New York Co.
*Maury, Rutson, 252 Madison Ave., New York, New York Co.
McBurney, Charles, 28 W. 37th St., New York, New York Co.
McCollom, William, 195 Lefferts Place, Brooklyn, Kings Co. Original.
McDonald, George E., Schenectady, Schenectady Co. Original.
McDougall, R. A., Duanesburgh, Schenectady Co.
McDougall, William D., Spencerport, Monroe Co. (San José, Cal.)
McEwen, Robert C., Saratoga Springs, Saratoga Co. Founder.
McGann, Thomas, Wells, Hamilton Co.
McGillicuddy, T. J., 776 Madison Ave., New York, New York Co.
McGowen, John P., 137 E. 28th St., New York, New York Co.
McIlroy, Samuel H., 330 Alexander Ave., New York Co.
McLeod, Johnston, 247 W. 23d St., New York, New York Co.
McLeod, S. B. Wylie, 247 W. 23d St., New York, New York Co.
Founder. -
McLochlin, James A., 410 E. 10th St., New York, New York Co. Original.
McNamara, Daniel, 243 W. Genesee St., Syracuse, Onandaga Co. Original.
McNamara, Laurence J., 126 Washington Place (West), New York, New
York Co. Original.
McPherson, George W., Lancaster, Erie Co.
McWilliams, F. A., Monticello, Sullivan Co.
Meacham, Isaac D., Binghamton, Broome Co.
Meier, Gotlieb C. H., 210 E. 53d St., New York, New York Co.
Menzie, R. J., Caledonia, Livingston Co. Original.
Merritt, George, Cherry Valley, Otsego Co. Original.
Miller, William T., 310 W. 27th St., New York, New York Co. Original.
Milliken, S. E., 157 Madison Ave., New York, New York Co.
Minard, E. J. Chapin, 243 Quincy St., Brooklyn, Kings Co. Orignal.
Miranda, Ramon L., 349 W. 46th St., New York, New York Co. Original.
Mitchell, Howard E., 84 Fourth St., Troy, Rensselaer Co. Founder.
Mitchell, Hubbard W., 747 Madison Ave., New York, New York Co.
Original.
Moore, Edward M., 74 S. Fitzhugh St., Rochester, Monroe Co. Founder.
Moore, Edward M., Jr., 74 S. Fitzhugh St., Rochester, Monroe Co.
Original.
Moore, Richard Mott, 74 S. Fitzhugh St., Rochester, Monroe Co. Original.
Moore, William A., Binghamton, Broome Co.
Moran, James, 352 W. 51st St., New York, New York Co.
Moriarta, Douglas C., Saratoga Springs, Saratoga Co.
Morrow, William B., Walton, Delaware Co.
Mott, Valentine, 62 Madison Ave., New York, New York Co.
Moyer, Frank H., Moscow, Livingston Co. Original.
Mudge, Selden J., Olean, Cataraugus Co.
Munger, Charles, Knoxborough, Oneida Co.
Munson, J. A., Woodbourne, Sullivan Co. Original.
Munson, W. W., Otisco, Onondaga Co. Original.
*Deceased.
818 IVEW YORK STATE MEDICAL ASSOCIATION.
Murdoch, James Bissett, 4232 Fifth Ave., Pittsburgh, Pa. (Non-resident.)
Murdock, George W., Cold Spring, Putnam Co. Founder.
Murphy, John, 219 E. 37th St., New York, New York Co. Original.
Murray, Byron J., Saratoga Springs, Saratoga Co. Original.
Murray, S.J., 133 W. 87th St., New York, New York Co. Original.
Murray, William D., Tonawanda, Erie Co. Original.
Nelson, William H., Taberg, Oneida Co.
Newman, George W., 234 Leonard St., Brooklyn, Kings Co.
Newman, Robert, 68 W. 36th St., New York, New York Co. Original.
Nichols, Calvin E., 25 First St., Troy, Rensselaer Co. Founder. -
Nichols, H. W., Canandaigua, Ontario Co. Founder.
Nichols, William H., West Sand Lake, Rensselaer Co. Founder.
Nicholson, A. R., Madison, Madison Co. Original.
Nicoll, Henry D., 51 E. 57th St., New York Co. Founder.
Nold, John B., 165 North Ave., Rochester, Monroe Co.
North, Nelson L., 627 Bedford Ave., Brooklyn, Kings Co. Original.
Nutten, Wilbur F., Newark, Wayne Co.
Oberndorfer, Isidor P., 1037 Lexington Ave., New York, New York Co.
Original.
O’Brien, Frederick Wm., 234 E. 112th St., New York, New York Co.
O’Brien, M. Christopher, 161 W, 122d New York, New York Co.
Ochs, Benjamin F., 773 Lexington Ave., New York, New York Co.
O'Hare, Thomas A., 157 State St., Rochester, Monroe Co. Original.
Oliver, William, Penn Yan. Yates Co.
Oppenheimer, H. S., 49 E. 23d St., New York, New York Co.
Oppenheimer, S., 533 E. 120th St., New York, New York Co.
Orton, John G., Binghamtom, Broome Co. Founder.
Ostrander, George A., 61 Greene Ave., Brooklyn, Kings Co.
Packer, Thurston G., Smyrna, Chenango Co.
Paine, Arthur R., 99 Lafayette Ave., Brooklyn, Kings Co. Original.
Palmer, Edmund J., 1842 Lexington Ave., New York, New York Co.
Palmer, F. A., Mechanicsville, Saratoga Co.
Palmer, George M., Warsaw, Wyoming Co. Original.
Palmer, Henry C., cor. Genesee and Hopper Sts., Utica, Oneida Co.
Palmer, Walter B., 30 South St., Utica, Oneida Co.
Parent, J. S., Birchton, Saratoga Co.
Park, Roswell, 510 Delaware Ave., Buffalo, Erie Co.
Parr, John, Buel, Montgomery Co.
Parsons, Israel, Marcellus, Onondaga Co. Founder.
Parsons, John, Kingsbridge, New York, New York Co. Original.
Parsons, W. W. D., Fultonville, Montgomery Co.
Pease, Joseph, Hamlin, Monroe Co. Original.
Perry, John Gardner. 48 E. 34th St., New York, New York Co.
Perry, Nathaniel M., Troupsburgh, Steuben Co. Original.
Peters, Samuel, 86 Mohawk St., Cohoes, Albany Co. Founder.
Pettit, John A., 519 Swan St., Buffalo, Erie Co. Original.
Phelan, Michael F., 339 Congress St., Troy, Rensselaer County.
ALPEIA BETIONAL LIST OF FELLOWS. 819
Phelps, Charles, 34 W. 37th St., New York, New York Co.
Phelps, George G., 239 Blandina St., Utica, Oneida Co.
Phelps, William C., 146 Allen St., Buffalo, Erie Co.
Pierce, Edward A., Binghamton, Broome Co.
Pierson, George E., Kirkwood, Broome Co.
Pilgrim, Charles W., State Hospital, Willard, Seneca Co. Original.
Piper, Charles W., Wurtsborough, Sullivan Co.
Place, John F., Jr., Binghamton, Broome Co.
Pohlman, Julius, 539 Niagara St., Buffalo, Erie Co.
*Pollard, Abiathar, Westport, Essex Co. Original. (Retired list.)
Pooler, Hiram A.,, 34 Gramercy Park, New York, New York Co. Original.
(Retired list.)
Porteous, James G., Poughkeepsie, Dutchess Co. Founder,
Porter, Harry N., 1910 Harewood Ave., Washington, D. C. Founder.
(Retired list.)
Porter, P. Brynberg, 8 W. 35th St., New York, New York Co. Original.
Potter, Vaughn C., Starkville, Herkimer Co. Original.
Potts, E., Port Jervis, Orange Co.
Pray, S. R., 523 Bedford Ave., Brooklyn, Kings Co. Original.
Preston, John R., Schuylerville, Saratoga Co. Original.
Price, Henry R., 485 Franklin Ave., Brooklyn, Kings Co.
Prince, Alpheus, Byron, Genesee Co.
Pritchard, R. L., 72 W. 49th St., New York, New York Co.
Pultz, Monroe T., Stanfordville, Dutchess Co. Founder.
Purple, Samuel S., 36 W. 22d St., New York, New York Co. Founder.
Putnam, Frederick W., Binghamton, Broome Co. Founder.
Putnam, James W., 388 Franklin St., Buffalo, Erie Co. Original.
Quin, Hamilton S., 171 Genesee St., Utica, Oneida Co.
Race, W. F., 115 W. 25th St., Kearney, Nebraska. Original.
Rae, Robert, Portageville, Wyoming Co. Original.
Rand, Hannibal W., Keene, Essex Co. Original.
Ransom, H. B. (in 'care S. W. White and Co.), 36 Wall St., New York,
New York Co.
Rau, Leonard S., 72 W. 55th St., New York, New York Co.
Rave, Edward G., Oyster Bay, Queens Co. Original.
Raynor, F. C., 163 Clinton St., Brooklyn, Kings Co.
Read, Ira B., 66 E. 126th St., New York, New York Co.
Reagles, James, Schenectady, Schenectady Co. Original.
Reed, Henry B., 12 Verona Place, Brooklyn, Kings Co.
Reid, Christopher C., Rome, Oneida Co.
Reitz, Charles, Webster, Monroe Co.
Reynolds, Tabor B., Saratoga Springs, Saratoga Co. Founder.
Rice, George, Mechanicsville, Saratoga Co.
Richards, Charles B., Binghamton, Broome Co. Founder.
Richardson, John E., 127 S. Oxford St., Brooklyn, Kings Co.
* Deceased,
52
820 NEW YORK STATE MEDICAL ASSOCIATION.
Richmond, Nelson G., Fredonia, Chautauqua Co.
Ricketts, Benjamin M., 137 Broadway, Cincinnati, Ohio. Original.
Riley, Andrew W., 207 S. 16th St., Omaha, Neb. Original.
Risch, Henry F. W., 521 3d St., Brooklyn, Kings Co.
Robb, William H., Amsterdam, Montgomery Co. Founder.
Robinson, Ezra A., Geneva, De Kalb Co., Ill. Original.
Rochester, De Lancey, 469 Franklin St., Buffalo, Erie Co.
Rochester, Thomas M., 326 DeKalb Ave., Brooklyn, Kings Co.
Rodgers, Harris 6., 1 Wall St., Binghamton, Broome Co.
Rogers, S. Frank, 31616th Ave., Troy, Rensselaer Co. Original.
Rolph, R. T., Fredonia, Chautauqua Co.
Roper, P. B. Alpine, Schuyler Co.
Ross, Frank W., 251 Baldwin St., Elmira, Chemung Co. Original.
Roth, Julius A., 308 E. 79th St., New York, New York Co.
Rousseau Zotique, 99 2d St., Troy, Rensselaer Co. Founder.
Rudgers, Denton W., Perry, Wyoming Co.
Ruggles, Augustus D., 239 W. 14th St., New York, New York Co.
Rulison, Elbert T., Amsterdam, Montgomery Co. Original.
Rulison, L. B., West Troy, Albany Co.
Rushmore, John D., 129 Montague St., Boooklyn, Kings Co. Founder.
Russell, Charles P., 198 Genesee St., Utica, Oneida Co.
Russell, William G., 27 McDonough St., Brooklyn, Kings Co. Original.
Sabin, William B., 1425 Broadway, West Troy, Albany Co. Founder.
Sabine, Gustavus A., 8 E. 24th St., New York, New York Co. Original.
Sanders, E., 126 E. 82d St., New York, New York Co.
Sawyer, Conant, Auburn, Cayuga Co. Founder.
Saxer, Leonard A., 514 Prospect Ave., Syracuse, Onondaga Co. Original.
Sayre, Lewis A., 285 Fifth Ave., New York, New York Co. Founder.
Sayre, Reginald H., 285 Fifth Ave., New York, New York Co.
Schmid, H. Ernst, White Plains, Westchester Co. Original.
Schopp, Justin H., 127 E. Main St., Rochester, Monroe Co.
Scully, Thomas P., Rome, Oneida Co.
Seaman, Louis L., 18 W. 31st St., New York, New York Co.
Seaman, Frank G., Seneca Falls, Seneca Co.
Sears, F. W., 326 Montgomery St., Syracuse, Onondaga Co.
Segur, Avery, 281 Henry St., Brooklyn, Kings Co. Founder.
Selden, O. G., Catskill, Greene Co. Original.
Selden, Robert, Catskill, Greene Co. Original.
Seymour, Ralph A., Whitney’s Point, Broome Co.
Seymour, W. Wotkyns, 105 3d St., Troy, Rensselaer Co. Founder,
Sharer, John P., Little Falls, Herkimer Co. Original.
Shaw, Henry B., 21 E. 127th St., New York, New York Co.
Shea, Dennis L., 116 Waverly Place, New York, New York Co.
Shepard, A. Warner, 126 Willoughby St., Brooklyn, Kings Co. Original.
Sherer, John D., Waterford, Saratoga Co. Original.
Sherman, F. J., Ballston, Saratoga Co.
Shrady, John, 149 W. 126th St., New York, New York Co.
ALPEIABETICAL LIST OF FELLOWS. 821
Shrady, John Eliot, 149 W. 126th St., New York, New York Co.
Shunk, Albert, 232 W. 22d St., New York, New York Co.
Silver, Henry M., 39 7th St., New York, New York Co.
Simmons, Charles E., 742 Lexington Ave., Brooklyn, Kings Co.
Simmons, E. W., Canandaigua, Ontario Co. Founder. (Retired list.)
Simons, Frank E., Canajoharie, Montgomery Co.
Sizer, Nelson Buell, 336 Greene Ave., Brooklyn, Kings Co. Original.
Skinner, Smith A., Hoosick Falls, Rensselaer Co. Original.
Slater, Frank Ellsworth, Binghamton, Broome Co.
Small, John W., New Rochelle, Westchester Co.
Smeallie, James A., 12 W. 40th St., New York, New York Co.
Smelzer, Baxter T., Havana, Schuyler Co.
Smith, F. A., Corinth, Saratoga Co.
Smith, George C., Delhi, Delaware Co.
Smith, H. Lyle, Hudson, Columbia Co. Original.
Smith, J. Lewis, 64 W. 56th St., New York, New York Co. Original.
Smith, Samuel L., Smithville Flats, Chenango Co.
Smith, Samuel W., 24 W. 30th St., New York, New York Co. Original.
Smith, Stephen, 574 Madison Ave., New York, New York Co. Original.
Smyth, Arthur W. H., Amsterdam, Montgomery Co.
Snook, George M., Parma, Monroe Co.
Southworth, Malek A., Little Falls, Herkimer Co. Original.
Southworth, Richmond Joseph, 1220 36th St., N. W., Washington, D. C.
Original.
Spicer, Walter E., 41 N. Moore St., New York, New York Co.
Sprague, John A., Williamson, Wayne Co. Original.
Sprague, L. S., Williamson, Wayne Co. (Retired list.)
Squibb, Edward H., 148 Columbia Heights, Brooklyn, Kings Co.
Founder.
Squibb, Edward R., 152 Columbia Heights, Brooklyn, Kings Co.
Founder.
Squire, Charles L., 409 E. Church St., Elmira, Chemung Co.
Steinke, Carl Otho Hermann, 220 17th St., Brooklyn, Kings Co.
Original.
Stephenson, F. Halleck, 101 Warren St., Syracuse, Onondaga Co.
Stephenson, James A., Scio, Allegany Co. Original.
Stewart, F. E., Watkins, Schuyler Co.
Stockschlaeder, P., 186 South Ave., Rochester, Monroe Co.
Stockton, Charles G., 436 Franklin St., Buffalo, Erie Co.
Stone Frank L., Le Roy, Genesse Co.
Strong, Orville C., Colden, Erie Co.
Strong, Thomas D., Westfield, Chautauqua Co. Founder.
Stubbs, Roland H., Waterford, Saratoga County. Original.
Sullivan, John D., 74 McDonough St., Brooklyn, Kings Co.
Sutton, H. C., Rome, Oneida Co.
Sutton, Richard E., Rome, Oneida Co.
Swan, William E., Saratoga Springs, Saratoga Co.
822 NEW YORK STATE-MEDICAL ASSOCIATION.
Swamick, R. A., Saratoga Springs, Saratoga County.
Swartwout, H. B., Port Jervis, Orange Co.
Swartwout, Leander, Prospect, Oneida Co.
Sweet, Joseph J., Unadilla, Otsego Co. Original.
Sweet, Joshua J., Unadilla, Otsego Co. -
Sweetman, J. T., Jr., Ballston, Saratoga Co.
Taber, R. C., Tonawanda, Erie Co.
Taylor, John H., Holley, Orleans Co. Original.
Tefft, Charles B., Room 20, Arcade, Utica, Oneida Co.
Thomas, T. Gaillard, 600 Madison Ave., New York, New York Co.
Founder.
Thompson, R. A., Norwich, Chenango Co.
Thompson, Amos W., Saratoga Springs, Saratoga County.
Thompson, Von Beverhout, 111 W. 43d St., New York, New York Co.
Thornton, William H., 572 Niagara St., Buffalo, Erie Co.
Thwing, Clarence, Sitka, Alaska.
Tiemann, Paul E., 161 W. 104th St., New York, New York Co.
Todd John B., Parish, Oswego Co.
Tompkins, Fred J., 1282d Ave., Lansingburgh, Rensselaer Co.
Tompkins, H. C., Knowlesville, Orleans Co. Founder.
Tompkins, Orren A., East Randolph, Cattaraugus Co. Original.
Townsend, Charles E., Middletown, Orange Co.
Townsend, Morris W., Bergen, Genesee Co. Founder.
Traver, Richard D., 144th St., Troy, Rensselaer Co. Original.
Travis, Edward M., Masonville, Delaware Co.
Tremaine, Wm. S., 217 Franklin St., Buffalo, Erie Co. Founder.
Tripp, John D., Auburn, Cayuga Co. Original.
Truax, J. G., 17 E. 127th St., New York, New York Co.
Trull, H. P., Williamsville, Erie Co. .
Tucker, Carlos P., 43 W. 26th St., New York, New York Co. Founder.
Turner, Melvin H., Moriah, Essex Co. Original.
Twohey, John J., 170 E. Utica St., Buffalo, Erie Co.
Wanderhoof, Frederick D., Phelps, Ontario Co. Original.
Wanderveer, J. C., Monroe, Orange Co.
Wanderveer, J. R., Monroe, Orange Co.
Van de Warker, Ely, 104 Fayette Park, Syracuse, Onondaga Co.
Founder.
Wan Fleet, Frank, 158 E. 81st St., New York, New York Co.
Van Hoevenberg, Henry, Kingston, Ulster Co. Original.
Van Vranken, Adam T., 1603 3d Ave., West Troy, Albany Co. Original.
Van Wagner, L. A., Sherburne, Chenango Co.
Van Wyck, Richard C., Hopewell Junction, Dutchess Co. Original.
Van Zandt, Henry C., Schenectady, Schenectady Co. Original.
Warney, Miles E., Saratoga Springs, Saratoga Co.
Wedder George W., Philmont, Columbia Co.
Weeder, Andrew T., Schenectady, Schenectady Co.
Won Dönhoff, Edward, 210 W. 4th St., New York, New York Co.
ALPHABETICAL LIST OF FELLOWS, 823
Vincent, Ludger C., 52 W. 26th St., New York, New York Co.
Wagner, Charles Gray, State Hospital, Binghamton, Broome Co.
Wakeley Benjamin C., Angelica, Allegany Co. Original.
Wales, Theron A., Elmira, Chemung Co. Original.
Wall, Charles A., 306 Hudson St., Buffalo, Erie Co.
Wallace, Edwin E., Jasper, Steuben Co.
Wallach, Joseph G., 7 W. 82d St., New York, New York Co. Original.
Walser, William C., Port Richmond, Richmond Co.
Walsh, Simon J., 9 E. 129th St., New York, New York Co.
Ward, Charles S., 30 W. 33d St., New York, New York Co. Founder.
Ward, John J., Ellenville, Ulster Co.
Ward, R. H., 534th St., Troy, Rensselaer Co.
Warner, Frederic M., 66 W. 56th St., New York, New York Co.
Warner, John W., 107 E. 72d St., New York, New York Co.
Waterworth, William, 3 Hancock St., Brooklyn, Kings Co.
Webster, W. B., Schuylerville, Saratoga Co.
Weeks, John E., 154 Madison Ave., New York, New York Co.
Welles, S. R., Waterloo, Seneca Co.
Wells, E. H., Binghamton, Broome Co.
Wells, William L., New Rochelle, Westchester Co. Original,
West, Joseph E., 171 Genesee St., Utica, Oneida Co.
*West, M. Calvin, Rome, Oneida Co.
Weston, Albert T., 226 Central Park West, bet. 82d and 83d Sts., New
York, New York Co.
Wheeler, Isaac G., Marilla, Erie Co.
Wheeler, John T., Chatham, Columbia Co.
Whippler, Electa B., 491 Porter Ave., Buffalo, Erie Co.
White, Charles B., 107 W. 72d St., New York, New York Co.
White, J. Blake, 1013 Madison Ave., New York, New York Co.
White, Whitman W., 1024 Park Ave., New York, New York Co. Founder.
White, William T., 130 E. 30th St., New York, New York Co. Founder.
Whitford, James, Onondaga Valley, Onondaga Co. Original.
Wieber George, 181 South 5th St., Brooklyn, Kings Co. Original.
Wiener, Joseph, 1046 5th Ave., New York, New York Co. Founder.
Wiggin, Frederick Holme, 55 W. 36th St., New York, New York Co.
Williams, George O., Greene, Chenango Co.
Williams, Henry Smith, Randall's Island, New York, New York Co.
Williams, William H., 207 17th St., Brooklyn, Kings Co. Original.
Williamson, Edward A., Westchester Road, Westchester Co.
Willoughby, M., 1335 Main St., Buffalo, Erie Co.
Wilson, Thomas, Claverack, Columbia Co. Founder.
Witbeck, Charles E., Cohoes, Albany Co.
*Woodend, William D., Huntingdom, Suffolk Co. Founder.
Woodend, William E., 171 E. 116th St., New York, New York Co.
Woodruff, E. Gould, Watkins, Schuyler Co.
Woodruff, R. Allen, Philmont, Columbia Co.
*Deceased
824 NEW YORK STATE MEDICAL ASSOCIATION.
Woodworth, T. Floyd, Kinderhook, Columbia Co.
Wright, Theodore Goodell, Plainville, Hartford Co., Conn. (Non-resi-
dent.)
Wyckoff, Cornelius C., 482 Delaware St., Buffalo, Erie Co. Founder.
Wyckoff, Richard M., 532 Clinton Ave., Brooklyn, Kings Co. Founder.
Wyeth, John A., 27 E. 38th St., New York, New York Co. Original.
Young, Augustus A., Newark, Wayne Co. Original.
Young, John, Fishkill-on-Hudson, Dutchess Co. Original.
Young, John D., Starkville, Herkimer Co. Original.
Young, William, Cold Spring, Putnam Co. Founder. (Retired list).
Zeh, Edgar, Waterford, Saratoga Co.
Zeh, Merlin J., 1521 Broadway, West Troy, Albany Co.
Of 164 Founders, 116 remain on the list ; of 286 Original Fellows, 228
remain on the list. Total Fellowship, 800.
RETIRED FELLOWS.
Charles G. Bacon, Fulton, Oswego County (1891).
M. M. Bagg, Utica, Oneida County (1891).
George B. Banks, Hartsdale, Westchester County (1892).
Lyman Barton, Willsborough, Essex County (1890).
F. R. Bentley, Cheshire, Ontario County (1891).
William N. Bonesteel, Troy, Rensselaer County (1890).
Alonzo Churchill, Utica, Oneida County (1890).
C. L. Dayton, Buffalo, Erie County (1891).
*James Ferguson, Glens Falls, Warren County (1891).
Philip DuB. Hoorn Beek, Wawarsing, Ulster County (1891).
Samuel Ingraham, Palmyra, Wayne County (1890).
Jonathan S. Kneeland, Onondaga County (1890).
*Abiathar Pollard, Westport, Essex County (1890).
H. A. Pooler, 34 Gramercy Park, New York, New York County (1892).
H. N. Porter, Washington D. C. (1891).
E. W. Simmons, Canandaigua, Ontario County (1892).
L. S. Sprague, Williamson, Wayne County (1891).
William Young, Cold Spring, Putnam County (1891),
* Deceased.
NON-RESIDENT FELLOWS.
James Bissett Murdoch, M.D., 4232 Fifth Ave., Pittsburgh, Pa.
Theodore Goodell Wright, M.D., Plainville, Hartford County, Conn.
HONORARY FELLOWS.
Sir John Simon, 40 Kensington Square, London, England (1890).
CORRESPONDING FELLOWS,
William Goodell, M.D., 1418 Spruce St., Philadelphia, Pa. (1890).
Henry O. Marcey, M.D., 116 Bolyston St., Boston, Mass (1890).
DECE ASED FELLOWS.
YEAR of ,
NAME. AGE. County. PLACE OF BIRTH. DATE OF DEATH. MEDICAL COLLEGE. GRAD-
UATION.
Adams, John G. (F)+ . . 77 ||New York . . |New York City . . . . June 19, 1884. Coll. Phys. and Surg., N. Y. . 1830
Allaben, O. M. (O)* . . . . 83 |Delaware . . . . . . . . . . . . . . . . . . . . . . . . . . Nov. 27, 1891. . . . . . . . . . . . . . . . . . . . . . . . . . . . . tº e º e
Andrews, John S. (O) . , | 61 |Kings . . . [Bristol, Conn. . . . . Jan. 3, 1889. Univ. City of New York . . 1849
Ashton, Isaiah H. . . . . 39 Westchester . Philadelphia, Pa. . . . [Feb. 16, 1889. University of Pennsylvania . 1870
Avery, George W. (F) . . . 61 |Chenango . . Earlville, N. Y. . . . . [Nov. 1, 1888. Albany Medical College . . . 1850
Ayres, Alexander (F) . . 74 |Montgomery . Oppenheim, N. Y. . . . Aug. 27, 1886. Castleton, Vt. . . . . . . 1842
Babcock, Myron N. (F) . . 73 Saratoga. . . West Berkshire, Vt. . . [May 21, 1892. Vermont Medical College
Barker, A. M. (O). . . . . 37 |Erie . . . . Kendall, Orleans Co., N.Y. Dec. 6, 1887. University of Buffalo . . . 1877
Bathgate, James (O) . . . 65 |New York . . New York. . . . . . March 27, 1891. Coll. Phys. and Surg., N. Y. . 1846
Baynes, William T. (O) . . . . . Rensselaer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Bemus, William P. . . . 63 |Chautauqua . Chautauqua Co. . . . . [Sept. 19, 1890. Berkshire Medical College . . 1847
Blakeman, William N. (O). 85 |New York . . Roxbury, Conn. . . . . Aug. 10, 1890. Yale . . . . . . . . . 1832
Bucklin, Daniel D. (O) . . 70 Rensselaer . . [Brunswick, N. Y. . . . April 19, 1890. Albany Medical College . . . 1846
Budd, J. Henry (O) . . . . 45 Ontario . . . United States. . . . . [Feb. 25, 1890. Buffalo Medical College . . . 1875
Burwell, George N. (O) . . . . . [Erie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . University of Pennsylvania . e tº e e
Case, Mary W. . . . . . 33 Rensselaer . . |New York State . . . . [Aug. 19, 1889. Women’s Med. Coll., Phila. . 1882
Chace, William (F) . . . 58 Chautauqua . St. Catharine's, Canada . Dec. 27, 1891. Coll. Phys. and Surg., N. Y. . 1858 .
Church, Allen S. (F) . . . . 62 |New York . . Great Barrington, Mass. . [Oct. 24, 1884. Castleton, Vt.
1848
Clark, Alonzo . . . . . 80 ||New York . . Chester, Mass.
. . . [Sept. 13, 1887. Coll. Phys. and Surg., N. Y. . 1835
º
Clark, Simeon T. (O) . . ... [Niagara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e e e
Coit, William N. (F). . . 52 Clinton . . . |Plattsburgh, N. Y. . . [Aug. 4, 1886. University of Pennsylvania. . 1856
Collins, Isaac G. (F) . . . 53 Westchester Granville, N. Y. . . . . [Dec. 18, 1885. Albany Medical College . . . 1858
DECEASED FELLOWS.
• e º e e a e e s e t e e s e e s e e s a e º e * * * * * * * * * * * * * *
1 (F) Founder. 8 (O) Original Fellow.
1851
1860
1880
1852
1850
1840
1860
1829
1835
1848
1858
1864
1878
1841
1833
1845
1855
1861
1836
1846
1849
1856
1844
1878
1850
1869
1877
Collins, Thomas B. (O) .
Cooper, William S. (F) .
Cornell, F. O. (O).
Cotes, J. R. .
Creamer, Joseph .
Cruttenden, Albert G.
Damainville, Lucien . .
Davidson, John (F)
De La Mater, S. G. (F) .
Du Bois, Abram (F) .
Eager, William B. (O)
Earll, George W. (F).
Edgerly, Edward F. (F)
Elder, Jennie S. tº ſº
Ferguson, James (O).
Flint, Austin (F) & ºt
Flood, Patrick Henry (O)
Fox, Eli . . . . . .
Fuller, Winfield S. (O) .
Garrish, John P. (O) .
Gay, Charles C. F. (F) .
Gray, John Perdue (F) .
Gray, John W. (F)
Green, Caleb (F)
Griswold, Gaspar (O)
Guernsey, Desault (F)
Hall, H. C. (O).
Hall, John E. (O).
61
70
29
54
75
52
91
73
81
65
53
50
32
74
73
72
57
48
76
66
61
53
73
29
55
41
38
Monroe .
Rensselaer .
Montgomery .
. |Batavia, N. Y.
Genesee .
Kings
Ontario .
New York .
Queens .
Schenectady
New York .
Orange .
Onondaga .
Essex
Onondaga .
Warren .
New York .
Chemung .
Herkimer
Monroe .
New York .
Erie .
Oneida .
Livingston .
Cortland
New York .
Dutchess
Broome .
Albany .
. Mendon, N. Y. .
. Scotland
. Covington, N. Y.
. Erie, Pa. tº e
. |New York City . . .
. Bethlehem, Alb. Co., N.Y.
. Red Hook, N. Y.
. Orange Co. . .
. |Mottville, N. Y.
. Moriah, Essex Co. .
. Syracuse, N. Y. .
, Kortright, N. Y.
. Petersham, Mass.
. Pennsylvania
. Columbia, N. Y.
. Walworth, N. Y.
. Pittsfield, Mass. .
. Half Moon, Pa. .
. America tº tº
. |La Fayette, N. Y. .
. |New York City
. |America • * *
. |New Marlboro’, Mass. .
Glenville, N. Y. . . .
tº gº tº º e º 'º º tº º e º e º 'º e º gº ſe e º 'º
New Brunswick, N. J.
Wilton, N. Y.
. Feb. 17, 1888.
. |May 26, 1890.
. |Dec. 3, 1884.
. |March 20, 1884.
tº º $ tº e º º ºs e º 'º e º º
. June 7, 1890.
. |Dec. 15, 1891.
. Dec. 26, 1884.
June 23, 1888.
. Aug. 29, 1891.
. Jan. 18, 1890.
. July 8, 1890.
. June, 23, 1889.
. |Feb. 2, 1889.
. Oct. 27, 1892.
. |March 13, 1886.
. |March 12, 1886.
... [Oct. 13, 1890.
. Jan. 13, 1888.
. April 1, 1891.
. |March 27, 1886.
. |Nov. 29, 1886.
. April 17, 1886.
. |May 10, 1893.
. |March 4, 1886.
. Dec. 9, 1885.
. |June, 1, 1887.
Nov. 3, 1886.
Jefferson Med. Coll., Phila.
Albany Medical College
Albany Medical College
Med, Dep. Univ., Buffalo .
Coll. Phys. and Surg., N. Y. .
Willoughby Univ., Ohio
Long Island Coll. Hosp.
Lic. N. Y. St. Med. Soc.
Albany Medical College
Coll. Phys. and Surg., N. Y. .
Coll. Phys. and Surg., N. Y. .
Buffalo Medical College.
Albany Medical College.
Med. Dept. Syracuse Univ.
Castleton, Vt. e e º º
Harvard Medical College
Geneva Medical College.
Med. Dept. Univ. City of N. Y.
Coll. Phys. and Surg., N. Y. .
Jefferson Med. Coll., Phila.
Berkshire Medical College .
University of Pennsylvania
University of New York
Geneva Medical College. &
Bellevue Hospital Med. Coll. .
Coll, Phys. and Surg., N. Y. .
University of New York
Albany Medical College
DECEASED FELLOWS.—
Continued
NAME. AGE. County. PLACE of BIRTH.
Hamilton, Frank H. (F) 73 ||New York . . [Wilmington, Vt.
Higgins, Seabury M. (O) 67 |Onondaga. . . |Brewster, Mass. . . .
Hinds, Frederic J. (O) 32 Washington . East Greenwich, N. Y.
Hollister, Edwin O. (O). 41 |Ontario . . |Batavia, N. Y.
Hunt, James EI. (O) . 66 |Orange . & e º 'º sº e º e s = e s e º ºs º e º & tº e º ºs e e
Husted, N. C. (F). * ... Westchester . Round Hill, Conn. .
Hutchison, Joseph C. (F) 60 |Kings . |Old Franklin, Mo. .
Hyde, Frederick (F). 80 |Cortland . Whitney Point, N. Y. .
Johnston, Francis U. (F) 66 |Richmond . . New York City . ,
King, James E. (O) 66 Erie . . Warren, Pa. . . g
Knapp, Edwin A. (O) 67 |Onondaga . . New York State
Knapp, John H. (O) . 67 |Cortland . |New Fairfield, Conn. .
Lamont, John Campbell, 47 |Wayne . . . [Edinburgh, Scotland .
Lauer, Eugene (O) e 40 ||New York . . [Germany .
Lester, Sullivan W. (O) . 40 ||Rensselaer . . Niantic, Conn.
Linsly, Jared (F) . 84 ||New York . . [Northfield, Conn.
Matthews, David . ... New York . . . . . . . . . . . . . . . . . . . . . . . . . .
Maury, Rutson . . . . . . . . . New York . . . . . . . . . . . . . . . . . . . . . . . . .
McClellan, Christopher R. . 73 ||Kings . |Maryland .
McTammany, George H. . 31 |Rensselaer . . Troy, N. Y.
McTammany, Wm. F. (O). 36 Rensselaer . . Troy, N. Y.
DATE of DEATH.
. Aug. 11, 1886.
Dec. 9, 1889.
. April 26, 1887.
... [Oct. 8, 1887.
* * * * * * * * * * * * * >
. Nov. 19, 1891.
. |July 17, 1887.
... [Oct. 15, 1887.
. Nov. 20, 1892.
. Jan. 21, 1888.
. Dec. 7, 1890.
. April 30, 1886.
. Dec. 13, 1887.
... [Oct. 31, 1886.
. Jan. 5, 1890.
. July 12, 1887.
July 9, 1891.
April 1892.
. Jan. 13, 1887.
. |April 12, 1891.
. July 21, 1888.
YEAR of
MEDICAL College. GRAD-
UATION.
University of Pennsylvania 1835
University City of New York 1848
Bellevue Hospital Med. Coll. . 1876
Bellevue Hospital Med. Coll. . 1874
Bellevue Hospital Med. Coll. . 1872
University City of New York. 1850
University of Pennsylvania 1848
Fairfield Medical College 1836
Coll. Phys. and Surg., N. Y. . 1852
Buffalo Medical College . 1848
Geneva Med. Coll. . . 1851
Chenango County Med. Soc. 1843
} Geneva Med. Coll. . * 1861
Med. Dept. Univ. City of N. Y. 1862
Giessen and Marburg . . . . 1868
Med. Dept. Univ. City of N. Y. 1881
Coll. Phys. and Surg., N. Y. . 1829
University of Maryland . . 1835
Albany Medical College . 1884
Bellevue Hospital Med. Coll. . 1880
1859
1832
1884
1851
1836
1837
1850
1862
1851
1830
1848
1862
1848
1856
1876
1848
1860
1852
1846
1877
1854
1847
1857
1848
1886
1874
1864
1877
Moore, Joseph W. (F)
Morrell, Isaac
Pask, William (O).
Peck, M. R. (O)
Pollard, Abiathar .
Pomeroy, Charles G. (F)
Pryer, Wm. Chardavoyne (F)
Purdy, Isaac (O) e
Reynolds, Rufus C. (F).
Ring, William (F).
Robinson, Joseph W. *
Rochester, Thomas F. (F) .
Sabin, Robert Hall (F) .
Sayre, Lewis Hall (F)
Schoonmaker, E. J. (F).
Skiff, George W. (O).
Slack, Henry (F) .
Slocum, J. O. (F)
Smith, David M.
Smith, Joseph T. (F)
Smith, Marcellus R. (O)
Sprague, William B. (F)
Squire, Truman Hoffman .
Steele, Charles G. . . .
Steinführer, Gustavus A.(F.)
Stevens, Frederick P. (O) .
Stevenson, William G. .
47
79
55
62
90
'71
54
57
79
63
49
63
56
38
65
53
57
65
35
60
74
55
66
27
37
31
44
|Albany
Chemung .
Erie
Warren
Essex
Wayne.
Westchester
Sullivan
Monroe
Erie
Steuben
Erie
Albany
New York
Seneca .
New York
Dutchess .
Onondaga .
Yates
Ontario
Cortland
Genesee
Chemung .
Erie
New York
Rockland .
Schenectady .
Troy, N. Y.
Cornish, Maine
... [England . . .
Sand Lake, N. Y.
. |Bridgewater, Vt.
... [New York
New York City
Walkill, N. Y. *
Columbia, Herkimer Co.
United States
Angelica, N. Y.
. |Rochester, N. Y. .
Saxton’s River, Vt.
New York City
Ulster Co., N.Y. .
Pike, N.Y.
Albany, N.Y. .
Pompey, N. Y.
New York City
Farmington, N. Y.
Taylor, N.Y. .
Pavilion, N. Y.
Russia, Herkimer Co.
Buffalo, N.Y. .
Germany
Ithaca, N. Y.
. Troy, Ohio .
. Jan.
Aug. 19, 1889.
. Jan.
... [Dec.
. Feb.
. |Mar.
Sept. 9, 1886.
Sept. 8, 1887.
Aug. 24, 1884.
April 4, 1884.
April 15, 1893.
. Dec. 14, 1887.
Sept. 24, 1888.
Dec. 6, 1885.
Dec. 22, 1886.
. |April 20, 1887.
. Jan. 4, 1887.
. |May 24, 1887.
Dec. 4, 1888.
2, 1890.
28, 1890.
10, 1886.
3, 1885.
Dec.
Mar.
Mar.
9, 1890.
Dec. 11, 1890.
NOV.
12, 1888.
July 2, 1890.
Dec. 4, 1884.
Feb. 3, 1888.
19, 1891.
16, 1891.
27, 1889.
Castleton, Vt. . . . .
Bowdoin Medical College .
Med. Dept. Univ. Buffalo
Albany Medical College
Castleton, Vt. . . . . .
Ontario County Med. Soc. .
} Jefferson Medical College
Coll. Phys. and Surg., N. Y.
Castleton, Vt. . . . . .
Fairfield Med. College, N. Y.
University of Buffalo
Buffalo Medical College
University of Pennsylvania
Albany Medical College
Bellevue Hospital Med. Coll.
Geneva Medical College
Univ. City of New York .
Albany Medical College
Castleton, Vt. . . . . .
Bellevue Hospital Med. Coll.
Jefferson Med. Coll. Phila.
Geneva Medical College
University of Buffalo
Coll. Phys. and Surg., N. Y.
University of Buffalo
Coll. Phys. and Surg., N. Y.
Bellevue Hospital Med. Coll.
Bellevue Hospital Med. Coll.
DECEASED FELLOWS-Concluded.
NAME.
Sutton, George Samuel .
Taylor, Isaac E. (F) .
Van Dusen, Melville E.
Vaughn, Frank O. (O) .
Webb, Edwin (O)
West, M. Calvin
White, Francis W.
Willis, A. B. . . . .
Winship, Cornelius A. (O).
Wood, Charles S. (F) *
Woodruff, William D. (F)
Young, Oscar H. (O)
YEAR OF
County. PLACE OF BIRTH. DATE of BIRTH. MEDICAL College. GRAD-
UATION.
Dutchess . . Louisville, N. Y. . Sept. 6, 1888. Coll. Phys. and Surg., N. Y. 1859
New York . |Philadelphia, Pa. . . Oct. 30, 1889. University of Pennsylvania 1834
Steuben . Wheeler, N. Y. . June 15, 1891. Med. Dept. Univ. Mich. . 1879
|Erie ... [Buffalo, N. Y. . . . [Mar. 18, 1891. Med. Dept. Buffalo Univ. iº 1880
Queens . Devonport, England . . Jan. 29, 1890. Coll. Phys. and Surg., N. Y. 1825
Oneida . . |Rome, N. Y. . . Oct. 20, 1891. Michigan University . . 1860
New York. . |New York City Oct. 9, 1889. Univ. City of New York . 1855
Schenectady . Coeymans, N. Y. . May 10, 1891. Albany Medical College 1870
Rensselaer Litchfield, Conn. Feb. 14, 1888. Albany Medical College . 1858
New York Litchfield, Conn. . Feb. 1, 1890. Jefferson Med. College, Phila. 1851
Suffolk . Portsmouth, Wa. . |Mar. 10, 1893. University of Pennsylvania 1855
Delaware . Pennsylvania Jan. 21, 1889. Jefferson Med. College, Phila. | 1876
IND EX
Abdominal hysterectomy for my-
oma, Dr. F. A. BALDWIN, 421.
Address of welcome, Dr. J. G.
TRUAx, 15.
of the president, 18.
Address on surgery, Dr. FREDERIC
S. DENNIS, 201.
Alcoholism, some personal observa-
tions and reflections upon ; the
effects of alcoholic abuse upon
posterity ; and the treatment of
alcoholism, Dr. H. E. SCHMID,
545.
Alienist and the general practitioner,
Dr. J. B. ANDREWS, 18.
American surgery, achievements of,
Dr. FREDERIC S. DENNIS, 201.
ANDREWS, JUDSON B., president's
address, 18.
operations for epilepsy, 166.
acute pleurisy, 273
examination and commitment of
insane, 377, 378.
cominitment of drunkards and
morphinists, 558.
Antiseptic injections in obstetrics,
Dr. D. CoIVIN, 86.
Appendicitis, chronic recurring, Dr.
F. W. Ross, 740.
Appendicitis, recent cases of, Dr.
N. JACOBSON, 64
ARMSTRONG, S. T., should we treat
fever ? 576.
mitral stenosis in pregnancy, 386.
AYRES, DOUGLAS, puerperal eclamp-
sia, 98.
paper jackets for lateral curva-
ture, 715.
BABCOCK, MYRON N., memoir of,
723.
BALDWIN, FREDERICK A., abdom-
inal hysterectomy, 421.
Brain surgery, clinical contribu-
ſº to, Dr. Roswell, PARK,
Branch, First, officers for 1893, p. 4,
report of, 737.
Second, officers for 1893, p. 4,
report of, 738.
Third, officers for 1893, p. 4,
report of, 740.
Fourth, officers for 1893, p. 5,
report of, 756.
Fifth, officers for 1893, p. 6,
report of, 758.
BROOKS, L. J., examination and
commitment of insane, 377.
BROWN, CHARLES W., paraplegia,
130.
BRYANT, JosLPH. D., treatment of
fractures of the patella, 512.
early extirpation of tumors, 185.
BULL, C. S., tumors of the orbit,
105.
CHACE, WILLIAM, memoir of, 736.
Cholera, winter, in Poughkeepsie,
Dr. JAMES G. PortEous, 521.
CHRYSTIE, T. M. LUDLOW, muscu-
lar traction for hip disease, 60.
Climatology in its relation to dis-
ease, Dr. S. J. MURRAY, 559.
COLVIN, DARWIN, antiseptic injec-
tions, 86.
Committee of arrangements for
1891–92, 2.
report of, 15,
Coughing made easy in bronchiec-
tasis, Dr. H. D. DIDAMA, 250.
Council, annual report of the, 778.
COUTANT, RICHARD B., memoir of
. athaniel Clark Husted, M. D.,
27.
COWLEs, EDWARD, the mental
symptoms of fatigue, 441.
CRONYN, JOHN, operations for epi-
lepsy, 166. , -
acute pleurisy, 272.
mitral stenosis in pregnancy, 386.
abdominal hysterectomy for my-
oma, 426.
DAMAINVILLE, LUCIEN, memoir of,
725.
Dºº, LDEN W., appendicitis,
7
puerperal eclampsia, 104.
DENNIS, FREDERIC S., address on
surgery, 201.
832
INDEX.
erence to lesions of the brain
Substance, DR. C H A R L E S
PHELPs, 274.
Histº F. W., acute pleurisy,
mitral stenosis in pregnancy, 386.
Orton prize essay—the control of
scarlet fever, 746.
HUBBELL, ALVIN A., extraction of
Steel from the eye with electro-
magnet, 427.
HUSTED, NATHANIEL CLARK, me.
moir of, 727.
Identity of diphtheria, membranous
Croup, and follicular tonsillitis,
a study on the, Dr. E. G.
DRAKE, 743.
INGRAHAM, H. D., ectopic preg-
nancy, 77
abdominal hysterectomy for my-
Oma, 425.
Insane, examination and commit-
ment of the public, in New
York city, Dr. MATTHEW D.
FIELD, 365.
Insane, the limit of responsibility in
the, Dr. JoBIN SHRADY, 540.
Insurance sponge, the, Dr. H. D.
DIDAMA, 253.
Intercranial lesion ; ante-mortem
localisation; autopsy. Dr. J.
G. ORTON, 753.
Intestinal amastomosis, Dr. BEN-
JAMIN M. RICKETTS, 187.
JACOBSON, NATHAN, appendicitis,
64
JANvrin, J. E., cancer of the
uterus, 92.
ectopic pregnancy, 84.
KAHLo, G. D., compound depressed
fracture of skull, 189.
Rings County Medical Association,
annual report, 764.
Lateral curvature of the spine,
treatment of neglected cases of
rotary, Dr. R. H. SAYRE, 687.
List of Fellows registered at the
ninth annual meeting, 10.
of presidents, 7. e
of delegates and invited guests,
14
Dermic and hypodermic therapeu- |
tics, Dr. S. F. RogFRs, 676.
DIDAMA, H. D., memoranda, prac-
tical and suggestive, 245.
acute pleurisy, 272.
District Branches—see Branch.
Diphtheria, membranous croup and
follicular tonsillitis, identity of,
Dr. E. G. DRAKE, 743.
DOUGLAS, GEORGE, commitment of
drunkards and morphinists,
558.
DRAKE, E. G., identity of diph-
theria, membranous croup and
follicular tonsillitis, 743.
DU BOIS, ABRAM, memoir of, 716.
Electricity in midwifery, Dr. O. C.
LUDLOW, 388.
Eye, extraction of steel from, with
electro-magnet, Dr. A. A. HUB-
BELL, 427.
Fatigue, the mental symptoms of,
DR. EDWARD COWLEs, 441.
FERGUSON, E. D., recent experience
in renal surgery, 678.
pneumotomy for abscess of lung,
38
treatment of rotary lateral curva-
ture, 715.
FERGUSON, JAMES, memoir of, 735.
Fever, should we treat f Dr. S. T.
ARMSTRONG, 576.
FIELD, MATTHEW D., examination
and commitment of the insane,
365.
FLANDREAU, THOMAS M., memoir
of M. Calvin West, M. D., 721.
FLINT, AUSTIN, memoir of Lucien
Damainville, M. D., 725.
Fracture, compound, depressed, of
skull, Dr. G. D. KAHLO, 189.
Fractures of the patella treated by
continuous extension ; patients
not confined to bed, Dr. J. D.
BRYANT, 512.
Gastric ulcer, aetiology of, Dr. C.
G. STOCKTON, 354.
GOULD, GEORGE M., the mental
symptoms of fatigue, 466.
GoulBY, JoHN W. S., early extir-
pation of tumors, 167.
HANNAN, J. C., examination and
commitment of insane, 378.
Head, injuries of. A clinico-patho-
logical study, with special ref-
of Fellows by district and county,
783.
of Fellows alphabetically, 806.
of deceased Fellows, 826.
INDEX.
833
of honorary Fellows, 824,
of corresponding Fellows, 824.
of non-resident Fellows, 824.
of retired Fellows, 824.
LUDLow, OGDEN C., electricity in
midwifery, 388.
pelvic version, 574.
LUSIK, ZERA. J., mitral stenosis in
pregnancy, 379.
gastric ulcer, 364.
MANLEY, THOMAS H., lesions of the
ankle-joint, 39.
MARTINE, G. R., memoir of James
Ferguson, M. D., 735.
Materia medica, pharmacy, and
therapeutics of the year ending
November 1, 1892, brief com-
ments on, Dr. E. H. SQUIBB,
588.
Maternal impressions, the question
of, Dr. H. S. WILLIAMS, 135.
MCGILLICUDDY, T. J., pelvic ver-
Sion, 567.
Membranous croup, diphtheria, and
follicular tonsillitis, identity of,
Dr. E. G. DRAKE, 743.
Memoirs—
MYRON N. BABcock, M. D., 723.
WILLIAM CHACE, M. D., 736.
LUCIEN DAMAINVILLE, M. D.,
725.
ABRAM DU BoIS, M. D., 716.
JAMES FERGUSON, M. D., 735.
NATHANIEL CLARK HUSTED,
M. D., 727.
M. CALVIN WEST, M. D., 721.
Memoranda, practical and sugges-
tive, Dr. H. D. DIDAMA, 245.
Microbes, the rôle of in disease, Dr.
N. B., SIZER, 405.
Midwifery, the use of electricity in,
Dr. O. C. LUDLow, 388.
Mineral waters, crude and refined,
Dr. H. D. DIDAMA, 248.
Mitral stenosis in pregnancy, Dr. Z.
J. LUSIK, 379.
MOORE, E. M., injuries of the upper
extremity, 469.
lesions of the ankle-joint, 58.
appendicitis, 75.
ectopic pregnancy, 84, 85.
th; ºnal Symptoms of fatigue,
68.
MURRAY, S. J., climatology and
disease, 559.
Muscular traction for hip-joint dis-
º Dr. T. M. L. CHRYSTIE,
New York County Medical Associa-
tion, annual report, 767.
NORTH, NELSON. L., the commitment
of drunkards and morphinists,
558.
obº, M. C., pelvic version,
574.
Officers and council for 1891–'92, 1.
1892–'93, 3.
of the branch associations, 4.
ORTON, J. G., an intercranial
lesion ; ante-mortem localisa-
tion ; autopsy, 753.
Orton prize essay—the control of
Scarlet fever, 746.
Palliative treatment of cancer of the
uterus and its adnexa, not amen-
able to radical operative meas-
ures, Dr. J. E. JANVRIN, 92.
Paraplegia, Dr. CHARLEs W.
BROWN, 130.
PARK, ROSWELL, brain surgery,
146.
PARSONS, FRANK S., acute pleurisy,
256
Patella, fractures of, treated by
continuous extension ; patients
not confined to bed, Dr. J. D.
BRYANT, 512.
Pelvic version, Dr. T. J. MCGILLI-
CUDDY, 567.
PHELPs, CHARLEs, injuries of the
head, 274.
early extirpation of tumors, 184.
Pleurisy, acute, Dr. F. S. PARSONs,
256.
Pleurisy, early aspiration in, Dr. H.
D. DIDAMA, 245.
Pneumotomy for tubercular abscess,
Dr. J OHN B. WHITE, 30.
PORTEOUS, JAMES G., winter cholera
in Poughkeepsie, 521.
Pregnancy, ectopic, Dr. H. D. IN-
GRAHAM, 77.
Pregnancy, mitral stenosis in, Dr.
Z. J. LUSIR, 379,
Poºngs, ninth annual meeting,
74.
Puerperal eclampsia at the seventh
month ; suggestions as to treat-
ment, Dr. DOUGLAS AYRES, 99,
PURPLE, SAMUEL S., memoir of
Abram Du Bois, M. D., 716.
PUTNAM, JAMES W., brain surgery,
165
the mental symptoms of fatigue,
834
INDEX.
Quarantine, suggestions relating to
improvement of, Dr. STEPHEN
SMITH, 531.
Renal surgery, some recent expe-
rience in, Dr. E. D. FERGUSON,
678.
REYNoLDs, T. B., memoir of Myron
N. Babcock, M. D., 723.
RICKETTS, BENJAMIN M., intestinal
anastomosis, 187.
RoGERs, H. C., typho-mania, 742.
RogFRS, S. F., dermic and hypo-
dermic therapeutics, 676.
Ross, FRANK W., appendicitis, 74.
brain surgery, 165.
examination and commitment of
the insane, 378.
mitral stenosis in pregnancy, 385.
abdominal hysterectomy for my-
oma, 426.
cº recurring appendicitis,
740. &
SAYRE, REGINALD H., treatment of
neglected cases of rotary lateral
curvature, 687.
Scarlet fever, the control of, Dr. F.
H. HIGGINS, 746.
SCHMID, H. ERNST,
and posterity, 545.
SCHRADY, JoHN, responsibility in
the insane, 540.
SIZER, NELSON B., microbes in dis-
ease, 405.
acute pleurisy, 273.
Skull, compound depressed fracture
of, Dr. G. D. KAHLO, 189.
SMITH, SPEPHEN, improvement of
quarantine, 531.
alcoholism
SQUIBB, E. H., materia medica,
pharmacy and therapeutics for
1892, 588.
Steel, extraction of from the eye
with the electro-magnet, Dr. A.
A. HuBBELL, 427.
STOCKTON, CHARLES G., gastric ul-
cer, 354.
STRONG, THOMAs D., memoir of
William Chace, M. D., 736.
Traumatic osteo-arthritic lesions of
the ankle-joint, Dr. THOMAS H.
MANLEY, 39.
TRUAx, JoHN G., address of wel-
come, 15.
pneumotomy for abscess of lung,
38
abdominal hysterectomy for my-
oma, 426.
Tumors, a plea for the early extir-
pation of, Dr. JoHN W. S.
Goul, EY, 167.
Tumors of the orbit. Nineteen
cases illustrating a previous
paper, Dr. C. S. BULL, 105.
Typºmania, Dr. H. C. RogFRS,
742.
Upper extremity, a review of some
ºries of, Dr. E. M. MooRE,
69.
WEST, M. CALVIN, memoir of, 721.
WHITE, JoHN B., pneumotomy for
abscess of lung, 30.
WILLIAMS, H. S., maternal impres-
sions, 135.
paraplegia, 134.
th: ºnal symptoms of fatigue,
67.
MAN 2 3 1917
ſ UNIVERSITY OF
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